Bharat Patel details the protocols every dental nurse should know in order to manage medical emergencies.

While dentists play a central role in any dental treatment, dental nurses are essential members of the dental team, and are the backbone of all treatment procedures.

A dental nurse’s role involves chairside assistance during dental treatment, such as handling instruments and providing proper suction in the dental field. They also play a role in preparing the treatment room by organising the relevant instruments, sterilising the instruments and the workstation, besides providing patient care and support.

Dental nurses also help to address patients’ anxiety issues and offer guidance on oral hygiene measures and post-operative care. Most importantly, dental nurses play a crucial role in the event of any dental emergency.

Dental emergencies occur when a medical condition that may suddenly threaten life happens during a dental treatment. Every clinic must prepare protocols that every dental nurse should know to manage dental emergencies.

Prevalence of medical emergencies

Medical emergencies in dental practices are considered rare, but they do occur. Recently, a study revealed that medical emergencies are more prevalent than previously thought, most of them non-life-threatening, with syncope being the most frequent emergency.

Dental nurses and practitioners must be prepared for any medical emergency in the dental office by recognising the early signs of an emergency and promptly managing it to save the patient’s life.

Being prepared for medical emergencies

To manage a medical emergency in the dental office, a dental nurse must know how to handle such situations effectively. When is it considered an emergency? What should you use to handle it?

The answer to these questions lies in having knowledge about medical emergencies, recognising the signs and symptoms of an emergency, and having an emergency kit readily available to follow the emergency management protocol specific to the situation.

Knowledge

To be registered in the UK General Dental Council (GDC), the dental nurse must complete a continuous professional development (CPD) course. Medical emergencies are integral to the Continuing Professional Development (CPD) with a 10-hour study.

Signs and symptoms

During dental treatment, the nurse must observe and notice any signs of an emergency. For example, a change in lip colour or skin turning blue (cyanosis) may indicate a problem in the heart or circulatory system. An abnormal breathing pattern or shortness of breath may indicate anaphylactic shock.

So, the early spotting of any abnormal signs or symptoms may facilitate early intervention in treating an emergency condition.

An updated medical history detailing current or previous medical conditions, medications, and allergies is crucial for effectively managing a medical emergency.

An emergency kit

An emergency kit containing essential drugs and equipment is mandatory in every dental clinic. The aim is to provide the dental nurse with the necessary tools and medications to stabilise the patient’s condition until further emergency assistance arrives.

The essential emergency drugs include Glyceryl trinitrate (GTN) spray for angina, Salbutamol aerosol inhaler for an asthma attack, Adrenaline injection in case of anaphylaxis, Glucagon injection or oral glucose solution for hypoglycemia, and Diazepam for epileptic seizures.

The minimal emergency equipment includes a portable oxygen cylinder with a pressure reduction valve and flow meter, an oxygen face mask with reservoir and tubing, a basic set of oropharyngeal airways, an automated blood glucose measurement device, an automated external defibrillator, and single-use sterile syringes and needles.

When the dental nurse has these three items on hand, they can assist in following the proper protocol for managing emergency cases to save the patient’s life.

The most common dental emergencies and protocols

During a medical emergency, the dental nurse must remain calm and confident. Once emergency signs are evident, call the emergency services and act promptly to apply the necessary emergency protocol.

Vasovagal attack (fainting/syncope)

Syncope is a condition characterised by a loss of consciousness caused by reduced blood flow to the brain. It probably occurs due to stress and anxiety during dental treatment. The signs and symptoms include nausea, dizziness, low blood pressure, a thready pulse, dilated pupils, shallow breathing, and loss of consciousness. If loss of consciousness is improperly recognised and treated, it may lead to airway obstruction and death.

Emergency management of syncope:

1 Place the patient in the Trendelenburg position (supine position with the feet at a higher level than the head). When dealing with pregnant women, position them on their left side and elevate their legs.

2 Maintain a clear airway and prevent obstruction by the tongue. 3 Use an aromatic ammonia inhaler to stimulate breathing and regain consciousness.

4 Oxygen administration, if necessary.

5 Carefully monitor the vital signs until they return to their normal baseline.

Sedation before commencing dental treatment may be advantageous in calming patients with dental procedure anxiety and preventing vasovagal attacks.

Chocking and aspiration (airway obstruction)

Airway obstruction occurs when breathing becomes difficult or impossible due to inhaling a foreign object. It may occur during root canal treatment due to the small size of instruments used or because of a tooth fragment fracturing during extraction. Using a rubber dam during root canal treatment eliminates the risk of choking.

