Medical Emergencies Part 1 – CORE CPD for Dentists – PDP241

Teaser:
So you want their head down, if the bed’s not quick enough getting up or it’s not working or whatever, you actually can just manually lift the legs and hold them up or get their relative, if they’ve got a relative in with them or somebody that’s come in and then just keep them like that until they come round.

When histamine is released into the patient, they get widespread vasodilation and bronchoconstriction. So those two things combined is a bit of a car crash. Even 0.5 because really you’re going to get an ambulance within five minutes. 

It’s true, you’re not though. You need to be carrying two at all times and people don’t. And particularly if you’re teenagers, you know you’ve got a handbag that doesn’t fit it. It’s tricky I actually think that in a medical center am feels better- 

Jaz’s Introduction:
When you are dealing with a medical emergency in your chair. That stuff can get really scary for dentists. It’s not pleasant to have to deal with it, but we need to be sharp, we need to know exactly what to do because our patient’s life actually depends on this. 

This is why it’s a legal requirement in the UK and probably around the world to do medical emergencies training every year, and I’m proud that after six years of podcasting and creating CPD, we can finally now cover this topic in the true protrusive way, and now give you core CPD or CE credits.

The GDC recommends 2 hours per year and in a five year cycle, that means 10 hours of medical emergencies training for the dental team, and this is mandatory. Now, most practices arrange some sort of group session where they’re doing simulation and hands-on CPR, which is amazing, but sometimes we’re left to our own devices and we’re watching these little bit slightly boring videos and lectures online. Always scrambling to buddy up with a neighboring practice to actually get this training done on time. 

Now, in this episode, I’ve got a Lead nurse, an educator in medical emergencies. Her name is Rachel King Harris, and one of her roles as well as working in acute medicine is to teach dental teams everything they need to know about their medical emergence training every year. So I’m proud to say that after listening to this Part 1 and the next episode, you’ll give a massive tick box for your annual requirement of CPD.

But the key thing is that you do it in a true protrusive way. We’re going to make it tangible. I’m hoping that Rachel and I, and mostly Rachel, we’ll present things in a way that it actually sticks. Sometimes when the patient is feeling unwell in your chair, we start to get a bit of panic and confusion. Is this just a Vasovagal Syncope or could there be something going on with the patient’s heart?

Is this an anaphylaxis? Should I be giving oxygen? All these questions can come at you a million miles an hour, and you have palpitations and you’re sweating, and medical emergencies are just no fun to deal with. 

But after today and the next episode, you’re going to smash your annual requirement of CPD and in a way that you’re going to retain this information because every episode we make some premium notes and we just deliver it in a way that’s a bit easier to listen to, it’s not someone lecturing at you. 

You are there by osmosis absorbing these things. And I really told Rachel, I told her I want to create a really compelling piece of content for the dental team. Which makes it tangible and relatable and real world.

What I mean by that is the topics we cover in this 2 hour training are actually medical emergencies that you are likely to actually see in your practice and talking about some details that are really important, but no one ever talks about some. 

I’m hoping through that, that should you be in that unfortunate scenario that you will face a medical emergency because of this training, you’ll be feeling much more confident, much better prepared, and of course you won’t be panicking in December trying to make sure you’ve done your medical emergencies mandatory CPD, because we got you covered.

Now to listen to this episode is free for all. Okay? The podcast is free for you, but to actually get the certification, you have to answer some questions and do some reflections, and that’s possible on the protrusive guidance app. 

You can listen via Spotify through the app, all Apple Podcasts, again through the app, or watch the video on the app, and the benefit of that is you just scroll down and answer the questions and our CPD Queen Mari will look after you.

And once you start doing more CPD with us, we actually send you quarterly certificates and an annual summary of all your certificates, how many hours you’ve done, and watch this space. There’s some cool stuff regarding PDP coming your way as well. The point of saying that is why don’t you get started? 

Come and join one of our paid plans. I guarantee you’ll love it because the nicest and geekiest community of dentists in the world and you get all the CPD, which is not just a tick box for me CPD was like easy, I’d love learning, I have CPD coming out my ears, I probably claim way less hours than I actually do because getting CPD for me was never an issue. 

But in this busy world, sometimes getting that mandatory training can be difficult. So why don’t you head to protrusive.co.uk/ultimate, sign up and make this one the first one that you claim CPD on, and then it’ll unlock the over 350 hours of CPD that’s currently on Protrusive to date.

Dental Pearl
Now, every PDP episode, since its inception, I give you a Protrusive Dental Pearl. This one’s going to help you so much, and your practice manager and your principal will absolutely love you because a really good thing that we do in the practice I work in is when you open the medical emergency drug kit, there is just the best cheat sheet ever.

Like there’s these laminated pages joined together, and they’re such a great cheat sheet so that when you are kind of in panic mode and you open up this drug kit, it tells you exactly what you need to know in a time of emergency. I’m pretty sure the CQC will also love you when they see you’ve got this already there.

It’s a fantastic aid memoir of what symptoms you’re looking for, what drug to do and the management. Should you call the ambulance, should you not? Should you give oxygen? Should you not? It’s all there. So what I’ve done is I’ve prepared it as a download for you. If you’re watching this on the premium part of the app, just scroll down.

The zip folder is there, you can download it, laminate it, and put it in your medical emergency drug kit. If you’re not on the app, you can still download this for free. To take advantage of these medical emergencies cheat sheet, head over to protrusive.co.uk/me. That’s M- E, Medical Emergencies.

Enter your email and I’ll email it to you directly. Don’t worry. Oncall Jaz always has your back. I promise you, the entire team at your practice will absolutely love this. Anyway, let’s join the main episode and I’ll catch you in the outro. 

Main Episode:
Rachel King Harris, welcome to the producing of the podcast. How are you? 

[Rachel]
Jaz, I’m good, thank you. Thank you for having me. I’m excited. 

[Jaz]
So those of you who don’t know, Rachel, okay, I’ll introduce you. She does our training in practice about once a year, and I’m always there in the front row. Heckling is the best way. And you know what? 

[Rachel]
He does it well. 

[Jaz]
And Rachel’s a good banter, right? She’s a good banter. She makes this topic fun. 

[Rachel]
Thank you. 

[Jaz] And of all the sort of mandatory training we have to do, like radiation stuff, right? That can get very dry very quickly. But this is one training which is, lifesaving. This is super important. So what I wanted to achieve with today’s show is to make it tangible. Okay. 

Because why is it so often that we forget, right? And we need that annual reminder. And so I’m hoping that the way we’re going to cover it today with some of the stories and analogies, yeah, it’ll help someone down the road. But also it ticks a box. 

[Rachel]
It does.

[Jaz]
But it ticks it in a painless way so people can be chopping onions. So you don’t know this, Rachel, but the joke that we have, the running joke in the podcast is people are chopping their onions as they listen to a podcast. Someone wants— two people have told me that they did this early on and I just adopted it. So I always, when I imagine the listeners or Protruserati, I imagine them just chopping onions as they’re listening, right?

[Rachel]
Hopefully they can chop some more onions while listening to us. 

[Jaz]
That’s right. I say we’ll continue the onion chopping. And so I wanted to make just a more fun, upbeat piece content around this topic rather than someone just watching like a lecture. And so that’s the idea. But Rachel, just tell us about yourself.

