Statement: “Any patient can have a medical emergency during dental treatment”
Of course, everyone hopes it will never happen to them – but what if it does? Would you be prepared and able to cope – are your drugs and equipment in date and ready for use?
The Resuscitation Council UK publish a list of recommended equipment which includes both drugs and equipment. It is recommended that to accommodate the most common types of medical emergencies encountered in general dental practices, the following items should be kept:
Glyceryl trinitrate (GTN) spray (400micrograms/dose)
Salbutamol aerosol inhaler (100micrograms/actuation)
Adrenaline injection (1:1000, 1mg/ml)
Aspirin dispersible (300mg)
Glucagon injection 1mg
Oral glucose solution / tablets / gel / powder
Midazolam 5mg/ml or 10mg/ml (buccal or intranasal)
These drugs, with the exception of the oxygen, should be stored together in a secure, purpose made storage box – identified as such and care should be taken to ensure that all drugs are kept within the ‘use by’ dating.
Oxygen cylinders should be portable, to accommodate their use in any part of the building. Recommendations and opinions vary as to the cylinder size – in some cases ‘D’ with 340 gaseous litres is seen as adequate, whereas more latter thinking trends towards ‘E’ with 680 gaseous litres. In either case, enough oxygen should be available to allow for a minimum flow rate of 10 litres per minute for up to 30 minutes (300 g/litres). If an ‘E’ size cylinder is used, then it will require support in the form of a cylinder trolley. There are various styles available, differing only in cost and slight variation of construction.
It is vital to make sure enough gas is available and the oxygen does not run out during an emergency. Both these cylinder sizes require the use of a pressure reducing regulator with a pin index fitting. In an emergency situation, it is preferable to use a robust dialreg type. This enables the user to dial the percentage of flow, instead of the more common rotometer with flow knob, these can be prone to accidental damage, causing leakage. It is recommended that a spare cylinder is kept and that this equipment is checked on a regular basis to ensure it is ready for use at all times. The MHRA bulletin MDA/2003/016 – Medical gas regulators and flowmeters, aimed at staff responsible for servicing and replacement of gas regulators, states that a system should be in place for regular inspection and replacement of gas regulators in line with manufacturers instructions. These vary slightly from four to five years.
If spare oxygen cylinders are kept, then the storage area should be identified with a compressed gases sign.
Apart from the above, the minimum list of equipment recommended is:
Oxygen face mask & tubing
Basic set of oropharyngeal airways (sizes 1,2,3 and 4)
Pocket mask with oxygen port
Self-inflating bag and mask apparatus with oxygen reservoir and tubing (Staff should be appropriately trained to use this)
Variety of well fitting adult and child facemasks for attaching to self-inflating bag
Portable suction with appropriate suction catheters and tubing e.g. Yankauer suction tubes – adult and child
Single use sterile syringes and needles
‘Spacer’ device for inhaled bronchodilators
Automated blood glucose measurement device
NIBP / Pulse Oximeter
Automated External Defibrillator
With the exception of the last two items, all the above are relatively inexpensive items. Components such as the oxygen facemask/tubing, airways, pocket mask and self-inflating bag are all, nowadays, designated as single patient use items and come with a decent shelf life. All items should be latex free.
The AED is a different matter and the requirement to have one is a slightly contentious issue at the present time, mainly due to cost.
As a background to the use of AEDs, in July 1999 the Department of Health issued a white paper ‘Saving Lives: Our Healthier Nation’ with the intention to invest £1 million in installing AEDs in busy public places. They then committed a further £1 million to training for use and basic life support. As a result of this, AEDs have been installed in railway stations, airport, coach stations and ferry ports – approximately 110 locations to date with more than 6,000 volunteers trained in AED and Basic Life Support skills. The criteria being that an incident can be responded to within two minutes. This initiative is now widening to include public places such as shopping centres and theatres.
The Resuscitation Council UK in their “Medical Emergencies and Resuscitation” published July 2006 state ‘It is an expectation of the public that AEDs should be available in every healthcare environment and the dental surgery is not seen as an exception’.
