medical emergencies in a special care setting prof. mark greenwood mds, phd, fds, mb chb, frcs,...
TRANSCRIPT
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Medical Emergencies in a Special Care Setting
Prof. Mark Greenwood MDS, PhD, FDS, MB ChB, FRCS, FRCS(OMFS), FHEA
Newcastle University
BDA CDS GROUP YORKSHIRE AND THE HUMBER DIVISION, JUNE 2010
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PREVENTION!
• Attitude and environment
• Usually a clue in the history
• Airway protection
• Drills – roles, training, contact numbers
• Do not work alone
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IN A SPECIAL CARE SETTING
• Particular issues could include access, patient movement, pre-existing conditions
• Potential for increased “pressure” from carers
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IN A SPECIAL CARE SETTING
• The principles of management are essentially the same but may require common sense modifications
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THE ABCDE APPROACH
A – Airway
B – Breathing
C – Circulation
D – Disability
E – Exposure
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AIRWAY
• Finger sweep
• Suction
• Head tilt/Chin lift
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Head Tilt/Chin Lift
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AIRWAY
• Finger sweep
• Suction
• Head tilt/Chin lift
• Jaw thrust- injury or flexion deformity
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BREATHING
Look, listen and feel
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CIRCULATION
Central pulse e.g. carotid for the competent/experienced practitioner – no longer includes some dental practitioners
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DISABILITY
Neurological (conscious status) e.g. Post head injury/seizure
A lertness
V ocal stimuli response
P ain response
U nresponsive
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EXPOSURE
For examination of rash/application
of defibrillator paddles (AED)
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AED
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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)
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POSSIBLE ROUTES OF DRUG ADMINISTRATION
• Oral
• Sublingual
• Subcutaneous
• Intramuscular
• Inhalation
• Rectal
• Intravenous
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IN DENTISTRY
• Oral
• Sublingual
• Subcutaneous
• Intramuscular
• Inhalation
• Rectal!
• Intravenous only if experienced
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Deltoid
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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
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CARDIAC ARREST
• Main cause arrhythmia (VF)
• AED
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REMEMBER RATIOS OF CPR
• No “rescue breaths”
• 30 compressions to 2 ventilations in adults
• Importance of early defibrillation
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CPR IN PREGNANCY
• Left lateral position
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SPECIFIC MEDICAL EMERGENCIES in Dentistry
• Uncommon – including the simple faint, occur once every 3 to 4 years per dentist
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VASO-VAGAL SYNCOPE
• Commonest
• Lie flat, raise legs
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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
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ANAPHYLAXIS –MANAGEMENT
• ADRENALINE! (Epinephrine)
• 0.5ml (500 micrograms) 1 in 1000 solution IM repeated after 5 minutes if no clinical improvement
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ADRENALINE (EPINEPHRINE)
• Alpha adrenergic action leads to vasoconstriction increasing myocardial and cerebral perfusion
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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
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ADRENALINE (EPINEPHRINE)
• Adverse effects are extremely rare when appropriate doses are given intramuscularly
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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
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ANAPHYLAXIS - MANAGEMENT
• Adrenaline is indicated when there are signs of stridor, wheeze, respiratory distress or clinical signs of shock
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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
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THE ROLE OF CHLORPHENAMINE(Chlorpheniramine)
AND HYDROCORTISONE
• Still used in the treatment of anaphylaxis by “First Medical Responders”
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THE ROLE OF HYDROCORTISONE
The U.K. Resuscitation Council (www.Resus.org.uk) recommend the use of corticosteroids for all severe anaphylactic reactions
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PREFERRED SITE FOR ADRENALINE INJECTION
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An EpiPen
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OTHER CONSIDERATIONS
• Resuscitation Council recommends doses of adrenaline should be halved in patients on beta blockers, tricyclics and Monoamine Oxidase Inhibitors
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ANAPHYLAXIS
• The wheezing can be helped by giving inhaled salbutamol
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“PANIC ATTACKS”
• Sometimes mistaken for anaphylaxis
• Anxiety driven
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“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
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CARPAL SPASM
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MANAGEMENT
• Rebreathing exhaled air
• Worth having handy a paper bag!
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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
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SPACER DEVICE
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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
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MYOCARDIAL INFARCTION
• If aspirin has been given, the hospital MUST BE INFORMED
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EPILEPSY
• Medication should only be given if convulsive seizures are prolonged or
last 5 minutes or more or are repeated rapidly
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EPILEPSY
• 10mg buccal Midazolam
• In prolonged or recurrent seizures, midazolam intranasally – single dose of 200 micrograms per kilogram
• In children, rectal diazepam
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HYPOGLYCAEMIA –SYMPTOMS AND SIGNS
• Shaking/trembling• Sweating• “Pins and Needles” in lips and tongue• Hunger• Slurring of speech• Confusion• Change of behaviour
• Unconsciousness
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HYPOGLYCAEMIA - MANAGEMENT
• Glucagon 1mg IM/SC
• Once regains consciousness, oral glucose
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INHALED FOREIGN BODY
• Prevention!
• Allow them to cough vigorously
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INHALED FOREIGN BODY
• Ask “Are you choking”?!
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CHOKING - MILD
• Patient answers “YES”!
• Victim is able to cough and breathe
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CHOKING - SEVERE
• Unable to speak
• Unable to breathe
• Wheezy
• Attempts at coughing are silent
• Unconsciousness
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ADRENAL CRISIS
• Signs and symptoms – Loss of consciousness– Rapid, weak or impalpable pulse– Blood pressure falls rapidly
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ADRENAL CRISIS - TREATMENT
• Lay patient flat and raise their legs
• Clear airway and administer oxygen
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ADRENAL CRISIS – TREATMENT
• 200mg Hydrocortisone I.V.
• I.V. fluids
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ADRENAL CRISIS - TREATMENT
• Do not discharge!
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DEVELOPMENTS IN MEDICAL EMERGENCY MANAGEMENT
• Rationalisation of the Drug Box contents
• Practical delivery routes for drugs
• Resuscitation Guidelines particularly the AED
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USEFUL REFERENCE
• Medical Emergencies and Resuscitation Standards for Clinical Practice and Training for Dental Practitioners and Dental Care Professionals in General Dental Practice – A statement from the Resuscitation Council (UK) July 2006. Revised May 2008.
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CONCLUSIONS
• The use of emergency drugs is safe – when the diagnosis is correct!
• The drug kit should be checked regularly to ensure that it is up to date
• In a special care setting, the best approach is to stick to basic principles