[Rachel]
So obviously my name is Rachel. I have been a nurse now for 15 years. I qualified at the University of Surrey in Guilford, doing my adult nursing and realized very early on how much I loved emergency medicine. 

So kind of the hustle and the bustle and the fast paceness of it all. So I started my career at the Royal Berks in a sort of a acute medical unit, and then realized that actually any emergency department was where I wanted to be. So I moved there and have kind of worked there for about 10 years. But I also had this passion for teaching and education, so I did some—

[Jaz]
Inspired probably by your parents, right? Because- 

[Rachel]
Yes, they’re both in education. We talked about this earlier. And then, yeah, I did all of my advanced courses, so adult advanced life support, European pediatric life support, and then just kind of built my profile from there, really. 

And then I met you guys, I think you’re one of my first clients, actually through a colleague of mine and have been teaching here for probably my 3rd- 4th year now with you guys, so, I think. My passion is emergency medicine, and I also love education on the side of it. So this is-

[Jaz]
This is perfect. 

[Rachel]
Perfect. 

[Jaz]
This is perfect. So I’m so pleased to have you and your expertise because you know what I’m like most dentists I forget.

[Rachel]
Yeah. 

[Jaz]
We forget that this stuff. And so you are our expert who’s going to help us with these things, and help to make it more memorable for us. Yeah. And make it more fun and engaging.

[Rachel]
And the reason people forget is because if you’re not doing something every day. Then it goes to the back of our brain, doesn’t it? Whereas, because I tend to practice most days, it stays at the forefront. 

And I think that’s why yearly updates are great because it refreshes you on those things that you kind of park. It’s great that you are doing this because actually anyone can listen any time, even six months down the line. Oh, I’ve forgotten what she said about X. So it’s always recorded, isn’t it? 

[Jaz]
That’s true. And I like this. You know, I know a lot of people are watching on YouTube or Protrusive Guidance on the video format, but many people will be listening on a train on an airplane, and then they can answer the questions later and get their CPD. 

So call CPD it is, which is great. But what you reminded me here, Rachel, is Dental Trauma. I know you all think of trauma as a medical world, but dental trauma, again, we see it seldom. It comes in really rarely like an evulsion. 

So someone’s actually lost their front tooth, the whole thing, bring it in some milk or saliva medium. That’s such a rare thing and whatever happens is that, I end up googling it. So if I know a patient’s coming, I’m like, “Okay, what’s the latest guidelines?” Okay—- 

[Rachel]
Yeah. 

[Jaz]
And I’m not saying that’s the wrong thing to do by any—

[Rachel]
No, no, no. 

[Jaz]
Because, when I was a teenager, I used to go to the doctors and I noticed that any issue we have, the doctors sometimes used be Googling it. And I used to think to myself, “What kind of doctor is this? because who’s Googling it?” 

But actually, why should they be an Oracle all-knowing orbs what they’re doing is they’re checking the latest guidelines, they’re checking information and then using their medical knowledge. To use those guidelines with the patient history and diagnosis to then give a recommendation.

[Rachel]
Yeah. And that’s, like you’ve just said, guidance publications change all the time. And actually, the correct thing to do is always look up the latest guidance, latest publications, because I can say one thing today, but actually even in a year, it could be effectively out of date when the particularly the recess council update their guidance. So this is why it’s so important to refresh, because things change and you can’t just–

[Jaz]
So it’s important to refresh because A, it’s just so important anyway. And so it’s like life or death, really. 

[Rachel]
Yeah. 

[Jaz]
So that’s why it’s born also because we seldom see it, and though therefore we need that refresher. And of course, like you said, guidance keeps changing. Like in many things in dentistry, medicine, so we stay abreast of it. So three good reasons to listen to the end today and answer a question and get your CPD guys. 

[Rachel]
And the fourth good reason actually is that it’s a good life skill. So despite using it in dentistry, everything we talk about today can be transferable to just being out and about. And the fact that you are medical professionals, people do expect you to know what to do even though you might not know at the time. So having those transferable skills into the community with friends, family, even strangers is the fourth really good reason to listen. 

[Jaz]
Excellent. I love it. The direction we’re going to be going in guys, is I want like tackle the most common medical emergencies first because it’s all good and well, learning about the really niche and rare ones. 

Like academic, but then that’s what it becomes, it becomes very academic. I want it to be very tangible. Like, I always say, something you can apply on Monday morning. Now hopefully no one will need to apply any of this stuff on Monday morning. 

[Rachel]
Yeah. 

[Jaz]
But-

[Rachel]
It’s there. 

[Jaz]
The most likely, like 1% chance, would be like a vasovagal syncope. Perhaps we could start with that. And then eventually I definitely want to come at Anaphylaxis. Because I think this is so- especially with the media and stuff and prayer and all these things and how important it is in life or death. It is. And then I want to just talk about hyperglycemia and a few others. Then I want to talk about the drug kit, what should be in it. 

[Rachel]
Yeah. 

[Jaz]
And I think that’ll be particularly useful, not just for associates, the practice principles. I’m sure you’ve seen where they kind of make that face like, “Oops, I didn’t know we’re not supposed to have that anymore.” Or, “Yeah, I was supposed to order that in and we can cover.” That kind of stuff.

[Rachel]
Yeah.

[Jaz]
That sounds all right? 

[Rachel]
Sounds perfect. 

[Jaz]
Alright!

[Rachel]
Let’s do it. 

[Jaz]
So in your background in nursing, how often do you actually see a Vasovagal Syncope and explain what that is. 

[Rachel]
So Vasovagal Syncope is essentially another fancy word for a faint, essentially, and just through the nature of what we do pretty much blood tests is the biggest one to cause fainting, Vasovagal Syncope. So we probably see them more frequently than you’d think. 

It tends to be when you draw up the- you get the needle out, it’s coming towards the patient, they’re suddenly looking at the needle, and then it pierces the skin. And then what you find is that patients kind of well faint, essentially.

So it’s actually more common than people think. You don’t even need to be needlephobic to not like the look of a needle coming towards you. And I don’t know what it’s like in dentistry, but from the experience of talking to other dentists that I’ve taught. A lot of it is just instruments being around their face. And I must admit, there’s a lot of people that are afraid of dentists isn’t there, and- 

[Jaz] Understand-

[Rachel]
The thought of going in, the thought of sitting there, lying there, and then having them fiddling around with your mouth is enough to make people faint. So I guess it’s good to know– actually, we don’t really need to panic but this is what is really helpful when somebody does faint. 

[Jaz]
But you should differentiate and diagnose what that is. And thankfully it’s been fairly smooth. So in my experience, Rachel, the most common time I’ve noticed this is straight after LA. So straight after giving the injection. 

[Rachel]
Yeah. 

[Jaz]
So I haven’t actually had anyone. Yeah. So for example, sometimes people are so nervous they don’t want to sit in the chair, so we always sit on the sofa first that you see there. And then we have like, you know, calm them down and sound like we’re on your side, we’re very gentle here, etc. So everyone’s fine on that side. But once they’ve had a local anesthetic, that’s classically what I see and so what I see them go pale, lose their color. 

[Rachel]
Yeah. 

[Jaz]
Right. 

[Rachel]
And that’s because all the blood pressure’s dropping, isn’t it? And so therefore they’re losing their fresh face and they’re going pale and gray.

