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Symptoms and signs
.
Paraesthesia,
flushing,
and swelling of face
.
Generalised itching,
especially of hands and feet
.
Bronchospasm and laryngospasm (with wheezing
and difficulty in breathing)
.
Rapid weak pulse together with fall
in blood pres-
sure and pallor; finally cardiac arrest
Management
First-line
treatment
includes
securing
the
airway,
restoration of
blood pressure (laying the patient
flat
and raising the feet,
or
in the recovery position if
unconscious or nauseous and at risk of vomiting),
and
administration of
adrenaline (epinephrine)
injection
(section 3.4.3).
This
is
given intramuscularly in a
dose of 500 micrograms (0.5 mL adrenaline injection 1
in 1000);
a dose of 300 micrograms (0.3 mL adrenaline
injection 1 in 1000) may be appropriate for
immediate
self-administration
. The dose is repeated if necessary at
5-minute intervals according to blood pressure,
pulse,
and respiratory function. Oxygen administration is also
of primary importance (see section 3.6).
Arrangements
should be made to transfer
the patient
to hospital
urgently.
For further details on the management of
anaphy-
laxis including details of paediatric doses of adrena-
line,
see p.
197
Asthma
Patients with asthma may have an attack while at the
dental
surgery.
Most attacks will
respond to 2 puffs of
the patient’s short-acting beta
2
agonist inhaler such as
salbutamol
100 micrograms/puff;
further
puffs
are
required if
the patient does not respond rapidly.
If
the
patient is unable to use the inhaler effectively,
further
puffs should be given through a large-volume spacer
device (or, if not available, through a plastic or paper cup
with a hole in the bottom for the inhaler mouthpiece). If
the response remains unsatisfactory,
or if
further dete-
rioration occurs,
then the patient should be transferred
urgently to hospital.
Whilst
awaiting transfer,
oxygen
(section 3.6) should be given with salbutamol
5 mg or
terbutaline 10 mg by nebuliser; if a nebuliser is unavail-
able,
then 2–10 puffs of
salbutamol
100 micrograms/
metered inhalation should be given (preferably by a
large-volume spacer),
and repeated every 10–20 min-
utes if necessary. If asthma is part of a more generalised
anaphylactic reaction, an intramuscular injection of adr-
enaline (as detailed under Anaphylaxis above)
should
be given.
For a table describing the management of acute asthma,
see p.
173
Patients with severe chronic asthma or whose asthma
has deteriorated previously during a dental
procedure
may require an increase in their prophylactic medica-
tion before a dental procedure. This should be discussed
with the patient’s medical practitioner and may include
increasing the dose of inhaled or oral corticosteroid.
Cardiac emergencies
If there is a history of
angina
the patient will
probably
carry glyceryl trinitrate spray or tablets (or isosorbide
dinitrate tablets)
and should be allowed to use them.
Hospital
admission is not
necessary if
symptoms are
mild and resolve rapidly with the patient’s own medica-
tion.
See also Coronary Artery Disease on p.
29.
Arrhythmias
may lead to a sudden reduction in cardiac
output
with loss of
consciousness.
Medical
assistance
should be summoned.
For advice on pacemaker inter-
ference,
see also Pacemakers,
p.
29.
The pain of
myocardial
infarction
is similar to that of
angina but generally more severe and more prolonged.
For general advice see also Coronary Artery Disease on
p.
29
Symptoms and signs of myocardial infarction
.
Progressive onset
of
severe,
crushing pain across
front
of
chest;
pain
may
radiate
towards
the
shoulder and down arm,
or into neck and jaw
.
Skin becomes pale and clammy
.
Nausea and vomiting are common
.
Pulse may be weak and blood pressure may fall
.
Breathlessness
Initial management of myocardial infarction
Call
immediately for medical
assistance and an ambu-
lance,
as appropriate.
Allow the patient to rest in the position that feels most
comfortable;
in the presence of
breathlessness this is
likely to be
sitting position,
whereas
the
syncopal
patient should be laid flat;
often an intermediate posi-
tion (dictated by the patient) will
be most appropriate.
Oxygen may be administered (see section 3.6).
Sublingual glyceryl trinitrate may relieve pain. Intramus-
cular
injection of
drugs
should be avoided because
absorption may be too slow (particularly when cardiac
output is reduced) and pain relief
is inadequate.
Intra-
muscular injection also increases the risk of local bleed-
ing into the muscle if the patient is given a thrombolytic
drug.
Reassure the patient
as much as possible to relieve
further anxiety.
If
available,
aspirin in a single dose of
300 mg should be given. A note (to say that aspirin has
been given)
should be sent
with the patient
to the
hospital.
For further details on the initial
management
of myocardial infarction,
see p.
156.
If the patient collapses and loses consciousness attempt
standard resuscitation measures.
For an algorithm of
the procedure for cardiopulmonary resuscitation, see
inside back cover.
Epileptic seizures
Patients with epilepsy must continue with their normal
dosage of
anticonvulsant
drugs
when attending for
dental
treatment.
It
is
not
uncommon for
epileptic
patients not to volunteer the information that they are
epileptic but there should be little difficulty in recognis-
ing a tonic-clonic (grand mal) seizure.
Symptoms and signs
.
There may be a brief warning (but variable)
.
Sudden loss of consciousness, the patient becomes
rigid,
falls,
may give a cry,
and becomes cyanotic
(tonic phase)
.
After 30 seconds,
there are jerking movements of
the limbs;
the tongue may be bitten (clonic phase)
.
There may be frothing from mouth and urinary
incontinence
.
The seizure typically lasts a few minutes; the patient
may then become flaccid but remain unconscious.
After a variable time the patient regains conscious-
ness but may remain confused for a while
BNF 61
Prescribing in dental practice
27
Prescribing in dental practice