Date: 5 th July 2016 DERBYSHIRE COUNTY LOCAL DENTAL COMMITTEE Venue: Topic: Facilitator: Higham Farm Hotel, Higham Medical Emergencies in the Dental Practice R Bolt, Clinical Research Fellow, Department of Oral Surgery, Charles Clifford Dental Hospital. Dr North welcomed everyone and introduced Dr Bolt, a Clinical Research Fellow at the Department of Oral Surgery, Charles Clifford Dental Hospital, who was facilitating the session for the evening. The Aims and Objectives of the course were as follows: Aims and objectives: To cover the likely medical emergencies encountered in a dental practice To review management of each scenario and why the patient was managed in this way To give an overview of what happens after a patient leaves the care of the GDP Introduction Dr Bolt introduced himself and explained that he was going to be talking about medical emergencies, covering all types and not CPR. The reasons for the training was that it was a GDC/CPD requirement, that practitioners had a duty of care to patients, whether elective or emergency, and that GDPs were expected to have a level of knowledge to apply the principles of emergency care. Dr Bolt acknowledged that medical emergencies teaching tends to be uninteresting and he outlined why such teaching tends to be uninspiring: It is repetitive There is a lack of explanation as to why things are done There is a lack of explanation as to what happens to the patient after they leave the practice. Most Common Medical Emergencies in Dental Practice (From 4,000 dentists over 10 years) Vaso-vagal 15,407 Mild Allergic Reaction 2,583 Angina Pectoris 2,552 Postural Hypotension 2,475 Seizures 2,195 Asthmatic Attack 1,392 Hyperventilation 1,326 Adrenaline Reaction 913 Hypoglycaemia 890 Cardiac Arrest 331 Anaphylaxis 304 Myocardial Infarction 289 1
Many of these events are preventable, or at least the chances of them occurring can be reduced and Dr Bolt would cover the most common. Epilepsy The first medical emergency covered was epilepsy. Firstly Dr Bolt explained what epilepsy was and what the possible triggers of a seizure were. He then explained what a practitioner needed to do to manage such a situation, which was: Place patient in a supine position Protect from injury Administer oxygen if safe Suction mouth secretions and turn head to side if vomiting occurs-clear airway Monitor vital signs (pulse, colour, breathing commence CPR if indicated) Initiate further support/treatment if needed Dr Bolt explained that there had been a recent change in definition based on early management being more effective: previously fitting had to be continuous for 30 minutes now it was if a patient was fitting for 5 minutes or consecutive fits without recovery of consciousness between Dr Bolt said that it was important for practitioners to be aware of what to use and how it should be used. There were two drugs that could be used for dental management of a seizure: Midazolam Buccal and Diazepam PR both were alternatives to Lorazepam and he stressed that it was important to treat early as seizures tended to beget seizures. Only one dose of Buccal Midazolam could be given in a dental practice and the 5:5 10:10 rule should be followed: Under 5 years of age 5mg should be administered, over 10 years old, 10mg should be administered and in between 7.5mg should be given. It was very important to note what drugs had been administered and when and how long the patient had been fitting and this information should be passed onto the paramedics. Practitioners should check if any carers or parents were carrying Diazemuls, and these people were usually happy to administer as they were used to dealing with the situation. If patients were also diabetic glucose should also be administered if safe to do so as not all fits were epileptic in origin. Dr Bolt then gave an overview of patient management when they were admitted to the emergency department and outlined what drugs would be administered and when and further treatment if the patient s condition did not improve. In closing this section, Dr Bolt high-lighted the possibility of a patient exhibiting psychogenic, non-epileptic seizure, which was a mental health condition. There were subtle differences between the two seizures, mainly that in a psychogenic fit the patient tended to bit the tip of their tongue, whereas, a patient experiencing a true epileptic fit would also bite along the tongue lateral. It was important to appreciate that someone exhibiting a psychogenic fit was not necessarily feigning. Asthma Dr Bolt explained that asthma was a reversible airway obstruction, which created problems for the patient in exhaling. There were two causes: intrinsic and extrinsic. Extrinsic this was the classic model and usually environmental caused when allergens such as dust, pollen, pet fur, were inhaled into the lungs. This exposure to allergens caused the release of histamine which then led to bronchoconstriction. 2
