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MedicalEmergencies
This article counts towards
one of the five core subjects
introduced in 2007 by the GDC.
Mark Greenwood
Medical Emergencies in Dental
Practice: 2. Management of Specific
Medical Emergencies
Abstract: In the second of two papers on the diagnosis and management of medical emergencies, the measures needed to manage
specific medical emergencies are discussed. Each emergency requires a correct diagnosis for effective and safe management. Signs and
symptoms are highlighted at the beginning of each section describing patient management. The basis of management in contemporary
dental practice avoids the intravenous route of drug administration, where drugs are required.
Clinical Relevance: All dental practitioners require a knowledge of the management of specific medical emergencies.
Dent Update 2009; 36: 262
268
In the first paper, general principles of Their signs, symptoms and management Vasovagal syncope (faint)
medical emergency management (the will be discussed. Hyperventilation/’panic attack’
ABCDE approach) were discussed. These Acute asthma attack
principles should be applied in all cases. Vasovagal syncope (simple Angina/myocardial infarction
Certain medical emergencies, however, faint) Epileptic seizures
require treatment specific to the particular Diabetic emergencies
situation. Emergencies can sometimes be Simple faint is the most Allergies/hypersensitivity reactions
anticipated as a result of having obtained a common medical emergency seen Choking and aspiration
thorough medical history.1 in dental practice and results in loss
It is important to recognize of consciousness due to inadequate Adrenal insufficiency
and diagnose what is happening in order cerebral perfusion. It is a reflex which is Cardiac arrest (see paper 1)
to manage the particular emergency mediated by autonomic nerves, leading Table 1. Summary of medical emergencies that
appropriately. A consideration of presenting to widespread vasodilatation in the may be encountered in dental practice
signs and symptoms is the key to this. The splanchnic and skeletal vessels, and
administration of specific drugs, if required, bradycardia resulting in diminished
varies according to the situation and these cerebral perfusion. Fainting can be
are discussed below. precipitated by pain or emotional stress, fainting include:
Specific emergencies that can changes in posture or hypoxia. Some Patient feels faint/light headed/dizzy;
arise in dental practice are listed in Table 1. patients are more prone to fainting than Pallor, sweating;
others and it is wise to treat fainting- Pulse rate slows;
prone patients in the supine position. Low blood pressure;
A similar clinical picture may Nausea and/or vomiting;
be seen in ‘carotid sinus syndrome’. Mild Loss of consciousness.
Mark Greenwood, PhD, MDS, FDS, FRCS, pressure on the neck in such patients Treatment for fainting involves
FRCS(OMFS), FHEA, Consultant, Honorary (usually elderly) leads to a vagal reaction the following:
Clinical Professor, Oral and Maxillofacial producing syncope. This situation may Lie the patient flat and raise the legs
Surgery, School of Dental Sciences, progress to bradycardia or even cardiac recovery will normally be rapid;
Newcastle University, Framlington Place, arrest. A patent airway must be maintained;
Newcastle upon Tyne NE2 4BW, UK. The signs and symptoms of If recovery is delayed, oxygen (10 litres
262 DentalUpdate June 2009
pg262-268 Medical emergencies 2.indd 1 3/6/09 14:24:56
MedicalEmergencies
Hypertension of the face may become weak. As stroke 2. Shafer DM. Respiratory emergencies
Smoking causes an upper motor neurone lesion, the in the dental office. Dent Clins N Am
Diabetes Mellitus forehead muscles of facial expression will 1995; 39: 541554.
Cardiac and peripheral vascular be unaffected. Speech may become slurred. 3. Royal Pharmaceutical Society of Great
disease Initial management of a stroke Britain. Prescribing in Dental Practice.
Atrial fibrillation includes the following: British National Formulary, 2008:
Previous Transient Ischaemic Attack The airway should be maintained and an 2125.
(TIA) – focal CNS disturbances caused ambulance called; 4. Assael LA. Acute cardiac care in dental
by vascular events such as microemboli High flow oxygen (10 litres per minute) practice. Dent Clins N Am 1995; 39:
and occlusion leading to ischaemia. By should be given; 555565.
definition, symptoms last for less than The patient should be carefully monitored 5. Chapman PJ. Chest pain in the dental
24 hours for any further deterioration. surgery; a brief review and practical
Obesity points in diagnosis and management.