[Jaz]
My first ever experience of this, I was a fourth year Dental student, we were on outreach, so like clinics around Yorkshire and I remember it was like a 20 something or maybe a 19-year-old male. So I remember maybe reading or coming across something at a time. Is it true that young males are more susceptible to this or– 

[Rachel]
We hear that? I mean, to be honest, I have to say it tends to be a lot of female teenagers that I’ve come across that have tended to kind of have one of these episodes in the emergency department. And it’s– they hate needles. 

And that’s their kind of trigger when you come near in with a needle. But I have heard that boys happen to have these kind of reaction when, particularly in the dentistry world. So I’m not surprised you’ve said it, but I haven’t personally, it has tended to be more the female sector. 

[Jaz]
And then quite classically, I used to think that okay, it’s because our anesthetic contained adrenaline, and I used to wonder is that- because they often describe “Oh yeah, my heart’s going.” 

And then they start to go a bit pale. And so what we do, and then just to make sure we’re doing the right thing, is I was always taught bring their head back, legs up, let the blood, so the reverse of what’s happening, if their blood is drained from their face, if they’re looking pale, you want to do the opposite. You want to get the blood back down. 

[Rachel]
Absolutely. So when you faint, essentially your blood pressure drops. So that quick event that happens, what you need to do is actually try and I don’t know whether your dentistry beds tilt, but tilting is actually the best. So our medical beds in hospital, we can tilt them like this so that-

[Jaz]
So like left and right?

[Rachel]
Up and down.

[Jaz]
Okay. 

[Rachel]
So the feet actually come straight up and the head down–

[Jaz]
It doesn’t tilt, but we can actually do it so that the head goes below the legs.

[Rachel]
Perfect. That’s exactly what we want. So we want the head down, and then if you can’t, you know, if the bed’s not quick enough getting up or it’s not working or whatever, you actually can just manually lift the legs and hold them up or get their relative, if they’ve got a relative in with them or somebody that’s come in and then just keep them like that until they come round. 

We used to talk about throwing water over people and giving them a shake and a tap, but actually it’s a very basic thing. It pulls that blood pressure back up to the central perfusion and they’ll recover a lot quicker. 

[Jaz]
I remember the first three or four times this happened to me, I was really scared. Which I was like, as a young dentist student. I was like, “Oh my God, like everything angina, heart attack.” It was like trying to think what was the latest guidance? What I do, but just falling back on that advice.

Of just doing that and remaining calm. Now I don’t want to say that it’s blasé. I don’t want to be blasé about it. But now if it happens, I’m really calm. Like, “Okay, that’s fine. Let’s bring you back.” I’m just speaking out loud in a nice hypnotic tone almost for a patient. 

[Rachel]
And they’re scared because they come around but I’ve got a really funny story actually. When I was– I say newly qualified, I probably worked in ED for about, I don’t know, 2-3 weeks. And one of my patients needed some GTN spray. So a nitrate and what a nitrate does, is it vasodilates. So–

[Jaz]
So why do they need the GTN spray? 

[Rachel]
Because they had some pain in their chest, which is separate to the Vesovagal Syncope. 

[Jaz]
So they had angina. 

[Rachel]
They did okay. Yeah, it was prescribed PRN, which basically means as much as they require as such. So I went along as kind of a new nurse in ED and I didn’t check the blood pressure before I gave the GTN, which in hospital settings is actually really helpful because if they’ve already got a lower blood pressure and then you go and give them a drug that vasodilates the blood pressure drops even more. So he already had a lower blood pressure than normal for him. I went along, gave him two sprays–

[Jaz]
Because the chest rate, which is the right thing, is away.

[Rachel]
And he basically fainted on me straight away. Now because I was new and fairly inexperienced at the time, I’d only been qualified for about a year or two. I panicked and I pulled the crash bell. Everyone came rushing in and I stood there and went, I think I’ve killed the patient. 

And I burst into tears and I’ll never forget one of the consultants who sat tilting the bed for me. And they’re like, as we just discussed, tilting the bed and saying, “No, you haven’t. Go and pull yourself together and make yourself a cup of tea.” 

And I kind of walked off sobbing thinking, “Oh, he is dead and it’s all because of me.” But actually what I’d done was, is given him, I should have given him one spray, reassessed, checked the blood pressure to make sure he was okay and then given him a second if he had needed it or what I did was just go. And then I gave him basically. 

[Jaz]
At that point, the blood pressure scenario and the syncope wasn’t your number one worry. It was the fact that he was a patient with angina– 

[Rachel]
Correct. 

[Jaz]
Or, the associate that with cardiac issues and therefore I could see— 

[Rachel]
I saw a treat. 

[Jaz]
Yeah. Yeah. Fine. So that makes sense.

[Rachel]
It’s a lesson. One spray reassess, second spray, reassess. Don’t just go in gung ho, because actually sometimes you can make it a bit worse for yourself, even though I know you’re treating the angina. But you will cause a Vasovagal Syncope, basically. 

[Jaz]
Interesting. Now, later we’ll be talking about angina.

[Rachel]
Yeah. 

[Jaz]
So if you just jump that a little bit now for our angina patients. GTN spray, classically, I was taught it runs out of date really quickly so always check that it’s in date. Correct. And then I always literally get them to keep it right there, like by that telling, I say keep it there basically. And I’ve never need to use it. 

[Rachel]
Yeah. 

[Jaz]
But would just to have It would, yeah. Would, yeah. Exactly. Would you recommend then also doing the same as what you did in terms of what you’re recommending, which is one spray and then reassess? 

[Rachel]
I always recommend one spray and reassess. Even though they may say, “Oh, you know, I take two or three sprays for this one” I get it. That’s fine if they want to do that at home. But when they’re in your surgery, when they’re in your practice, you’ve got a lot of instruments around, the last thing you need is them standing up and collapsing.

So I would always do one spray, check how it works, see how they feel. Has it improved their pain? No it hasn’t. Give it a couple of minutes, give them another spray. Because you are trying to protect them from injuring themselves, hitting their heads, causing themselves more harm than is necessary. 

[Jaz]
Okay. So that makes sense and we’ll expand more on that. When it comes to the GTN and angina part, back to Vasovagal Syncope, then it sounds fairly straightforward. But the reason I mentioned the fear as a young dentist when you’re facing a medical emergency is, which one could it be? Is it this one? Is it that one?

And so what advice would you give to a dentist if something’s happening and they’re seeing that the patient is in some sort of distress. And to just think logically. And to give them a sort of a guide to figure out which one it is. 

Obviously common things happen commonly. So maybe assume it could be a Vasovagal Syncope, but by assuming that always, is it that we might be missing something a bit more sinister. And so what advice would you give to a dentist regarding that? 

[Rachel]
I guess my advice would be checking– because what you worry about with a Vasovagal is that because they have those moments of unconsciousness is this actually a cardiac? And what we have tend to happen in hospitals is that we start shaking the patient and checking their breathing to make sure that we haven’t actually caused it, or the patient hasn’t gone into cardiac arrest. The advice that we kind of give our colleagues in the hospital is you check the breathing and that’s the most simple thing to do. So you lay them flat if they’re not already flat.

[Jaz]
So let’s assume that you think it is a Vasovagal Syncope. But you’re a little bit unsure and you are a little bit scared so you do the first step anyway: Lay them flat, which flat works for both.

[Rachel]
Yeah. 

