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Common medical emergencies in general dental practice

Patients with asthma (both adults and children) may have an attack while at the
dental surgery. Most attacks will respond to a few ‘activations’ of the patient’s own
short-acting beta2-adrenoceptor stimulant inhaler such as salbutamol
(100 micrograms/actuation). Repeat doses may be necessary. If the patient does not respond rapidly, or any features of severe asthma are present, an ambulance should be summoned. Patients requiring additional doses of bronchodilator should be referred for medical assessment after emergency treatment. If the patient is unable to use the inhaler effectively, additional doses should be given through a large-volume spacer device. If the response remains unsatisfactory or if the patient develops tachycardia, becomes distressed or cyanosed (blueness around the lips or extremities), arrangements must be made to transfer them urgently to hospital. Symptoms and Signs
Clinical features of acute severe asthma in adults include:
 Inability to complete sentences in one breath.  Respiratory rate > 25 per minute.  Tachycardia (heart rate > 110 per minute).
Clinical features of life threatening asthma in adults include:
 Cyanosis or respiratory rate < 8 per minute.  Bradycardia (heart rate < 50 per minute).  Exhaustion, confusion, decreased conscious level.
Whilst awaiting ambulance transfer, oxygen (15 litres per minute) should be given.
Assuming the patient’s nebuliser is unavailable, up to 10 activations from the
salbutamol inhaler should be given using a large-volume spacer device and
repeated every 10 minutes if necessary until an ambulance arrives. All emergency
ambulances in the UK carry nebulisers, oxygen and appropriate drugs.
If asthma is part of a more generalised anaphylactic reaction or if signs of life-
threatening asthma are present, an intramuscular injection of adrenaline (see
Anaphylaxis) should be given.
The perceived risk of giving patients with chronic obstructive pulmonary disease
too much oxygen is often quoted but this should not distract from the reality that
ALL sick, cyanosed patients with respiratory difficulty should be given high flow
oxygen until the arrival of the ambulance. This short term measure is far more
If any patient becomes unresponsive always check for ‘signs of life’ (breathing and
circulation) and start CPR in the absence of signs of life or normal breathing
(ignore occasional ‘gasps’).

For further information about the management of the the patient with asthma see:

Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity
reaction. It is characterised by rapidly developing life-threatening airway and/or
breathing and/or circulation problems usually associated with skin and mucosal
Anaphylactic reactions in general dental practice may follow the administration of a
drug or contact with substances such as latex in surgical gloves. In general, the
more rapid the onset of the reaction, the more serious it will be. Symptoms can
develop within minutes and early, effective treatment may be life saving.
Anaphylactic reactions may also be associated with additives and excipients in
medicines. It is wise therefore to check the full formulation of preparations which
may contain allergenic fats or oils (including those for topical application,
particularly if they are intended for use in the mouth).
Symptoms and signs
The lack of any consistent clinical manifestation and a wide range of possible
presentations can cause diagnostic difficulty. Clinical assessment helps make the
Signs and symptoms may include:
 Urticaria, erythema, rhinitis, conjunctivitis.
 Abdominal pain, vomiting, diarrhoea and a sense of impending doom.
 Flushing is common, but pallor may also occur.
 Marked upper airway (laryngeal) oedema and bronchospasm may develop,
causing stridor, wheezing and/or a hoarse voice.  Vasodilation causes relative hypovolaemia leading to low blood pressure and collapse. This can cause cardiac arrest.  Respiratory arrest leading to cardiac arrest.

Use an ABCDE approach to recognise and treat any suspected anaphylactic
reaction. First-line treatment includes managing the airway and breathing and
restoration of blood pressure (laying the patient flat, raising the feet) and the
administration of oxygen (15 litres per minute).
For severe reactions where there are life-threatening airway and/or breathing
and/or circulation problems, i.e., hoarseness, stridor, severe wheeze, cyanosis,
AND DENTAL CARE PROFESSIONALS IN GENERAL DENTAL PRACTICE pale, clammy, drowsy, confusion or coma (see Appendix (vi) Anaphylactic reaction
– Initial treatment
), adrenaline should be given intramuscularly (anterolateral
aspect of the middle third of the thigh) in a dose of 500 micrograms (0.5 mL
adrenaline injection of 1:1000); an autoinjector preparation delivering a dose of
300 micrograms (0.3 mL adrenaline injection 1:1000) is available for immediate
self-administration by those patients known to have severe reactions. This is an
acceptable alternative if immediately available. The dose is repeated if necessary
at 5 minute intervals according to blood pressure, pulse and respiratory function.
The paediatric dose for adrenaline is based on the child’s approximate age or
weight. Guidance on the correct adrenaline dose for children is given in Appendix
(vi) Anaphylactic reaction – Initial treatment.
In any unconscious patient always check for ‘signs of life’ (breathing and
circulation) and start CPR in the absence of signs of life or normal breathing
(ignore occasional ‘gasps’).
In less severe cases any wheeze or difficulty breathing can be treated with a
salbutamol inhaler as detailed above in the section on Asthma.

