SOP of Medical Emergencies
Introduction
Medical emergencies do occur in
dental practice. Fortunately these are rare. But none the less this can be
potentially life threatening when occur. So the dental team must be adequately
prepared and equipped to deal with common life threatening conditions. We must
remember
●
Medical
emergencies can occur at any time.
●
All the
staff member need to know their role in the event of a medical emergency.
●
The entire
staffs need to be trained in dealing with such an emergency.
Preparations for emergencies
The number of emergencies that arise in a dental office is inversely
proportional to the preventive measures taken by the dental surgeon.
●
A comprehensive medical history: Must be recorded for all the patients and updated
regularly.
●
Training: All staff in the dental department should be
adequately trained, and /or well organized treatment plan should be worked and
rehearsed.
●
Equipments and Drugs: An emergency tray containing all the necessary drugs
should be readily available.
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Inj
Adrenalin (1:1000, 1 mg/ml)
●
Inj.
Atropine
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Inj.
Hydrocortison Sodium Succinate
●
Inj. Avil
●
GTN spray
or tablets
●
Salbutamol
inhaler
●
Inj.
Dextrose 25%
●
Inj. Pause
(tranxemic acid)
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Oral
Glucose powder
●
5% Dextrose
Equipment :
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Sthethoscope
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Blood pressure recording instrument.
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Oxygen
delivery system for delivering high flow of oxygen (5-10 litres / min)
●
Syringes
and Needles
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Bag mask
device with oxygen reservoir.
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Basic
airway adjunct (Oropharygneal and naso pharyngeal airways)
●
Spacer
device to deliver salbutamol.
EMERGENCY SITUATIONS AND SPECIFIC RESPONSE
1. Allergy
(a) Anaphylaxis (Type -1 Hypersensitivity)
It is a potentially life threatening
immune reactions to foreign material and develop quickly.
Presentation
●
Urticaria
●
Angioedema
●
Hypotension
●
Tachycardia
●
Bronchospasm
Management
It is depended on the severity of
presentations.
●
Stop administration of drug
●
Assess the
degree of cardiovascular collapse (from pulse and blood pressure)
●
Assess the
degree of airway obstructions (upper – angioedema Lower – bronchospasm)
●
Activate CODE BLUE or arrange evacuation to A&E.
●
Put patient
in supine position
●
Assess
breathing difficulty (stridor, wheeze, can’t speak) and administer oxygen.
●
Monitor
consciousness, airway, breathing, circulation, pulse, BP.
●
If in shock
it may be angioedema or bronchospasm.
●
If B.P. is
low put patient in trendelenberg position.
(Drugs to be administered)
●
Inj.
Hydrocortison Sodium Succinate 100 mg IV with sterile water
●
Inj. Avil
50 mg IM/IV
●
Inj.
Adrenaline 2 mg IV
●
Start IV
fluid and maintain IV link
(b)Delayed reaction
Most drugs at one time or other can
have allergic reaction.
Presentation
●
Swellings
at the site of injections
●
Angio-neurotic
oedema
●
Pruritus
●
Urticaria
Management
Inj. Avil IV/IM
(2) Asthma
Assess the patient
●
Acute /
severe
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Patient
unable to speak in complete sentences
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Pulse
> 110/min
●
RR
> 45
Life
threatening asthma
●
Silent
chest
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Cyanosis
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Sweating
●
Hypercarbic
flush
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Bradycardia
●
hypotension
●
confusion,
agitation
Management
If any of the
above is present transfer to A& E,
otherwise
●
High flow
of oxygen
●
Salbutamol
inhalation
●
Activate CODE BLUE or evacuate to A&E.
(3) Chest pain(Angina) / Myocardial Infarction
Presentation
●
Persistent
central chest pain, with possible radiation to the left or right arms, jaw or
neck.
●
Nausea,
vomiting
●
A sense of
impending doom
●
Restlessness
●
Shortness
of breath
●
Pallor,
Cold and clammy skin
●
Hypotension,
Tachycardia
Management
If Angina or acute MI is suspected:
●
Reassure
the patient.
●
Put the
patient in comfortable position.
●
Give
Nitrogyclerine Tablets (Isosorbide Nitrate Tablet) to put it sublingually.
●
Give high
flow of oxygen
●
In the
meantime activate CODE BLUE
(4)Diabetes
The most common
diabetics related emergencies are:-
●
Hypoglycaemia – due to low blood sugar.
