Acute situations in dental practice - General and specific pathology in dentistry
Acute situations in dental practice
Fortunately, acute medical situations are not common in dental practice. If acute situations do arise, they can be associated with a disease that the patient suffers from. Sometimes the dental treatment itself is a causal factor.
To be able to estimate an acute situation immediately, it is important to have a current medical history of the patient within reach. The anamnesis is usually stored in the digital patient file. The name and telephone number of the general practitioner and the medical specialist are also noted here.
It is wise that someone is present in practice at all times with an emergency response certificate. BHV stands for company emergency services. Refresher courses must be taken once a year to keep the knowledge up to date. All other practice staff must be instructed so that they know what to do in the event of an emergency. There is often a practical protocol for acute medical situations.
Some practices have an AED, an automatic external defibrillator on the wall. An emergency case may also be present in practice (see image below).
Automatic external defibrillator (AED).
Loss of consciousness
Loss of consciousness can occur with:
- Vasovagal collapse (Fainting);
- Hypoglycaemia (Sugar deficiency in diabetic patients);
- Cardiac arrest
- Epileptic seizure.
Often the cause of the loss of consciousness is not immediately clear. Place the patient on his back on a flat surface and check his consciousness. If he does not respond to touch and your voice, you cry out loudly for help. The dentist or emergency response person will take over the patient from you. Stay close. Your help may be needed!
As has been noted in the case history, some patients know that they faint quickly. To prevent a patient from fainting or having a vasovagal collapse, a number of precautions are to be taken: loosening tight clothing, laying the patient flat, possibly reclining the chair and a calm manner of treatment are generally sufficient to prevent a collapse to avoid.
You can tell by the face of the patient when he threatens to faint. Drops of sweat appear on his forehead and upper lip. He turns pale and gets dark edges around his eyes. He also becomes restless. Then lay the patient flat and let him raise his legs. It is best to place the head lower than the body. It usually takes ten minutes for the patient to feel better again. Don't let him get up too quickly from the treatment chair. Ensure that the patient goes home under supervision.
With hyperventilation, the patient breathes too quickly or too deeply. He feels tingling in his hands and around the mouth and is anxious. Reassuring the patient usually has sufficient effect. After a while the treatment can be continued.
Chest pain is caused by lack of oxygen in the heart muscle. This is the case with angina or a heart attack.
- Angina pectoris is a narrowing of the coronary arteries of the heart muscle. Emotions or pain during dental treatment may cause the heart muscle to require more oxygen and the blood supply will then fall short. The patient has a pressure sensation in the middle of the chest. The pain can radiate to the left jaw corner and left arm. Treatment must be stopped. By melting a tablet of nitroglycerin under the tongue, the blood supply of the heart muscle is improved. Nitroglycerin causes the vessels to (temporarily) dilate.
- With a heart attack, a blood clot seals a coronary artery from the heart muscle. As a result, part of the heart muscle does not receive oxygen. The patient is pale and perspires. He has a pressing feeling in the middle of the chest. The pain can radiate to the left jaw corner and left arm. Treatment must be stopped. Because the symptoms can be about the same as with angina, the patient is usually given a tablet of nitroglycerin first. But with a heart attack, this medicine does not work and an ambulance must be alerted as soon as possible.
If the circulation suddenly stops, it is necessary to take immediate action. If the brain has to be without oxygen for four minutes or more, irreversible damage will occur. The oxygen supply via the brain is provided by two functions: blood circulation and breathing. If the blood no longer flows around, then we speak of a circulatory arrest. If the patient no longer breathes, there is a respiratory arrest or apnea.
Characteristics of a circulatory arrest are:
- Pulse no longer felt in the carotid arteries. These can be felt normally next to the larynx in the so-called trigonum caroticum.
- Unconsciousness. The patient is not approachable and does not respond to anything anymore.
- Apnea or respiratory arrest.
- Gray skin color and blue discoloration of fingers and nose.
In the event of a cardiac arrest, an ambulance must be alerted as soon as possible. Until the ambulance arrives, the circulation must be started again and maintained by applying external heart massage. Ventilation is also required.
External heart massage
The heart lies between the breastbone and the spine. When you press the sternum in the direction of the spine, you press the heart empty. This simulates the pumping action of the heart.
In order to properly simulate the pumping action by means of external heart massage, the patient must lie on his back on a hard surface; there is not enough pressure on the breastbone with a soft surface. Place the mouse of one hand in the center of the victim's chest. Place the mouse of the other hand on top of the first hand and hook the fingers together.
