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Asthma

Themes assessed
Asthma Algorithm
Salbutamol mode of Action

Opening statement
A 24 year old patient with known asthma is having an amalgam
restoration replace in your surgery. Your nurse notices that the patient
is becoming increasingly restless; the patient begins to cough and
wheezes slightly. You notice that he is finding it difficult to breathe.

Core questions
1) What do you thing is happening?
The patient is beginning to suffer an acute severe asthmatic attack.
2) What are the clinical signs of an acute severe asthmatic attack?
-Inability to complete sentences in one breath
-Respiratory rate of more than 25 per minute
-Tachycardia, heart beatings of more than 110 per minute
3) How will you manage this patient?
-Stop the treatment.
-Remain calm and reassure the patient to reduce his anxiety
-Sit the patient up (usually most comfortable position)
-Give the patient his own medication (Salbutamol inhaler) or Salbutamol from
Emergency Drug Box (4-6 activations using a large spacer).
4) If the patient fails to respond to the initial treatment, what do you
do?
-Repeated doses of Salbutamol may be needed every 10 minutes
-CALL 999
-Give Oxygen 10L per minute
-Monitor vital signs (signs of life- ABCDE)
-ADRENALINE: if Asthma is part of an Anaphylactic Reaction or shows signs or
symptoms of life threatening Asthma
5) What are the clinical signs of Life Threatening Asthma that you as
a dentist could elicit?
-Cyanosis or respiratory rate of less than 8 per minute
-Bradycardia (heart rate of less than 50 per minute)
-Exhaustion, confusion, decreased conscious level

Supplemental questions

1) What is Salbutamol?
It is a SHORT ACTING BETA 2 ADRENOCEPTOR STIMULANT (OR AGONIST)
INHALER- delivers 100 micrograms per actuation.
It is a RELIEVER inhaler (there are preventer and relievers).
2) How does it work? MODE OF ACTION
On the airway- It binds to beta 2 adrenoceptors in the smooth muscles of the
bronchioles causing their relaxation and consequent bronchodilator. It also
stabilizes mast cells decreasing the production of chemical mediators such as
histamines, prostaglandins and leukotrienes. It has a rapid onset, acts in 5-15
minutes.
3) What are the adverse effects? SIDE EFFECTS
-Tremor of the extremities
-Palpitations
-Headache
4) What other acute medical condition can mimic an asthma attack?
Anaphylaxis

5) What are the advantages of using a LARGE VOLUME SPACER


DEVICE?
Overcoming the difficulty in coordinating the administration and patient’s
inspiratory movement during the crisis consequently increasing absorption
of the drug into the lungs.

Anaphylaxis
Themes assessed
Anaphylaxis algorithm
Adrenaline mode of action and doses
Intra Muscular injection technique

Opening statement
You have given an adult patient who needs antibiotics cover 3 g of
Amoxicillin orally and asked him to seat in the waiting room. Whilst you
are treating your next patient, your receptionist rings through to tell
you that the patient you have just sent to the waiting room is behaving
strangely and appears to be flushed, is making wheezing noises and his
face and lips are becoming swollen.

Core questions
1) What do you think is happening?
The patient is suffering from Anaphylaxis.
2) What do you thing caused the reaction?
The most likely trigger will be the oral antibiotic.
3) What is your immediate management of the patient?
-First CALL 999 AND
GIVE ADRENALINE INTRAMUSCULARLY (adults 0.5 ml of 1:1000 solutions, which
means 500 micrograms or 0.5 mg of adrenaline 1mg/1ml)
-2nd Give Oxygen 10L per minute
-3rd Aim to restore blood pressure by laying patient flat and raising the legs
-If the patient is feeling breathless give Salbutamol inhaler 4-6 actuations in a
large volume spacer device.
-Reassure the patient and monitor vital signs
(If the patient is suffering from a VERY MILD reaction- ABCDE+ Oxygen 10L per
minute+ Salbutamol)
*when the paramedics arrive: 2nd line treatment: -intravenous fluid
-Antihistaminic
(Chlorphenamine)
-Steroids
(Hydrocortisone) to reduce inflammatory response
4) Where would you inject the adrenaline?
At the antero-lateral aspect of the middle third of the thigh, muscle VASTUS
LATERALIS. Landmarks: half way from the knee to iliac crest.
5) Why choose the antero-lateral middle third of the thigh?
It offers easy access to a large muscle (the vastus lateralis) and there are no
major structures such as nerves or arteries that can be accidentally damaged.
The bulk of muscle is easy to get and rapid absorption of drug given is
guaranteed.
6) Is anaphylaxis easy to diagnose?
No, there is a wide range of possible presentations making diagnosis difficult,
clinical assessment helps to make the diagnosis.
7) What other signs and symptoms may be seen?
-Urticaria, erythema, rhinitis, conjunctivitis
-Abdominal pain, vomiting, diarrhoea, sense of impending doom
-Flushind OR Pallor
-Oedema and bronchospasm
-Vasodilation causes relative hypovolaemia leading to low blood pressure and
collapse. This can cause cardiac arrest.
-Respiratory arrest leading to cardiac arrest.

