1-7

Themes assessed
Asthma Algorithm
Salbutamol mode of action

Opening statement

A 24 year old patient with known asthma is having an amalgam restoration

replaced 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 think is happening?

The patient is beginning to suffer an acute asthmatic attack.

2. What are the clinical signs of acute severe asthma?

1- Inability to complete sentences in one breath
2- Respiratory rate of >25/min
3- Tachycardia (heart rate >110/min)

3. How will you manage this patient?

1-Stop treatment and remove all instruments from the mouth
2-Sit the patient in most comfortable position
3-Reassure the patient
4- Give the patient their usual medication (salbutamol) from drug box 4- 6 activations via
a spacer
5- Oxygen 10L/min
6- Monitor vital sign

4. If they fail to respond to the initial treatment what do you do?

Repeated dose of salbutamol may be necessary every 10 minutes
Call the 999
Monitor vital signs

5. What are the clinical signs of life threatening asthma which you as a dentist could elicit?
1 Cyanosis (blue tinge to peripheries – fingers, lips)
2 Respiratory rate <8/min
3 Bradycardia (heart rate <50/min)
4 Exhaustion
 5 Confusion
6 Decreased conscious level Inability to complete full sentences

Supplemental questions

1. What is Salbutamol?
Short acting Beta-2 agonist.

How does it work?

On the airway - activation of the beta-2 receptors results in relaxation of the bronchial smooth
muscle resulting in bronchodilatation.
It has a rapid onset providing relief within 5-15 mins
Stabilizes the mast cells so decrease in production of chemical mediators
What are its adverse effects?
Tremor of extremities, palpitations and headache

2. What other acute medical condition can initially mimic an asthma attack?
Anaphylaxis
2 - 36
Themes assessed

1] Anaphylaxis Algorithm
2] Adrenaline mode of action and doses
3] IM injection technique

Opening statement

You have given an adult patient who needs antibiotics cover 3g of amoxicillin
orally and asked him to take a 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
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

What do you think caused the reaction?

The most likely trigger will be the oral antibiotic

2] What is your immediate management of the patient?

1 Call emergency services 999
2 Give 500mcg of adrenaline [0.5 ml of 1:1000 solution] intramuscularly
3 Administration of oxygen 10L/min
4 Aim to restore blood pressure by laying the patient flat and raising the legs
5 If patient is feeling breathless give salbutamol inhaler 4-6 activation with spacer devices
6 reassure the patient and monitor vital sign

3] Where would you inject the adrenaline?

LATERAL aspect of the thigh
Landmarks hand span from iliac crest or halfway from the knee to iliac crest

4] If candidate suggests deltoid ask why this site may not always be appropriate & why
choose the lateral thigh?
It offers easy access to large muscle and there are no major structures such as nerves or arteries
that can be accidentally damaged .bulk of muscles so easy and rapid absorption of drug given

4] Is anaphylaxis easy to diagnose

No there are a wide range of possible presentations making diagnosis difficult clinical
assessment helps make the diagnosis.

5] What other signs and symptoms may there be

1 Urticaria
2 Rhinitis
3 Conjunctivitis
4 Abdominal pain
5 Vomiting
6 Diarrohea
7 A sense of impending doom
8 Stridor
9 Wheeze
10 Oedema
11 Respiratory arrest leading to cardiac arrest
12 Uncompensatable hypovolaemia may also result in cardiac arrest

Supplemental questions
1] How does the adrenaline work?
ADRENALINE HAS TWO ACTIONS
1- ALPHA RECEPTOR ACTION ON SKELETAL MUSCLE CAUSING
VASOCONSTRICTION .THIS REDUCES OEDEMA AND ELEVATE BLOOD PRESSURE
2- BETA 1 ACTION - IS POSITIVE IONOTROPIC ACTION THIS INCRESES FORCE OF
CONTRACTION AND RATE OF CONTRACTION THUS INCREASING AFTER LOAD
AND CORRECTING HYPOVOLAEMIA AND HYPOTENSION
3- BETA 2 EFFECT ON BRONCHIAL SMOOTH MUSCLE WILL CAUSE
BRONCHODIALATATION WHICH WILL CORRECT DIFFICULTY IN BREATHING.
4- STABLIZES MAST CELL SO REDUCES RELEASE OF FURTHER HISTAMINE AND
OTHER CHEMICAL MEDIATORS
5-elevates glucose by increasing catalysis of glycogen in the liver.
6-boosts oxygen supply and glucose to the brain and muscles

2] What are the differences between a preloaded adrenaline syringe and an epipen / auto
injector?
An epipen contains a smaller dose of adrenaline – 330 mcg per dose compared to a pre-filled
adrenaline syringe where a higher dose of 500mcg can be given
ALSO EPIPEN OR ANAPEN ARE SELF INJECTABLE DEVICES TO USE BY COMMOMN
PEOPLE WHO ARE AT RISK.AND NOT RECOMMENDED TO KEEP IN MEDICAL
EMERGENCY KIT IN DENTAL PRACTICE
3] What are the adverse reactions associated with an adrenaline injection?

