‘A patient could collapse on any premises at any time, whether they have received treatment or not. It is therefore essential that ALL registrants are trained in dealing with medical emergencies, including resuscitation, and possess up to date evidence of capability’ (General Dental Council ‘Scope of Practice, 2013)
Cardiorespiratory arrest is rare in primary dental practice but there is a public expectation that dental practitioners and all other dental care professionals should be competent in treating cardiorespiratory arrest (Resuscitation Council UK).
Primary Dental Care Quality standards for CPR:
These standards are written with resuscitation in mind, the Resuscitation Council prepared the following statement within the document.
“Those requiring information on medical emergencies encountered in dental practice (other than cardiorespiratory arrest) are referred to the relevant section in the British National Formulary (BNF). Further enquiries should be directed to the Dental Advisory Group of the BNF or the British Dental Association who contributed to the advice within the BNF.”
https://www.resus.org.uk/library/quality-standards-cpr/primary-dental-care
Medical vs Dental Patient:
Patients arriving at a dental practice for dental treatment are within a healthcare environment that is suitable and able to offer a care pathway or solution for their clinical presentation. Modern dental practices are equipped to effectively deal with dental problems. The issue arises when a dental patient arriving at the dental practice transitions into a medical patient with a dental problem.
Dental practices are not fully equipped to diagnose, treat, and discharge medical patients. Once a patient transitions from a dental patient to a medical patient, priorities shift. Patients are no longer dental patients, but medical patients and in some circumstances, this can become life threatening. Once identification of a medical problem is confirmed, it is important to put into action the care pathways, clinical assessment and treatment standards that are available/required. To deny a patient accurate clinical evaluation including a simple physiological examination could be determined as negligence. A basic vital sign assessment and evaluation is difficult to accomplish in a dental environment due to a lack of diagnostic equipment not to mention more advanced assessments such as electrocardiography.
When reviewing the standards from the GDC & Resuscitation Council the word “Manage” medical emergencies can have many definitions from “to be in charge of”, “maintain control over” to “have the position of supervising”.
Given the complex nature of medical models, standards of treatment and diagnostic processes, along with available care pathways which must be recalled, it is always advisable to seek further assistance from emergency medical clinicians.
Example of Medical Emergencies in the Dental Practice
A patient attending the practice with a toothache is placed into the dental chair, a medical history is quickly reviewed and reveals no significant issues. An examination is carried out and the decision to extract a tooth is made. Following the administration of local anesthetic, the patient starts to experience the following symptoms.
- Pallor
- Lightheadedness
- Nausea
- Tachypnea
The above symptoms are commonly encountered in the dental practice and can be attributable to syncope. However, the diagnosis of syncope is often placed upon the presenting signs and symptoms from a process which involved asking the patient several questions, relating the answers to the signs and symptoms, along with an analysis against previously acquired knowledge and experience. Actual physiological investigation into why the above signs and symptoms are present may not have been accurately carried out in accordance with medical standards.
A medical patient, when under the duty of care of a medical clinician, should receive a number of focused physiological examinations; this would run alongside the application of diagnostic equipment and an overall evaluation of their presentation to formulate a working diagnosis. Once differential diagnoses have been excluded, treatment is then targeted at the diagnosed presenting condition. In a medical emergency this process is paramount, should anything be missed due to lack of assessment or evaluation, the welfare of the patient could be at risk. It would be negligent not to perform such basic, fundamental evaluations such as:
- DRABCDE assessment & Collection of vital signs
- Key systems analyses (respiratory, cardiovascular, central nervous system)
- Electrocardiography
Recall the above signs & symptoms of syncope. The patient is experiencing medical symptoms that have become apparent during a period of induced stress. Those symptoms require investigation to rule out more sinister medical problems that might now be present because of stress. Performing the above assessments would rule out potential life-threatening issues and, in most cases, following assessment, a diagnosis is achieved, and focused treatment begins. Some chronic progressing conditions such as cardiac arrhythmias are asymptomatic for quite lengthy durations and may only become symptomatic during certain circumstances e.g., stress or illness.
The below list contains several medical problems that can manifest with the above signs and symptoms, therefore before placing a simple diagnosis of syncope clinicians should rule out the following.
- Silent myocardial infarction
- Transient or resident cardiac arrhythmias
- Adrenal insufficiency (Addison’s disease - potentially undiagnosed?)
