Medical Emergency

Question 1

ABCDE

Answer 1

Airway

Breathing

Circulation

Disability

Exposure

Question 2

ABCDE Startegy

Answer 2

assess each, perform to fix, then move on

complete and treat as you meet

continualy reassess

trends are key - see how pt is behaving and responding

Question 3

Airway

Answer 3

cause of airway obstruction?

• loss of consciousness
• infection
• inflammation
• swelling
• dental infection, cotton wool roll, sedation increases risk

Recognition

• talking
• sounds
• look

Tx

• head tilt
• chin lift
• jaw thrust
• adjuncts

Question 4

aid for triple maneuverer

Answer 4

head tilt with chin lift or jaw thrust

Involves you holding their head – hence oropharyngeal airways

• Orange – size 3 – adult male
• Green – size 2 – adult female

Size by end by angle of mandible and bite block under flange should be vertical height of upper incisors

Question 5

breathing

Answer 5

causes

• demand
• infection
• inflammation

recognition

• rate
• look
• listen
• feel

treatment

• posture
• oxygen
• bronchodilators

Question 6

breathing sensitivity

Answer 6

Changes immediately – sensitive indicator for physiology

• Inc rate is physiological normal response to stress and demand

Respiratory rate – feel chest movement, tell them your doing something else

Look for chest expansion

• see symmetrical hands on chest

Look at their colour

• as o2 saturation fall, discolouration of fingers and lips 82%, tongue pale 60%

Tripod position – hanging over things, open up help breathe

Question 7

circulation

Answer 7

causes

• arrhythmia
• ACS
• HF
• loss of fluids and bloods

recognition

• pulse check
• capillary refill
• limb temp

treatment

• treat cause
• elevate legs
• apply pressure

Question 8

how to check circulation

Answer 8

Press on nail bed, reprofuse in under 2 secs is normal

Pulse – wrist (easy to access)

60 to 90 normal

Question 9

bradycardia

Answer 9

less than 40 resting heart rate

normal physiological for athlete, rest sick (failing organs etc)

Question 10

rhythm check

Answer 10

regularity of pulse, want normal sinus rhythm not arrhythmia

Fast arrhythmia – atrial fibrillation

Question 11

normal rate but irregular rhythm

Answer 11

ectopic beats

if all well then ok

Question 12

temperature range to know

Answer 12

Normally warm – highest is 37.8

If unwell – then 37.8 is lowest

Question 13

how to take BP

Answer 13

By taking pulse – can palpate easily then lowest is 100 odd (100+ is adequate to perfuse all vital organs)

If unable to feel easily – BP dropped to 70mmHg or below then move up to brachial then if not below 60

Then neck then 50

Wrist is adequate BP

Question 14

disability

Answer 14

causes

• drugs
• brain injury
• hypoglycaemia

recognition

• ACVPU/GCS
  
  • first section of Glasgow Coma Scale
    
    • alert
    • confused (new confusion unless otherwise known)
    • verbal response
    • pressure - press on trapezius and see if respond normally - knock away/move away but if abnormal (e.g. expand) alert
    • unresponsive
      
      • not the same as unconcious

treatment

• optimise ABC

Question 15

how to assess disability

Answer 15

Check pupillary response – light goes away see if they do, same at same time and equal

Check motor response – squeeze your hand, can they lift leg

Go through ACVPU

• Alert
• Confused (new confusion unless otherwise known)
• Verbal response
• Pressure – press on trapezius and see if respond normally – knock away or move away but if abnormal (e.g.expand) alert
• Unresponsive
  
  • Not the same as unconscious

Question 16

exposure

Answer 16

limited in dental setting

look for clinically relevant information

• See eye – whites clear?
• Colour of face
• Neck – trachea in midline, congested veins
• Swollen ankles
• Spoiled themselves?

Then REASSESS

• See if any changes and think why? Are they behaving as expected? Are they deteriorating?

Question 17

important thing to do when doing ABCDE assessment

Answer 17

keep differentials open

think of what category problem falls in rather than dx

Question 18

emegency conditions

Answer 18

• Anaphylaxis
• Angina/MI
• Asthma
• Cardiac arrest
• Choking
• Hypoglycaemia
• Seizure/fits
• Syncope

Question 19

oxygen

Answer 19

• 1.5l via a non rebreathing mask
  
  • Tight seal
  • Delivers 90% O2 – never 100% as never able to get a proper seal
• GDC advice – give to anyone who is sick
• 25mins worth of O2 from tank

Question 20

anaphylaxis ABCDE

Answer 20

A – swelling, stridor

• Lips, tongue
• Sound hoarse – lower down swelling, concern

B - increased rate, wheeze (due to bronchospasm)

• Follow bell curve of unwell people

C – inc rate, hypotension

• Heart rate inc as struggling to perfuse organs
• Bronchoconstricted so gas exchange not happening so more inc rate
• As vasodilated
• Vasculature becomes leaky - swelling

