page48
Management
During a convulsion try to ensure that the patient is not
at risk from injury but make no attempt to put anything
in the mouth or between the teeth (in mistaken belief
that this will protect the tongue).
Give oxygen (section
3.6) to support respiration if necessary.
Do not attempt to restrain convulsive movements.
After convulsive movements have subsided place the
patient in the coma (recovery) position and check the
airway.
After the convulsion the patient may be confused (‘post-
ictal
confusion’)
and may need reassurance and sym-
pathy.
The patient should not be sent home until
fully
recovered. Seek medical attention or transfer the patient
to hospital if it was the first episode of epilepsy, or if the
convulsion was atypical,
prolonged (or repeated),
or if
injury occurred.
Medication should only be given if convulsive seizures
are prolonged (convulsive movements lasting 5 minutes
or longer) or repeated rapidly.
Either midazolam buccal liquid or midazolam injection
solution can be given by the buccal
route [unlicensed
use] in a single dose of 10 mg. For further details on the
management
of
status epilepticus,
including details of
paediatric doses of midazolam, see p.
296.
Focal seizures similarly need very little active manage-
ment
(in an automatism only a minimum amount
of
restraint should be applied to prevent injury). Again, the
patient should be observed until post-ictal confusion has
completely resolved.
Hypoglycaemia
Insulin-treated diabetic patients
attending for
dental
treatment under local
anaesthesia should inject insulin
and eat meals as normal.
If
food is omitted the blood
glucose will
fall
to an abnormally low level
(hypoglyc-
aemia).
Patients
can often recognise the symptoms
themselves and this state responds to sugar in water
or a few lumps of
sugar.
Children may not have such
prominent changes but may appear unduly lethargic.
Symptoms and signs
.
Shaking and trembling
.
Sweating
.
‘Pins and needles’
in lips and tongue
.
Hunger
.
Palpitation
.
Headache (occasionally)
.
Double vision
.
Difficulty in concentration
.
Slurring of speech
.
Confusion
.
Change of behaviour; truculence
.
Convulsions
.
Unconsciousness
Management
Initially glucose 10–20 g is given by mouth either
in
liquid form or
as
granulated sugar
or
sugar
lumps.
Approximately 10 g of
glucose is available from non-
diet
versions of
Lucozade
c
Energy Original
55 mL,
Coca-Cola
c
100 mL,
Ribena
c
Blackcurrant
18 mL (to
be diluted),
2 teaspoons sugar,
and also from 3 sugar
lumps
1
.
If
necessary this may be repeated in 10–15
minutes.
If glucose cannot be given by mouth,
if it is ineffective,
or if the hypoglycaemia causes unconsciousness, gluca-
gon 1 mg (1 unit) should be given by intramuscular (or
subcutaneous)
injection;
a child under
8 years or
of
body-weight
under
25 kg should be given 500 micr-
ograms.
Once the patient
regains consciousness oral
glucose should be administered as above. If glucagon is
ineffective or
contra-indicated,
the patient
should be
transferred urgently to hospital.
The patient must also
be admitted to hospital if hypoglycaemia is caused by an
oral antidiabetic drug.
Syncope
Insufficient blood supply to the brain results in loss of
consciousness.
The commonest
cause is a vasovagal
attack or simple faint (syncope) due to emotional stress.
Symptoms and signs
.
Patient feels faint
.
Low blood pressure
.
Pallor and sweating
.
Yawning and slow pulse
.
Nausea and vomiting
.
Dilated pupils
.
Muscular twitching
Management
.
Lay the patient as flat as is reasonably comfortable
and,
in the absence of
associated breathlessness,
raise the legs to improve cerebral circulation
.
Loosen any tight clothing around the neck
.
Once consciousness is regained, give sugar in water
or a cup of sweet tea
Other possible causes
Postural
hypotension can be a consequence of
rising
abruptly or of standing upright for too long;
antihyper-
tensive drugs predispose to this.
When rising,
suscep-
tible patients should take their time.
Management is as
for a vasovagal attack.
Under stressful circumstances, some patients hyperven-
tilate. This gives rise to feelings of faintness but does not
usually result in syncope.
In most cases reassurance is
all that is necessary; rebreathing from cupped hands or a
bag may be helpful but calls for careful supervision.
Adrenal insufficiency or arrhythmias are other possible
causes of syncope,
see p.
26 and p.
29.
Medical problems in dental practice
Individuals presenting at
the dental
surgery may also
suffer from an unrelated medical
condition;
this may
require modification to the management of their dental
condition. If the patient has systemic disease or is taking
other medication, the matter may need to be discussed
with the patient’s general
practitioner or hospital
con-
sultant.
For
advice
on
adrenal
insufficiency,
anaphylaxis,
asthma,
cardiac emergencies,
epileptic seizures,
hypo-
glycaemia and syncope see under Medical Emergencies
in Dental Practice.
1.
Proprietary products
of
quick-acting carbohydrate (e.g.
GlucoGel
c
,
Dextrogel
c
,
Hypo-Fit
c
)
are
available
on
prescription for
the patient
to keep to hand in case of
hypoglycaemia
28
Prescribing in dental practice
BNF 61
Prescribing in dental practice