Medical Emergencies in a Special Care Setting

1. Prof. Mark Greenwood MDS, PhD, FDS, MB ChB, FRCS, FRCS(OMFS), FHEA Newcastle University BDA CDS GROUP YORKSHIRE AND THE HUMBER DIVISION, JUNE 2010 Medical Emergencies in a Special Care Setting

2. PREVENTION! • Attitude and environment • Usually a clue in the history • Airway protection • Drills – roles, training, contact numbers • Do not work alone

3. IN A SPECIAL CARE SETTING • Particular issues could include access, patient movement, pre-existing conditions • Potential for increased “pressure” from carers

4. IN A SPECIAL CARE SETTING • The principles of management are essentially the same but may require common sense modifications

5. THE ABCDE APPROACH A – Airway B – Breathing C – Circulation D – Disability E – Exposure

6. AIRWAY • Finger sweep • Suction • Head tilt/Chin lift

7. Head Tilt/Chin Lift

8. AIRWAY • Finger sweep • Suction • Head tilt/Chin lift • Jaw thrust- injury or flexion deformity

9. BREATHING Look, listen and feel

10. CIRCULATION Central pulse e.g. carotid for the competent/experienced practitioner – no longer includes some dental practitioners

11. DISABILITY Neurological (conscious status) e.g. Post head injury/seizure A lertness V ocal stimuli response P ain response U nresponsive

12. EXPOSURE For examination of rash/application of defibrillator paddles (AED)

13. AED

14. DRUGS FOR EMERGENCY DRUG BOX • Adrenaline (Epinephrine) 1 in 1000 • Aspirin (300mg) • Glucagon (1mg) (Glucose) • GTN tabs/sprays • Oxygen • Salbutamol inhaler • Midazolam buccal liquid or Midazolam injection solution via buccal or nasal route (10mg)

15. POSSIBLE ROUTES OF DRUG ADMINISTRATION • Oral • Sublingual • Subcutaneous • Intramuscular • Inhalation • Rectal • Intravenous

16. IN DENTISTRY • Oral • Sublingual • Subcutaneous • Intramuscular • Inhalation • Rectal! • Intravenous only if experienced

18. Deltoid

19. COLLAPSE OF UNKNOWN CAUSE • Lie patient flat, raise legs – most recover • Maintain airway, give oxygen • Check breathing - agonal gasps • If not breathing/abnormal breathing (no pulse) = cardiac arrest • No “signs of life” • If normal breathing give sc/im glucagon 1mg • Get help at an early stage

20. CARDIAC ARREST • Main cause arrhythmia (VF) • AED

21. REMEMBER RATIOS OF CPR • No “rescue breaths” • 30 compressions to 2 ventilations in adults • Importance of early defibrillation

23. CPR IN PREGNANCY • Left lateral position

24. SPECIFIC MEDICAL EMERGENCIES in Dentistry • Uncommon – including the simple faint, occur once every 3 to 4 years per dentist

25. VASO-VAGAL SYNCOPE • Commonest • Lie flat, raise legs

26. ANAPHYLAXIS – SIGNS AND SYMPTOMS • Paraesthesia, flushing, facial swelling • Generalised itching – hands and feet • Bronchospasm and laryngospasm (wheezing and breathing difficulty) • Rapid weak pulse together with fall in blood pressure

27. ANAPHYLAXIS –MANAGEMENT • ADRENALINE! (Epinephrine) • 0.5ml (500 micrograms) 1 in 1000 solution IM repeated after 5 minutes if no clinical improvement

28. ADRENALINE (EPINEPHRINE) • Alpha adrenergic action leads to vasoconstriction increasing myocardial and cerebral perfusion

29. ADRENALINE (EPINEPHRINE) • Reverses peripheral vasodilatation and reduces oedema • Beta receptor activity dilates the airway, increases the force of myocardial contraction • Beta activity suppresses histamine and leukotriene release

30. ADRENALINE (EPINEPHRINE) • Adverse effects are extremely rare when appropriate doses are given intramuscularly

31. ANAPHYLAXIS –MANAGEMENT • ADRENALINE! (Epinephrine) • 0.5ml (500 micrograms) 1 in 1000 solution IM repeated after 5 minutes if no clinical improvement • Lie flat, maintain airway, supplemental oxygen

32. ANAPHYLAXIS - MANAGEMENT • Adrenaline is indicated when there are signs of stridor, wheeze, respiratory distress or clinical signs of shock

33. ANAPHYLAXIS - MANAGEMENT • Adrenaline is indicated when there are signs of stridor, wheeze, respiratory distress or clinical signs of shock • The U.K. Resuscitation Council has said that in the past, adrenaline has been under used

34. THE ROLE OF CHLORPHENAMINE(Chlorpheniramine) AND HYDROCORTISONE • Still used in the treatment of anaphylaxis by “First Medical Responders”

35. THE ROLE OF HYDROCORTISONE The U.K. Resuscitation Council (www.Resus.org.uk) recommend the use of corticosteroids for all severe anaphylactic reactions

36. PREFERRED SITE FOR ADRENALINE INJECTION

37. An EpiPen

38. OTHER CONSIDERATIONS • Resuscitation Council recommends doses of adrenaline should be halved in patients on beta blockers, tricyclics and Monoamine Oxidase Inhibitors

39. ANAPHYLAXIS • The wheezing can be helped by giving inhaled salbutamol

40. “PANIC ATTACKS” • Sometimes mistaken for anaphylaxis • Anxiety driven

41. “PANIC ATTACKS” • Signs and symptoms: • Anxiety • Weak, dizzy, light-headed • Paraesthesias • Palpitations • Carpo-pedal spasms • An “anxiety rash” could be confused for the rash in anaphylaxis

42. CARPAL SPASM

43. MANAGEMENT • Rebreathing exhaled air • Worth having handy a paper bag!

44. ASTHMA • Most attacks will respond to 2 puffs of the patients beta2 – adrenoceptor stimulant inhaler • If no rapid response, repeat • Administer oxygen • Repeat inhaler – every 10 minutes

45. SPACER DEVICE

46. CHEST PAIN, ANGINA, MYOCARDIAL INFARCTION • Diagnosis of the problem • A,B,C – supplemental oxygen • Use the GTN spray • Aspirin should be given (300mg) in MI • Entonox is helpful

47. MYOCARDIAL INFARCTION • If aspirin has been given, the hospital MUST BE INFORMED

48. EPILEPSY • Medication should only be given if convulsive seizures are prolonged or last 5 minutes or more or are repeated rapidly

49. EPILEPSY • 10mg buccal Midazolam • In prolonged or recurrent seizures, midazolam intranasally – single dose of 200 micrograms per kilogram • In children, rectal diazepam

50. HYPOGLYCAEMIA –SYMPTOMS AND SIGNS • Shaking/trembling • Sweating • “Pins and Needles” in lips and tongue • Hunger • Slurring of speech • Confusion • Change of behaviour • Unconsciousness