[Jaz]
And then next step will be check with-

[Rachel]
Oh, not their airway. So head tilt, chin lift. So really pull that head back, making sure that as long as they’ve not-

[Jaz]
So we’ve got this little headset here that is handy to bring the head back. 

[Rachel]
Yeah. And then you look, listen and feel for breathing. And as long as you can see that chest go up and down, that’s breathing. So then you pretty much know then that this is actually faint. And then the next step that I would do is raise those legs straight away and reassure the patient and talk to the patient. And then they should come round very quickly. 

Like if it’s a sort of, I say a simple, well, nothing’s ever simple, but if it’s a faint, they should come round quite quickly. But it’s the difference between knowing if this is a serious unconscious event where we need to start thinking of ruling in or ruling out. What it could be is really checking whether they’re breathing or not.

And once you can confirm that they’re breathing, you buy yourself some more time because then you can start raising the legs to see if that works and so forth. Obviously if they didn’t come round, you’d start to think about have they taken anything? Has anyone given them anything? You know, why suddenly, is this a blood sugar event? 

Those kind of things. But initially, if you’ve done something to the patient or they’re nervous or anxious, you can pretty much say this is probably a Vasovagal Syncope. 

[Jaz]
Perfect. So the advice here is commonly Vasovagal Syncope is the most common one that we all face. Bring their head back, but then if you’re unsure just first thing, do a check for breathing 

[Rachel]
Check-

[Jaz]
And that reassures you. In my experience they usually come around nine seconds to two minutes. 

[Rachel]
Correct. 

[Jaz]
Feels like two hours when it happens. Alright. How apart. 

[Rachel]
And it does for medical professionals too. Yeah. You’re not the only ones that feel like, are we missing something here? But it’s about taking your own deep breath to be honest and thinking they’re safe. They’re on a bed, they’re breathing, almost have a check with yourself and say, “They’re fine. We just need to work out what this is.” Raise the legs. 

[Jaz]
Everything in our decision making just works way better when our mind is calm. And that takes, it’s very difficult, I mean, it’s easy for me to say. 

[Rachel]
It’s very-

[Jaz]
But it’s difficult. But I’m going to give a story which is relevant. It’s similar, but it’s not a medical emergency.. I do a lot of occlusal appliances, splints. It’s my area of interest, TMDs and bruxism and that kind of stuff. So occasionally you get one from the lab, which is really tight. Right? So it goes in the patient’s mouth and they are not able to remove it. 

[Rachel]
Yeah. 

[Jaz]
Okay. And so again, in my early days I start panicking thinking, am I not going to be able to remove it? 

[Rachel]
Yeah.

[Jaz]
Now it’s like, if they see the panic on my face, that’s game over.

[Rachel]
Yeah. So true. 

[Jaz]
Now I am just really relaxed about it. Because wherever it is, I’ll get it out. I’m really just calm about that because compared to a medical emergency, there’s nothing. Right. Let’s face it, right. So if you put things in perspective it’s really no big deal and I’ve always been able to get it out.

[Rachel]
Yeah. 

[Jaz]
So it’s one of those things that, it really helps me to just not to stay really calm-

[Rachel]
Yeah. Stay calm and work through the process in your head. It’s Occam’s razor, isn’t it? If what it’s usually is what it is. In other words, we can word that better, but essentially if it talks like a duck and walks like a duck, it’s usually a duck. So if they’ve just seen a big instrument come towards them and they already don’t like you, and no offense Jaz, but you’re about to do something like a root canal in their mouth.

They’re already feeling insecure. They get, some patients are prone to fainting and some more than others. I mean, I’ve never fainted in my life. But my husband has a couple of times and if he sees blood, he gets a bit **, whereas I thrive in that kind of situation, it just depends on your personality. 

[Jaz]
I mean, one thing we haven’t mentioned though is we, as Dental Professionals, one thing we always do when the patient comes in, even if you’re seeing them third time that week, is just check the medical health- medical history. 

[Rachel]
Yeah. 

[Jaz]
And so that again, if they don’t have any cardiac history, the young patient, no cardiac history, then it will again strengthen the cause for Vasovagal Syncope. Whereas the time waking up is a little hairy, a bit confusing for us because they already have a known angina and they have had a stamped place before and that kind of stuff.

[Rachel]
Awaiting a bypass.

[Jaz]
Exactly. That’s when it gets a little bit hairy. Yeah. But again, check for breathing is a top tip basically and– 

[Rachel]
Real top tip because if they’re breathing, you’ve got time. 

[Jaz]
Yeah. 

[Rachel]
Yeah. It’s when they’re not breathing, but then we go down a whole different route. 

[Jaz]
We will explore that. Before we move away from Vasovagal Syncope and then maybe go to anaphylaxis. Is there any other point that you want to make on that? 

[Rachel]
I don’t think so. I think the main key points are laying them flat and raising their legs. To be honest, it’s actually one of the simplest things that you can treat. So in a way, my advice would be to not overthink it. 

[Jaz]
Good. Stay calm. Don’t overthink it. And this is, check the breathing. This is the one. Yeah. Check the breathing. And this is the one that we’ll be doing. For your long career, this is the one that will tally up the most, maybe into three figures by the time you come to the end of your career.

[Rachel]
Correct. 

[Jaz]
Right. So Rachel, now moving on to anaphylaxis. 

[Rachel]
Yeah. 

[Jaz]
This is one which I think is more- would you say is more common than some of the other ones that, if you were to rank in order what a dentist may typically see or-

[Rachel]
Yeah. I feel like you would end up seeing anaphylaxis more out in the community than you probably would in the dental practice, just because you’ve probably given yourself quite a lot of protection over the years of removing things that could cause it. Like you’re probably a nut free surgery. You’d probably not use latex, am I right? 

[Jaz]
No, I mean I don’t think anything here is latex. 

[Rachel]
Yeah, so you probably removed a lot of the things that might trigger. 

[Jaz]
We talked about it earlier actually. So there was a concern when I was studying at the school about chlorhexidine. Some people had severe anaphylaxis for chlorhexidine. And my Perio tutor, she’s freaked out and then she stopped using it. 

Whereas I speak a lot to dentists and actually it has got some good efficacy in reducing something called dry socket. After extraction you can get a dry socket and so people use chlorhexidine gel and a lot of procedures to disinfect the mouth. 

We use chlorhexidine mouth rinse. So people have different attitudes and I think it’s one that is still quite rare. At the back of our minds, that’s one that’s always in my mind now from my experience. 

[Rachel]
And do you use it in surgery? 

[Jaz]
See, because of my bias now because I’ve been kind of, she put that fear into me. Now I don’t use it so much, but yeah, we have it, for example, wisdom teeth. If I’m irrigating wisdom teeth, sometimes I’ll use that. 

[Rachel]
Yeah. 

[Jaz]
And so that’s one I can think of that may be more relevant. 

[Rachel]
I feel like the big ones are you, and particularly the ones you’re not necessarily going to know about are the bees and the wasps. Obviously there’s all the nut family, strawberries, kiwis, they’re big ones. 

But again, these are things that you wouldn’t really expect to have in a dental surgery. But because you are an environment medical practice, there’s nothing stopping somebody being stung out into-

[Jaz]
You have a story about this?