●
Hyperglycaemia
(diabetic keto acidosis) – due to high blood sugar
Hyperglycaemia and Ketoacidosis
Presentation
●
Dehydration
●
Progressive
reduction in the level of consciousness
●
hypotension
●
Coma
Management
●
Primary
assessment
➢
Resuscitation followings ABC line of management
i.e. securing airway breathing and circulation.
➢
Immediate activation of CODE BLUE or evacuation to
the A&E.
Hypoglycaemia
Presentation
●
Sweating
●
Hunger
●
Tremor
●
Agitation
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Progressive
drowsiness
●
Confusion
●
Coma
Managements
●
Glucose
powder neat or dissolved in water.
●
If the
patient improves it is followed up with food (Carbohydrate)
●
If the
patient is unconscious follow ABC line of management and activate CODE BLUE OR evacuate
to A&E.
Note :
Any diabetic with impaired consciousness will be assumed to have
hypoglycaemia until proven otherwise.
(5)Epilepsy
Presentation
●
Sudden
spasm of muscles producing rigidity (tonic phase)
●
Jerking
movements of head. arms, and legs may occur (Chronic clonic phase)
●
May become
unconscious
●
May have
noisy or spasmodic breathing, salivation and urinary incontinence
Managements
●
Inj.
Diazepam IV 5-10 mg.
●
Mouth gag
placement to prevent self inflicted bite injury.
●
Put the
patient on the floor.
●
Remove all
objects from patients mouth (denture etc ).
●
Loosen
tight clothing
●
Turn victim
to stable side position as soon as seizure stops. Maintain clear airway, avoid
aspirations.
●
Shift to A&E.
(6)
Upper airway obstructions due to foreign body
During dental procedure teeth or other
small objects might inadvertently
get displaced and enter into the oropharynx, larynx, trachea or
oesophagus.
Prevention
●
Gauze
screen should always be placed to block off oropharynx from mouth.
Presentation
●
Distress
●
Chocking
●
Coughing
●
Apnea
●
Cyanosis
●
Altered
sences or loss of consciousness
Managements
●
Put the
chair in upright position
●
Patient
instructed to hold perfectly still and not swallow until the object can be
retrieved
●
Encourage
the patient to cough up.
If the above procedure fails, and
the patient shows increased respiratory distress,
Then manage as follows:-
●
Put the
patient in upright position, turn patient side on in chair. Support chest with
one hand and deliver five sharp back blows between the shoulder blades with the
other hand supporting the chest.
●
If back
flow fails give five abdominal thrust (Heimlich procedure)
●
If the
victim is unconscious commence CPR and activate
CODE BLUE .
●
If the
patient shows no sign of respiratory distress, the foreign body might have been
swallowed.
●
Confirm
position by radiograph and manage accordingly.
(7) Vasovagal syncope
It is transient loss of
consciousness due to Vagal stimulation
Presentation
●
Patient
feels light headed and dizzy
●
Nauseous,
uncomfortable or agitated
●
Cold and
Clammy skin
●
Thready ,
slow pulse
●
Hypotension
●
Transient loss
of posture.
Managements
●
Put the
patient in trendelenberg (lying posture) position (left lateral position for
pregnant patient)
●
Reassure
the patient
●
Loosen the
clothing
●
Maintain
airway (follow ABC line of management)
●
Administer
oxygen if respiratory distress present.
●
Mild
respiratory stimulus like spirit of ammonia can be used or sensory stimulus
like pinching of ear lobule can help.
●
Patients
usually recover soon then slowly raise him to seated position.
●
If the
patient has H/o significant medical problem or syncope is prolonged, then evacuate immediately.
(8) Toxic reaction to local anaesthetics
Presentation
●
Initial
excitatory phase followed by marked depression.
●
Patient may
be talkative and anxious
●
Nausea,
vomiting may be there
●
Convulsion
may be there but rare.
Management
●
Most reactions are of minor nature and can be
treated palliatively.
●
Any sign of reaction noted during injection of
LA, needle should be withdrawn immediately.
●
Inj. Hydrocortison 100mg IV and Inj. Avil 25mg.
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Administer oxygen.
●
If convulsion occur and becomes intensive give
diazepam intravenously.
●
In case of severe CNS stimulation / depression
activate CODE BLUE.
