Introduction to ME3

Skills Stations

• 3 rooms (45 mins each)

• Skills taught:

  • Drugs

  • Assessing the sick patient

  • Airway

Skills Stations - Seminar

• 4 scenarios (-30 mins each)

• Rotate through, each room will have 2 different medical emergencies

• Each group has 4/5 students therefore everyone will get a practice scenario

Individual Test Moulage

• Same rooms as per scenario day

• Attend and have an assessment of a medical emergency

To complete this component you must:

• Have demonstrated BLS competency

• Attend the entire course

• Complete the CANVAS assessment

• Pass individual test moulage

Why do we have to do this?

• GDC requirement

• Resus council expectation

• Public and professional expectation

• Ethical duty

• Might appear in an OSCE

Incidence of Medical Emergencies

• Thankfully rare

• Majority occur in adult patients

• Paediatric medical emergencies are fast and without warning (child’s under-developed physiology coupled with small oxygen reserves)

Classification

• Infants are <1 years old

• Children are 1-12

• Adults are 12+

What is a Medical Emergency?

• Situation where a patient becomes “ill”, may become unconscious, and ultimately their life may be at risk

• Can be sudden onset (CVA, cardiac arrest)

• Can be slow and progressive

Team Effort

• Team leader or team member

• Recognise the problem and get help

• Assess and monitor the “sick” patient

• Get emergency drugs and equipment

• Assist patients to self-medicate

• Prepare emergency drugs for use

• Deal with airway obstruction/choking and cardiac arrest

• Liaise with paramedics

• Need a leader

Sequence of Events in a Medical Emergency

• Recognise a problem

• Get help

• Assess patient

• Interventions as necessary - oxygen, chair position, drugs, BLS, etc

• Monitor

• Transfer to paramedics

Physiology of Us

• Adequate oxygen entering the airway

  • All vital organs need oxygen

  • There must be sufficient oxygen entering the lungs

• Upper airway must be open

  • Problem in unconscious patients and choking patients

• Oxygen needs to be absorbed

  • Oxygen is absorbed into the blood via the lungs

  • Lower airway must be clear and open

  • Problem in asthma, anaphylaxis and hyperventilation

• Sufficient blood volume present

  • Sufficient blood volume must be present in the circulation to absorb the oxygen and transport it to vital organs

  • Problem in anaphylaxis and faints

• Pump power

  • The heart must be pumping properly

  • There must be sufficient blood pressure to circulate the blood

  • Problem is angina, MI, cardiac arrest, faints and anaphylaxis

• The brain has overall control

  • The brain is the greater user of oxygen

  • The nervous system must be functioning properly

  • Problem in CVA, hypo/hyperglycaemia and seizures

Summary: Four Fundamental Things

• Sufficient oxygen absorbed into the blood via the lungs

• Sufficient blood present to absorb the oxygen

• Sufficient pump power to circulate the oxygenated blood

• A functioning nervous system to control all of the above

What Happens in a “Medical Emergency”?

• There is a failure of one or more of the fundamental elements

• This will progress to a failure of all of them

• To treat we need to compensate for the failure, not necessarily diagnose the cause

• Using a systematic assessment method will help us to find the primary element affected

Identification of the Primary Failure

• Using a standardised ABCDE approach

• Note down all observations

• Re-assess each time an intervention is done

• Re-assess each time something changes

When Someone Starts to Feel Unwell

• In an emergency, stay calm

• Ensure that you and your staff are safe

• Look at the patient generally to see if they “look unwell”

• In a conscious patient ask, “How are you?”

• If they respond normally - they have a clear airway, are breathing and have brain perfusion with oxygen

ABCDE Assessment

• Is the first link in the chain of survival

• Treat the problems as we discover them and reassess regularly after each intervention to monitor a patient’s response to treatment

Airway Assessment and Management

• Are they able to speak to you?

• Look for signs of airway obstruction or swelling

• Listen for stridor/gurgling/snoring (partial airway obstructions)

• Look in mouth

Opening the Airway - Infants

• Aim for a neutral position

• Glabella and chin are horizontally aligned

Opening the Airway - Child

• Head tilt and chin lift - hand on forehead and two fingers under the mandible

• Jaw thrust

Opening the Airway - Adult

• Head tilt and chin lift - hand on forehead and two fingers under the mandible

• Jaw thrust

Airway Adjuncts

• Unconscious or low-conscious patients may need help to keep the airway open

• Oropharyngeal Airways (OPAs)

  • Incisors to the angle of the mandible

  • Suitable for unconscious patients with no gag reflex

  • 00 (babies) - 4 (adults)

  • Enter at 180 degrees until past the hard palate and then rotate into the correct position

