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AUSTRALIAN DENTAL ASSOCIATION INC.

GUIDELINES FOR GOOD PRACTICE ON

EMERGENCIES IN DENTAL PRACTICE

INTRODUCTION: Dentists and their staff should be prepared for emergency situations which will occur at any time in their practices. These emergencies range from the minor such as the common faint [vaso-vagal syndrome] and hyperventilation, to the life-threatening such as cardiac arrest or anaphylaxis. An Australian study [Chapman, 1997] showed that about one in seven dentists surveyed had had to resuscitate a patient, whilst an American study covering a ten year period revealed that over 30,000 emergencies arose from a surveyed population of some 4,000 dentists [Malamed, 1992.] If it is possible to over-prepare, however, and it is the aim of this code to be as simple as practicable since over preparation without appropriate experience will be counterproductive and even dangerous [eg. excessive drugs and equipment.]

FIVE STEPS IN THE PREPARATION FOR EMERGENCIES. Step 1. Medical History.

Step 2. Assessment of patient/Recognition of cause of emergency

Step 3. Resuscitation - knowledge, training and practice.

Step 4. Emergency Drugs and Devices.

Step 5. Calling for Medical Assistance.

pallor. therefore. medicines. The conditions will exhibit a range of clinical features and the dentist should be vigilant regarding the patient's medical history and the circumstances which may have provoked the condition. This aspect of practice is constantly covered and. MEDICAL HISTORY. hypotension. Prompts: Penicillin Local anaesthetic Antiseptics Latex. monitor vital signs. b. . telephone number and address. Prompts: Heart disease [Ischaemic heart disease/congestive heart failure] Blood pressure Stroke Rheumatic heart disease Diabetes Asthma d.-2Step 1. weakness. Physician's name. Allergies to drugs. pills. Prompt: <What medicine. tablets or drugs are you taking or have you taken recently [in the last six months]? Where there is any doubt regarding the patient's medical status. Blood transfusion history Prompt: If positive: <Are you being treated by a doctor at present?' e. initiated or aggravated by emotional stress and stress minimisation techniques can assist in the prevention of such conditions. antiseptics. Past and present serious illnesses. -3CONDITION 1 Vasovagal syncope [fainting] approximately 40%. The first five are stress related. STEP 2. lowered pulse rate. elevate feet. TREATMENT/ RESPONSE Lie horizontally. f. Present Medication. sweaty skin. CLINICAL FEATURES Faintness. oxygen. ie. the dentist should consult the patient's medical practitioner. Date of birth. c. will not be laboured but should include:a. ASSESSMENT OF PATIENT. The following conditions are recognised as the predominant causes of medical emergencies in dental surgeries.