All patients treated for an anaphylactic reaction should be sent to hospital by
ambulance for further assessment, irrespective of any initial recovery.
Antihistamine drugs and steroids, whilst useful in the treatment of
anaphylaxis, are not first line drugs and they will be administered by the
ambulance personnel if necessary.

For further information about the management of the patient with an emergency
anaphylactic reaction see http://www.resus.org.uk/pages/reaction.pdf.
Cardiac emergencies
The signs and symptoms of cardiac emergencies include chest pain, shortness of
breath, fast and slow heart rates, increased respiratory rate, low blood pressure,
poor peripheral perfusion (indicated by prolonged capillary refill time) and altered
mental state.
If there is a history of angina the patient will probably carry glyceryl trinitrate spray
or tablets (or isosorbide dinitrate tablets) and they should be allowed to use them.
Where symptoms are mild and resolve rapidly with the patient’s own medication,
hospital admission is not normally necessary. Dental treatment may or may not be
continued at the discretion of the Dental Practitioner. More severe attacks of chest
pain always warrant postponement of treatment and an ambulance should be
Sudden alterations in the patient’s heart rate (very fast or very slow) may lead to a
sudden reduction in cardiac output with loss of consciousness. Medical
assistance should be summoned by dialing 999.
Myocardial infarction

The pain of myocardial infarction is similar to that of angina but generally more
severe and prolonged. There may only be a partial response to GTN.
Symptoms and signs of myocardial infarction
 Progressive onset of severe, crushing pain in the centre and across the front of chest. The pain may radiate to the shoulders and down the arms (more commonly the left), into the neck and jaw or through to the back.  Skin becomes pale and clammy.  Nausea and vomiting are common.  Pulse may be weak and blood pressure may fall.  Shortness of breath. Initial management of myocardial infarction
Call 999 immediately for an ambulance.
Allow the patient to rest in the position that feels most comfortable; in the presence
of breathlessness this is likely to be the sitting position. Patients who faint or feel
faint should be laid flat; often an intermediate position (dictated by the patient) will
be most appropriate.
Give sublingual GTN spray if this has not already been given.
Reassure the patient as far as possible to relieve further anxiety.
Give aspirin in a single dose of 300 mg orally, crushed or chewed. Ambulance
staff should be made aware that aspirin has already been given as should the
hospital. Many ambulance services in the UK will administer thrombolytic therapy
before hospital admission. Any dental treatment carried out that might
contraindicate this must be brought to the attention of the ambulance crew.
High flow oxygen may be administered (15 litres per minute) if the patient is
cyanosed (blue lips) or conscious level deteriorates.
If the patient becomes unresponsive always check for ‘signs of life’ (breathing and
circulation) and start CPR in the absence of signs of life or normal breathing
(ignore occasional ‘gasps’).
Epileptic seizures

Patients with epilepsy must continue their normal dosage of anticonvulsant drugs
before attending for dental treatment. Epileptic patients may not volunteer the
information that they are epileptic, but there should be little difficulty in recognising
a tonic-clonic (grand mal) seizure.
Symptoms and signs
 There may be a brief warning or ‘aura’.  Sudden loss of consciousness, the patient becomes rigid, falls, may give a cry, and becomes cyanosed (tonic phase). STANDARDS FOR CLINICAL PRACTICE AND TRAINING FOR DENTAL PRACTITIONERS 29
AND DENTAL CARE PROFESSIONALS IN GENERAL DENTAL PRACTICE  After a few seconds, there are jerking movements of the limbs; the tongue  There may be frothing from the mouth and urinary incontinence.  The seizure typically lasts a few minutes; the patient may then become  After a variable time the patient regains consciousness but may remain  Fitting may be a presenting sign of Hypoglycaemia and should be considered in all patients, especially known diabetics and children. An early blood glucose measurement is essential in all actively fitting patients (including known epileptics).  Check for the presence of a very slow heart rate (<40 per minute) which may drop the blood pressure. This is usually caused by a vasovagal episode (see Syncope section below). The drop in blood pressure may cause transient cerebral hypoxia and give rise to a brief seizure.