    • In children, you can enter the correct way as they have larger soft palates than adults

• Nasopharyngeal Airways (NPAs)

  • Tip of nose to tragus of the ear

  • Suitable for conscious/unconscious patients with a gag reflex

    • Not suitable for patients with suspected head injuries or skull fractures

  • Enter with the bevel facing the septum, with the tube well lubricated (ensure lube isn’t over the end of the adjunct)

Oxygen

• Should always be given

• 15l/min

• Venturi mask also called a non-rebreathe mask

• If not breathing ventilate with a pocket mask or bag/valve mask 12 per min

Breathing

• Recognition of breathing problems ( for no longer than 10s)

• Look for respiratory distress, accessory muscles, cyanosis, respiratory rate (above 20 per min indicates a breathing problem) and chest deformity

• Listen for noisy breathing and breath sounds

• Feel for

  • Expansion, bilateral; equal

  • Pulse oximeter if available

Oxygen and Pulse Oximetry

• Pulse oximetry: simple, non-invasive tool, provides an instant measure of the arterial blood oxygen saturation

• Pulse oximeter probe is designed as a clip to be placed on the finger, having LEDs on one side and a photoreceptor on the opposite

• The amount of light transmitted through the tissue is used to calculate the oxygen levels in the blood

  • In cardiac arrest it’s not very reliable or accurate so we will deliver 100% oxygen

  • Does not mean there is adequate oxygen in the tissues

• Pulse oximetry results are not affected by anaemia, skin colour or jaundice

• Pulse oximetry inaccuracies can be the result of:

  • Haemoglobins such as those present in sickle cell disease

  • Carbon monoxide poisoning

  • Nail varnish

  • Motion artefact

  • Hypotension/vasoconstriction

Bag Valve Mask

• If a patient isn’t breathing on their own or has a reduced respiratory rate (<6 breaths per min)

• Used on its own or with oxygen (21% oxygen in air and 85% oxygen with high flow)

• 2-person technique - good seal and administration of air

  • Gentle squeezing of the bag with each breath lasting approximately one second

Pocket Mask

• Problems are airtight seal, additional oxygen and tiring

Circulation

• Count the patient’s pulse - rate, rhythm, both central and peripheral (radial)

• Measure capillary refill time (CRT). Apply cutaneous pressure for 5 seconds on the nailbed at heart level (or just above) with enough pressure to cause blanching. Time how long it takes for the skin to return to the colour of the surrounding skin after releasing the pressure. The normal refill time <2s. A prolonged time suggests poor peripheral perfusion.

• Look for signs of cyanosis: under the tongue, at the colour of their hands and fingers: are they blue, pink, pale or mottled?

• Are you able to measure blood pressure?

Treatment for Circulatory Problems

• IV fluids

• Chair position

• Drugs

Chair Position

• The instinct is to put the patient flat

• Will prevent and reverse limb pooling

• Will increase direct load on the heart

• Will cause BP to rise

• If patient is conscious then leave them alone unless fainting

• If unconscious then put flat for airway control

Disability

• Conscious level ACVPU

• Pupils (PEARL)

• Blood glucose

Make a rapid initial assessment of the patient’s consciousness level using ACVPU

• Alert

• Confused

• Responsive to Voice

• Responsive to Pain (squeeze trapezius muscle)

• Unresponsive

• Check blood glucose level (normal 4-6)

• We can also consider signs of neurological injury:

  • Stroke (FAST) - call 999

  • PEARL

• Place unconscious patients in the recovery position if their airway is not protected

• Hypoxia - administer oxygen

• Hypoperfusion - raise legs above the heart

Exposure

• Rashes, ankle oedema, wounds

• Avoid heat loss

• Respect the patient’s dignity and minimise heat loss

• This will allow you to see any rashes (e.g. anaphylaxis) or ankle oedema (heart failure)

• Other wounds?

Review of Sequence

Transfer to Paramedics

• 999 calls routed via a controller-specify emergency and “update” if necessary

• Documentation is very helpful - record of assessments, etc

• Good “handover” helps everyone

What Happens When You Phone an Ambulance?

Handover

Situation - “Hi I am…from…

Background - Patient X attended and…occurred…We have given….

Assessment - I think the problem is…

Recommendation - I need you to admit the patient…Is there anything we can do while awaiting paramedics?”

Emergency Drugs

• Patient may carry them (e.g. GTN, EpiPen, Salbutamol inhaler, etc)

• Practice will have an emergency drugs kit

• There are different routes of administration

Where do we get our Guidance From?

