Medical Emergencies

Basic Life Support (BLS)

If a person seems to be in a life-threatening condition requiring immediate first aid, follow this protocol:

CPR
 Cardiopulmonary resuscitation (CPR) is an emergency procedure undertaken on a person who is in cardiac arrest
(sudden stop in blood flow due to failure of the heart to effectively contract)
 It involves chest compressions, often with artificial ventilation, in an effort to manually preserve intact brain
function until further measures are taken to restore spontaneous blood circulation and breathing
 Aim = delay tissue death and brain damage
 For certain heart rhythms, administration of an electric shock to the heart (defibrillation) may be effective
 CPR is continued until the person has a return of spontaneous circulation or is declared dead

Epilepsy/Seizures
A group of disorders characterized by chronic and recurrent epileptic seizures which involve brief episodes of signs or
symptoms due to abnormal, excessive, or repetitive activity in the brain.
Signs/Symptoms
 1/3 of patients have a prior aura
 Collapse
 Tonic phase (30 seconds)
o Loss of consciousness
o Rigidity
o Cyanosis (bluish skin colour due to poor circulation)
 Clonic phase (few minutes)
 o Jerking movements
o Tongue biting
o Head rocking
o Urinary incontinence
 Post-seizure
o Gradual return to consciousness
o Headache
o Confusion
Risk Factors
 History of epilepsy
 Failure to take anti-epileptic medication
 Stress
 Pain
Action
 Cease dental treatment
 Protect the patient from falling off the chair and injuring themselves on surrounding equipment
o Lower the chair or lift patient onto the ground if possible
 Avoid restraining the patient during the seizure unless it is essential to avoid injury
 Wait until obvious fitting has subsided
 Assess consciousness by talking to the patient
 Maintain airway
 If there is vomit, remove it from the mouth and pharynx by high volume suction
 If the patient recovers completely, keep them under observation for at least a further 30 minutes
 Do not allow the patient to drive themselves home and advise them to urgently see their GP
 If the seizure or loss of consciousness lasts for more than five minutes, or if recurrent seizures occur without
recovery of consciousness between attacks:
o This is referred to as status epilepticus
o Call OOO
o Maintain airway
o Monitor the patient until assistance arrives
o Administer BLS if necessary
Other
 Types of seizures to be aware of:
o Absence seizures (petit mal)
 Generally, lasts a few seconds and are characterized by a blank stare
o Tonic-Clonic or convulsive seizures (grand mal)
o Clonic seizures
o Tonic seizures
o Myoclonic seizures
 Brief shock-like jerks of a muscle or group of muscles
 Rubber mouth prop (bite block) may be used while treating patients with seizure history to prevent them
from biting the clinician’s finger

Asthma Attack
Signs/Symptoms
 Cough
 Expiratory wheeze
 Altered speech
 Cyanosis (indicates life-threatening asthma)

Risk Factors
 Exposure to allergens
 Poorly controlled asthma
 Systemic illness
 Action
 Cease dental treatment
 Determine if the asthma attack is mild or moderate/severe
o Mild = NO HOSPITALISATION
 Talks in sentences
 No physical exhaustion
 No loss of consciousness
o Moderate-Severe = HOSPITALISATION
 Talks in phrases or words
 Possible physical exhaustion
 Possible loss of consciousness
 Pulse
 Adults: > 100 (moderate), >120 (severe)
 Children: 100-200 (moderate), >200 (severe)
 Bradycardia indicates imminent respiratory arrest
 If the attack is MILD:
o Give 4 puffs of a short-acting bronchodilator via a spacer – giving 1 puff at a time and asking the
patient to take 4 breaths in and out of the spacer after each puff
 If a spacer is not available, give 4 puffs of the inhaler alone – giving 1 puff at a time and
asking the patient to hold their breath for 4 seconds (or for as long as is comfortable) after
each puff, then breath out slowly away from the inhaler
o Wait 4 minutes
 Improvement
 Temporize dental state (complete treatment another time)
 Make another appointment to complete dental treatment if needed
 Discharge when breathing fine
 Advocate strict use of asthma medication (if prescribed)
 Refer to GP for evaluation
 No improvement
 Repeat above protocol
 If still no improvement, then manage as moderate-severe
 If the attack is MODERATE-SEVERE:
o Call 000
o Give oxygen by mask at a flow rate of 6 L/min
o Give 4 puffs of a short-acting bronchodilator via a spacer – giving 1 puff at a time and asking the
patient to take 4 breaths in and out of the spacer after each puff
 If a spacer is not available, give 4 puffs of the inhaler alone – giving 1 puff at a time and
asking the patient to hold their breath for 4 seconds (or for as long as is comfortable) after
each puff, then breath out slowly away from the inhaler
o Wait 4 minutes
o Keep doing this until assistance arrives

Other
 Instruct patients with asthma to bring their reliever with them when presenting for treatment, and to use it
before beginning if necessary

Airway Obstruction (Inhaled / Swallowed Objects)

Signs/Symptoms
 Partial = wheezing, noisy and slow breathing, cough spasms, cyanosis
 Full = inability to breathe, speak, or cough, agitation, and loss of consciousness