Supplemental questions
1) How does the adrenaline work?
-Alpha receptors in skeletal muscles- cause vasoconstriction reducing oedema
and elevating blood pressure
-Beta 1 receptors in the heart- cause the increase of force and rate of
contraction, thus increasing load and correction of hypovolaemia and
hypotension
-Beta 2 receptors in the bronchial smooth muscle- cause bronchodilation
which will correct difficulty in breathing
-Stabilizes mast cells reducing release of histamine and other chemical
mediators
-Boost Oxygen supply and glucose (by increasing catalysis of glycogen in the
liver) to the brain and muscles.
2) What are the differences between a preloaded adrenaline syringe
and an epicene/ auto injection?
An Epipen contains a smaller dose of Adrenaline (300 micrograms or 0.3 mg)
compared to a pre-filled adrenaline syringe where a higher dose of 500
micrograms (or 0.5mg) can be given. Also the Epipen or Ana Pen is self injectable
devices to use by common people who are at risk and it is not recommended to
keep in the Medical Kit in Dental Practice.
3) What are the adverse reactions associated with an adrenaline
injection?
-Palpitations
-Tachycardia
-Anxiety
-Headache
-Tremor
-Hypertension
**DOSAGE:
Adults: 500 micrograms (0.5mg) 0.5ml of 1:1000
Children 6-12ys: 300 micrograms (0.3mg) 0.3 ml of 1:1000
Children less than 6ys: 150 micrograms (0.15mg) 0.15 ml of 1:1000

Syncope
Themes assessed
Faint in a general dental practice
Management of patient with syncope

Opening statement
You have just given an injection to a patient for a filling. You turn your
back to pick something up on the desk and the nurse informs you that
the patient is dropping his head and you see the patient pass out.

Core Questions
1) What do you think is happening?
The patient is most probably experiencing a vasovagal syncope or a simple faint.
2) What are the clinical signs of vasovagal syncope or faint?
-Patient may feel dizzy/ light headed/ faint
-Slow pulse rate
- Low blood pressure
-Pallor and sweating
-Nausea and vomiting
-Loss of consciousness
3) What are the causes for a faint?
Most common triggers in a dental surgery: STRESS, ANXIETY, FEAR, PAIN.
Others: -Dehydration
-Extremes of temperature
-Starvation
-Drug effects and interactions
-Intravascular injection of Local Anaesthetic
4) How will you manage this patient?
-Lay the patient flat with the legs slightly raised (10 degrees tilt of the
dental chair) - that will increase Venous return and raise the Blood Pressure
decreasing hypoxia
(If the patient is pregnant place her in a left lateral position as laying her flat will
cause pressure on the inferior vena cava by the foetus further reducing venous
return)
-Loosen clothing especially around neck;
-Give Oxygen 10L per minute
-Keep monitoring Vital Signs (ABC)
-If recovery is not rapid (few minutes) reconsider diagnosis, CALL 999
-Unresponsive? Signs of life (B+C) - CPR????

Supplemental questions
1) What is the pathophysiology behind vasovagal syncope?
Vasovagal syncope is due to a disorder of autonomic control of the
cardiovascular system. It commonly occurs in normal people of all ages.
Precipitating factors include alcohol consumption, fatigue, pain, hunger, and
prolonged standing. It can also be triggered by situations causing anxiety,
such as having blood drawn, as well as by hot or crowded situations. The
initial responses appear to be venous pooling and increased activity
of the sympathetic nervous system. This causes the heart to contract
forcefully while relatively empty, triggering ventricular
mechanoreceptors and vagal nerve fibres. This reduces sympathetic
activity and stimulates parasympathetic activity, resulting in
bradycardia and vasodilation, followed by syncope. This mechanism
is probably not the only explanation. Some inciting factors, such as hunger or
anxiety, do not involve venous pooling. Also, patients with transplanted hearts
(which are not innervated) also exhibit vasovagal syncope–like episodes. The
prognosis is usually good, although prolonged hypotension or asystole may
cause damage. In addition, if syncope occurs without warning, injury may
occur as a result of falling. Vasovagal syncope is often recurrent and may
require treatment.