protect from injury.2 Hyperventilation approx. throbbing headache. Adrenalin 1:1000 IM [1/2 ml] as injection or epipen. 11 Severe Allergic reaction. Suspect in anginal patient who says pain is much worse than usual. faintness. loss of consciousness should never occur. Repeat dose in 5 minutes after first checking BP and again after another 5 minutes if pain persists. hypertension. use up to 4 metered doses of aerosol bronchodilator. History of allergies. early defibrillation. audible wheezing.] Slurred speech.restlessness. oxygen. then loss of consciousness. If no improvement after 15 minutes. 8 Toxic effects from LA [rare]. Give orange juice. Dissolved aspirin tablet and one glyceryl trinitrate dose stat and one repeat in 5 minutes after check of BP. temporary aspnoea and cyanosis in tonic phase. 6 Cardiac arrest. 2.] Sudden unconsciousness. following drug administration. Reassure. diabetes. palpitations. 7 Epilepsy [Grand Mal] [Inquire as to control of condition. Adrenaline toxicity . arrange transfer to hospital for bronchoscopy. 100% oxygen. 1.first CNS stimulation then depression with convulsions.5 back blows with patient leaning forward. If loss of consciousness occurs. CPR if cardiac arrest occurs. Asthma like symptoms. medication. glucose drink or sugar lumps at first sign which will rapidly terminate event ie. NB. [Medical History. place one glyceryl trinitrate tablet 0. cyanosis. angina pectoris.effects should terminate rapidly. cyanosis. inability to catch breath. acute myocardial infarction. [Irreversible brain damage in 3-5 minutes] Call 000 immediately. Dyspnoea. violent coughing spasms. involuntary movement of limbs in clonic phase. [Medical history especially angina and acute myocardial infarction. Initiate cardio pulmonary resuscitation. sweating. apprehension. palpitations. Stop treatment.30% [frequently confused with syncope]. radiating to left arm. 9 Hypoglycaemia [History of insulin dependent diabetes.] Chest pain similar to angina but unrelieved by up to 3 glyceryl trinitrate tablets over 10 minutes.] 10 Acute airway obstruction [choking]. 5 Acute myocardial infarction. no breathing. LA base toxicity .6 mg under tongue or spray under tongue. May need to repeat dose after 5 minutes. 4 Angina Pectoris [Medical History] Moderate to crushing central chest pain. paraesthesia of extremities. Basically supportive . oxygen. rapid breathing. Call 000. If unable to remove. will need parenteral therapy [glucose or glucagon.] Sudden unconsciousness. rebreath expired air with a paper bag. [sneezing and dyspnoea] circulatory collapse. or if this is first ever episode of chest pain. altered behaviour. rapid full pulse. treat as acute myocardial infarction. neck or mandible. Encourage slower breathing. . eg. Call 000. cardiac arrest. rapid pulse. medical assistance. Sudden aspnoea or dyspnoea cyanosis. Place in lateral position. Always check that respiratory distress not due to other causes. monitor vital signs. 100% oxygen. last episode. [Anaphylaxis]. Monitor vital signs. administer oxygen. 3 Asthma [Medical History] Dyspnoea. pallor. no pulse. Try to remove cause .

KNOWLEDGE. Check if the patient is responding. Check the airway for obstruction. Airway Breathing Circulation UNCONSCIOUS Turn on side Face slightly downward Clear airway Head tilt Jaw support/jaw thrust Check for breathing Leave BREATHING on side in position Observe. RESUSCITATION . there is no time for delay and an immediate diagnosis must be made and definitive treatment initiated. They should also encourage their staff to attend resuscitation courses and run practice drills with surgery staff. they should be able to assess breathing and circulation and to carry out effective expired air resuscitation [EAR] and Cardio-pulmonary resuscitation [CPR] if required. Further annual refamiliarization courses are recommended to main competence in basic life support [BLS]. That is. A wall poster can assist in retention of learnt techniques. or bronchospasm associated with anaphylaxis. PULSE ABSENT CPR [EAR and ECC] Check pulse and breathing after 1 minute and then at least every 2 minutes . COLLAPSE Check response. shake and shout CONSCIOUS Make comfortable Observe. FLOW CHART FOR ABC OF RESUSCITATION. All dentists should be competent in BLS resuscitation. Assess breathing. Airway Breathing Circulation lateral Turn NOT BREATHING on back 5 full breaths [10 seconds] EAR Check carotid pulse Continue PULSE PRESENT EAR Check pulse and breathing after 1 minute and then at least every 2 minutes. The Australian Resuscitation Council recommends the DRABC basic sequential steps for all emergency situations.-4STEP 3. These steps are to ensure an adequate delivery of oxygenated blood to the brain prior to the delivery of definitive care – D R A B C = = = = = Check for danger. Assess circulation. TRAINING AND PRACTICE. When an emergency is immediately life threatening such as complete laryngeal obstruction. cardiac arrest associated with acute myocardial infarction.

EAR and ECC .EAR ECC CPR Expired air resuscitation External cardiac compression Cardiopulmonary resuscitation ie.