D – LOC

E – rash, swelling

• 80% swelling and rash, 20% don’t – typically young women
• Gut disturbance – cramps, vomiting, diarrhoea, reactions to food
• Clinically more likely reaction to drug

Question 21

anaphylaxis when to tx

Answer 21

ABCDE, happening right now -> adrenaline

See any airway involvement -> adrenaline (hoarse, tongue or lip swelling)

breathing - peripheral cyanosis -> adrenaline

Brachial pulse not there (circulation) -> adrenaline

Rather give one inappropriate dose of adrenaline rather than one non-inappropriate

Question 22

side effects of adrenaline

Answer 22

Tremor

Heart rate inc

Resp rate inc

No mortality

Question 23

key tx steps for anaphylaxis

Answer 23

Legs above their head – 350ml of blood to central cavity

• Adrenaline peripheral constrictor so if more blood in central cavity works better

Preload reduce, ventricles don’t fill up so risk of cardiac arrest if stand up (postural change)

NEVER GET THEM TO STAND

If still unwell after 5 mins, give every 5 mins

But vary sites

Question 24

how to inject adrenaline

Answer 24

Z track technique

Tension on muscle pull skin, place needle, aspirate, no blood advance another mm, inject

Once deposited, withdraw half, release tension, then fully out

Question 25

adrenaline dose

Answer 25

Adult dose 0.5mg 1:1000 * Epipens – only 0.3mg as non clinical person giving it We have 2 doses – take half at a time

Question 26

key action points of adernaline

Answer 26

Peripheral vasoconstrictor Central vasodilator – more blood to brain Relive bronchospasm relax smooth muscle Relive swelling

Question 27

ABCDE angina and MI

Answer 27

A -talking B – increased C – increased D – alert E – pale, clammy, central chest pain

Question 28

stable angina Vs unstable and acute coronary syndromes

Answer 28

Plaques in coronary artery blocks 1/3 or more than on exersion blood not able to flow freely enough, chest pain, Rest to alleviate – stable angina, not acute Acute coronary syndrome 3 things * rupture so larger blockage * Inflammation causes artery to constrict * Thrombis formation Rest doesn’t alleviate

Question 29

tx angina and MI

Answer 29

Time is muscle, need early decision and ambulance GTN spray, 400micrograms per dose, 2 puffs under tongue (easy into circulation) * Vasodilator * Venous only not arteries * Reduce preload, reduce strain on heart * Pain relief – not tx * Take pulse * Need satisfactory BP before giving Aspirin 300milligrams crushed or chewed if MI * Don’t swallow * Needs absorbed in oral mucosa – don’t want it diluted * Wait 10 mins before water * Edentulous – crush between 2 spoons * Slows down platelet aggregation

Question 30

ABCDE asthma

Answer 30

A – difficult B – inc rate with wheeze C – inc rate D – alert E - tripods

Question 31

mild/moderate asthma Vs acute/severe asthma

Answer 31

Mild/moderate – normal HR and resp rate but some chest tightness Acute/severe – resp rate 25 breaths/min or more, HR 120bpm or more Life threatening – heart rate 140 or below, resp 8 or below and ??? Change tx depending on which one Cannot complete sentence – straight to hospital big concern

Question 32

tx asthma

Answer 32

Cannot complete sentence – straight to hospital big concern Tx * Salbutamol 100micrograms per actuation * Spacer device when appropriate Breathe in hold breath for 10 secs If no improvement – HR increasing, use spacer – 10 times into it, allow them to breath into into 20 secs no more, anymore breath in their own CO2 – bad *Bronchoconstrictor so BVM goes into stomach, risk of contents going into lungs – need intubated*

Question 33

tx choking

Answer 33

"Can you cough?" If yes, able to breathe If cannot breathe in – 5 back blows, then 5 ab thrusts *If unable to ab thrust – chest compressions – gets higher airway pressure, more success*

Question 34

hypoglycaemia ABCDE

Answer 34

A – initially talking B – initially inc rate C- initially increased rate D – initially alert E – irritable, confused, pulse * Type 1 diabetics tend to* * Not normal people as able to control blood glucose*

Question 35

hypoglycaemia Tx

Answer 35

Glucose of any description * 3 sweets in emergency bag = 20mg Glucagon 1milligram IM injection * If unconscious * Pierce vile, gently roll to combine, draw and inject with Z track technique * Then give sugar – if not will relapse into hypo

Question 36

seizure/fits ABCDE

Answer 36

A – compromised B - ? C - ? D – unresponsive E – seizure activity, incontinence

Question 37

Tx seizure/fits

Answer 37

* Ensure safe environment * If repeated or prolonged consider Midazolam 10milligrams via the buccal mucosa * Resp depression * Hypotension * Unpredictable drug

Question 38

syncope ABCDE

Answer 38

A – compromised B – reduced rate C – reduced rate and pressure D – unresponsive E – pale, clammy * Mainly young females* * Vagal nerve – breaks heart rate, if severed 300bpm*

Question 39

Tx syncope

Answer 39

elevated legs