Chapter 1 Medical emergencies in the conscious patient By M H Thornhill, M N Pemberton and G J Atherton
Acute chest pain Causes Severe acute chest pain is usually the result of myocardial ischaemia. The main differential diagnosis is between angina (reversible ischaemia) and myocardial infarction (irreversible ischaemia). Either may be precipitated by exercise, stress, emotion or anxiety. Prevention
• Take a good medical history
• Identify patients with a history of angina, myocardial infarct or other
cardiovascular disease. If there is a history of worsening angina control, liaise
with the patient’s general medical practitioner for assessment prior to treatment
• As far as possible, keep to appointment times for these patients
• Do not overburden their capacity for exertion
• If possible, use a downstairs surgery
• Ensure they have taken their normal medication
• If they are supposed to carry any drugs for prophylaxis of angina, such as
glyceryl trinitrate, ensure these are readily to hand while they are in the dental
surgery
• It is essential to minimise stress, anxiety and pain in patients with a history of
angina.
SIGNS AND SYMPTOMS
• Severe, crushing retrosternal pain
• Pain may radiate to the arm neck and jaw, usually on the left side (see Figure 1)
Features suggesting angina The pain is short lasting and is relieved by rest and glyceryl trinitrate (GTN) Features suggesting myocardial infarction (MI)
6
Is your practice missing a
vital piece?
Pearl Dental Software The FASTEST growing dental software. One Off £275 for installation + training, Monthly £44 add £22 for each additional surgery. (Prices Exclude VAT). Call us on 0116 275 9995 or 0800 086 8133 for more information, or email us at info@bhasoftware.com.
Find out more at www.pearldentalsoftware.com 7
• Pain is persistent and more severe
• Pain is not eased by rest or GTN
• There may be breathlessness, nausea and vomiting, loss of consciousness and
the pulse may be weak or irregular
MANAGEMENT
• If the patient has their own anti-angina drugs, these should be administered,
otherwise use glyceryl trinitrate spray sublingually
• Monitor carefully until the angina pain has resolved
• Postpone planned treatment until another occasion.
If there is no relief of pain in 3 minutes, the cause is likely to be an infarct
• Summon assistance - call for an ambulance
• Keep the patient in a comfortable position – if conscious this is usually sitting up -
• If you have an RA machine, give nitrous oxide and oxygen (50/50) to relieve
laying them flat may make breathlessness worse pain and anxiety
• If nitrous oxide is not available, give oxygen
• If the patient is not allergic, give 300mg aspirin. This can be left to dissolve in
the buccal sulcus or swallowed if the patient is able. (N.B inform the ambulance
personnel that aspirin has been given)
• Reassure and monitor the patient
If the patient loses consciousness, initiate basic/advanced life support
Asthma attack Causes Exposure to an allergen, anxiety, cold, exercise or infection can precipitate an acute asthmatic attack in a patient predisposed to bronchospasm. Most attacks come on rapidly (within 30 minutes) and occur in patients with a known history. An acute asthma attack should not be taken lightly; if a patient fails to respond to treatment, they should be referred to hospital. Prevention Avoid anxiety, pain and known allergens. Ensure that the patient has had their normal prophylactic medication and has their bronchodilator readily available. If a nebuliser is not available a similar effect can be obtained by administering 4-6
8
Clupeaharengus harengus Clupea Clupea harengus
harengus ClupeaClupea harengus
Mostofofour our clients Most Most of our clients Most of ourclients clients Most of our clients chooseNOT NOT to offer choose choose to offer choose NOTtotooffer NOTNOT offer choose to offer c DentalAccident Accidentand andEmergency Emergency n Dental Dental Accident and Emergency e Clupea harengus Dental Accident andDental Emergency Accident and Emergency g r Insurance to their plan patients* e ien ts r Insurance patients* Insurance to their plan patients* Insurancetototheir theirplan plan Insurance patients* to their plan patients* s n m e ffe E pat gu i n l e Most of our clients c o nd n ar h Why? Because they can! r a harengus Why? Why? - Because they can! u to t a pla Clupea eto ! choose NOT offer Why?