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Cap. 21. MEDICAL Emergeencies in Dental Practice
Cap. 21. MEDICAL Emergeencies in Dental Practice
21 EMERGENCIES IN
DENTAL PRACTICE
Mark McGurk
Background
Which dental factors affect the risk of
encountering an emergency?
The risk of encountering a medical emergency depends in
part on the type (specialisation) of dental practice, and also
the characteristics of the population being treated. Serious
medical emergencies are unlikely to be encountered in a
young population treated by orthodontists. Provision of
dental treatment under general anaesthetic has now ceased
but dental practices still specialise in provision of intra-
venous sedation. The risk of a medical emergency in a
practice specialising in intravenous or inhalation sedation
is 8.5 and 6 times that expected in a traditional dental
practice.
Table 21.1
Number of emergencies a dental practitioner is likely to
encounter in a working lifetime of 40 years in general practice.
Fits/seizures 2.75
Swallowed foreign body 1.52
Asthma 1.31
Diabetic 1.02
Angina 0.98
Drug reactions 0.89
Other events 0.24
Cardiac arrest 0.13
Myocardial infarction 0.11
Stroke 0.09
Inhaled foreign body 0.06
Total 6.32
Specific emergencies
Fits and seizures
Occurrence: three times in a working lifetime of 40 years.
This category of emergency does not relate solely to
patients with epilepsy but rather is dominated by patients
who faint in the dental chair. In the process of a faint
the blood pressure falls, reducing the flow of blood to
the brain. If this is not restored by quickly placing the
patient in supine position, the faint may be accompanied
by jerky body movements similar to a seizure. The
commonest medical emergency in dental practice is a
faint.
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Epileptic seizure
Signs and symptoms:
ü Sudden loss of consciousness or lack of response
ü Initial rigidity and then jerking of limbs
ü Urinary incontinence may occur
ü Post-fit drowsiness and confusion
ü Most patients recover spontaneously.
Treatment:
ü Make sure patient is safe
ü Do not attempt to recover objects from mouth
ü Only attempt treatment if the fitting is prolonged
>5 minutes
ü Give oxygen 15 L/minute
ü Intravenous diazepam 10 mg can be used with care
ü Call emergency services.
patient does not cough the object has not passed into
lung. Unless the patient is absolutely sure a foreign body
has been swallowed the patient should be assessed in hos-
pital. This also applies to ingestion of sharp objects.
Treatment:
ü Ask patient to cough
ü Attempt retrieval if visible within oral cavity
ü Shoulder blows/Heimlich manoeuvre
ü Oxygen 15 L/minute
ü Do not attempt a surgical airway unless you have
been trained to do so.
Asthma attack
Occurrence: 1.3 times in a working lifetime of 40 years.
Approximately 5.1 million people suffer from asthma in
the UK population. In the majority of incidences the condi-
tion is mild and controlled easily by the patient. A small
proportion of patients are prone to acute attacks of asthma
that are frightening to the patient and dentist alike. About
1500 patients die from asthma each year, including 25 chil-
dren and 500 adults under the age of 65.
Patients prone to status asthmaticus should be identi-
fied and preparation made prior to attendance to deal
with an emergency situation if it occurred (ready access
to appropriate drugs and oxygen). Status asthmaticus
can occur quickly and may catch the dental team
unawares.
Treatment:
ü Two puffs of salbutamol inhaler
ü Oxygen 15 L/minute
ü If no response further inhaler/salbutamol nebuliser
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ü Call emergency services.
Treatment:
ü If conscious, oral glucose drink
ü If unconscious 1 mg glucagon intramuscularly
followed by glucose drink when consciousness
regained
ü Intravenous glucose can be given but this requires a
large cannula in a large vein as it is like treacle.
Angina pectoris
Occurrence: one per working lifetime of 40 years.
The mean age of the UK population is slowly increas-
ing and at the same time a greater proportion of the pop-
ulation are retaining their natural dentition. Consequently
the population at risk of developing angina during dental
treatment is increasing. Patients with angina are familiar
with their symptoms and usually can control them
easily with medication prescribed. Those with unstable
angina and symptoms that are easily provoked should
be identified. Urgent referral is indicated in patients
where symptoms of angina are not responding to 283
Severe reaction
ü Adrenaline (epinephrine) 0.5–1 mL of 1 : 1000 (IM or
SC – not IV). This may need to be repeated at
5-minute intervals
ü Oxygen 15 L/minute
ü Chlorpheniramine 10 mg IM or slow IV
ü Hydrocortisone 100 mg IV
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ü Call emergency services.
Cardiac arrest
Signs (Fig. 21.1):
ü Unresponsive
ü No respiratory effort
ü Pulseless.
Treatment:
ü Basic life support (Fig. 21.2) until patient recovers or
emergency services take over.
Table 21.2
Cause of death in dental surgery: a
survey of 1341 medical emergencies.
Cardiac arrest 5
Stroke 2
Myocardial infarction 3
If breathing:
Check breathing Look, listen and feel
recovery position
Myocardial infarction
Signs and symptoms:
ü Prolonged crushing central chest pain, worse than
angina, with radiation to left arm, neck and jaw
ü Sweating, pallor and anxiety
ü Shortness of breath, severe if acute heart failure.
Treatment:
ü Sit patient in comfortable position, likely to be
upright
ü Oxygen 15 L/minute
ü Aspirin 300 mg dissolved or chewed
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Stroke
Signs and symptoms:
ü Lack of response, difficulty speaking
ü Tingling or weakness of one side of the body.
Treatment:
ü Place patient in a safe comfortable position
ü Oxygen 15 L/minute
ü Call emergency services.
288