Emergency management of airway obstruction:

1 Assess the patient’s ability to breathe and ask if they can talk and breathe.

2 If the patient can respond, encourage them to cough to dislodge the foreign object. Once the foreign object is expelled, no additional assistance is required.

3 If the patient cannot breathe with a wheezing sound upon inhalation, call 999 immediately and perform the Heimlich Maneuver promptly. Stand behind the patient, wrap your arms around their waist, and apply abdominal thrusts below the ribcage and just above the navel. Push inward and upward until the foreign object is dislodged.

4 If necessary, apply CPR or rescue breaths.

5 Even after the condition clears up, advise the patient to seek medical consultation to prevent the risk of laryngeal oedema.

Epileptic seizures

Epileptic seizures occur due to abnormal brain activity, which can be triggered by anxiety during dental treatment. It starts with dizziness and audio and visual disturbances. Then, the patient may lose consciousness and experience tonic-clonic seizures, hyperventilation, increased salivation, and tongue biting.

Emergency management of seizures:

1 During a seizure, place the patient in a supine position. Protect the airway and apply suction if necessary. Guide the extremities without restraint.

2 After the seizure, place the patient on their side for recovery, monitor vital signs, and administer oxygen if necessary.

3 If the patient suddenly becomes unresponsive, consider cardiac arrest: call 999, apply CPR, and use the defibrillator if necessary.

Hypoglycaemia

If the patient suffers from low blood glucose levels, they may experience fatigue, sweating, dizziness, twitching, and tremors.

Emergency management of hypoglycaemia:

1 If the patient is conscious, give a glucose tablet or drink to raise the glucose level in the blood.

2 If the patient is conscious but uncooperative, apply glucose gel to the buccal sulcus.

3 If the patient is unconscious, call 999, administer a glucagon injection from the emergency drugs, and provide oxygen. Once the patient regains consciousness, provide them with a glucose drink and wait for emergency medical services to arrive.

Cardiac emergencies

Angina pectoris is a condition characterised by transient myocardial ischemia caused by atherosclerosis of the coronary arteries. The condition is triggered by stress or anxiety, leading to an increased demand for oxygen. The main symptom is a squeezing, tight pain radiating to the left shoulder, accompanied by a regular, fast pulse.

Myocardial infarction means a heart attack. It is caused by a long-term blockage of a coronary artery, depriving the heart tissue in that area of blood supply, ultimately leading to its death. It is a serious life-threatening condition that may lead to cardiac arrest, so prompt management is crucial to prevent fatalities. It has the same pain as angina, but the pulse is irregular.

Emergency management of angina:

1 Put the patient in a sitting position, as lying down will increase the load on the heart.

2 Administer glyceryl trinitrate (GTN) under the tongue.

3 If the symptoms subside, allow the patient to rest before leaving. If the symptoms do not improve, suspect a myocardial infarction.

Emergency management of myocardial infarction:

1 Place the patient in an upright position and call 999.

2 Start administering oxygen and aspirin unless the patient is allergic to it or taking another anticoagulant.

3 Monitor the vital signs until the emergency services arrive.

4 If the patient becomes unconscious, consider cardiac arrest. Proceed with CPR and use the defibrillator where necessary.

Anaphylaxis

Anaphylaxis is a hypersensitivity reaction triggered by exposure to an allergen. A detailed medical history is the primary tool to prevent such emergencies. Within one to 15 minutes following allergen administration, the patient experiences coughing, wheezing, palpitations, flushing, and urticaria.

Emergency management of anaphylaxis:

1 Place the patient in a supine position.

2 Select an epinephrine auto-injector appropriate for the patient’s body weight.

3 Call 999.

4 Monitor the vital signs and administer oxygen if needed.

Asthma attack

Asthma is a chronic inflammation of the respiratory airways. Asthma patients typically carry their inhalers with them at all times. Minimise stress during the treatment of a patient with asthma. Look for signs of asthma attacks such as wheezing, shortness of breath, chest tightness, and coughing.

Emergency management of an asthma attack:

1 Put the patient in a comfortable position.

2 Use the patient’s inhaler or salbutamol inhaler from the emergency kit.

3 Make sure that the airway is clear.

4 Administer oxygen.

Conclusion

Nurses are the backbone of the dental practice. Although the emergency dentist may appear as the hero who saves the day, the role of a dental nurse is essential for the success of any dental treatment and to ensure a pleasant dental experience for the patients. Dental nurses also play a crucial role in saving patients’ lives by managing medical emergencies that may arise in the dental office.

References available on request.

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