• GDC

• National INstitute for Health and Care Education

• Resuscitation Council UK

• Care Quality Commission

Minimum Equipment

• Adhesive defibrillator pads

• AED

• Clear face masks for self-inflating bag (sizes 0-4)

• OPA (sizes 0-4)

• Oxygen cylinder (CD size)

• Oxygen masks with reservoir

• Oxygen tubing

• Pocket mask with oxygen port

• Portable suction e.g. Yankauer

• Protective equipment - gloves, aprons, eye protection

• Razor

• Scissors

• Self-inflating bag with reservoir (adult and child)

Drugs

• GTN spray 400mcg per actuation

• Salbutamol inhaler 100mcg actuation

• Adrenaline (1:1000)

• Aspirin 300mg

• Glucagon injection 1mg

• Oral glucose

• Midazolam (buccal)10mg (conc 5mg/ml)

• Oxygen (size CD) cylinder lasts approx 30 mins

Drugs and the Law

• Under the Human Medicines Regulation 2012, legal status for all licensed medicines is determined by the MHRA

• All medicines marketed in the UK are classified according to one of the three following categories:

  • POM - available only on prescription

  • P - available under the supervision of a pharmacist

  • GSL - available in general retail outlets such as supermarkets

  • CD - all CDs are POM but with additional restrictions in place

Misuse of Drugs Act 1971

• Main purpose of the act is to prevent the misuse of controlled drugs

• The only drug in our kit that is a CD is Midazolam

• The law currently (Dec 2021) prevents dental therapists from administering a CD (even in the event of an emergency)

• Therapists can only administer midazolam under the direct instruction of a dentist or if following a PSD

Human Medicines Regulations 2012

• Permits dental hygienists and therapists to hold emergency drugs on their premises, but not to purchase the medicines directly

• A dental hygienist/therapist practice needs to ensure that they hold emergency drugs on-site

• Hygienist/therapist practices without an on-site dentist can obtain an emergency kit through a prescribing dentist or doctor under a PGD.

Quality Assurance Process

• At least every week, check:

  • Expiry date for emergency medicines

  • Equipment and availability of oxygen

  • The manufacturer’s instructions must be followed about the use, storage, servicing and expiry of equipment. A planned replacement programme should be in place for disposable equipment items that have been used or that reach their expiry date

Individual Medical Emergencies

Choking

• The Resuscitation Council provides us with algorithms on how to manage choking

Infant Choking

• Lay them face-down on the forearm with our hand supporting their mandible

• Give 5 back blows

• Turn over and do 5 chest thrusts with 2 index fingers

Faints/Syncope

• Also called syncope, vasovagal syncope or vasovagal attack

• 50% will experience at least once

• 3% recurrent episodes

Triggers

• Prolonged standing

• Prolonged exposure to heat

• Sudden extreme emotion

• Fasting and dehydration

• Stress and anxiety

• Painful or unpleasant stimuli

Physiology

• Trigger produces an effect on the brainstem

• Increases activity of parasympathetic nervous system

• Drop in heart rate and drop in BP

• Decreased activity in the sympathetic nervous system

• Dilation of blood vessels causing pooling in the limbs

• Reduced venous return causes a further drop in BP

• Cerebral hypoxia and loss of consciousness

Symptoms

• Hot and sweaty

• Pallor

• Auditory and visual disturbances

• Light-headed and dizzy

• Loss of consciousness

• Tonic clonic movements may occur

Management

• Place patient flat with legs elevated

• Give oxygen

• Reassure

• Slow return to upright position

• Pregnant women positioned on their side

Asthma

• 5.2 million sufferers in the UK

• 1200 deaths per year

• Patients usually have preventative medication and reliever medication

Physiology

Symptoms

• Difficulty breathing

• Coughing

• Expiratory wheeze

• Progresses to use of accessory muscles

• RR drops

• Loss of consciousness

Avoidance

• Be aware of allergens e.g. pollen

• Avoid excess exertion

• Reduce stress

• Weather has effect

• Pre-treatment use of inhaler

Treatment

• Stop any treatment

• Administer high-flow oxygen

• Administer patients/surgery’s rescue medications (salbutamol 100mug per actuation)

  • 2-10 puffs, each puff is to be inhaled separately, repeat every 10-20 mins

  • Same for adult and child

Hypoglycaemia

• Low blood sugar level (outside 4-6)

• Nervous tissue cannot store glucose therefore needs to access glucose in blood to function properly

• If sufficient glucose available fails to function

Signs and Symptoms

• Pallor, sweating, cold

• Irritable, irrational, confused, aggressive

• Loss of consciousness

• Coma

Avoidance

• Ensure all medication taken as normal

• Ask patient if control levels are good

• Assess blood glucose levels (monitor)

• Consider timings of appointments

Diabetes

• Type 1 - cannot produce insulin therefore must inject

• Type 2 - Cells are resistant to the effects of insulin, diet or tablet-controlled