[Rachel]
Yes. So one of my other surgeries that dental practices that I taught, the exact same scenario. They were near the dental practice and they got stung by a wasp or bee. And unfortunately they didn’t know which one it was. So they walked into the practice, they went to the reception area and they said, “Oh, I’ve come for my checkup, but actually I’ve just been stung and I’m not feeling great.”

Obviously the receptionist kind of went into a bit of a, “What do we do? What do we do?” So she sat her down in the waiting area, got her a cup of water. And then within five minutes this lady had started to develop something called a strider, which is an upper respiratory sound where there’s a narrowing of the airway. You get kind of a higher pitch sound going through it. So it’s like a noise when they take a breath in.

She then developed an expiratory wheeze. So when they took a breath out, they had this kind of widespread, wheeze she noticed some sort of tingling in her lips. And when the dentist arrived, come out of seeing another patient at this point, he asked her to sort of stick her tongue out and it was definitely enlarged. 

So there was obvious swelling there. She felt terrible, so we talk about something called impending deo. I don’t know if you’ve ever heard of it, but it’s essentially where the patient feels like they’re going to die. And actually, if you left anaphylaxis, unfortunately that is something that could well happen.

[Jaz]
And that happens through a collapse of the upper airway. Right? 

[Rachel]
Collapse of the upper airway, blood pressure dropping. Because when histamine is released into the patient, they get widespread vasodilation and bronchoconstriction. So those two things combined are a bit of a car crash.

 Because of course your blood pressure’s dropped and your lungs have just gone really tight, so that’s why they get that feeling. And obviously their airways are struggling as well. So she was short of breath, she had obvious swelling, she had a stride or she felt terrible. 

[Jaz]
Would you have a rash?

[Rachel]
Yes, you can develop a rash, but you’re not waiting for the rash. And I think that’s what you know is the key message is that a lot of people wait for the rash to develop to diagnose anaphylaxis. 

[Jaz]
So I’m so glad you mentioned this because I remember DF1, so that’s the first year I’ve attended Dental School. We had this simulation in London Deck and in London by Waterloo. And I failed that station by the way, but it was like, they put you in a simulation. 

[Rachel]
Yeah. 

[Jaz]
And this patient’s like, “I don’t feel so well, I don’t feel– and I’m like, oh, is it cardiac? What kind of thing? Is it respiratory? What is it? And then the clue was that had I undone the top few buttons, they’d put these red stickers there. And so that’s always stuck with me now so rush. But you don’t always get one. 

[Rachel]
But you should. It’s funny you should say that because when I did my advanced life support course, when the first time I ever did it, they did exactly the same. So the patient was short breath, I was like waiting, waiting, waiting, waiting for the rash. And then they didn’t say it was a rash, so I kind of went down the wrong path. So don’t wait for the rash as my kind of top tip. 

Because actually if you’ve been stung, you’ve got an upper airway, stride, strider with some swelling, the patient feels terrible, you can pretty much go down the anaphylactic route with this one. So they fortunately recognized it very quickly in the dental surgery and they got their emergency kit out and they administered the correct dose of adrenaline.. I am adrenaline. 

[Jaz]
And let’s talk about this just a moment, but let’s just make it really tangible for dentists because let’s say there is a patient who is allergic, sorry to use the chlorhexidine, I don’t want to make people bias to think that they should be worried about using chlorhexidine so much, but that’s the only one I can think of right now. So let’s say they’re using chlorine gel and they put it in the mouth, okay? And what do you think a patient would start to– what are the clues, initial onset symptoms? 

[Rachel]
Initially they start, say that it feel well that’s kind of the classic, like I’m not feeling very well. Sometimes the rash can develop before the airway, so it could happen that way around. 

[Jaz]
So maybe perioral rash in– 

[Rachel]
Yeah, it tends to be more of a chest sort of urticaria rash. That can develop over time, or it can develop quite quickly. They’ll probably say they’re not feeling great, and that they may have some pins like tingling feeling around their lips. And that they feel that their throat’s tight. Tight is a real key. 

[Jaz]
So yes my cousin, who’s got a severe peanut allergy, I’ve been to him twice now. Bless him. Where the tightness. Like, he literally- he’s a fan himself, almost like the way he looks like, like this is not good. Can-

[Rachel]
It’s so tight. You can’t quite, and you’re trying to swallow. Because you’re so nervous about the fact that you can’t swallow your own saliva because of course there’s a narrowing there. 

[Jaz]
And it looks sweaty. 

[Rachel]
They look sweaty, they look very flushed in the face. People talk about blue, blue doesn’t happen. Like it’s, it’s flushed. 

[Jaz]
Okay. 

[Rachel]
Blues a very late sign. And they, they kind of tell you they feel dreadful. Fortunately, you are lying them down already, so you are already halfway there. But those are the kind of first key signs in. 

[Jaz]
And then the voice change.

[Rachel]
Voice changes, and then if it’s that severe. You will get that stride door. But you are at a very critical point when you hear the stride door, because that’s a real emergency airway issue. Because if you’re hearing such a narrowing that you’ve got that noise, it’s dangerous and we need to do something well.

[Jaz]
So that’s a little bit later. So hopefully before then we would’ve acted. So we’re looking for just in the impending doom, not feeling well hanging—

[Rachel]
Doom not feeling well. Maybe tingling. Tingling, shortness of breath. They’ll always be short of breath at the- 

[Jaz]
Always short breath. Okay. 

[Rachel]
Anaphylactic. And may or may not develop that as cial rash quite quickly. 

[Jaz]
I’m glad you said that because I was kind of just from memory, I was  waiting for the rash. I’ve learned something. Let’s not wait for the rash guys. 

[Rachel]
Yeah. 

[Jaz]
So, we know articaine.. Sorry, not articaine. Articaine is a little more under anesthetic. Adrenaline. So adrenaline is the answer here. And so our emergency drug kit should have adrenaline. Now, is that usually kept in the fridge or–

[Rachel]
No, you don’t need to keep adrenaline in the fridge. The ampules can be kept in the bag. A lot of practices actually just have an anaphylactic box and some of them even keep them in each, like in one of the rooms it’s easy. 

Because with the bag right, it’s big, it’s clunky, you’ve got to fish through it. The last thing you want to be doing when somebody’s got Anaphylaxis reaction is trying to wrestle your way through an emergency bag to try and find it. So—

[Jaz]
Well, you’re going to love what we have. What I’ll do now is I’ll just go bring it. And then we can actually talk through it actually. 

[Rachel]
Perfect. Yeah. 

[Jaz]
Okay. So I’m back. I have, for those of you who are listening, I’m holding the emergency drug kit labeled exactly so in a lovely green box, but really cool. Next to it was a laminated A four, which I love it’s from the BDA, it’s a Warsaw healthcare emergency drugs in the dental practice, and it’s just got an adrenaline aspirin. The names of the drugs indication, the dose. It’s a lovely little cheat sheet to it’s find. Is it more for practice to have this? Yeah. 

[Rachel]
No, not every practice has this. 

[Jaz]
It’s genius, I think. That’s a simple thing. 

[Rachel]
Sometimes they give practices which any practice can get essentially is download the resuscitation guidelines and they give you access but they definitely don’t give you the rest. So this is perfect. 

[Jaz]
Yeah, this is good. It’s got all the main ones which will–

[Rachel]
As long as it’s updated. I think that’s the key thing. 

[Jaz]
Yes. So we’ll find out today if it’s updated or not. 