Adreno Cortical Insufficiency


Themes assessed
Acute adreno-cortical insufficiency
Management of unconscious patient
Opening statement
You have just taken a patient in your surgery and are about to start
work when your nurse informs you that the patient is collapsed in the
chair and is looking unconscious.

Core Questions
1) What do you think is happening? And how will you assess the
situation?
It looks like a complete loss of consciousness that may be caused by a series of
factors, the most common being a vasovagal syncope (faints),
hypoglycaemia, seizures, etc. I will assess the Airway, Breathing, and
Circulation, and if the patient does not show vital signs, then I would diagnose as
a cardiac arrest and act likewise. The medical history should have been checked
before the patient came in for history of previous medical treatment or history of
syncope.
If it looks like a simple faint I would lay the patient flat, raise legs, loosen clothing
around neck, give Oxygen 10L per minute and keep monitoring his vital signs.
At this point the examiner tells candidate that the patient is actually on
PREDNISOLONE 15mg for the last 6 months
So the patient is probably suffering from an Adrenal Cortical Insufficiency.
2) What are the clinical signs of acute adrenal cortical insufficiency?
-Rapid Loss of Consciousness
-Rapid fall of Blood Pressure
-Pallor
-Irregular weak and rapid Pulse
-Confusion
-Shock like features
-HYPOVOLEMIC SHOCK
3) Why is it caused? Give aetiological factors.
The cause is acute deficiency of glucocorticoides and all the others are
predisposing factors:
-Iatrogenic (surgical or drug induced, e.g.: pt on systemic steroids)
-Stress / trauma
-Infection
-Pathological (Patient presenting Adrenal Disorders such as Addison’s Disease,
Post Adrenalectomy, Congenital Adrenal Aplasia, Hypopituitarism)
-Patient on systemic steroids
4) How will you manage this patient?
-CALL 999
-Lay the patient flat and raise his/her legs;
-Give Oxygen 10 L per minute
-Maintain airway and monitor vital signs
-Measure blood glucose if it is possible
-Keep monitoring vital signs until emergency arrives
-Be prepared for BLS as the patient’s condition may deteriorate rapidly

Medical Emergencies in Dentistry on Resuscitation Council UK DOES


NOT include steroids in the management of Adrenal Cortical
Insufficiency by a dentist (most other books recommend Hydrocortisone IM
immediately adult or children over 12 dose of 200mg)

Supplemental Questions
1) What is the pathophysiology for the Adrenal Cortical
Insufficiency?
Cortisol levels respond within minutes to stressful stimuli, protecting the
organism from the damaging effects of the stressor. Without this response,
humans could not resist physical or mental stress, and thus, any minor illness
could result in death. The reasons why elevated glucocorticoid levels protect the
organism under stress are not completely understood, but it helps to maintain
blood pressure in a variety of ways.

Hypoglycaemic Shock
Themes assessed
Diagnosis of acute hypoglycaemia coma
Management of a patient in your surgery for a hypoglycaemia attack

Opening statement
You have just taken a known diabetic patient in your surgery and are
about to start work, when your nurse informs you that the patient is
collapsed in the chair and is looking partially unconscious.

Core Questions
1) What do you think is happening?
Acute Hypoglycaemia
2) What are the clinical signs of acute hypoglycaemia attack?
- Patient shaking and trembling
- Sweating
- Headache
- Difficulty of concentration
- Slurry of speech
- Aggression/ confusion
- Fitting
- Unconsciousness
3) How will you manage this patient?
The management depends on the status of the patient.
Initially, if the patient is conscious and cooperative with intact gag
reflex:
Stop the treatment,
Reassure the patient,
Squeeze Hypostop in the buccal sulcus or give about 25 g of glucose in form of
glucose tablets, Dextrosol, 2-4 cubes of sugar or 2-4 table spoons of granulated
sugar diluted in milk, or water.
In more severe cases, when the patient has impaired consciousness, is
uncooperative or is unable to swallow safely:
give glucose gel (buccal sulcus-quickly absorbed transmucosally across the
vascular oral mucosa AND/OR Glucagon 1mg/ml + Glucose + carb drink as soon
as patient recovers in order to bring sugar levels back to normal.
*Patient can go home if fully recovered with an escort/ Inform patient’s GP, if
after re-checking blood glucose levels (after 10 minutes) it has risen up to 5.0
mmol/L and the patient had a significant mental status improvement.
4) If they fail to respond to the initial treatment, what do you do?
As said above:
-Inject glucagon IM 1mg/ml
-Monitor patient’s vital signs
-Pt should regains consciousness in 5-10 minutes
-Once conscious and able to swallow, I would give high sugar containing drink
and complex sugars such as biscuit or bread
-Check for full recovery, check glucose levels, and check patient’s response to
treatment.
-Call someone to accompany patient home
-Inform patient’s GP and make notes
-Identify predisposing factors and take further precautions.