- -Because Becausethey theycan! Why? can! - Because can! o n n T lC upthey f r a O ide ei o Emergency c Dental and N t Privilege Plan – a completely different kettleAccident of fish y sdifferent c kettle edifferent thfishof fish Privilege Plan – a– completely different Privilege kettle of fish –fish a completely c oof s Privilege Plan a completely Privilege different Plan kettle –Plan a of completely kettle of he Most our clients o A Insurance to their plan patients* o t t M d *78% of our clients elect not to include Dental A&E cover as a plan benefit, l A&E cover o Dental e e ly a *78% of our clients elect not to include Dental A&E *78% cover ofas our a plan clients benefit, elect not to include as a plansbenefit, h c t e *78% of our clients electtonot toout include *78% of A&E ourcover clients aselect a plan benefit, to include Dental A&E cover as a plan benefit, visit privilegeplan.co.uk find whatDental our clients say about us. not c NOT ton offer choose t u visit privilegeplan.co.uk to find out what our clients visit sayprivilegeplan.co.uk about us. to find out whatnour clients say about us. le a visit privilegeplan.co.uk to find out whatvisit our clients privilegeplan.co.uk say about us.to find out what our e clients say about us. ca p r Why? - Because they can! de m e Emergency u lu Dental DAccident and o c s B n a c t to i out w Tel: 01536 771219 • E-mail: info@privilegeplan.co.uk In – ? Tel: 01536 771219 • E-mail: info@privilegeplan.co.uk Tel: 01536 771219 • Insurance E-mail: info@privilegeplan.co.uk o their plan n patients* Tel: 01536 771219 • E-mail: info@privilegeplan.co.uk Tel: 01536Privilege 771219 • E-mail: y kettle Planinfo@privilegeplan.co.uk – a completelyto different fishct n find aof www.privilegeplan.co.uk l h le to P www.privilegeplan.co.uk www.privilegeplan.co.uk www.privilegeplan.co.uk www.privilegeplan.co.uk e s e .uk W t g n *78% of our e n.co 9 clients elect not to include Dental A&E coverileas a planclibenefit, : in a visit privilegeplan.co.uk to find out what our clients say vabout us.urcan! Why? - Because ithey pl ail r e o g -m f P 8%
o
ile
riv
9
•E
n
la
puffs of a bronchodilator into a large volume spacer and getting the patient to inhale through the spacer. This can be repeated every 10 minutes if necessary. A makeshift large volume spacer can be formed by administering the bronchodilator through a hole in the base of a large disposable cup or 500ml soft drink bottle that the patient holds to their mouth. Signs and symptoms
• Breathlessness and a tight chest
• Wheezing on expiration
• Accessory muscles of respiration in action
Features of an acute severe attack
• Inability to complete a sentence in one breath
• Respiratory rate greater than 25 per minute
• Heart rate greater than 110 per minute
Features of life threatening asthma
• Exhaustion, confusion
• Feeble respiratory effort or cyanosis
• Heart rate less than 50 per minute
Management
• Keep the patient sitting upright- laying them flat will increase breathlessness
• Encourage them to use the bronchodilator they normally use
• Offer a salbutamol inhaler if they do not have their own available
• If available administer 4-6 activations from a salbutamol inhaler via a large
volume spacer device
• Give oxygen
• Patients requiring additional doses of inhaled bronchodilator to control
their asthma should be referred to their general medical practitioner for further
assessment of their asthma control
• Note: Bronchodilator inhalers are blue, steroid inhalers are brown.
If the patient continues to be distressed or develops features of severe or life threatening asthma
• Call for an ambulance
• Give nebulised salbutamol 5mg (VentolinR) with oxygen, or continue to give 4-6
activations from a salbutamol inhaler via a large volume spacer device 10
Quality in implantology. Made by DMG. to the relining of implant supported dentures and through to precision-fit temporary restorations: DMG has the perfect solution. More information on the complete DMG range of products is available at www.dmg-dental. com.
The importance of implants as permanent, highlyaesthetic dental restorations is increasing rapidly. DMG has long been supporting dentists in this challenging field with superior quality, practice building materials. From impression taking and bite registration,
Recomm en for imp ded especially lantolog y by the Br책nem
ark Cen ter
11 AZ_Implantologie_190x277_2015-07.indd 1
31.07.15 09:46
• Give Oxygen
If the asthma is life threatening or part of an anaphylactic attack
• Give 0.5mL of 1:1,000 (500μg) adrenaline (epinephrine) i/m
Inhaled foreign body Causes Inhalation of a foreign body such as a tooth, inlay, crown or reamer is an everpresent risk in dentistry. An object lodged in the upper airways may cause respiratory obstruction. Smaller objects may be inhaled into the lower airways where, if left, may result in a lung abscess.