Palpitations, tachycardia, anxiety, headache, tremor and hypertension

3
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?

1 Premonitory Dizziness, Weakness
2 Pt Feels Light Headed And Faint
3 There Is Sweating, Cold Clammy Skin
4 Pallor
5 Pulse Initially slow And Weak Changing To Rapid And Full
6 Pt Might Be Confused

3] What are the causes for a faint?

1 Stress
2 Anxiety
3 Fear
4 Pain
5 Dehydration
6 Extremes Of Temperature
7 Starvation
8 Drug Effects And Interactions
9 Intravascular Injection Of La

4. How will you manage this patient?

1 Put The Pt In A Head Low Position With The Legs Raised(10 Degree Tilt To The Dental
Chair
 2 If Pregnant Lt Lateral Position As Laying Her Flat Causes Pressure On The Inferior Vena
cava By The Featus Further Reduces Venous Return
3 Maintain Airway; Monitor Pulse, Breathing, Consciousness
4. If Recovery Not Rapid(Few Minutes)Reconsider Diagnosis Supply Oxygen And Call
Emergency Services
5. Beware Of Possible Head Injury If The Pt Had A Fall

Supplemental questions

What is the pathos-physiology behind vasovagal syncope?

1.Vagal Stimulation Causes Bradycardia (Decrease Force And Rate Of Cardiac Contraction
Vaso: Pooling Of Blood In The Extremities And Reduced Venous Return( Which Occur Due To
Sudden Loss Of Peripheral Sympathetic Tone)
resulting into poor venous return  poor preload poor after load which is compounded by
bradychardia  hypotension as a result of hypovolaemia  reduced blood supply to brain 
reduced oxygen to brain  loss of consciousness.
4-20
Themes assessed

Acute adreno-0cortical 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. I will asses the airway breathing and I will check
the medical records for any mention of medical treatment history of syncope and then act
likewise. If AB is not working then the case will be diagnosed as cardiac arrest.
EXAMINER TO TELL CANDIDATE AT THIS POINT THAT PT IS ON
PREDNISOLONE 15mg FOR LAST 6 MONTHS

2] What are the clinical signs of acute adrenal-cortical?

Insufficiency?

1 Rapid Loss of Consciousness

2 Rapidly Falling Bp
3 Pallor
4 Irregular Weak And Rapid Pulse
5 Confusion
6 Shock like features

3] Why is it caused? Give etiological factors.

CAUSE IS ACUTE DEFFICIENCY OF GLUCOCORTICOSTEROIDS AND ALL OF
OTHERS ARE PREDISPOSING FACTORS

1 Iatrogenic( Surgical Or Drug Induced)

2 Stress/ Trauma
3 Infection
4 Pathological
4]. How will you manage this patient?

1 Call Emergency Services

2 Lay The Pt Flat On The Floor With Legs Raised
3 Give Oxygen
4 Maintain Airway And Monitor vital signs
5 Blood Glucose Estimation If Available
6 Wait For The Emergency Services To Arrive
7 Be prepared for BLS

Medical Emergencies In Dentistry(Rcuk2006) Does Not Include Steroids In The

management of this emergency by a dentist

Most Other Text Books Recommend

Hydrocortisone Im Immediately
Followed By The Above Steps
Dose: Adult > 12 Yrs 200 Mg

Supplemental questions

What is the patho physiology for the adrenal cortical insufficiency?

Cortisol enhances gluconeogenesis. Cortisol indirectly induces insulin secretion to

counterbalance hyperglycemia but also decreases insulin sensitivity.

To check and write down [ Ketan]

5-24
Themes assessed

Diagnosis of acute hypoglycemic coma

Management of a patient in your surgery for a hypoglycemic 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 hypoglycemic attack?