Hyperlipidaemia Local anaesthetic emergencies Aust Dent J 2002; 47: 259261.
Excess alcohol intake 6. Chandu A, Macisaac RJ, Smith AC, Bach
Allergy to local anaesthetic is LA. Diabetic ketoacidosis secondary
Table 7. Risk factors for stroke. rare but should be managed like any other to dento-alveolar infection. Int J Oral
case of anaphylaxis. When taken in the Maxillofac Surg 2002; 31: 5759.
context of the number of local anaesthetics 7. Meechan JG, Skelly AM. Problems
administered, complication rates are low.11 complicating dental treatment
to have a prophylactic increase in steroid The signs and symptoms in allergy are with local anaesthesia or sedation:
dose.10 those of anaphylaxis. Fainting in association prevention and management. Dent
The guidance for patients with with the injection of local anaesthetic is Update 1997; 24: 278283.
Addison’s Disease is to double the patient’s more common and can usually be avoided 8. Adult Basic Life Support Resuscitation
steroid dose before significant dental by administering the local anaesthetic while Guidelines 2005. Resuscitation Council
treatment under local anaesthesia and the patient is supine. (UK).
continue this for 24 hours.10 9. Thomason JM, Girdler NM, Kendall-
The treatment of adrenal crisis Conclusions Taylor P, Wastell H, Weddell A, Seymour
includes the following: RA. An investigation into the need
Lay the patient flat and raise his/her legs; After correct diagnosis, prompt for supplementary steroids in organ
Ensure a clear airway and administer appropriate management will deal with transplant patients undergoing
oxygen; medical emergencies effectively. It is gingival surgery. J Clin Periodontol
Call an ambulance. important that each member of the dental 1999; 26: 577582.
team knows what his/her role should be in 10. Medical Emergencies and Resuscitation
Stroke the event of a medical emergency. Training Standards for Clinical Practice and
should be updated regularly and at least on Training for Dental Practitioners and
Stroke may be either an annual basis. Dental Care Practitioners in General
haemorrhagic or embolic in aetiology but Dental Practice – A statement from
clinically the effects are essentially the same. References the Resuscitation Council (UK) July
Risk factors for stroke are summarized in 2006. Revised May 2008, Resuscitation
Table 7. Signs and symptoms vary according 1. Shampain GS. Patient assessment Council, UK.
to the site of brain damage. There may be and preventive measures for medical 11. Koerner KR, Taylor SE. Emergencies
loss of consciousness and weakness of emergencies in the dental office. Dent associated with local anaesthetics.
limbs on one side of the body. One side Clins N Am 1999; 43: 383400. Dent Today 2000; 19(10): 7279.
COVER PICTURES
Do you have an interesting and striking colour picture with a dental connection, which may be suitable for printing on the front cover?
Send your pictures to:
The Executive Editor, Dental Update
George Warman Publications (UK) Ltd, Unit 2, Riverview Business Park, Walnut Tree Close, Guildford, Surrey GU1 4UX
Payment of £200 will be made on publication.
268 DentalUpdate June 2009
pg262-268 Medical emergencies 2.indd 7 3/6/09 14:27:37
MedicalEmergencies
return the situation to normal. actuations from the salbutamol inhaler via a
spacer device should be used and repeated
every 10 minutes. In the British National
Asthma 3
Formulary a technique is described for a
Asthma is a potentially life- ‘home-made’ space device. A hole can be
threatening condition and should always cut out of the base of a paper or plastic cup.
2
be taken seriously. An attack may be The mouthpiece of the inhaler is pushed
precipitated by exertion, anxiety, infection through this. The open end of the cup can
or exposure to an allergen. It is important then be applied to the mouth when the
in the patient’s history to gain some idea inhaler is activated.
Figure 1. A demonstration of carpal spasm. of the severity of attacks. Clues include If asthma is part of a more generalized
the precipitating factors, effectiveness of anaphylactic reaction, or in extremis , an
medication, hospital admissions as a result intramuscular injection of adrenaline should
of asthma and the use of systemic steroids. be given (see section on anaphylaxis).
per minute) should be administered and It is important that asthmatic All patients, including those
other causes of loss of consciousness be patients bring their usual inhaler(s) who have chronic obstructive pulmonary
considered. with them if the inhaler has not been disease, should be given high flow oxygen
brought it must be in the emergency kit as, even if these patients are dependent on
Hyperventilation (panic attack) or treatment should be deferred. If the ‘hypoxic drive’ to stimulate their respiration,
asthma is in a particularly severe phase, they will come to no harm in the short term.