[Rachel]
Yeah, because it’s very easy, and I really want to make this clear that people can often go to a lot of effort in printing these things out, but actually they don’t then update them when new guidance comes out. So if you are going to print and not rely on computers, then please make sure that you’re checking them regularly.

[Jaz]
So little admission here, Rachel. I’ve never actually opened this box in my life. 

[Rachel]
That’d be a good thing. 

[Jaz]
It’s a good thing. 

[Rachel]
It’s a good thing that you’ve not used it. 

[Jaz]
Yeah. But now I’m literally like, I’ve opened it and I’m glad I’m doing this exercise because this could happen to me one day. And just to familiarize myself with it. So guys, as I’ve opened this, I’m seeing lots of laminated files and I’m seeing, the first thing I see is an anaphylaxis cheat sheet just a whole one so fainting is second. 

So first is anaphylaxis, fainting is second, then hypoglycemia. And it doesn’t say which company this is from or what resource from. So I can only assume it’s from research guidelines maybe, but it’s got like a summary. So rapid onset tells you about drug management, and it tells you airway, swelling, horse voice, breathing, rapid wheezing. It’s difficult breathing. The circulation will be pale, clammy to touch flushing. So it’s a really nice cheat sheet.

I quite like this. Yeah. If you’re in doubt. And then it says, okay, management. Okay, so if unconscious lay flat and raise legs, do not place anything in the mouth. It’s all like really? No. If I’m imagining being in that very stressful scenario, then this is exactly what you need. 

So what I’ll do, guys, I’ll make this available to everyone. Okay. So, in case your practice is not doing this, you can give this to your practice manager, get them to laminate it just like I have it here. And I think I’m really pleased to see this. As someone who’s imagining myself dealing with a scenario. 

[Rachel]
Because actually as we talked about earlier, when our own adrenaline is released we forget things. And having these kinds of crib sheets go-to sheets are perfect in an emergency. And even in hospitals, every crash trolley has guidance for our nurses and doctors, because we shouldn’t be remembering things in emergencies. 

[Jaz]
So I’ve already seen this, but like in our imaginary scenario, we’ve just diagnosed an anaphylaxis. I know what I’m looking for. So now I’ve come across these bags, right? These like massive, zip wallets. 

First one in massive writing says seizure. Okay, seizures. And so, I’m going to skip past that one. Then I got one says heart attack. Then I’ve got one says stroke. So already what you said, like the last thing you want to do is rummaging, but this is quite nice and neat and tidy, right?

[Rachel]
Neat. 

[Jaz]
I’m looking for low blood sugar. Skip past that one. Severe allergy, I found my zip wallet so I’m going to put the rest of the box away. So that was within about 20 seconds I can find it. I’m going to open it up, let’s see what’s inside another. This is the flow chart, this is the Reese’s Flow chart this is–

[Rachel]
So we need to update this. So you’ve currently got March, 2008, and actually what you need is the 2021 guidance. 

[Jaz]
So we’re only 13 years out come on. 

[Rachel]
So yeah, we do need to update that. So that’s a good thing that we checked. 

[Jaz]
Okay. But the lovely thing here is we are great. We know about the recess flow chart. We’ll get the up to date one. But now inside here, there are these pre-made packs. Okay. One, two, and three. Okay. So this is one–

[Rachel]
They’re needles, are they? 

[Jaz]
I think so.

[Rachel]
Yes they are, yeah. 

[Jaz]
Yes, because we use the compute system, so we’ll talk about that in a minute. So there’s one label for with the expiry date on as well. Okay. And is one for preterm small infants. There’s one for all ages and just tells you how much to use. 

[Rachel]
Yeah.

[Jaz]
And then large adults. Okay. So we got that as well, basically. So that’s really handy. I know my patient is an adult so I’m going to go for this one for example. Yeah. And so here’s the thing. I had this training from Chris a while ago on how to open the compule. I don’t even know where the compule is. 

[Rachel]
Oh, it’s there. Ampule you mean? 

[Jaz]
Oh, the ampule. 

[Rachel]
Yeah.

[Jaz]
Ampule. Because I use composites. 

[Rachel]
Yeah, yeah, yeah. I assume you don’t want me to open that.

[Jaz]
Don’t open it. 

[Rachel]
So, yeah. 

[Jaz]
But see already, right? In an ideal world, let’s be honest guys. An ideal world we’d have let epiPen or the Jext or whatever, right? So let’s talk about that. Because when an emergency like that happens, okay, you want something ASAP. Like I know I’ve been shown how to use it right now. If I had to open that, I would literally be sweating and be like— 

[Rachel]
And did dentists not draw up drugs? 

[Jaz]
No. Okay. Here’s the thing. Like everything we have nowadays, it’s prefilled. 

[Rachel]
It’s prefilled. 

[Jaz]
So I know Chris, he does Botox and stuff, so I imagine he does that stuff. 

[Rachel]
Yeah. 

[Jaz]
I don’t like, the only time I ever would do this is this. 

[Rachel]
Right. That makes sense. 

[Jaz]
So let’s talk about that, right? 

[Rachel]
Yeah. 

[Jaz]
To make it easy for dentists, the best thing is the pens. So I imagine this is cost effective to do it this way. 

[Rachel]
So don’t quote me on this, but I believe that one ampule is about 8P might have gone up recently. 

[Jaz]
Eight pens?

[Rachel]
Yeah. 

[Jaz]
An ampule– 

[Rachel] About that. 

[Jaz]
You think that is that, is that with the adrenaline inside?

[Rachel]
Yes. No, that’s just the glass. But as I say, don’t quote me, that was a long time I got told that. Whereas roughly nowadays, I believe a prefilled auto-injector is about 40 pounds, something like that. So in terms of cost saving. If people are happy drawing up drugs you’re medical professionals, you’re going to clearly go for the ampules. The other thing is, you’ve got 20 doses here because one milligram vial gives you two adult doses because it’s 500 mics. So you get two doses in one vial. 

[Jaz]
Two doses, but once you’ve used one, once you’ve opened an ampule.

[Rachel]
You can still use it for your second dose. You just pop the second dose five second. 

[Jaz]
Okay. But like, it’s like really though, I know you’ve got 20 doses. 

[Rachel]
Yeah. 

[Jaz]
But you’ve got 10 people there. Do you see what I mean? 

[Rachel]
Yeah, you’ve got 10 ampules, but you get two dose– 

[Jaz]
Two doses.

[Rachel]
In an ampule. Fine. So you’ve bought yourself a lot of time because we’ll talk about the in a minute, I’m sure you’ll ask about how often you give it? 

[Jaz]
Yes. 

[Rachel]
But this is clearly way more cost effective, than having–

[Jaz]
Let’s check the expiring on that. 

[Rachel]
Yeah. So you get a lot more on a box of ampules than you do with a–

[Jaz]
So more time more time before it expire 

[Rachel]
Yeah. Whereas with an autoinjector you get about a year to 18 months. 

[Jaz]
So this is two years. From here, basically I can see, so the date of manufacturers December 2023, expiry December 2025. 

[Rachel]
So you get an extra year, six months to a year on expiry. 

[Jaz]
So in balance, it’s not something we see often, right. Anaphylaxis as we already discussed. But when you have an ideal world, I’m just being a diva associate and be like, “Hey, why can’t we have EpiPen? Yeah. But really if I push company shelves, I’ll be able to get some G. I’ll break the thing. Yeah, I’ll draw it up. Okay. I might do a sloppy job of it. Okay. 

