1.3 Medical Emergencies in the Dental Chair & Management

1.3 Medical Emergencies in the Dental Chair & Management

Medical emergencies can occur at any time in dental practice. The Royal College of Surgeons of England and General Dental Council (GDC) require all clinical dental team members to maintain annual competency in managing medical emergencies. Protocol compliance must adhere strictly to Resuscitation Council UK (RCUK) and SDCEP standards.

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1. Primary Assessment: The Systematic ABCDE Approach

All deteriorating or collapsed patients must be systematically evaluated and treated using the ABCDE approach. Treat life-threatening conditions immediately as they are identified before moving to the next parameter.

• Airway (A): Assess patency. Look for signs of upper airway obstruction (stridor, gurgling, snoring). Perform a head-tilt/chin-lift or jaw-thrust. Insert an Oropharyngeal (Guedel) airway if the patient is unconscious and airway compromised.
• Breathing (B): Evaluate respiratory rate (normal: 12–20 breaths/min), chest expansion depth, symmetry, cyanosis, and SpO2. Administer 100% High-Flow Oxygen (15 L/min) via a non-rebreather mask with reservoir bag for all critical emergencies.
• Circulation (C): Measure capillary refill time (normal < 2 seconds), pulse rate, rhythm, volume, and blood pressure. Position patient flat (elevate legs if shocked; upright if acute heart failure or pulmonary edema).
• Disability (D): Assess neurological status using AVPU (Alert, Voice, Pain, Unresponsive) or Glasgow Coma Scale (GCS). Measure capillary blood glucose in any confused or unconscious patient.
• Exposure (E): Inspect skin for rashes, urticaria, surgical bleeding, or medical alert jewelry while maintaining patient dignity and preventing hypothermia.

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2. Mandatory UK Dental Emergency Drug Kit & Equipment

Under RCUK Quality Standards for Primary Dental Care, all dental surgeries must hold a centralized, standardized emergency drug box with regular expiration audits.

Essential Emergency Equipment

• Automated External Defibrillator (AED) with adult and paediatric pads.
• Bag-Valve-Mask (BVM) manual resuscitator with oxygen reservoir tubing.
• Oropharyngeal (Guedel) Airways (sizes 1, 2, 3, and 4).
• Portable Suction Unit equipped with wide-bore Yankauer suction tip.
• Pulse Oximeter and blood glucose meter.

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3. Specific Medical Emergency Management Algorithms

Anaphylaxis

Anaphylaxis is a severe, systemic Type I IgE-mediated hypersensitivity reaction causing rapid histamine and leukotriene release from mast cells. In dentistry, common triggers include penicillin, latex, chlorhexidine, and local anaesthetic preservatives (metabisulfites).

Diagnostic Criteria

Sudden onset skin changes (erythema, urticaria, facial angioedema) PLUS life-threatening ABC compromise:

• Airway: Laryngeal edema, hoarseness, inspiratory stridor.
• Breathing: Severe wheeze, bronchospasm, tachypnoea.
• Circulation: Profound hypotension, pale clammy skin, collapse.

Anaphylaxis Suspected → Call 999 + Position Flat (Elevate Legs)
  └── Administer ADRENALINE 1:1,000 IM (Anterolateral Mid-Thigh)
        ├── Adult (≥ 12 yrs): 500 micrograms (0.5 mL)
        ├── Child 6-12 yrs: 300 micrograms (0.3 mL)
        └── Child < 6 yrs: 150 micrograms (0.15 mL)
  └── Repeat Adrenaline after 5 minutes if no clinical improvement

Angina Pectoris vs Acute Myocardial Infarction (MI)

• Angina Pectoris: Transient myocardial ischaemia. Pain is retrosternal, crushing, radiating to left arm/jaw, precipitated by exercise/stress. Management: Stop procedure; sit patient upright; administer GTN spray 1-2 puffs (400-800 micrograms) sublingually. Pain resolves within 2–3 minutes.
• Myocardial Infarction (MI): Irreversible myocardial cell death. Severe, crushing chest pain lasting > 15 minutes, uninhibited by GTN, accompanied by pale cold sweating skin, dyspnoea, vomiting, and intense anxiety.

Management Protocol for Suspected MI

1. Call 999 immediately for emergency ambulance.
2. Sit patient in a comfortable upright position.
3. Administer GTN spray sublingually (if BP adequate).
4. Administer Aspirin 300 mg dispersible tablet—instruct patient to chew it to achieve rapid antiplatelet action.
5. Administer 15 L/min high-flow oxygen if SpO2 < 94%.
6. Keep patient calm; prepare AED for potential cardiac arrest.

Acute Severe Asthma Attack

• Signs of Acute Severe Asthma: Inability to complete sentences in one breath, respiratory rate > 25/min, heart rate > 110/min.
• Life-Threatening Signs: Silent chest on auscultation, cyanosis, bradycardia, confusion, exhaustion.

Protocol

1. Sit patient comfortably upright.
2. Administer Salbutamol inhaler (100 micrograms/puff) via spacer: give 4–10 puffs initially (1 puff every 30–60 seconds, shaking inhaler between puffs).
3. Administer 15 L/min oxygen via non-rebreather mask.
4. Call 999 if no improvement within 5 minutes, continuing salbutamol up to 10–20 puffs.

Status Epilepticus (Prolonged Seizure)

Status epilepticus is defined as a generalized tonic-clonic seizure lasting > 5 minutes, or repeated seizures without regaining consciousness in between.

Protocol

1. Protect patient from surrounding mechanical hazards; cushion head; do NOT insert objects into mouth or restrain limbs.
2. Note time of seizure onset.
3. Maintain airway once clonic phase stops; give 15 L/min oxygen.
4. If seizure persists beyond 5 minutes:
   • Call 999.
   • Administer Buccal Midazolam (Buccolam) 10 mg slowly into the buccal space between cheek and lower gums (Adult dose: 10 mg; Child 5–10 yrs: 7.5 mg; Child 1–5 yrs: 5 mg).

In-Hospital & Primary Care Cardiac Arrest

Cardiac arrest is diagnosed in any unresponsive patient with absent or abnormal (gasping) breathing.

Unresponsive & Not Breathing Normally → Call 999 + Request AED
  └── Start High-Quality CPR Immediately (30 compressions : 2 ventilations)
        ├── Rate: 100 - 120 compressions/min
        ├── Depth: 5 - 6 cm
        └── Attach AED as soon as available → Follow Voice Prompts

1. Call 999 immediately stating "cardiac arrest" and request the AED.
2. Commence Cardiopulmonary Resuscitation (CPR) at a 30:2 ratio (30 compressions to 2 ventilations with bag-valve-mask and 15 L/min oxygen).
3. Maintain compression rate at 100–120 bpm and depth at 5–6 cm on lower sternum.
4. Attach AED pads immediately (right upper sternum, left apex). Pause CPR only during AED rhythm analysis. If a shockable rhythm (VF / Pulseless VT) is identified, deliver 1 shock and immediately resume CPR for 2 minutes.