Hyperventilation is a more elective treatment may be best postponed.
common emergency than is often Drugs which may be prescribed by dental
thought. When hyperventilation persists practitioners, particularly non-steroidal anti- Chest pain of cardiac origin
it can become extremely distressing inflammatory drugs (NSAIDs), may worsen Most patients who suffer chest
to the patient. Anxiety is the principal asthma and are therefore best avoided. pain from a cardiac origin in the dental
precipitating factor. The signs and symptoms of surgery are likely to have a previous history
The signs and symptoms of asthma include: of cardiac disease. The history is clearly
hyperventilation include: Breathlessness (rapid respiration more important and, if a patient uses medication
Anxiety; than 25 breaths per minute); to control known angina, he/she should
Light-headedness; Expiratory wheezing; have brought this with them, or it should
Dizziness; Use of accessory muscles of respiration; be readily to hand in the emergency kit.
Weakness; Tachycardia. Similarly, it is important that the patient has
Paraesthesia; The signs and symptoms of life- taken his/her normal medication on the day
Tetany (see below); threatening asthma include: of the appointment.
Chest pain and/or palpitations; Cyanosis or slow respiratory rate (less Classically, the pain of angina
Breathlessness. than 8 breaths per minute); is described as a crushing or band-like
Treatment for hyperventilation Bradycardia; tightness of the chest which may radiate
involves the following: Decreased level of consciousness/ to the left arm or mandible. There are
A calm and sympathetic approach confusion; many variations, however. The pain of
from the practitioner as the diagnosis, Treatment for asthma involves the myocardial infarction (MI) will often be
particularly in the early stages, is not following: similar to that of angina but more severe
always as obvious as it may seem; Most attacks will respond to the patient’s and, unlike angina, will not be relieved by
Exclusion of other causes for the own inhaler, eg salbutamol (may need to GTN (glyceryl trinitrate). In cases of angina,
symptoms; repeat after 23 minutes); the patient should use his/her GTN spray,
Encouragement of the patient to If no rapid response, or features of severe which will usually remove the symptoms.
rebreathe their own exhaled air to increase asthma, call an ambulance; Dental treatment may be best left until
the amount of inhaled carbon dioxide a A medical assessment should be another day if there is an attack, according
paper bag placed over nose and mouth arranged for patients who require to the practitioner’s discretion. More severe
allows this. If no paper bag is handy, the additional doses of bronchodilator to end chest pain always warrants postponement
patient’s cupped hands would be a (less an attack; of treatment and an ambulance should be
satisfactory) alternative. A spacer device may need to be used if called.
Hyperventilation leads to the patient has difficulty using the inhaler; Features which make chest pain
carbon dioxide being ‘washed out’ of If the patient is distressed or shows any of unlikely to be cardiac in origin are: pains
the body, producing an alkalosis. If the signs of life-threatening asthma, urgent which last less than 30 seconds, however
hyperventilation persists, carpal (hand) and transport to hospital should be arranged; severe; stabbing pains; well-localized
pedal (foot) spasm (tetany) may be seen 10 litres per minute of oxygen should left submammary pain and pains which
(Figure 1). Rebreathing exhaled air helps to be given whilst awaiting transfer 46 continually vary in location. Chest pain
June 2009 DentalUpdate 263
pg262-268 Medical emergencies 2.indd 2 1/6/09 12:16:51
MedicalEmergencies
Angina Treatment for myocardial the blood pressure may drop to such an
MI infarction involves the following: extent that it causes transient cerebral
Pleuritic eg pulmonary embolism The practitioner should remain calm and hypoxia leading to a brief fit. This is not a
Musculoskeletal be a reassuring presence; true fit and represents a vasovagal episode.
