Dental CPD

dental emergenciesDentist’s hold some medical drugs that you find in the emergency pack in dental surgeries. One of the drugs listed is adrenaline 1/1000, this is to be used for anaphylactic reactions. It comes in various presentations, the most common is, and one that the patients would often carry themselves is the EpiPen. There are multiple manufacturers, and you can see that those three different products are actually exactly all the same. Each one contains 300 micrograms of adrenaline 1/1000. This is to be administered via the intramuscular route. When a patient begins to have an anaphylactic reaction, it rapidly progresses, bronchospasm occurs, vasodilation happens, and the patient quickly becomes hypoxic and relatively hypovolemic.

Adrenaline works to reverse the bronchospasm and constrict the peripheral blood vessels, therefore supporting the circulation. It also increases heart rate and contractility. To use the EpiPen, first of all, we must identify which end will go towards the patient and which end activates the product. So, we remove the end and we place this against a big muscle. The upper outer thigh is a good target site and can actually be used in quite small patients as well. For the purposes of demonstration, I am going to place it against my deltoid muscle, and you can see how it would be used. So, I expose the muscle if at all possible, or alternatively, it will go through clothing. Place the delivery end against the patient’s skin and press, and hold for three seconds. We should start to see a recovery in quite a short space of time. It is fast acting; however, adrenaline wears off quickly and we may need to repeat the dose.

If an EpiPen is not available, adrenaline 1/1000 comes in a presentation of 1 milligram in 1 ml. This needs to be drawn up using a drawing up a needle and a syringe. The advantage of using adrenaline this way is that there are 1000 micrograms per ml, so essentially more than three doses of one of these.

If you have access to adrenaline in this presentation, then administer 500 micrograms to an adult and 150 micrograms to a child. Be prepared to repeat the dose if the signs and symptoms return. We first need to identify and check with somebody that it is the correct product and that it is in date. If we take the vial and gently flick until all the drug has run out of the top and identify a place where we can press to open the vial. This end is delivered into the sharps bin.

Checking the packaging and the date of the syringe, and the packaging and the date of the needle, keeping sterile, insert the needle into the vial and carefully withdraw the full 1 milligram in 1 ml. Check that the vial is empty, and dispose into a sharps container. Expel any air, replace the drawing up a needle with a hypodermic needle and similarly, give this intramuscularly in the same muscle as you would the EpiPen.

Other emergencies that may occur in the dental surgery are asthma attacks. In the emergency dental drug pack, we have a Ventolin inhaler. The presentation is the container which holds the medicine inside with the date and expiry date on the side, the bit that the patient seals their lips around. And to test that it is actually working, press down until the product is expelled. For the patient to use this effectively they need to exhale first, place the product in the mouth and press the button on the top and inhale simultaneously and then instruct the patient to hold their breath for a few seconds so the product is dispersed around the alveoli and the mechanism will be as such.

We titrate this to the patient’s response. There is no maximum dose; however, do be aware that the patient may develop tachycardia or tremors in large doses. Salbutamol may also be useful in a patient who is suffering from an anaphylactic reaction. First of all, administer the adrenaline. If the patient is still wheezing and in bronchospasm then follow the adrenaline with the Salbutamol inhaler.

Other emergencies that may occur in the dental practice are chest pains. The two drugs that are in the dental pack are GTN spray and aspirin. Aspirin is delivered via the oral route, but we ask the patient to chew the tablet, and then give the patient a little sip of water and allow it to be absorbed through buccal mucosa rather than swallowing the aspirin. This way it is active much quicker and will work to dissolve the platelet plugs and the clots. If the patient’s blood pressure is over 100 millimetres systolic, we can administer GTN spray. The patient will often have this on themselves. There are 400 micrograms per spray, we can repeat the dose depending on the patient’s response. Remove the top, ask the patient to open their mouth and lift the tongue, spray under the tongue and then immediately get the patient to close their mouth. Explain to the patient that they may develop a throbbing headache for a short space of time. It is important after administering GTN that we monitor the patient’s blood pressure. If the pain is persistent for more than 20 minutes, there is a likelihood that it is not actually an angina attack but it could well be a heart attack, in which case emergency assistance is required.

One of the other drugs that are available inside the emergency drug pack is glucose gel and Glucagon. The question is, which one would you use in a diabetic emergency? If a patient is able to tolerate oral glucose, then GlucoGel is by far the easiest and most efficient to administer. Twist the top of the pack and administer this inside the buccal mucosa, rubbing the product in so that it is absorbed. We would expect to see quite a rapid recovery from the administering of GlucoGel. If that is not effective, there is an option to deliver Glucagon via the intramuscular route. However, this is not without risks as it is an intramuscular injection and it can often cause vomiting. It also is not effective in reversing hypoglycaemia in patients with low carbohydrate stores, so perhaps, patients who are malnutritioned, alcoholics, perhaps homeless people, then glucose gel is by far the most effective way of administering sugar.

In the case of a patient beginning to fit whilst in the surgery, in your drug pack you have Midazolam. This is 10-milligram doses and it is to be administered by the buccal route. It often comes in a pre-filled syringe. And if there is a parent with the child, they will probably be well versed in the administration of this, but perhaps will look to you for guidance. Insert it into the mouth and here again, rub the product into the gums so that it is absorbed. It is a benzodiazepine, so, therefore, can adversely affect the respiratory rate and blood pressure, and these must be monitored continuously after the seizure has stopped.

And finally, it is worth remembering that all these products have a use by date and it should be part of your routine practice to check that the packaging is intact, that all the drugs are present, they are all in date, and they are all fit for use in an emergency situation that may arise in your surgery.