Treatment

• Conscious - sugar, glucose drink, chocolate, coca cola

• Unconscious - glucagon IM 0.5-1mg

The Heart

• Size of a fist

• Middle of the chest, a little to the left, under the sternum

• Beats 100,000 times a day

• Muscular organ that pumps blood around the circulatory system

  • Pumps 5l of blood continuously

All living tissues of the body require oxygen for life

Blood picks up oxygen as it passes through the lungs

Blood travels from the lungs to the heart before being pumped around the body, delivering oxygen as it goes

It makes its way back to the heart so that it can be returned to the lungs again

Heart Anatomy

• Pulmonary veins bring oxygenated blood from the lungs to the left atrium

• Aorta carries oxygenated blood from the left ventricle for circulation around the body

• Vena cava: carries deoxygenated blood from the body back to the right atrium of the heart

• Pulmonary artery carries deoxygenated blood from the right ventricle to the lungs

Layers of the Heart Wall

• Pericardium: thin outer lining that protects and surrounds the heart

• Myocardium: thick muscular tissue of heart that contracts

• Endocardium: thin inner lining

• The heart needs its own blood supply

  • Coronary arteries

  • Narrow if atheroma builds up inside the vessel wall

  • Risk and lifestyle factors

Heart Attack

• MI

• Supply of blood to the heart itself (via coronary arteries) is blocked by thrombus or blood clot

• Obstruction of blood supply = infarction

• Symptoms: chest pain, may travel to the back, arm, neck or jaw, sense of impending doom, squeezing, nausea, sweats

• The longer the delay for treatment - the worse the damage

• Every minute matters

• Heart does not stop beating

• Person usually remains conscious

Management:

• ME

• Administer GTN (1 dose every 5 mins, under tongue)

• Call 999

• Administer 300mg aspirin

GTN MOA

• Rapidly absorbed through the buccal and sublingual mucosa

• Peak concentration at 4 mins

• Relaxes smooth muscle to produce arterial and venous dilation

• Reduce venous return and improves myocardial perfusion

• Reduces work of the heart and therefore oxygen demand

• Side effects: headaches (due to vasodilation), palpitations and hypotension

Cardiac Arrest

• Electrical malfunction of the heart

• Causes arrhythmia

• Without rhythm, the heart can not beat effectively

• Disrupted pumping action means the heart can’t supply the body (or brain) with oxygenated blood

• Rapidly leads to loss of consciousness

• Death occurs without rapid treatment

Management

• Can be reversible

• CPR

• Defibrillation

  • Non-shockable: asystole or pulseless electrical activity (PEA)

  • Shockable: ventricular fibrillation (VF) or ventricular tachycardia (VT)

Reversible Causes of Cardiac Arrest

4Hs:

• Hypovolemia

• Hypoxia

• Hyper/hypokalemia

• Hypothermia

4Ts:

• Toxins

• Tension pneumothorax

• Thrombosis

• Tamponade

Epilepsy

• Generic term for a range of conditions that produce seizures

• May be partial or general

• Range from periods of “absence” through to tonic-clonic convulsions

Symptoms

• Auditory or visual disturbances (aura)

• Intense feeling of fear or happiness

• Loss of consciousness

• Tonic phase - all muscles contract, stiffness, air forced out of the lungs (cries)

• Clonic phase independent contraction and relaxation of all muscles - uncoordinated jerky movements, bruxing, vomiting, voiding of bladder and bowels

Management

• Prevent the patient from harming themselves

• Avoid being harmed yourself

• Oxygen

• If lasts longer than 5 mins > status epilepticus > paramedics

• Midazolam - buccal or nasal

  • Child 3-11m: 2.5mg

  • Child 1-4y: 5mg

  • Child 5-9y: 7.5mg

  • 10+: 10mg

Anaphylaxis

Common Allergens:

• Pollen

• Penicillin

• NSAIDs

• Shellfish (haemostats)

• Latex

• Peanuts

• Chlorhexidine

Symptoms

• Flushing

• Tingling

• Itching

• Wheezing

• Swelling

• Disorientation

• Light-headed/dizzy

• Collapse

Treatment

• Oxygen and airway support

• Chair position

• Adrenaline IM, second dose after 5 mins

  • Child <6: 0.15mg

  • Child 6-11: 0.3mg

  • 12+: 0.5mg

• Salbutamol if severe wheeze

Other auto-injectors: 3 MHRA approved - Epipen, Jext, Emerald

Respiratory Arrest

• Causes

  • Airway obstruction

  • Decreased respiratory effort

• Maintain airway

• Correct ventilation rate

• Check pulse every minute