Dental Emergency Response Guide

• Medical emergencies can occur in the dental practice.
• Two posters, 'Medical Emergencies in the Dental Practice' and 'Emergency Drugs in the Dental Practice', help dental care professionals respond to medical emergencies safely and effectively.
• The posters have been revised to align with current national guidelines and recommendations.
• Both posters can be downloaded from https://www.bda.org/advice/Pages/Patient-care.aspx.

Introduction

• Dental team members must ensure they provide effective and safe service to patients.
• The satisfactory performance in a medical emergency includes equipment, training, standards of care, clinical governance, risk management, and clinical audit.
• The revised poster is designed to help the dental team manage medical emergencies effectively.
• An overview of the revised poster is provided to help manage medical emergencies.

General Dental Council and medical emergencies

• The General Dental Council (GDC) states that a patient could collapse on any premises, and registrants must be trained in dealing with medical emergencies.
• Planning should ensure at least two people are available to handle medical emergencies.
• Dental team members must maintain their knowledge and competence in dealing with medical emergencies, so continuing professional development (CPD) is important.

Incidence of medical emergencies

• Medical emergencies in dental practices include vasovagal syncope, angina, hypoglycaemia, epileptic seizures, choking, asthma, anaphylaxis, and cardiac arrest.
• It is estimated that a general dental practitioner (GDP) will experience a medical emergency at least once every two years.
• Vasovagal syncope is the most common emergency encountered, with one study showing that 4.8% of all GDPs observed 22% of all syncopes.

Risk management

• Risk management reduces the risk of medical emergencies, so primary care dental facilities should have a process for medical risk assessment of their patients.
• Potential medical emergencies should be anticipated by taking a thorough medical history, which is revised, updated, and checked each time the patient presents for treatment.
• An updated medical history minimizes the risk of a medical emergency occurring.

National guidance on the management of medical emergencies

• The National Institute for Clinical Excellence's (NICE's) 'Medical Emergencies in Dental Practice' section of the British National Formulary (BNF) provides guidelines on the management of common medical emergencies.
• Specific guidance is provided by authoritative bodies, including NICE, Addison's Disease Self-Help Group, British Thoracic Society, British Heart Foundation, and Epilepsy UK.

Medical Emergencies in the Dental Practice poster

• The 'Medical Emergencies in the Dental Practice' A3 poster was first produced in 2009 to assist the dental team in safely managing medical emergencies occurring in the dental practice.
• The poster is intended to be placed on the wall in the surgery for easy access in an emergency.
• The emergencies covered are listed in alphabetical order: adrenal crisis, anaphylaxis, asthma, cardiac emergencies, epileptic seizures, hypoglycaemia, red flag sepsis, stroke and syncope.
• Important signs and symptoms, principles of safe and effective treatment, recommended doses of drugs (including paediatric doses), and routes of administration are stated.
• Further copies of the poster can be downloaded from https://www.bda.org/advice/Pages/Patient-care.aspx.

Summary of updates and revisions: Adrenal crisis

• A 2013 UK survey found that 8% of steroid-dependent patients developed adrenal crisis while undergoing a dental procedure.
• The NHS Specialist Pharmacy Service¹⁴ has published guidance regarding steroid supplementation required to prevent adrenal crisis in patients with primary adrenal insufficiency undergoing a dental procedure.
• For minor procedures, advise the patient to take an additional oral dose of glucocorticoid one hour before their appointment, while for more complex procedures, prescribe steroid supplementation before the procedure and for a full 24 hours afterwards.
• Patients with primary adrenal insufficiency should bring their emergency hydrocortisone injection kit to all appointments, as well as their personalised adrenal crisis letter.
• If the patient develops adrenal crisis, call 999 and administer intramuscular (IM) hydrocortisone per instructions in the patient's adrenal crisis letter.