During a seizure try to ensure that the patient is not at risk from injury but make no
attempt to put anything in the mouth or between the teeth (in the mistaken belief
that this will protect the tongue). Do not attempt to insert an oropharyngeal airway
or other airway adjunct while the patient is actively fitting.
Give high flow oxygen (15 litres per minute).
Do not attempt to restrain convulsive movements.
After convulsive movements have subsided place the patient in the recovery
position and reassess.
If the patient remains unresponsive always check for ‘signs of life’ (breathing and
circulation) and start CPR in the absence of signs of life or normal breathing
(ignore occasional ‘gasps’).

Check blood glucose level to exclude hypoglycaemia. If blood glucose <3.0 mmol
per litre or hypoglycaemia is clinically suspected, give oral/buccal glucose, or
glucagon (see Hypoglycaemia section below).
After the seizure the patient may be confused (‘post-ictal confusion’) and may
need reassurance and sympathy. The patient should not be sent home until fully
recovered and they should be accompanied. It may not always be necessary to
seek medical attention or transfer to hospital unless the convulsion was atypical,
prolonged (or repeated), or if injury occurred. The National Institute for Clinical
Excellence (NICE) guidelines suggest the indications for sending to hospital are:
 Status epilepticus.  High risk of recurrence.  First episode.  Difficulty monitoring the individual’s condition. STANDARDS FOR CLINICAL PRACTICE AND TRAINING FOR DENTAL PRACTITIONERS AND DENTAL CARE PROFESSIONALS IN GENERAL DENTAL PRACTICE Medication should only be given if seizures are prolonged (convulsive movements
lasting 5 minutes or longer) or recur in quick succession. In this situation an
ambulance should be summoned urgently.
With prolonged or recurrent seizures, ambulance personnel will often administer IV
diazepam which is usually rapidly effective in stopping any seizure. An alternative,
although less effective treatment, is midazolam given via the buccal route in a
single dose of 10mg for adults. For children the dose can be simplified as follows:
child 1-5 years 5mg, child 5-10 years 7.5mg, above 10 years 10mg. This might
usefully be administered while waiting for ambulance treatment, but the decision to
do this will depend on individual circumstances. (See Appendix (viii) Emergency
use of buccal midazolam
Patients with diabetes should eat normally and take their usual dose of insulin or
oral hypoglycaemic agent before any planned dental treatment. If food is omitted
after having insulin, the blood glucose will fall to a low level (hypoglycaemia). This
is usually defined as a blood glucose <3.0mmol per litre, but some patients may
show symptoms at higher blood sugar levels. Patients may recognise the
symptoms themselves and will usually respond quickly to glucose. Children may
not have such obvious features but may appear lethargic.
Symptoms and signs
 Shaking and trembling.  Sweating.  Headache.  Difficulty in concentration / vagueness.  Slurring of speech.  Aggression and confusion.  Fitting / seizures.  Unconsciousness.
The following staged treatment protocol is a suggested depending on the status of
the patient. If any difficulty is experienced or the patient does not respond, the
ambulance service should be summoned immediately; ambulance personnel will
also follow this protocol.
Confirm the diagnosis by measuring the blood glucose.
Early stages - where the patient is co-operative and conscious with an intact gag
reflex, give oral glucose (sugar (sucrose), milk with added sugar, glucose tablets
or gel). If necessary this may be repeated in 10 -15 minutes.
In more severe cases - where the patient has impaired consciousness, is unco-
operative or is unable to swallow safely buccal glucose gel and / or glucagon
should be given.
AND DENTAL CARE PROFESSIONALS IN GENERAL DENTAL PRACTICE  Glucagon should be given via the IM route (1mg in adults and children >8 years old or >25 kg, 0.5mg if <8 years old or <25 kg). Remember it may take 5-10 minutes for glucagon to work and it requires the patient to have adequate glucose stores. Thus, it may be ineffective in anorexic patients, alcoholics or some non-diabetic patients.  Re-check blood glucose after 10 minutes to ensure that it has risen to a level of 5.0 mmol per litre or more, in conjunction with an improvement in the patient’s mental status.  If any patient becomes unconscious, always check for ‘signs of life’ (breathing and circulation) and start CPR in the absence of signs of life or normal breathing (ignore occasional ‘gasps’).
It is important, especially in patients who have been given glucagon, that once
they are alert and able to swallow, they are given a drink containing glucose and if
possible some food high in carbohydrate. The patient may go home if fully
recovered and they are accompanied. Their General Practitioner should be
informed and they should not drive.
Inadequate cerebral perfusion (and oxygenation) results in loss of consciousness.
This most commonly occurs with low blood pressure caused by vagal overactivity
(a vasovagal attack, simple faint, or syncope). This in turn may follow emotional
stress or pain. Some patients are more prone to this and have a history of
repeated faints.
Symptoms and signs
 Patient feels faint / dizzy / light headed.
 Slow pulse rate.
 Low blood pressure.
 Pallor and sweating.
 Nausea and vomiting.
 Loss of consciousness.