- Internal bleeding (causing hypotension)
- Central nervous system disorders
- Transient ischemic attack
The above is just a short list of differential diagnoses that would need ruling out before confirmation of syncope could be clinically and accurately confirmed. It is highly unlikely that a dental environment could offer such focused investigation, therefore the assistance of trained medical professionals should be sought.
Emergency Medications
Emergency medications are a standard requirement in a dental practice. The British National Formulary (BNF) and its associated drug protocols is a mainstream clinical reference manual that has been previously noted as the dental professional standard reference for managing medical emergencies.
In most circumstances, the administration of emergency medication within the dental practice is a simply due to the patient not preparing adequately for the visit/treatment, or withholding the self-use of prescriptive medications, such as Salbutamol.
Basic standards of prescribing include.
- Indications
- Contra-indications
- Interactions
- Side effects
- Cautionary notes
- Basic pharmacological knowledge of the actions of the substance
Utilising a reference manual at this point is imperative for patient safety and considered standard practice in medicine. The aim is to deliver focused treatment that serves to preserve life, prevent deterioration, and promote recovery. It is quite a mental task to recall every bit of information about every drug that is available to utilise during a medical emergency especially when one is stressed!
Not only does the BNF contain all this information, but it also has a section that specifically focuses on common medical emergencies in the dental practice. The BNF is a professional reference tool that is listed by the Resuscitation Council UK within the primary dental care training and quality standards. It is the primary resource for drug protocols to ensure that clinically correct management and treatment is delivered to a patient that is categorised as a “medical emergency”.
The relevant section within the BNF includes information on the following:
- Syncope with a consideration for Addison’s /Cardiac Arrhythmia
- Addison’s disease
- Anaphylaxis • Cardiac emergencies (MI, IHD)
- Epileptic Seizures
- Hypoglycemia • Acute Asthma
As medical emergencies are complex in nature and cause stress to healthcare professionals not working within that area of expertise, it is important that high quality training, acquisition of correct equipment and the use of the British National Formulary are part of practices’ protocols to manage medical emergencies.
Training
Training is an important part of being able to manage a medical emergency in the dental practice.
Principle 6.6 (Standards for the Dental Team, 2013)
Medical emergencies can happen at any time in a dental practice. You must make sure that:
- There are arrangements for at least two people to be available within the working environment to deal with medical emergencies when treatment is planned to take place.
- All members of staff, including those not registered with the GDC, know their role if there is a medical emergency.
- All members of staff who might be involved in dealing with a medical emergency are trained and prepared to do so at any time, and practise together regularly in a simulated emergency so they know exactly what to do.
The GDC also state that registrants must follow the guidance on medical emergencies and training updates issued by the Resuscitation Council (UK).
Dental practitioners and other dental care professionals must be trained in cardiopulmonary resuscitation (CPR) so that in the event of cardiorespiratory arrest occurring they can:
- Recognise cardiorespiratory arrest
- Summon help immediately (dial 999)
- Start CPR, using chest compressions and provide ventilation with a pocket mask or bag-mask device and supplemental oxygen (evidence suggests that chest compressions can be performed effectively in a fully reclined dental chair)
- Attempt defibrillation (if appropriate) within 3 minutes of collapse, using an AED
- Provide other advanced life support skills if appropriate and if trained to do so.
Dental practitioners and other dental healthcare staff should update their knowledge and skills in resuscitation at least annually.
As well as training, staff members must get together to carry out/rehearse different medical emergency scenarios to ensure everyone is aware of procedures and protocols to be followed. Evidence of training completed, and scenarios rehearsed must be recorded for audit purposes. Resuscitation and Medical Emergency training must form part of all new staff induction programmes.
Conclusion
Through the acquisition of thorough and correct training, working within the guidance and protocols of the BNF and careful selection of equipment/drugs, dental professionals can deliver a patient focused management plan from, knowledge, skills, and references. This promotes preservation of life, prevents deterioration, and promotes recovery whilst awaiting the arrival of the Emergency Medical Services.
DD offer Medical Emergencies in the Dental Practice and Basic Life Support/AED/Specialised Resuscitation training. Sessions are carried out by DDs Practice Support Consultant within your own practice environment, all offer verifiable CPD and combine theory and practical elements.
Training Courses - Dental Business Support - DD (ddgroup.com)
Supporting Information:
https://www.resus.org.uk/library/quality-standards-cpr/primary-dental-care
https://www.resus.org.uk/library/quality-standards-cpr/primary-dental-care-equipment-list
