SOP of Medical Emergencies

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.

●        Inj Adrenalin (1:1000, 1 mg/ml)

●        Inj. Atropine

●        Inj. Hydrocortison Sodium Succinate

●        Inj. Avil

●        GTN spray or tablets

●        Salbutamol inhaler

●        Inj. Dextrose 25%

●        Inj. Pause (tranxemic acid)

●        Oral Glucose powder

●        5% Dextrose

Equipment :

●        Sthethoscope

●        Blood pressure recording instrument.

●        Oxygen delivery system for delivering high flow of oxygen (5-10 litres / min)

●        Syringes and Needles

●        Bag mask device with oxygen reservoir.

●        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

●        Patient unable to speak in complete sentences

●        Pulse  > 110/min

●        RR      > 45

 Life threatening  asthma

●        Silent chest

●        Cyanosis

●        Sweating

●        Hypercarbic flush

●        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

●        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.

●        Administer oxygen.

●        If convulsion occur and becomes intensive give diazepam intravenously.

●        In case of severe CNS stimulation / depression activate CODE BLUE.