[Rachel]
Do you know what a lot of my other dental practices do, is they get those large oranges and then when their adrenaline expires, they all practice, they all go around with a needle and they practice injecting it into the opening ampule and injecting it into the orange. And they find it really helpful because just even opening a glass ampule, people get nervous because they think it’s going to cut.

So my top tip for opening an ampule is you need to go on the blue dot of the ampule and I always get a paper towel and then I pop the paper towel with the ampule when I crack it. 

Because then if it does split off, it’s not going to go in my thumb because I’ve been there and done that where I’ve had a bit of adrenaline in my thumb where I cracked it. My other top tip is to make sure you get the little fluid out of the top of the ampule. If you just slide it across the workstation, it just takes the fluid out of the top bit. 

[Jaz]
Explain that one again. 

[Rachel]
So in every ampule you’ll usually get where it shakes around, you’ll get a bit of a fluid in the actual bit where you are capping it off. 

[Jaz]
Yes. 

[Rachel]
So then you’ve got adrenaline everywhere and you’ve lost a little bit of your fluid by just dragging it across the surface, but it just takes the fluid out. 

[Jaz]
So dragging itself before you open. 

[Rachel]
Before you open it. 

[Jaz]
Okay, now I got it. 

[Rachel]
And then what happens is it drops the bit of fluid back down into the bottle. So when you crack it open, you don’t get adrenaline your thought. 

[Jaz]
We don’t get a mess and you don’t get wasted. So let’s say let’s open the box, get some tissue paper. Break open the ampule using the blue dot side, basically. 

[Rachel]
Correct. 

[Jaz]
And then I will get the needle. So the needle is the one that’s already been labeled? Okay. So I like the system. I’m liking this. And then the dose is already written here on a sicker, so my adult over 12 years has 0.5 mil, 0.5 mil it’s 500 micrograms. 

[Rachel]
Micrograms of the 1 in 1000. 

[Jaz]
Yes. 

[Rachel]
There’s two types of strength of adrenaline. You’ve got the one in 10,000 which is what we use, or what is recommended for cardiac arrest. And then you’ve got the one in 1000, which is used for–

[Jaz]
So much stronger. 

[Rachel]
Yeah. So, your practice isn’t going to usually buy the wrong thing and you’re not going to have a cardiac arrest, so you don’t need to get confused about what’s in your bag. But you are going to take 500 micrograms, which essentially is 0.5 mls because in each vial you get one milligrams. 

[Jaz]
So I would be drawing up half the liquid basically. Yeah. And then I’m going to be giving it to my patient and that this is me. From my memory. Upper outer thigh. 

[Rachel]
Yep, because you’re going to it’s intramuscular. So the thigh is a very good muscle to inject into. If you’re doing it correctly, you should go in and then pull back to make sure you’re not in a vessel. But a lot of people don’t do that, and they just literally inject straight in. 

[Jaz]
That’s what you see in the movies like.

[Rachel]
Yeah. 

[Jaz]
No one shows it where they just check. 

[Rachel]
No one does a little fallback, and then you instantly reassess your patient. So once you’ve done something in medical practice, you reassess to make sure that it’s worked. So you— 

[Jaz]
How quickly, I mean, have you ever had to do this from a patient?

[Rachel]
Yeah. Loads. Yes. 

[Jaz]
Tell us how soon-

[Rachel]
It works very quickly. I mean, within the minute, I’d start to hope to see an improvement within my patients. 

[Jaz]
So what it isn’t it- 

[Rachel]
It’s an amazing drug. Yeah, it is lifesaving because what it does is it acts in the reverse of what histamine being released does. So we talked about earlier that histamine causes vasodilation and bronchoconstriction, while adrenaline causes bronchodilation, vasal restriction. So you are basically reversing the effects or hoping to of the anaphylaxis. 

[Jaz]
But the fact that you’re getting all the symptoms up here and then, and the upper out thigh and how quickly it travels is remarkable. 

[Rachel]
It is remarkable. I mean, you are hoping that it’s going to show that. It might not patients might need back to back. And we talked about the dose, but actually the time between doses is five minutes. So every five minutes–

[Jaz]
I mean that five minutes is like five hours.

[Rachel]
It will be, especially when your patient’s saying I can’t breathe and they’re looking awful. And you know, in hospitals we’ve got them attached to monitoring and we can actually see how awful they are. Whereas in a way, being blind is sometimes helpful because you can’t see the fact that blood pressure’s dropped. 

You can’t see the fact that they’re tachycardic. So you’re kind of waiting, you set your stopwatch because you shouldn’t have to try and find a clock and be like, oh, just remember what time we gave it. So set your stopwatch for five minutes and then when the five minutes goes off, you give another dose if there’s–

[Jaz]
Should you need to. Right?

[Rachel]
Should you need to. It’s no improvement. 

[Jaz]
Yeah. So in your experience, how many patients have you jammed who are getting real anaphylaxis? 

[Rachel]
Gosh, in my whole career? 

[Jaz]
Yeah.

[Rachel]
Not as many as you’d probably think, but maybe like 50. 

[Jaz]
Okay. So of them, how many needed the second dose? 

[Rachel]
40? 

[Jaz]
Oh, so we will need it then. Okay–

[Rachel]
Absolutely. 

[Jaz]
See, that’s useful. No one talks about that. Yeah. Right. Even you should have told us that last time you were here. 

[Rachel]
Sorry, I’ll put it in my script for next time, but no, you’re not. Particularly if they’re as severe as we’ve described this, we are describing a very severe case of anaphylaxis, and actually one shot is not going to necessarily get them better. It’ll help, but you may need to give a second dose, a third dose, and just remember that the GPS only actually prescribes patients with two autoinjectors, so they’ve only got 10 minutes. And then they need an ambulance with them to potentially give them the next dose. Obviously you are hoping that it will make a big improvement and it’ll buy time.

But there have been some, big cases that we’ve heard about in the news where patients have even had other people’s EpiPens that they kind of volunteered their EpiPen forward or to inject should I say. 

And even then, they’ve not been enough. So having the– I always think having ampules is better because we talked about the fact you’ve got 20 doses in there, whereas if you just had one EpiPen, that’s one dose. 

[Jaz]
I didn’t think about it that way. And actually you’ve actually changed my perception of it. Because I was thinking, ah, this is a cheap way of doing it. Yeah. And it’s annoying for me. But you’re right. But you, if a practice hasn’t an auto-injector to use the correct word, will they only have one? 

[Rachel]
So usually they only purchase one because they’re so expensive–

[Jaz]
And therefore is good for two shots, right? Or–

[Rachel]
And no. So there’s three main ones on the market that I know of. You’ve got epiPen, Jext, and Emerade. 

[Jaz]
So epiPen’s like the Hollywood one, everyone’s heard of– 

[Rachel]
Everyone– because everyone calls all of them EpiPen. It’s actually an autoinjector.  Yeah. So you’ve got EpiPen,  Jext, and Emerade.. Now EpiPen and Jext are a 300 micro crown dose. Now if you look up your chart—

[Jaz]
How do we do that?