Anaphylaxis

• Ongoing supply issues relating to AAIs led to the MHRA approving the extension of expiry dates for specific batch numbers of Epipen and Jext AAI devices.
• Dentists should periodically check the viewing window in the label of the AAI device to ensure the liquid inside is still clear and colorless; if discolored, the device should not be used.
• Supply issues led to the Chief Dental Officer for England requesting dental practices that stock AAIs to renew them with adrenaline ampoules, to preserve national stocks.
• The coroner reported concerns to MHRA regarding the length of the needle (16 mm) and the dose of adrenaline (300 mcg) in adult Epipen AAIs.
• The Resuscitation Council (UK) has since reiterated that the recommended needle length for IM injections is 25 mm, and healthcare professionals should be administering 500 mcg of adrenaline for a patient over 12 years of age.
• Dental practices should ensure they have adrenaline 1:1000 (1 mg/ml) ampoules in their emergency drugs kit.

Asthma

• Deaths from asthma attacks are the highest they have been in the last decade and have increased by more than 33% over the last ten years.
• The guidelines for the management of acute asthma in the dental practice stress early use of a spacer device.
• The salbutamol (beta-2 agonist) inhaler should be administered via the spacer one puff at a time with tidal breathing; according to response, give another puff every 60 seconds up to a maximum of ten puffs.
• A patient safety alert from the MHRA32 has highlighted the potential risk of choking when using a pMDI.

Cardiac emergencies

• Standard management of a patient who is suspected of having a heart attack outside hospital has been revised to include calling 999 immediately and asking the patient to chew dispersible aspirin 300 mg.
• It is particularly important to be vigilant with women who may be having a heart attack.
• NICE has reiterated the importance of not routinely administering oxygen in a suspected heart attack. However, if the patient is hypoxaemic, adjust the oxygen flow rate to achieve a target oxygenation saturation.

Epileptic seizures

• NICE updated guidelines saying all patients with epilepsy should have a personalized care plan that is brought to every dental appointment
• Buccal (oromucosal) midazolam is advised for prolonged (lasting five minutes or longer) or repeated seizures.

Hypoglycaemia

• The latest NICE guidelines now include the importance of being particularly alert in patients with impaired awareness of hypoglycaemia (IAH).
• If the patient is conscious and cooperative, offer 15-20 g of quick-acting carbohydrate.
• Glucagon is still advised if the patient is unable to have oral quick-acting carbohydrate. GlucaGen HypoKit can be stored at refrigeration temperatures but must not be frozen.

Red flag sepsis

• The UK Sepsis Trust has developed three age-specific sepsis decision support tools to help the dental team identify and appropriately manage patients with suspected sepsis.
• The UK Sepsis Trust's definition of red flag sepsis identifies a set of easy-to-identify clinical parameters the presence of one, which, in the context of infection, identifies sepsis with a high risk of death and requires urgent treatment and transfer to hospital.

Stroke

• NICE's updated guidelines recommend FAST approach to assess someone with a suspected stroke outside hospital.

Equipment and Drugs for Medical Emergencies

• A practice could be in a difficult position from a medico-legal point of view if a patient came to harm during dental treatment due to a lack of the emergency resuscitation equipment recommended by the Resuscitation Council (UK) or medical emergency drugs recommended by NICE in the dental section of the BNF.

Infection control

• The current COVID-19 outbreak has emphasized the need for adequate infection control measures, the principles of which still of course apply in a medical emergency setting. Resuscitation Council (UK) recommends level 3 personal protective equipment (PPE) before starting chest compressions and ventilations in the dental practice in a patient with, or suspected to have, COVID-19.

The 'Emergency Drugs in the Dental Practice' Poster

• The 'Emergency Drugs in the Dental Practice' A4 poster (Fig. 6) was first produced in 2012¹¹ and then revised in 2015.¹² It is designed as an aide-memoire to assist the dental team to safely administer medications in a medical emergency and is designed to be kept in the emergency drugs box for quick reference. The poster has been revised in line with current guidelines and terminology, and can be downloaded from...

Training in Medical Emergencies

• Running regular mock scenarios/drills themed around medical emergencies involving a team approach is advised.
• From the author's experience, some surgeries find it helpful to use the poster in the training session to increase familiarity in its use. Ensuring the dental team is kept up-to-date in the management of medical emergencies is essential.