Medical Emergencies
Anaphylaxis
This page discusses Anaphylaxis, a rare but potentially life-threatening condition, and one that can usually be readily managed by a prepared dental team should a patient have an attack at the dental surgery.
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The video provides essential guidance on recognising and responding to life-threatening allergic reactions. It emphasises the importance of the "Think ABC" approach, which stands for Airway, Breathing, and Circulation, when assessing a patient experiencing severe allergies.
Initially, the video outlines potential symptoms of a severe allergic reaction. It highlights airway obstruction indicators, such as hoarseness, a swollen tongue, and itching or swelling in the throat. Breathing difficulties may manifest as shortness of breath, wheezing, noisy respiratory sounds, a feeling of fatigue, or cyanosis around the mouth. Furthermore, signs of circulation impairment are discussed, including pale or clammy skin, a rapid or weak pulse, and symptoms such as confusion or agitation.
The video stresses the urgency of identifying whether the patient has encountered an allergen. If there are visible signs, like eaten food or contact with known allergens, this reinforces the need for immediate emergency treatment. The primary action recommended for managing an allergic reaction is the use of an adrenaline auto-injector. It is essential for allergy patients to have multiple injectors available for emergencies.
Finally, the video underscores that patients must always seek hospital care after administering an adrenaline injection, as ongoing monitoring is very important for at least six hours following the incident. This guidance aims to equip dental professionals with the knowledge to swiftly handle a potentially life-threatening allergic reaction in their practice.
If you prefer to view this page as didactic information, rather than as a self assessment, click the arrow below.
Didactic Information:
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Anaphylaxis is a severe allergic reaction. It is life-threatening, and associated with breathing and/or circulatory problems.
In dentistry it can be triggered by administration of a drug (e.g. penicillin). The drug itself may cause the reaction, or it may be due to additives in the medicine. It can also be caused by contact with latex in rubber dam, gloves, or (dissolved off) the bungs in some local anaesthetic cartridges.
Signs & Symptoms
There is a wide range of presenting symptoms that can make it difficult to diagnose. These may include:
Urticaria (raised areas of skin due to oedema), Erythema (red rash), Runny nose, inflamed eyes.
Difficulty breathing, wheezing, hoarse voice. Repeated coughing.
Patient may be pale and clammy, confused, or have a strong sense of doom.
Low blood pressure (caused by vasodilation), which may lead to collapse.
Respiratory arrest. Cardiac Arrest.
Precautions
Note if the patient has known allergies or sensitivities, or asthma. These patients may be more likely to have an anaphylactic episode.
If the patient has an epi-pen for self administration of adrenaline, ensure they bring it to the surgery.
Ensure the emergency drug kit contains Salbutamol aerosol inhaler (100 micrograms / actuation), and Adrenaline Injection 1:1000.
Ensure that emergency oxygen is available.
Management
Lay the patient flat, raise the feet.
Oxygen – 15 litres / minute.
Call an ambulance.
For mild anaphylaxis, wheezing and mild breathing difficulties can be treated with a Salbutamol Inhaler.
For more severe reactions, i.e. when there are major breathing or circulation difficulties, give intra-muscular Adrenaline (Adults: 0.5 ml Adrenaline Injection 1:1000) in the middle third of the antero-lateral aspect of the thigh. This can be repeated at 5 minute intervals depending on improvement in circulation and respiratory function.
Children under 6 years should be given 0.15 ml. 6-12 years should receive 0.3ml.
If the patient becomes unconscious, in the absence of Signs Of Life or normal breathing, start CPR.
Aftercare
All patients who suffer an anaphylactic reaction should be sent to hospital, irrespective of their initial recovery, as second-line drugs may be needed, such as steroids and anti-histamines (these will be carried by the ambulance).
For example, if the reaction is caused by a drug, the drug may still be present in the body after the adrenaline has worn off, precipitating a further episode. Steroids have a long half-life, which is why they are often given as a second-line treatment.
Self Assessment
What is anaphylaxis?
How can anaphylaxis be triggered in the dental surgery?
What are the signs and symptoms of anaphylaxis?
What precautions can be taken by the dental team?
How would you manage a mild anaphylactic episode? And a severe one?
Why should patients always be sent to hospital, even if they appear to have fully recovered?
Epi-pen Injection
Anaphylaxis can occur outside the surgery, for example if people have an allergy to nuts, or wasp stings. Many allergic people carry an epi-pen: this video shows how to use it to treat an anaphylaxis.
EpiPen 0.3mg auto-injector devices' shelf life is 24 months. The shelf life for EpiPen 0.15mg auto-injector devices is 19 months from the date of manufacture.
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In this video, viewers are guided through the process of administering an EpiPen to someone experiencing a severe allergic reaction. The instructions emphasise the importance of first obtaining the prescribed EpiPen before proceeding with the administration.
To begin, the video instructs users to remove the safety cap from the EpiPen and then to hold the device in their fist without touching either end. Positioning is very important; the EpiPen should be pressed firmly against the side of the person’s thigh, whether through clothing or against bare skin. It is important to hold the EpiPen in place for a full 10 seconds to ensure proper delivery of the medication.
After administering the EpiPen, users are advised to remove it by pulling straight out and to rub the injection site for about 15 seconds. The video highlights the significance of noting the time of the injection and disposing of the used EpiPen in a Sharps container for safety.
The video reassures viewers that the EpiPen typically takes effect within 15 seconds to a few minutes. However, it also emphasises the necessity of being prepared to administer a second dose if the initial dose is inadequate. Finally, it is very important to call for emergency assistance following the administration of the EpiPen to ensure further medical support for the individual in distress.
Emerade Auto Injector
An alternative to the Epi-pen. Shelf life is 30 months.
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The video discusses the Emerade, a new type of auto-injector that has recently been released in the UK. It is designed specifically for administering adrenaline to patients experiencing severe allergic reactions. The Emerade features a longer needle to ensure proper delivery of the drug as well as higher dosage options of 150, 300, and 500 micrograms. It also boasts a 30-month shelf life and does not have an upper temperature limit for storage, making it more convenient than other auto-injectors that can freeze.
To use the Emerade, the user must remove the cap and hold the injector in their hand, pressing it against the outer thigh for five seconds to release the medication. Unlike some other auto-injectors that require a 10-second press, this one is designed for a shorter duration. Following the injection, the area should be rubbed to ensure the adrenaline is properly distributed, and emergency services should still be contacted in case of severe reactions.
The development of the Emerade aligns with the UK Resuscitation Council guidelines, which recommend a 500 microgram dosage of adrenaline for most patients over the age of 12. This is significant because many available auto-injectors only offer lower doses, which may not be sufficient for most adults. The Emerade’s 25-millimetre needle length is longer than many existing auto-injectors, thus increasing the likelihood that the medication is delivered intramuscularly to patients.
Overall, the Emerade offers several improvements over existing auto-injectors, including higher dosage options and a longer needle, which together ensure that more patients receive effective treatment for anaphylaxis.