If the patient is lying on the floor, it is best to kneel as close as possible to the patient. That way you can use your own body weight to press the breastbone about five centimeters perpendicularly downwards. Because of the resilience of the chest, the breastbone naturally comes up again. The pace of the heart massage is around 100 to 120 compressions per minute.
After 30 heart massages, mouth-to-mouth breathing follows twice (see image below).
Mouth to mouth
Respiratory arrest is easier to detect than circulatory arrest. When a patient is not breathing, you will no longer see the chest moving up and down. Causes of respiratory arrest may include:
- Drug overdose
- Circulatory arrest
If the respiratory tract is blocked by choking or aspirating objects, first try to remove what is in the way. For people whose breathing is no longer functioning for other reasons, such as a circulatory arrest, breathing must be adopted. This can happen with mouth-to-mouth breathing.
First of all you check whether there are any objects in the mouth that can block the airway, for example a (partial) prosthesis that is no longer in place.
When someone is lying on their back, the tongue sinks backwards into the throat and the airway is closed. To clear the airway, tilt the head back and lift the chin. Pinch the nose with the thumb and forefinger of the hand lying on the forehead.
Places the lips around the victim's mouth and blows air into his lungs. Whether the air enters the lungs can be checked by seeing if the chest rises. It is important to check this because it is possible that air will get into the patient's stomach. After being blown in, the air will be automatically blown out again, the chest will drop again. If heart massage and mouth-to-mouth respiration are required at the same time, massage and ventilation must be performed in a 30: 2 ratio.
Continue CPR until the ambulance staff take over from you (see image below).
Mouth to mouth.
During dental treatments, materials or (parts of) teeth may end up in the pharynx. There is a risk that they end up in the windpipe (aspiration). They can be pieces of restoration material, but also dental instruments such as endo needles or drills. The obstacle in the airway must be removed as quickly as possible. As a reaction to choking, a reflex in the form of a coughing tune will occur. This has the effect that the clogging object is blown up. If the patient cannot cough the object himself, you give the victim five strokes between the shoulder blades. If hitting the back has no effect, you give abdominal punches, the maneuver of Heimlich. Put both arms around the patient's abdomen, fold the arms together and then pull the hands towards you in the stomach area of the patient with a powerful movement. Air that is still in the lungs is driven out with a powerful blow. With that, the object will probably also come out.
In the most extreme case, an emergency tracheotomy can be done. This means that a hole is made under the larynx in the neck between two cartilage rings of the windpipe. This allows the patient to breathe for the time being. An aspirated object does not have to close the airway. When an object ends up in the lungs, the patient must be referred to an ENT specialist. He can check whether the object is indeed in the lungs and take action on it (see image below).
A bronchial constriction narrows during an asthma attack. Incentives such as tobacco smoke can give cause for this. But effort and emotions also play a role.
During an attack, the patient starts breathing faster and howling. He is anxious and can lose consciousness. It is important to put the patient in a comfortable position (usually seated) and to have his medication taken. Patients with asthma usually have their own medication: "a puff".
In anaphylactic shock, a hypersensitivity reaction to administered drugs such as anesthesia fluid, glottis edema may occur in addition to an acute loss of consciousness. Glottis edema is the swelling of the glottis. If this swelling is severe, it may block the airway. The patient feels that his throat is being squeezed. In such a case, a physician must intervene with medication to reduce the swelling.
Patients with diabetes mellitus lack the normal regulation of blood sugar. Diabetic patients must take small meals several times a day to maintain their blood sugar levels. In addition, the patient may also give himself insulin by injection.
Hypoglycaemia occurs when the blood sugar level falls too far below a certain level. In fact, the patient should then eat something quickly. He suffers from a feeling of hunger and suddenly starts to sweat strongly. He can respond aggressively. Drowsiness can also occur, which changes into unconsciousness (coma).
The treatment of hypoglycaemia depends on the stage: if the patient is still conscious, it is best to give him a glass of sugar water. If unconsciousness has already occurred, a glucose solution will have to be administered intravenously.
The history must show whether a patient is suffering from seizures. When the patient has an attack, he must be placed in such a way that he cannot injure himself. Such an attack is not a pleasant sight, but no action needs to be taken to restore awareness to the patient. The attack usually lasts only a few minutes.