Dr Bolt then explained what Salbutamol was, which basically acted as an artificial adrenaline for the lungs, helping them to relax and the patient to breathe more easily. Dr Bolt advised that practitioners should use the ABC approach and administer Salbutamol, 2 doses initially, but which could be given repeatedly if required without having adverse effects for the patient. It was also necessary to note that not all inhalers were beneficial, Salmetrol and steroid inhalers were longlasting and would not provide any immediate relief. Oxygen should be administered at the highest rate possible and an ambulance should be called immediately if the patient was hypoxic or if there was no improvement or a worsening of the patient s condition after initial treatment. Dr Bolt then gave an overview of patient management if they were then admitted to the emergency department and outlined what drugs would be administered and when and further treatment if the patient s condition became life-threatening. In summary practitioners should: Salbutamol 2 puffs initially, with regular repeats (2-3 mins fine) Oxygen highest flow achievable (even COPD) Consider ambulance Practitioners should also note not to administer more than 2 puffs at a time if using a spacer to administer the inhaler. Heart Attack Most people found frightening the idea of someone suffering a myocardial infarction however: Only 15% suffer mortality within first 30 days The vast majority of deaths occur well beyond first hour of symptoms The only chance of a patient dying in the surgery is in a case of a disastrous event that a practitioner is unlikely to be able to influence There are two types of attack: Ischaemic or Infarction. The first is experienced in conditions like angina and the pain is ischaemic and in the second the pain is caused by muscle death. Dr Bolt explained about Acute Coronary Syndrome (ACS) which covered a spectrum of acute chest pain (this did not include stable angina, which tended to improve with rest, was similar to previous attacks and responded to GTN), but included unstable angina, NSTEMI and STEMI. It should be noted that 50% of patients with clinical symptoms of unstable angina had actually suffered an MI. The initial management of ACS could be covered by MONA : Morphine - for pain relief and diamorphine acted as a coronary artery relaxant. Oxygen although this was contentious and a pragmatic approach should be taken and if a patient was hypoxic or short of breath oxygen should be given. If the patient was a normal colour there was a lack of clarity around whether oxygen should be administered. Nitrates in a dental practice there should be GTN in the emergency cabinet. If the patient has some the expiry date needs to be checked as it has a shelf-life of 1-month. Any concerns the GTN from the emergency cabinet should be used. Aspirin - the dose for this is 300mg, even if the patient is already on 75mg a day. The tablet should be chewed as this increases the surface area for absorption. Overall the ABC approach should be taken. 3
Dr Bolt then gave an overview of patient management if they were then admitted to the emergency department which would include the therapies not delivered via MONA and they would then investigate which bit of ACS was the final diagnosis. He also explained that STEMI was managed differently to other ACS diagnoses. In summary when dealing with a suspected MI the GDP should: Take the ABC approach Use MONA, but administration of Nitrates and Aspirin were the key things Call an ambulance. Adrenal Crisis Dr Bolt stated that there was very little information available on the mechanism of this and a lack of clarity around how it comes about. He gave a brief summary of the role of the adrenal cortex in maintaining normal BP and explained that in an adrenal crisis (often caused by shock or stress) the adrenal gland was not working properly which resulted in inadequate vascular tone and cardiac output. Dr Bolt explained both the medical approach to management and that of a dental practitioner. The latter would include: Administering IV access & Fluids if available Place the patient in a supine position and raise legs Administer Hydrocortisone 100mg IM Supplement with O 2 Not part of protocol but there was no harm in assuming potentially low glucose and giving supplement The medical approach was the same initially but included checking glucose and supplementing if low and monitoring Na + (+ saline) and K + (cardiotoxic). To help avoid an adrenal crisis the patient should take a double dose of steroids on morning of surgery or 25mg Hydrocortisone IV at time of surgery. In vasovagal syncope the trigger process was similar to an adrenal crisis: the heart slows down and there is a reduced blood supply to the brain. Management of vasovagal syncope includes: Placing the patient in a supine position. Raising their feet Administer Oxygen Give a glucose drink when conscious The GDP is essentially waiting for the Sympathetic Nervous System and Cortisol to kick in (c.f. Adrenal Crisis) The GDP should not be put off a diagnosis syncope if the patient convulses for the first few seconds of becoming unconscious Hyperventilation The occurrence of this from anxiety is rare, hypoxia is a more common cause. Hyperventilation causes alkalosis. Hyperventilation should not be treated by getting a patient to breathe into a paper bag as this can create more problems such as increased hypoxia for MI or asthma sufferers and worsened acidosis for patients suffering from Diabetic Ketoacidosis with Kussmaul Respirations. The patient suffering from 4