Other than administering oxygen. glucose or sucrose drinks or sweets in small amounts [50-100 ml] every five minutes. GLYCERYL TRINITRATE TABLETS OR SPRAY. STEP 5. Patients with a history of angina usually have their tablets with them and administer their usual dose sublingually. will rapidly raise the blood sugar level and reverse the situation. There are no mandated lists of emergency drugs and equipment kits except in the practices that undertake intramuscular or intravenous sedation or general anaesthesia.3 ml . Oxygen powered resuscitators are considered part of advanced life support [ALS] because of the risk of gaseous distension of the stomach resulting in regurgitation. it is recommended that the dentist's emergency kit contain glyceryl trinitrate spray [which has a much longer shelf life than tablets] in case the patient does not have his/her glyceryl trinitrate [GTN] tablets. Pressure adrenaline kits [epipens] are available in adult and child doses. therefore. these should be displayed in a prominent place. The administration of emergency drugs is always secondary to providing life support during an emergency. floor of the mouth or other muscle is required. . though not mandated. All surgeries should have an oxygen source which is easily transported to the patient. EMERGENCY DRUGS AND DEVICES. Apart from the use of 000. Two such pre-loaded syringes should be kept. an injection of 0. Dentists who undertake the administration of oral conscious sedation on children or adults should have adequate training to deal with any side effects.-5- STEP 4.0. are not recommended. ORAL GLUCOSE.5 mg [0. OXYGEN. It is recommended. For insulin dependant patients who are exhibiting signs of hypoglycaemia. it is appropriate for a dentist to make established links with his nearest medical practitioner or facility. At a flow rate of 10L/minute this provides about 50% oxygen in the ventilated air. ADRENALIN 1:1000.0. However. it must be stressed that no drugs should be administered if a dentist is not adequately trained and confident of the diagnosis. Adrenaline is available as a 1 ml 1:1000 solution in a pre-loaded syringe. CALLING FOR MEDICAL ASSISTANCE. The mask should have an adjustable head strap. Therefore. It is now considered that these resuscitators require two operators.5 ml of 1:1000 solution] on to the tongue.3 . administration of orange juice. that a general practice retains on its premises the following : ! ! ! ! Oxygen Oral glucose Adrenaline 1:1000 Clyecryl trinitrate spray or tablets. When a severe anaphylactic allergic response is diagnosed. The simplest and safest way of administering oxygen to a non-breathing patient is via a pocket mask with a nozzle to which a low pressure oxygen line is connected. as the injection may need to be repeated.

FM. . Emergencies in Dental Practice. 6. Medical emergencies in dental practice and choice of emergency drugs and equipment: A survey of Australian dentists. 124: 40-53. Australian Dental Journal 19915. QEC.less is more. NHMRC. Canberra. Chapman. NHMRC. Herman. Canadian Dental Association Journal 1993. A questionnaire survey of dentists regarding knowledge and perceived competence in resuscitation and occurrence of resuscitation emergencies. Emergency drugs and devices . 40 (2): 98-103 Chapman. University of Queensland. PJ. Unpublished. 4. Malamed. PJ. 5. Managing Medical Emergencies. 127: 98-104. Journal of the American Dental Association 1996. 1981. JL. Resuscitation in the Electrical Industry. 7. Angina: an update for dentistry. 1. McCarthy.-6- REFERENCES. 1990. 9. 3. WW and Konzelman. February 19-25. Notes for Dental Students. Chapman. Emergencies in Dental Practice. Unpublished. PJ. 1993. Australian Government Publishing Service. GF. Journal of American Dental Association 1993. 8. 2.

GGP3 GUIDELINES FOR GOOD PRACTICE ON EMERGENCIES IN DENTAL PRACTICE Prepared by Dental Practice Committee. 1999 Adopted as Guidelines for Good Practice by Federal Council. November 11/12. June 2005 . 1999 Amended by Federal Council. 1999 Amended by Special Purpose Committee on Therapeutics & Drugs. November 11/12. February 13. April 15/16. 1998 Adopted as a Code of Practice by Federal Council.