SIGNS AND SYMPTOMS Upper airways obstruction
• An object lodged in the upper airway will stimulate a cough reflex
• If the patient is choking, the object is large enough to cause respiratory
obstruction
• The patient may grasp their throat
If the object blocks the airway completely they will be silent, unable to breathe or speak
• The skin will become cyanosed; this is especially evident in the lips
• They will make exaggerated efforts to take breath
• Eventually they will lose consciousness
Lower airways obstruction The patient may be totally unaware that they have inhaled anything
PREVENTION This event is far easier to prevent than to treat and the use of a rubber dam will prevent all but the most bizarre incidents. An efficient high volume aspirator is also useful in aiding retrieval of any object dropped in the mouth. Be especially careful when trying-in crowns or inlays or using small instruments in the mouth, ensure that burs are properly secured in the handpiece.
MANAGEMENT 1 If the patient is not choking or having difficulty breathing
12
Digital Impressions and CAD/CAM from 3Shape and ESM Digital Solutions
Restoration driven imp guide de
For several years, 3Shape has been regarded as the leading innovator in everything relating to Dental Restoration driven implant planning and CAD/CAM. guide design Firmly established as a household name in the laboratory world, 3Shape’s Digital Impression System TRIOS3 is following the same path as being the most Implant impressions for single and multiple units practical, flexible and user friendly intra-oral scanning solution on the market. ESM Digital Solutions is TRIOS3 by 3Shape, the worlds one of 3Shape’s most experienced and trusted Restoration driven implant planning and leading provider of CAD/CAM solutions for design distribution partners delivering and supporting the guide laboratories offers fast and flexible full range of 3Shape Dental solutions to the UK and powder-free scanning for the widest range of indications. Seamless integration Irish market. with the full suite of 3shape software offers you a system that will revolutionise ESM’s primary business objective is to deliver 3Shapethe way you practice, complementing your clinical skills and enhancing the technology and provide the ongoing support and patient experience. TRIOS3 CART
TRIOS3 POD
partnership to ensure our customers get the very TRIOS3 CART most from their investment. Whether you want to (020)with 8816 7840 use TRIOS3 as a communicationUK: tool your lab, info@esmdigitalsolutions.com Ireland: (01) 808 4446 Authorized Reseller take a step further and introduce virtual restorative,www.esmdigitalsolutions.com implant and orthodontic treatment planning or embrace an in-house milling system, ESM has the solution for you.
TRIOS3 CART
TRIOS3 POD
Implan
TRIOS provid labora powd range UK: with t Irela offers the w your c patien
Contact ESM Digital Solutions for further information at (020) 88167840 or sales@esmdigitalsolutions.com UK: (020) 8816 7840 info@esm Ireland: (01) 808 4446 www.esm 13
• Check if the object is still in their mouth or clothing
If the object cannot be found or is known to have fallen into the throat:
• If the patient is supine, do not allow them to sit up but place the dental chair
head down, allowing gravity to return the object to the oropharynx from where
it may be retrieved
• Rolling the patient into the recovery position and encouraging them to cough
may also help
If the object cannot be retrieved:
• Explain what has happened
• Refer to a hospital accident and emergency department for further
assessment. (chest and abdominal radiographs may be taken – a further
sample of the lost object shown to the accident and emergency doctor can
help with assessment and radiographic identification)
• If the object is found to be in the gastrointestinal tract (i.e., to have been
swallowed), it is normally left to pass per rectum
• If the object is found to be in the respiratory tract, removal may require
endoscopy or thoracic surgery
MANAGEMENT 2 If the object is larger and is causing breathing difficulties or choking
• Encourage the patient to cough forcefully to dislodge the object
• Lean the patient forward and give up to 5 sharp blows between the shoulder
blades (see below)
• If this does not dislodge the object, give up to 5 abdominal thrusts (see below)
• If this fails re-check the mouth and remove any obstruction and continue to
alternate 5 back blows with 5 abdominal thrusts
Dislodging an object from the airway Back blows Lean the patient forward, for example over a chair, so that when the obstructing object is dislodged it is ejected from the mouth rather than going further down the airway. Use the heel of your hand to give up to 5 sharp blows between the shoulder blades.
14
Abdominal thrusts (Heimlich Manoeuvre) Form a fist with one hand and grip it with the other hand while encircling the patient with your arms from behind; your arms should be positioned just below the patient’s ribs. Pull upwards and towards you, delivering a firm, upward, inward thrust to the patient’s diaphragm to expel air and the object from the chest. At any time the patient may become unconscious. Unconsciousness may relax the muscles around the larynx and allow air to pass into the lungs.
MANAGEMENT 3 If the patient becomes unconscious
• Lay them flat
• Commence CPR
Note. The pressure generated in the chest by performing chest compressions may also help to dislodge the foreign body.