1 Pt Is Irritated, Confused, Disorientated

2 Person May Become Physically Or Verbally Aggressive
3 May Appear Drunk
4 Tremor And Shaking
5 Thirsty, Sweaty(Clammy)
6 May Have Parasthaesia And Visual Disturbances
7 Bounding Pulse & Headache

3. How will you manage this patient?

1. Stop the tx
2. Reassure the pt
3. Squeeze hypostop in the buccal sulcus
4. Monitor vital signs

4. If they fail to respond to the initial treatment what do you do?

1. Inject glucagons IM 1mg/ml

2. Monitor the pt’s vital signs
3. Pt should regain consciousness in 5-10min
4. Once conscious and able to swallow give high sugar containing drink and complex sugars
such as biscuit or bread
5. Stabilise the Rx
6. Call someone to accompany the pt home
7. inform pt’s GP and make notes
8. Identify predisposing factor and take precautions

Supplemental questions

1,RESPONSE TIME FOR GLUCAGON

ANS- 5-10MIN
2- PHYSIOLOGY OF ACTION OF GLUCAGON
ANS - GIVEN IN GUYTON
GLUCAGON IS ABSORBED IN BLOOD AND REACHES TO HEPATIC PARENCHYMA
CELLS THEN IT ACTIVATE ADENYLYL CYCLASE WHICH ACTIVATE CYCLIC AMP
IT ACTIVATE ENZYTME PROTIENE KINASE REGULATORY PROTINE WHICH FORM
PROTINE KINASE IT ACTIVATE PHOSPHORYLASE B KINASE WHICH CHANGES
PHOSPHORYLASE B INTO PHOSPHORYLASE A WHICH BREAKS GLYCOGEN INTO
GLUCOSE MONOPHOSPHATE AND IT CHANGES INTO GLUCOSE AFTER
DEPHOSPHORYLATION.

3- IN WHOM GLUCAGON WILL NOT ACT AND WHY

INDIVIDUAL WITH POOR DIET AND POOR BLOOD GLUCOSE LEVEL AND HEPATIC
DAMAGE E.G ANOREXIA NERVOSA,BULIMIA, MARATHON RUNNER, ATHLETE,CHRONIC
ALCOHOLIC, AND THOSE WHO ALREADY HAD ONE DOSE OF GLUCAGON

4 WHAT IS THE MOST RELIABE INDICATOR FOR LONG TERM MANAGEMENT IN

DIABETIC PATIENTS
ANS- HB1AC LEVEL TAKEN EVERY 3-4 MONTHS
6

7-45
Themes assessed

Acute angina attack

Management of Angina
Action and adverse reaction of GTN
Opening statement

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

Core Questions

1] What do you think is happening?

The patient is most probably experiencing Angina

2. What are the clinical signs of acute severe ANGINA

1 Crushing Retro-sternal Chest Pain

2 Breathlessness
3 Nausea And Faint
4 Pain Radiates To The Jaw ,Lt Shoulder And To The Back
5 Pulse Rate Increased
6 Pulse Is Weak And Irregular
7 There May Be Peripheral Cyanosis
8 Pt May Feel Thirsty, Sweaty, Anxious , Cold And Clammy

3. How will you manage this patient?

1 Assist And Support

2 Calm The Pt Down
3 Sit The Pt Up In The Most Comfortable Position For Him with His Back Supported
4 Spray 1-2 Doses Of GTN sublingual Spray And Ask The Pt To Keep mouth Closed If
Possible(1spray = 400micrograms)
5 Spray 1 Dose Onto A Tissue First To Ensure The Pump Is Primed
6 Administer O2
7 Monitor Vital Signs

4. If they fail to respond to the initial treatment what do you do?

If Angina Does Not Respond To Gtn And O2 is Strongly Suggestive Of Mi

If No Response In 5 Mins. Assume Mi

Supplemental questions

1. What is Glyceryl trinitrate?

How does it work?

GTN HAS NITRATES WHICH FORM NITRIC OXIDE WITH THE REACTION TO
 TISSUE THIOL GROUPS .THIS NITRIC OXIDE IS POTENT VASODILATER

ITS VASODILATATION ACTION CAUSES POOLING OF THE BLOOD IN THE

PERIPHERAL SYSTEM RESULTING INTO REDUCED BLOOD RETURN TO HEART
 REDUCED PRELOAD  REDUCED VENTICULER FILLING PRESSUER
REDUCED HEART WORK  REDUCED OXYGEN DEMAND

ALSO IT DILATE CORONARY ARTERIES SO ENHANCES BLOOD SUPPLY TO

HART MUSCULATURE  INCRESE OXYGEN SUPPLY
THUS THE MISMATCH OF OXYGEN SUPPLY AND DEMAND IS CORRECTED SO
THERE WILL NOT BE ANY MORE PRODUCTION OF ADENOSINE CHEMICAL AND
PAIN WILL REDUCE.