Oesophageal reflux Call 999 immediately; Treatment of an epileptic fit
Hyperventilation Most patients will be best managed in includes the following:
Gall bladder and pancreatic disease the sitting position; The decision to give medication should
Patients who feel faint should be laid flat; be made if seizures are prolonged (with
Table 2. Possible causes of chest pain. Give high flow oxygen (10 litres per active convulsions for 5 minutes or more
minute); (status epilepticus) or seizures are occurring
Status epilepticus Give sublingual GTN spray; in quick succession). If possible, high
High risk of recurrence of fits Give 300 mg aspirin orally to be chewed flow oxygen should be administered. The
First fit (if no allergy) ensure that, when handing possibility of the patient’s airway becoming
Difficulty in monitoring the patient’s over to the receiving ambulance crew, they occluded should constantly be remembered
condition are made aware of this as thrombolytic and the airway must therefore be protected.
Table 3. NICE Guidelines for sending a patient with therapy is given by some ambulance crews; As far as possible, ensure safety of the
epilepsy to hospital after a fit. A patient who has had surgical dental patient and practitioner (do not attempt to
treatment should be highlighted to the restrain);
ambulance crew, as any significant risk of Midazolam given via the buccal or
haemorrhage may affect the decision to use intranasal route (10 mg for adults). The
thrombolytic therapy; buccal preparation is marketed as Epistatus
which improves on stopping exertion is If the patient becomes unresponsive, the (10 mg/ml). For children:
more likely to be cardiac in origin than one practitioner should check for ‘signs of life’ 15 years 5 mg;
that is not related. Pleuritic pain is sharp (breathing and circulation) and start CPR. 510 years 7.5 mg;
in character, well localized and worse on over 10 years 10 mg.
inspiration. Epileptic seizures The parents of some children with
Oesophagitis can produce a poorly controlled epilepsy will carry
retrosternal pain which worsens on bending The history will usually reveal rectal diazepam. As part of pre-treatment
1
or lying down. A complicating factor in the fact that a patient has epilepsy. A preparation, it is wise to arrange with the
differentiation from cardiac chest pain is history should include information with parent for them to be on hand to administer
that GTN, caused by action on the muscle of regard to the nature of any seizures, their this should a fit arise;
the oesophagus, may ease the pain. frequency and degree of control. The In the absence of rapid response to
Musculoskeletal pain will often type and efficacy of medication should treatment, call an ambulance.
be accompanied by tenderness to palpation be determined. Signs and symptoms vary Criteria for sending a patient
in the affected region. As mentioned earlier, considerably. with epilepsy, who has had a seizure, to
hyperventilation may produce chest pain. A The signs and symptoms of hospital have been developed by the
list of possible causes of chest pain is given epilepsy include: National Institute for Health and Clinical
in Table 2. The patient may have an ‘aura’ or Excellence and are summarized in Table 3.
It is clearly important to exclude premonition that a seizure is about to occur;
angina and myocardial infarction in the Tonic phase loss of consciousness
4,5 Diabetic emergencies
patient complaining of chest pain. If in patient becomes rigid and falls and
doubt, treat as cardiac pain until proven becomes cyanosed; The history should be used
otherwise. Clonic phase – jerking movements of the to assess the degree of diabetic control
The signs and symptoms of limbs, tongue may be bitten; achieved by the patient. A history of
myocardial infarction include: Frothing at the mouth, urinary recurrent hypoglycaemic episodes and
Severe, crushing chest pain which may incontinence; markedly varying blood glucose levels (from
radiate to the shoulders and down the The seizure often gradually abates after the patient’s measurements) suggest that
arms (particularly the left arm) and into the a few minutes but the patient may remain a patient attending for dental treatment
mandible; unconscious and may remain confused after is more likely to develop hypoglycaemia.
The skin becomes pale and clammy; consciousness has been regained; It is wise to treat diabetic patients first on
Shortness of breath; Hypoglycaemia may present as a fit any list and ensure that they have had their
Pulse becomes weak and patient may and should be borne in mind (including normal medication and something to eat
become hypotensive; in epileptic patients) blood glucose prior to attending.
Often there will be nausea and vomiting; measurement at an early stage is therefore A dentist in general practice
Not all patients fit this ‘classic’ picture wise. is much more likely to encounter
– may exhibit only some of the signs and In patients with a marked hypoglycaemia than hyperglycaemia since
symptoms above. bradycardia (less than 40 beats per minute) the latter has a much slower onset. It should
264 DentalUpdate June 2009
pg262-268 Medical emergencies 2.indd 3 3/6/09 14:25:36
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