Risk Factors
 Failure to use rubber dam

Action
 Partial:
o Call 000
o Encourage deep breathing and attempts to cough (might dislodge the object)
o May give patient back blows using heel of hand
  Complete:
o Call 000
o Put patient in recovery position
o Attempt to manually remove object to clear and open the airway
o If no breathing, 5 back blows
o If that is unsuccessful, proceed to 5 chest thrusts (NOT abdominal thrusts)
o If unconscious, institute BLS

Hyperventilation
Signs/Symptoms
 Rapid breathing
 Deep breaths
 Rapid pulse
 Altered consciousness
 Light headedness
 SOB
 Feelings of panic

Risk Factors
 History of anxiety or panic attacks
 CVD
 Most common in young women

Action
 Cease dental treatment
 Encourage patient to breath slowly
 Ask patient to rebreathe their expired air by cupping their hands close to their mouth, making sure not to
obstruct their mouth or nose
 Do not give oxygen (this will prolong symptoms)
 If acute symptoms persist for more than 5-10 minutes, call 000

Anaphylaxis
Signs/Symptoms
 Sudden urticaria
 Dramatic drop in BP (lightheaded, faint)
 Facial swelling
 Tongue swelling
 Wheezing
 Coughing
 Dyspnoea
 Loss of consciousness

Risk Factors
 Allergic phenotype

Action
 Cease dental treatment
 Remove/cease administration of allergen
 Call 000
 Give IM adrenaline
o Adrenaline 300 micrograms, IM, via pre-loaded auto-injector (EpiPen)
 Inject into anterolateral thigh
o Adrenaline 0.01 mg/kg up to 0.5 mg (= 0.5 ml of 1:1000 solution)
 Inject into anterolateral thigh, tongue or floor of mouth
 Lay patient flat
 Give high flow oxygen
 Repeat adrenaline every 3-5 minutes until response/assistance arrives
 The patient must be taken to an emergency department
Hyperglycaemia (Ketoacidosis)
Signs/Symptoms
 All the usual diabetic hyperglycaemic symptoms – polydipsia, polyuria, nocturia, lethargy, oral candidal
infection
 Acidotic respiration
 Breath smells fruity (due to acetone in the breath, a type of ketone)

Risk Factors
 Insufficient insulin therapy
 Patient has not adhered to insulin therapy

Action
 Call 000
 Insulin infusion (fixed rate) until blood ketones and acidosis resolves

NOTE – Hyperglycaemic events are usually more chronic (long term) than hypoglycaemic events, which are often short
and episodic.

Hypoglycaemia
Signs/Symptoms
 Pallor
 Sweating
 Shaking
 Dilation of eyes
 Palpitations
 Hunger

Risk Factors
 Medical
o Tight glycaemic control
o Excess insulin  mismatch between insulin and carbohydrate intake + exercise
 Lifestyle
o Stress and anxiety
o Alcohol consumption
o Irregular lifestyle
o Inadequate blood glucose monitoring  excess insulin
o Unplanned or excessive exercise
o Missed meal

Action
 Cease dental treatment
 If the patient is conscious and cooperative:
o Give 20-25 g of glucose, or if not available, then a fast-acting glucose containing food:
 Fruit juice
 Lemonade
 Jelly beans
 Honey
o This is to be followed by a lower glycaemic load carbohydrate meal
 Sandwich
 Dried fruit
o Post-emergency
 30 minutes monitor and rest
 Find someone to take them home
 Refer to GP for evaluation
 If the patient is drowsy, uncooperative, or unconscious:
o Call 000
o Monitor consciousness
 o Institute BLS if breathing stops

Syncope
Syncope, colloquially referred to as “fainting”, is defined as a short loss of consciousness and strength, characterised by fast
onset, short duration, and spontaneous recovery. It occurs due to a sudden decrease in bloodflow to the brain, usually due to
low blood pressure.
Types
 Neurological
o Stroke
o Epilepsy
o Postural syncope
o Vasovagal syncope
 Haematological
o Anaemia
 Cardiological
o Heart attack
 Diabetes
o Hypoglycaemic
 Respiratory
o Cough syncope

Signs/Symptoms
 Pale
 Sweaty
 Lightheaded
 Slow pulse (bradycardia)
 Loss of consciousness
 Collapse

Risk Factors
 Anxiety
 Pain
 Fatigue
 Fasting
 Low BP
 Underlying medical conditions – anaemia, diabetes, COPD