Background information Judging by the paucity of discussion of this subject in the literature, this type of event, although common, only rarely causes serious problems. The use of a rubber dam and tethering of fine hand instruments is advisable. Take extra care with those patients who may have a reduced gag reflex, such as those under sedation, who are more at risk of swallowing or inhaling an object. Positioning of the patient may be a factor; some believe that treating patients while they are supine decreases the risk of aspiration or swallowing, while others believe that this increases the likelihood of these events occurring. There are reports of objects passing into the trachea without eliciting a cough or any other symptom suggesting inhalation. The effect of a foreign object passing into the oropharynx depends on its size and shape and where it ends up. A sharp metallic object could theoretically pierce the lining mucosa at any point of its journey either into the respiratory or gastro-intestinal (GI) tracts and cause a mediastinal or abdominal infection. A pneumothorax may result if the lung wall is pierced. It may become impacted in the oropharynx; an object large enough to block the opening to the trachea may obstruct the airway and cause the patient to choke. If the object enters the respiratory tract it will lodge in the bronchial tree and it is important that it is retrieved as quickly as possible. The intense inflammatory response provoked by the object will make removal by bronchoscopy much more difficult if there is delay and surgical removal may then become necessary.
15
If the object passes down the oesophagus into the stomach, more than likely it will pass uneventfully through the GI tract. Sharp objects, such as reamers, tend to pass through the intestines with the sharp end trailing in the centre of the faeces once they reach the transverse colon. Bloody stools or abdominal pain suggest perforation of the gut wall. Many authorities suggest chest and abdominal radiographs to locate the object and, if it is in the GI tract, serial radiographs to monitor its passage. However, in the absence of symptoms, some may think repeated irradiation of the abdomen and reproductive systems, especially in growing patients, to be excessive. Results from a British survey suggest that objects passing beyond reach into the oropharynx are approximately 30 times more likely to be swallowed than inhaled. According to a review of the Japanese literature, the majority of dental foreign objects swallowed or inhaled were dentures and the majority of instruments ‘lost’ during dental treatment were reamers.
Hyperventilation Causes Extremely anxious or hysterical patients may hyperventilate in response to the stress of the dental surgery environment. The over-breathing washes out carbon dioxide from the lungs which results in over-excitability of nerves. They may complain of dizziness and tingling around the mouth; there is also tetany which is caused by hyper-excitability of nerves, characterised by spasms of skeletal muscle, especially the hands (carpo-pedal spasm) and the larynx; there may also be paraesthesia. If severe, there may be laryngospasm, which can obstruct the airway, and cerebral vasoconstriction, which can eventually lead to collapse. Signs and symptoms
• Flushed appearance
• Anxious or distressed
• Rapid pulse
• Dizzyness
• Tingling in face, hands or feet
• Tetany of muscles of face, hands or feet
Prevention
• Anxiety is the main precipitating factor for the hyperventilation response.
• A calm, inviting reception and friendly staff will help to allay many
patients’ fears
16
• Avoid keeping patients waiting and attend to their anxieties,
• Reassurance and pain free dentistry are important preventative measures.
In a patient with a previous history of hyperventilation, prophylaxis with an anxiolytic may be helpful e.g. diazepam 5 mg the night before and 5 mg 2 hours before the procedure or temazepam 20-40 mg one hour before the procedure. However patients should be warned of the sedative effects, to avoid driving or using machinery and the need to be accompanied. If tachycardia is a particular problem, prescription of a beta blocker by the patient’s GP may be helpful.
MANAGEMENT
• Reassurance and explanation
• Get the patient to re-breathe their expired air, containing exhaled CO2, by
breathing in and out of a paper bag held over the mouth and nose.
Background information When a patient hyperventilates, the excessive, hysterical over-breathing causes the patient to blow off carbon dioxide. The partial pressure of CO2 in the circulation falls (hypocapnia) and the blood pH rises (respiratory alkalaemia). There is a fall in the level of calcium ions and a consequent increase in nerve excitability. This causes numbness and tingling (paraesthesia) of the hands, feet and face and can be followed by muscle spasms of hands and feet (tetany) and stiffness of the face and lips, all of which may increase the anxiety. The alkalosis causes a constriction of cerebral blood flow resulting in blurred vision, dizziness and light-headedness. Loss of consciousness is not common as the cerebral hypoxia, resulting from vasoconstriction, causes the vessel walls to relax and the cerebral blood flow is reestablished. The episode of hyperventilation and the resulting alkalosis reduces the respiratory drive due to carbon dioxide and may well be followed by a period of depressed or even absent breathing then a period of intermittent breathing. This results in a build up of carbon dioxide in the blood and reversal of the alkalosis so that normal breathing eventually resumes. Increasing the CO2 concentration of the inhaled air, by getting the patient to re-breath their expired air, reverses the physiological changes induced by hyperventilation.
17