hyperventilation should be talked to, calmed down, given oxygen and encouraged to breathe steadily. Hyperventilation is not fatal although a patient may faint due to a reduction in oxygen, but they should be fine once breathing returns to normal. Diabetes Dr Bolt stated that patients were more likely to suffer from a hypo whereas hyperglycaemia was limited to undiagnosed DM, the patient not taking their insulin or a systemic infection. Symptoms of hypoglycaemia included: Hunger Nausea Cool, moist skin Shallow respirations Irritation Confusion Bizarre behavior In managing a hypo if the patient was conscious administer 10-20g carbohydrate (Glucogel/ Hypostop 10g glucose, 3 sugar lumps or 80 ml Coca Cola/ 100ml Lucozade. If the patient was unconscious give 1mg Glucagon IM. Some practitioners expressed concerns about administering glucose to a patient that turns out to be suffering from hyperglycaemia, but the amounts given in surgery would not have a detrimental effect. Anaphylaxis Dr Bolt said that, other than a patient suffering from a cardiac arrest, this condition was one where the patient could die in the surgery. Symptoms included: Urticarial Rash Orbital Oedema/ Angioedema Bronchospasm Laryngeal Oedema Hypotension Unconscious The latter 4 were the worst symptoms. Management should take place when there are more symptoms than just a rash but if they are present Adrenaline - 500mg IM (0.5ml 1:1000) should be administered and repeated after 5 minutes if there is no improvement. Also the patient should be Laid flat, legs raised and O 2 administered with IV access fluids should be given. There is no evidence that Antihistamine - Chlorphenamine 10mg IV or steroid- Hydrocortisone 200mg IV/IM has any immediate benefit, therefore, these do not have to be given in a dental practice. An additional tip is that bronchospasm will benefit from administering Salbutamol if it is available. Some patients may have Epipens which delivers 300 micrograms and is stated as a suitable alternative. It is favourable due to more rapid delivery. 6-12 yr olds can be administered 300 micrograms and 0-6 yr olds should be given 150 micrograms, but less likely to be giving LA etc. to this group. 5
Cardiac Arrest Early recognition and call for help will help to prevent a cardiac arrest and early CPR and use of a defib if possible and the heart has stopped will buy time. The ABC approach should be taken. Airways: Clear obstructions, etc. Open airway extend neck, jaw thrust Instruct assistant to get Oxygen immediately Breathing: Look Listen Feel Circulation: No longer 2 rescue breaths before assessing C Assess pulse Carotid If NO CARDIAC OUTPUT start CPR CENTRAL chest 30 compressions:2 breaths Depth of compressions 5-6cm Rate 100 min -1 Automated Extended Defibrillator: This only deals with those types of heart attack where there is still electrical activity and the pprinciples include: Some cardiac arrests can be improved by early use of defibrillators Can be classified as Shockable rhythms VF, PVT Non-shockable rhythms - Asystole and EMD The AED will automatically assess if defibrillation appropriate When a patient collapses and becomes unconscious a GDP is not necessarily going to know the cause. Firstly all possible diagnoses should be considered and these could include: Cardiac arrest Epilepsy DM hypo/ ketoacidosis/ HONK Stroke Alcohol Shock haemorrhagic, anaphylactic, addisonian The management of an unconscious patient begins with ABC but goes onto DEFG(H). Initially help should be called for as an ambulance if usually required and it can be cancelled for example, if the patient comes round from fit. Airway -patent, get O 2 straight away 6
Breathing - look, listen, feel and if the GDP has a stethoscope, auscultate Circulation - pulse; rate, rhythm, volume, signs of bleeding, insert a cannula Disability - AVPU, if becomes conscious FAST (Face, Arms, Speech, Time). Is there any paralysis in any aspect. Expose full exposure may not be appropriate, but assess limbs (warning tags, etc) and abdomen (is it soft, is there anything obvious?) Fluids Insert a cannula if this hasn t been done at C. Although it is unlikely to have IV fluids in practice it will help if subsequent vascular shutdown Glucose Don t Ever Forget Glucose History revisit Dr Bolt said that GDPs should instigate any individual management if cause noticed: A: Airway obstruction Cricothyroid stab C: No circulation cardiac arrest CPR Bleed apply pressure, attempt to arrest haemorrhage D: Stroke not much further you can do unless is conscious (300mg Aspirin) E: Dog tag - epilepsy: buccal midazolam - allergy: adrenaline - warning card: adrenal fluids, hydrocortisone G: Glucose if hypoglycaemia suspected Summary: Always revert to the ABC approach Oxygen, oxygen, oxygen Glucose, glucose, glucose In most emergencies the patient will leave the practice alive and practitioners should remember that everything that they do adds to the patient s long-term survival. Always assuming that an ambulance has been called. Questions were invited from the attendees and answered. Dr North thanked Dr Bolt for his presentation and everyone for attending. Attendees were reminded that they would receive a certificate upon completion of the on-line evaluation form. The group were informed that the next course was Safeguarding Children and Vulnerable adults on 20 th September. 7