Supplemental Questions
1) Response time for Glucagon
5-10 minutes
2) Physiology of action of Glucagon
Glucagon will act in the liver by breaking the stored glycogen into a form of
glucose that is able to be released into the blood stream. Glucose provides
essential energy for all the cells in the body system. Later on insulin (which is
also a hormone produced by the pancreas) will take up the glucose from the
blood stream and distribute it to all the body’s cells.
3) In whom glucagon will not act and why?
-In patients with poor dietary intake;
-Chronic alcoholics;
-Patients who don’t suffer of Diabetes;
-Athletes;
-Those that have already had one dose of glucagon;
4) What is the most reliable indicator for long term management in
diabetic patients?
(?) HB1AC level taken every 3-4 months

Angina
Themes assessed
Acute angina attack
Management of angina
Action and adverse reaction of GTN (Glyceryl Trinitrate)

Opening statement
You are treating a patient for an extraction. You are half way through
and the patient starts complaining of severe chest pain and trouble
breathing.

Core Questions
1) What do you think is happening?
The patient is most probably suffering from Angina
2) What are the clinical signs of acute severe angina?
-Chest pain
-Shortness of breath
-Fast and slow heart rates
-Increased respiratory rate
-Low Blood Pressure
-Poor peripheral perfusion
-Altered mental state
3) How will you manage this patient?
-Stop the procedure
-Sit the patient or place him in the most comfortable position (ask him)
-Give the patient’s Glyceryl Trinitrate spray-1 or 2 doses (or his Isosorbide
Dinitrate Tablets) or use the GTN from the Emergency Drugs kit (1 spray contains
400 micrograms of the drug)
-Administer Oxygen 10L per minute
-Monitor Vital Signs
(If the condition resolves rapidly, no hospital is required and dental treatment
may or may not continue)
4) If they fail to respond to the initial treatment what do you do?
If angina does not respond to GTN, it strongly suggests that patient is suffering
from a Myocardial Infarction. Assume Myocardial Infarction and treat accordingly
(CALL 999 + MI management).

Supplemental questions
1) What is Glyceryl Trinitrate? How does it work?
It is a potent vasodilator. It relaxes the muscle walls of the blood vessels and
reduces the workload of the heart.
It also dilates coronary artery and enhances blood supply to heart
musculature and increases oxygen supply. Consequently it relieves the pain
of angina as soon as it starts.
2) What are the side effects of GTN?
-HEADACHES
-Facial flushing
-Faintness
-Abnormal heart rate
-Dizziness
-Nausea
3) What other acute medical conditions can initially mimic an angina
attack?
-Myocardial Infarction
-Hyperventilation
-Epi-Gastric pain
-Muscle pain

Myocardial Infarction
Themes assessed
Myocardial infarction
Treatment of myocardial infarction and cardiac arrest

Opening statement
The same patient with Angina is now experiencing severe pain,
heaviness in the chest, difficulty in breathing and also vomiting. The
emergency medical help is on its way. You need to help the patient until
they arrive.

Core Questions
1) What do you think is happening?
The patient is having a myocardial infarct and probably expecting cardiac arrest
2) What are the clinical signs of Myocardial Infarction?
-Rapid onset of severe crushing chest pain (irradiates to jaw, arm-normally left,
and back)
-Pale and clammy
-Nausea and vomiting
-Pulse may be weak and blood pressure may fall
-Shortness of breath
-Rapid loss of consciousness
-Ashen skin colour rapidly progressing to cyanosis if cardiac function is poor
3) How will you manage this patient?
-CALL 999
-Place patient in the most comfortable position
-Give Oxygen 10L per minute (high flow oxygen)
-Give GTN (if this has not already been given)
-Reassure (relieving further anxiety)
-Aspirin 300 mg (crushed or chewed) SINGLE DOSE!
*Ambulance crew will give Thrombolytic Therapy; inform them of the Aspirin and
any dental treatment relevant.
*UNRESPONSIVE: ABC approach (vital signs) and CPR.