What are its sideeffects of GTN?

GTN Causes Headache Due To Dilatation Of Cerebral Vessels

2. What other acute medical condition can initially mimic an angina attack

Myocardial Infarct
PNUEMOTHOREX
PLUERACY
HYPERVENTILATION
EPIGASTRIC PAIN
MUSCLE PAIN

8
Themes assessed

Myocardial infarct
Treatment of Myocardial infarct 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 till 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 infarct?

1 As Per Angina
2 Pulse May Be Irregular, Difficult to Assess As Too Weak /Thready
3 Rapid Loss Of Consciousness
4 Ashen Skin Colour Rapidly Progressing To Cyanosis If Cardiac Function Is Poor

3] How will you manage this patient?

1 Check For Aspirin Allergy
2 Give Chewable Aspirin 300mg Once Only
3 Give O2
4 Call Emergency Services
5 Monitor Vital Signs And Prepare For BLS
6 Ask somebody to get AED
7 Nitrous Oxide/Oxygen May Be Helpful
8 Make A Note Of aspirin Administration And Inform The Paramedics

Supplemental questions

How does aspirin work?

Aspirin inhibits irreversibly production of thromboxane A2 and production of ADP in the

platelet thus it inhibits the aggregation of platelets and hence affects the clotting process.
9
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
patient’s eyes .There is startling reflex and the patient starts a fit on the chair

Core Questions

1] What do you think is happening?

Epilepsy
Sudden Onset Of Irregular Uncontrolled Surge Of Electrical Activity In The Brain

2. What are the clinical signs of epileptic fit

1 Aura Prior To Fit
2 Auditory Or Visual Disturbances Before Fit
3 Sometimes No Warning Signs Experienced
4 May Have Mild Transience’s Or Full Blown Tonic Clonic Seizures
5 Loss Of Consciousness
6 Post Ictal Drowsiness With Confusion Tremor And Shaking
7 Slow Recovery
8 Sometimes Incontinence
3] What are the etiological factors to start the fit?
1 Stress
2 Anxiety
3 Dehydration Starvation
4 Bright Or Flashing Lights
5 Extremes Of Temperature
6 Change of medication

4. How will you manage this patient?

1 Stop All Work In Case Of A Seizure

2 Make Sure The Surrounding Environment Is Safe For The Patient And The Staff. Protect
 From Injury Both Patient And Staff
3 Do Not Intervene, Let It Happen And Subside
4 Once The Fit Has Subsided Give Him Oxygen 10-15lts /Min (There Is Cerebral Hypoxia
Due To Fitting And If Oxygen Not Given Might Have A Fit Again)
5 Leave The Patient In The Chair Reclined At 30-40 Degree Under Supervision Until He
Recovers.
6 Most Of The Seizures Are Self Limiting And Require No Medical Intervention Other
Than Protecting The Pt From Injury.
7 Always Make Decent Noted Of The Episode
8 If seizure doesn’t stop within normal fitting time or arbitrary time of 5min,
9 Ask the accompanying person to administer normal drug by normal route OR
10 Midazolam Via Buccal Route In Single Dose Of 10mg For Adult >10yrs(5-10 Yrs – 7.5
Mg & 1-5 Yrs -5 Mg)
11 Give O2 and call 999
12 The First Effects Of Midazolam Will Start To Be Seen After Approximately 5 Minute
And Condition Controlled Within 10 Mins
13 Monitor Vital Signs ,Accompany The Patient Till Ambulance Arrives
14 Prepare For BLS
15 Urgent Shifting To The Hospital
16 THE BRAND NAME OF BUCCAL MIDAZOLE IS -EPISTATUS

4. What are the types of epileptic seizures?

1 Grand Mal Or Tonic Clonic Seizures

2 Petit Mal (Transient Seizures)
3 Status Epileptics (Continued Repeated Attacks With Little Or No Time Interval Between,
That Do Not Subside Naturally. Patient Can Become Hypoxic And Progress To Cardiac
Arrest

10
CHOKING

Treatment of choking
1. ask the person if he is choking
2. If the person is able to answer and breath he is not choking completely
3. encourage the person to cough and provide no active treatment
4. If the person is not able to answer or breath clutches hi neck with hand, then ask the pt to
bend forward, support the chest with one hand, give 5 back slaps with the palm of the
other hand between shoulder blades
5. Look if the object is dislodged, if not perform Heimlich manoeuvre
6. repeat until the object is dislodged or the pt becomes unconscious
7. If unconscious perform BLS and call 999
8. If object is dislodged, refer the pt to hospital for assessment of internal injuries