Action
 Cease dental treatment
 If patient feels faint:
o If patient is in the dental chair, tilt the chair back to a horizontal position (not head lower than heart
though)
o Raise the patient’s legs slightly
o Assess consciousness by talking to the patient
 If patient is unconscious:
o If patient is in the dental chair, tilt the chair back to a horizontal position (not head lower than heart
though)
o Measure the patient’s BP and pulse rate
o Place patient on their side (if pregnant  to the left)
o Stimulate and cool the patient by placing a cold compress on their forehead
o Call 000 if patient remains unresponsive
o Institute BLS if breathing stops
 Once recovered:
o Allow the patient to recover slowly under supervision
o Do not discharge them from care, especially if they are driving
o Refer patient to GP for evaluation
 Other
 Patients will usually be aware that something is wrong before they faint
 Prevalence of syncope episodes increases with age
 Vasovagal syncope is the most common type of syncope
o Parasympathetic nerve fibers from the Vagus nerve are activated, slowing down the heart rate
(increased vagal tone)
o At the same time, there is withdrawal of the sympathetic nervous system tone
o This causes hypotension and syncope

Angina
The sensation of chest pain, pressure, or squeezing, due to insufficient bloodflow to the heart because of obstruction or spasm
of the coronary arteries.
Signs/Symptoms
 Central crushing chest pain (usually transient, lasting no longer than 10 minutes)
 Pain may radiate to the left arm and/or left jaw
 Pulse remains regular

Risk Factors
 History of ischaemic heart disease (IHD)
 Patients with risk factors for IHD (e.g. hypertension, obesity)

Action
 If patient has a history of angina (stable angina)
o Measure patient’s BP and pulse rate, and assess consciousness by talking
o To shorten the attack, use:
 Glyceryl Trinitrate spray
 400 micrograms, sublingual
 Repeat every 5 minutes
 If symptoms persist, increase dose to maximum of 1200 micrograms
 Glyceryl Trinitrate tablet
 600 micrograms, sublingual
 Repeat every 5 minutes
 If symptoms persist, increase dose to maximum of 1800 micrograms
 Ask patient to sit or lie down during administration of GTN due to the possibility of
hypotension induced by the vasodilation  syncope
o After administration
 Improvement
 Do not proceed with dental treatment
 Refer to GP for evaluation
 No improvement
 If angina persists for more than 10 minutes, even after taking 2 doses of GTN, give a
third dose and proceed to manage as severe/new
 If the chest pain is new or severe (unstable angina)
o Call 000
o Administer oxygen
o Give Aspirin 300 mg, chewed or dissolved before swallowing
o Monitor patient’s vital signs and reassure them until assistance arrives
o If patient loses consciousness and stops breathing, institute BLS

Other
 The classic example is when a patient asks the clinician to stop leaning on their chest when in reality the
clinician is not doing so
 Ensure that the patient brings their medication (GTN) when presenting for dental treatment
 Stable angina
o Occurs during activity (walking, running, etc.)
o Symptoms resolve several minutes after activity, and recur if activity resumes
o At rest, there are minimal or no symptoms
 Unstable angina
 o Occurs at rest, or with minimal exertion
o Symptoms usually last more than 10 minutes
o Is severe and of new onset (i.e. within the last 4-6 weeks)

Cardiac Arrest
Sudden stop in blood flow due to failure of the heart to effectively contract.
Signs/Symptoms
 Loss of consciousness
 Lack of breathing
 Lack of pulse

Risk Factors
 Previous IHD
 Recent MI

Action
 Cease dental treatment
 Call 000
 Institute BLS
 Maintain BLS until patient regains consciousness or assistance arrives

Other
 By definition, if pulse is present, then patient has not suffered a cardiac arrest
 Exclude other causes of unconsciousness – vasovagal syncope, epileptic fit, MI

Myocardial Infarction
Colloquially known as a “heart attack”, it refers to a sudden loss of bloodlfow to a part of the heart, causing damage to the
heart muscle.
Signs/Symptoms
 Central crushing chest pain of more than 20 minutes duration - atypical of patient’s normal angina pain
 Irregular pulse
 Breathlessness
 Sense of impending doom

Risk Factors
 Old age
 Hypertension
 Hypercholesteremia
 Smoking
 Obesity
 Excessive alcohol consumption
 Lack of physical activity
 Drug abuse

Action
 Cease dental treatment
 Treat as per angina which is severe or new
o Call 000
o Administer oxygen
o Give Aspirin 300 mg, chewed or dissolved before swallowing
o Monitor patient’s vital signs and reassure them until assistance arrives
o If patient loses consciousness, institute BLS

Stroke
Also known as a cerebrovascular accident (CVA) or cerebrovascular insult (CVI), it refers to a sudden loss of bloodflow to the
brain causing neural cell death (necrosis).
Signs/Symptoms
 FAST
o Facial weakness – “can you smile”
o Arm weakness – “can you raise both arms”
o Speech problems – “speak to me”
o Time to call 000
 Other symptoms:
o Blurred vision
o Loss of vision
o Headache
o Difficulty swallowing (dysphagia)

Risk Factors
 Old age
 Hypertension
 Hypercholesteremia
 Smoking
 Obesity
 Diabetes mellitus
 History of TIA
 Previous stroke
Action
 Cease dental treatment
 Call 000
 Administer oxygen
 Do NOT administer aspirin as it is difficult to identify if the stroke is haemorrhagic or ischaemic
 Maintain airway
 Institute BLS

Other
 May be ischaemic – where blood vessels supplying the brain are occluded
 May be haemorrhagic – where blood vessels supplying the brain burst