Supplemental questions
How does aspirin work?
Aspirin has antiplatelet effect by inhibiting the production of Thromboxane, which
under normal circumstances binds platelets molecules together to repair
damaged blood vessels hence affects the clotting process.

Epileptic Seizures
Themes assessed
Epileptic fit
Management of Epilepsy
NICE guidelines for referral to hospital in case of Epileptic Fit

Opening statement
You are just about to start your dental treatment and switch on the
light pointing towards the patients eyes. There is startling reflex and
the patient starts a fit on the chair.

Core Questions
1) What do you think is happening?
Epilepsy fit
Sudden onset of irregular uncontrolled surge of electrical activity in the brain
2) What are the clinical signs of an Epileptic Fit?
-There may be a brief warning of “aura”
-Sudden loss of consciousness, the patient becomes rigid, falls, gives a cry and
becomes cyanosed (tonic phase)
-After a few seconds, there are jerking movements of the limbs; the tongue may
be bitten (clonic phase)
-There may be frothing from the mouth and urinary incontinence
-The seizure typically lasts a few minutes; the patient may then become floppy
but remain unconscious
-After a variable time the patient regains consciousness but may remain
confused
*Fitting may be a presenting sign of Hypoglycaemia and should be considered in
all patients, especially known diabetics and children. An early blood glucose
measurement is essential in all actively fitting patients (including known
epileptics).
*Check for the presence of a very slow heart rate (<40 per minute) which may
drop the blood pressure. This is usually caused by a vasovagal episode. The drop
in blood pressure may cause cerebral hypoxia and give rise to a brief fit.
3) What are the aetiological factors to start the fit?
-PATIENT FAILING TO COMPLY with THEIR MEDICATION REGIMEN;
-Recent changes in medication;
-Recreational drug use;
-Poorly controlled epilepsy;
-Concurrent infection or illness;
-Menstruation;
-Fasting;
-Sleep deprivation;
4) How will you manage this patient?
-Ensure the patient is not at risk
-Give Oxygen 10L per minute (high flow Oxygen)
-Do not attempt to restrain convulsive movements
-After movements have subsided, place the patient in the recovery position and
REASSESS
-Remains unresponsive? Check for signs of life (ABC approach)
-CPR in absence of signs of life- ignore occasional gasps
-Check blood glucose levels
-Reassurance and sympathy (post ictal phase)
-Send patient: HOME- when fully recovered with an Escort (patient cannot drive
even if he feels safe to do so)
HOSPITAL- STATUS EPILEPTICUS
-HIGH RISK OF RECURRENCE
-1ST EPISODE
-DIFFICULTY MONITORING THE INDIVIDUAL
CONDITIONS
-If the seizure does not stop within normal fitting time or arbitrary time
of 5 minutes or recur in quick succession:
-CALL 999
-Give Midazolam buccally or intranasally in single dose of 10mg for adults > than
10 years old/ 7.5mg for 5-10 years old and 5mg for 1-5 years old (the first effects
of Midazolam should be seen after 5-10 minutes of administration)
-Give Oxygen 10L per minute
-Monitor Vital Signs
-Be prepared for BLS
*The brand name for buccal Midazolam is Epistatus
5) What are the types of epileptic seizures?
-Grand mal or tonic-clonic seizures
-Petit mal (transient seizures)
-Status Epilepticus (continued repeated attacks with little or no time interval
between that do not subside naturally, patient can become hypoxic and progress
to cardiac arrest.

*What is an epileptic seizure (why does it happen)?


Epileptic seizures are convulsive events that result from abnormal
involuntary neuronal discharges in the cerebral cortex of the brain.
*What is the mode of action of Midazolam (benzodiazepines)?
Benzodiazepines inhibit the activity of the neurotransmitter GAMMA
AMINOBUTYRIC ACID decreasing Central Nervous System Activity. An
overdosage can lead to respiratory depression.

Choking
Treatment of choking
-Ask the person if he is choking
-If the person is able to answer and breathe he is not choking completely
-Encourage the person to cough and provide no active treatment
-If the person is not able to answer or breathe, clutches his neck with hand, and
then ask patient to bend forward, support the chest with one hand, and give 5
slaps with the palm of the other hand between shoulder blades.
-Look if the object is dislodged, if not perform Heimlich manoeuvre (abdominal
thrust)
-Repeat until the object is dislodged or the patient becomes unconscious
-If unconscious CALL 999 and perform BLS
-If object is dislodged, refer patient to the hospital for assessment of internal
injuries.