The expectation is therefore, that dental surgeries should recognise the need and make provision for the equipment and recorded staff training. This would be viewed as a mandatory requirement for Continuing Professional Development.
AED USE AND SPECIFICATION
AEDs are expected to have recording facilities and standardised components such as self-adhesive electrode pads and cables. Adult pads can be used on children over 8 but most machines have dedicated paediatric pads or a mode that allows the use on children between 1-8 years old. This would be particularly applicable in practices that specialise in paediatric work. Obviously staff should be familiar with the device in use on their premises and its operation and this also raises the issue of cost – both for the initial purchase of the AED and training in its use.
The equipment specification for automated external defibrillators require that the unit must be totally reliable, simple to operate, of low weight, require little routine maintenance and be competitively priced. Recording facilities are considered essential for evaluation and audit. An additional ancillary kit containing spare electrodes, scissors, gloves, antiseptic wipes, gauze and a mask is also strongly recommended as it may be occasionally necessary to cut through clothing and/or shave a victim’s chest for electrode placement. The MHRA issued a document; ‘Comparative specification of Defibrillators’ MHRA 04119 in December 2004. This can be used to compare the varying types available although it does not give any pricing information. The AED unit should also preferably be housed in a bracket or a wall mounted storage case with strobe light alarm, depending on location.
European Guidelines for the use of AEDs state that the initial training in CPR/AED should be 6-8 hours with a 2 hour refresher course every 6 months, although the Department of Health has developed an initial four-hour training specification for the defibrillator programme. Training costs can start from £150.00 upwards and are available from a variety of sources – local NHS Trusts often offering this service.
There are basically two types of defibrillator – manual and automatic.
Manual defibrillators – used in hospitals and emergency centres for over 30 years. Usually include an ECG monitor and other facilities. Professional expertise is needed to interpret the heart rhythm and decide whether to charge the defibrillator and deliver the shock
Automated external defibrillators (AEDs) – semi-automatic units, safe, simple and lightweight with two pads that are applied to the patient. The defibrillator guides the operator step-by-step through a programme protocol. Records and analyses the heart rhythm and instructs the user to deliver the shock using clear voice prompts, reinforced by displayed messages. Anyone trained in the use of these devices and in basic life support will be able to safely and effectively use an AED.
AEDs come as either semi-automatic or fully automatic units. In the latter, once the pads have been placed, the unit analyses and delivers a shock – if required, without the user having to do anything further.
Both these units monitor the heart’s activity and give instructions to the user, containing a built-in failsafe computer software that analyses cardiac rhythm. They will not deliver an electric shock to a person whose heart does not require this treatment and will also detect the presence of a pacemaker. Only if a victim is in ventricular fibrillation (VS) will the machine allow a shock to be delivered. Speed is vital: the quicker the shock is given after the victim collapses, the great the chance of success. Currently 95% of people with cardiac arrest occurring in the community die. Once somebody has suffered a cardiac arrest, there are only a few minutes in which defibrillation is likely to succeed. Prompt use of Basic Life Support (BLS) will buy time for the defibrillator to be brought to the patient.
At the present time in the UK there are no statutory requirements for the placement of defibrillators or training for potential users of AEDs. The Department of Health is not a regulatory body in these matters. However, all indications are that the desirability for having one of these units in all public places and health centres – dental surgeries included, will continue to gather pace. Dentists will have to decide for themselves at the present time on whether this is a vital piece of equipment or not.
CARE AND MAINTENANCE
Once you have established your resuscitation equipment, it needs to be maintained. Responsibility for checking equipment rests with the individual dental practice and care should designated to a named individual. Frequency of checks depends on circumstances, but ideally should be made weekly with some form of record kept. It is quite likely that these records would be required during a practice audit.
As previously mentioned, most of the manual items have quite a good shelf life – 6 years in the case of products such as self-inflating bags and pocket masks. A planned replacement programme should be in place for equipment and drugs that are used or reach their expiry date.