Lay the patient flat as soon as possible and raise the legs to improve venous
Loosen any tight clothing, especially around the neck and give oxygen (15 litres
per minute).
If any patient becomes unresponsive, always check for ‘signs of life’ (breathing,
circulation) and start CPR in the absence of signs of life or normal breathing
(ignore occasional ‘gasps’).
 Postural hypotension can be a consequence of rising abruptly or of
standing upright for too long. Several medical conditions predispose patients to hypotension with the risk of syncope. The most common culprits are drugs used in the treatment of high blood pressure, especially the ACE inhibitors and angiotensin antagonists. When rising, patients should take their time. Treatment is the same as for a vasovagal attack.  Under stressful circumstances, many anxious patients hyperventilate.
This may give rise to feelings of light headedness or faintness but does not usually result in syncope. It may result in spasm of muscles around the face and of the hands. In most cases reassurance is all that is necessary.
Choking and Aspiration
Dental patients are susceptible to choking with the potential risk of aspiration.
They may have blood and secretions in their mouths for prolonged periods. Local
anaesthesia may diminish the normal protective pharyngeal reflexes and
‘impression material’ or dental equipment is often within their oral cavity and poses
additional risks. Good teamwork and careful attention to detail should prevent
aspiration episodes and any risk of choking.
Symptoms and Signs
 The patient may cough and splutter.  They may complain of difficulty breathing.  Breathing may become noisy with wheeze (usually aspiration) or stridor  They may develop ‘paradoxical’ chest or abdominal movements.  They may become cyanosed and lose consciousness. Treatment
In cases of aspiration, allow the patient to cough vigorously.
Symptomatic treatment of wheeze with a salbutamol inhaler may help (as for
If any large pieces of foreign material have been aspirated, e.g., teeth or dental
amalgam, the patient should be referred to hospital for a chest x-ray and possible
Where the patient is symptomatic following aspiration they should be referred to
hospital as an emergency.
The treatment of the choking patient involves removing any visible foreign bodies
from the mouth and pharynx.
AND DENTAL CARE PROFESSIONALS IN GENERAL DENTAL PRACTICE Encourage the patient to cough if conscious. If they are unable to cough but
remain conscious then sharp back blows should be delivered. These can be
followed by abdominal thrusts if the foreign body has not been dislodged.
If the patient becomes unconscious, CPR should be started. This will not only
provide circulatory support but the pressure generated within the chest by
performing chest compressions may help to dislodge the foreign body.
See Appendix (iv) for the Resuscitation Council (UK) Adult and Child Choking
Adrenal insufficiency
Adrenal insufficiency may follow long term administration of oral corticosteroids
and can persist for years after stopping therapy. A patient with adrenal
insufficiency may become hypotensive when under physiological stress. The
nature of dental treatment makes this a rare possibility however and if a patient
collapses during dental treatment other causes should be considered first and
managed before diagnosing adrenal insufficiency.
Routine enquiry about the current or recent use of corticosteroids as part of the
medical history prior to dental treatment should alert the Dental Practitioner to the
patient at risk of this condition. Some patients carry a steroid warning card. Acute
adrenal insufficiency can often be prevented by administration of an increased
dose of corticosteroid prior to treatment.
Dental treatment that requires an increased steroid dose is that which may cause
significant physiological stress. Usually simple dental extractions and restorative
procedures, including endodontics, are not a cause for concern, but surgical
extractions or implant placement should be considered as a risk. Patients who are
systemically unwell from a dentally related infection are also recommended to
have a prophylactic increase in steroid dose in addition to any surgical and
antimicrobial treatment indicated.
Guidance on the management of those patients with known Addison’s disease is
available from the Addison’s Clinical Advisory Panel (http://www.addisons.org.uk/)
who recommend doubling the patient's steroid dose before significant dental
treatment under local anaesthesia and continuing this for 24 hours.

Source: http://warwickshireldc.org/files/Med_Emergencies_algorythms.pdf

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