[Rachel]
Exactly. We’ve tried looking this up over years and years about why they are erring on the side of caution by only putting 300 mic, which is actually a child’s between six and 12 dose. But we don’t know why they’ve done it. Whereas Emirate do a full 500 microgram dose. But the trouble with these autoinjectors, is that the shortages the one that every single time. 

So if I say, Emirate would be the best one to get. You can guarantee there’ll be a shortage of it. So it is kind of whatever you can get hold of. But when you think about it, most people get given two, but they’re only getting two 300 microliters. And also they usually only ever carry one. Because they leave the other one somewhere else. 

[Jaz]
So really got like three minutes or four, like if it works-

[Rachel]
I really need to carry two. That’s my advice for everybody that’s listening–

[Jaz]
That’s using those brands that have 0.3. 

[Rachel]
Well, even 0.5 because really you’re going to get an ambulance within five minutes. 

[Jaz]
It’s true. 

[Rachel]
You’re not. So you need to be carrying two at all times. And people don’t, and particularly if you’re teenagers, you know, you’ve got a handbag that doesn’t fit it. It’s tricky. And you need to make– so I actually think that in a medical center, Ampules are better. 

[Jaz]
There we are. There you are. 

[Rachel]
Plus saving plus you’ve got more doses. 

[Jaz]
I’ll have to apologize to Chris I hit my hand. Okay, fine, so that’s useful. Now we haven’t talked about this, right? So let’s say I’ve jabbed my patient. They’re starting to feel a bit better. But how much better do I want them to be before I give them five minutes to give them the next dose? And also we haven’t talked about whether I need to give them an auction and at what point do we call the ambulance? 

[Rachel]
So oxygen is a must because of course they’re short of breath. They’re going to– 

[Jaz]
So epipen first or oxygen first? 

[Rachel]
I would go epipen first. If I didn’t have multiple people doing multiple things, obviously in an ideal world, you’d have you and Chris and your Dental nurse and you’d all–

[Jaz]
Yeah. It’d be teamwork. We do a big shout out every camp. 

[Rachel]
Yeah. So one of you would be putting oxygen on one of you would be giving the autoinjector or the ampules, and the other one would be raising the legs, because of course, what’s happened with histamine being released, vasodilation. So what you want is to pull that perfusion back, raise the legs.

So yeah, oxygen is really important if you’ve got it. And you are in your dental practice. So there’s three parts to a cylinder. Usually you’ve got the little gray cap that you need to flip down. You’ve got the little–

[Jaz]
Shall I bring it? 

[Rachel]
Yeah, sounds good. 

[Jaz]
Okay. So we’ll still make it descriptive for those listening, but anyone who’s watching, we’ll make it visual. I walked in the room with this big green bag. It doesn’t actually say oxygen on it. It says lifeline emergency recess equipment. I actually wanted to say, O2 oxygen’s on it. So this is the first time I’ve ever had to get oxygen. 

Ah, I’ve never had to give oxygen either. So for me, that’s a thing I’m learning a lot here in terms of the actual experiential, real world simulation or what could happen in this practice. So there we are, so the green bag, I imagine stop at the top there, we ask, see I don’t know where the zip was guys. So this is definitely new for me. 

[Rachel]
And then the other one. 

[Jaz]
And the other one, look at that. So Rachel has been very, very helpful in terms of you’ve-

[Rachel]
It’s a nice bang. 

[Jaz]
It’s not, it’s not your first rodeo? 

[Rachel]
No. And then-

[Jaz]
Okay. Is a stroke. 

[Rachel]
Yeah. 

[Jaz]
And are they all like this?

[Rachel]
In hospital we just have them on the side of our trolleys, but yes, in the dental world and the GP world, they usually are. Yeah. 

[Jaz]
And so as soon as I open it again, laminated cards, and it’s a Resus. And this one is August, 2023. 

[Rachel]
So someone’s obviously put their own little— but yeah, they’re fine. Yeah. Perfect. 

[Jaz]
And this is for pediatric?-

[Rachel]
Because it’s the 2021 guidelines, which is exactly what you want. 

[Jaz]
Okay. Yeah. Perfect. So anyway, I’ve just diagnosed someone with anaphylaxis. I want to go straight for the kilt and we get this tank here. 

[Rachel]
So yeah, you want to pull the auction out of, its that will holder. 

[Jaz]
So there we are. It’s got a nice little so it’s got a brick on it guys. It’s got a brick now. Yes. This is what I want. Something that clearly has oxygen on it. 

[Rachel]
Yes. 

[Jaz]
Okay. So don’t actually do it because I don’t want to get down back, Chris. 

[Rachel]
No, I understand. So what you’ve got at the front is obviously how much is in there. So you can see it’s in the green. So you pretty much got a full tank. If it’s in the red, you need to replace that. And then you’ve got the gray part that I was talking about, which is essentially the bit you’re going to flip down. 

[Jaz]
Ah, that’s easy. 

[Rachel]
Yep. Really easy. And then that means now you’ve got your port to put the mask connected to. And then the other back part that I was talking about is this part here where it says open. Now they should be always set on clothes because obviously you don’t want any worries about leaking oxygen. 

So what you would do is turn it the way it says open, which don’t worry, this isn’t going to do anything. So you turn it really easy and then now you can just turn up your dial. Like so all the way to 15, which is the maximum that you can go and you would give your patient 15 liters of oxygen. 

[Jaz]
So in dentistry, am I right in saying it’s easy? Because the answer is always 15.

[Rachel]
To be honest, with a non rebreed mask, which is the one you are going to have in your bag. The answer is always 12 to 15. But I would just go 15 because why like, let’s not confuse matters. 

[Jaz]
No. 

[Rachel]
Because that’s the highest amount you can go. If they’re having a severe anaphylaxis, you’d want to give 15 liters anyway. But you can drop down to 12. I don’t want to overcomplicate things, but in hospital we might err on the side of caution if we have patients with long-term respiratory conditions and we wouldn’t want to flood them with oxygen. But in the community you are not thinking like that. You’re thinking I need to treat what’s in front of me. So I’m going to give them 15 liters. 

[Jaz]
Okay. So 12-15, I think I always remember 15. 

[Rachel]
Yeah. 

[Jaz]
So that’s easy to do. I mean, I was in the receiving end of oxygen recently. Actually last month I had a pneumothorax. A spontaneous pneumothorax. My lung collapsed and so I was there in hospital just like on oxygen. And actually, you know what, 15 liters for someone who wasn’t then, you know, yes, it was kind of acute, I guess, but I felt the flow. It was–

[Rachel]
I mean, piece of pneumothorax is pretty acute. 

[Jaz]
It was pretty acute, but even then I was like, whoa, this is a nice brush of box suit. 

[Rachel]
Yeah. So was it on the reservoir bag? 

[Jaz]
It was in a nasal tubes in my nose. 

[Rachel]
Okay. Yeah, you probably wouldn’t have as high as that, but–

[Jaz]
Okay. Admission guys. Here’s me being very honest, I think they said to me as 10 or eight. But then I was like, Hey, I’m a dentist. I’m number 15. So I turned it up myself was 15. 

[Rachel]
I love your honesty.

[Jaz]
So maybe it makes sense now. 

[Rachel]
Maybe that’s why I was so high. 

[Jaz]
Okay, so I found the oxygen, and I know where it looks now I know where the bag looks like. I know how to open the zip and the velcro now. 

[Rachel]
And the top tip for giving your patient via your non rebreed, because they’re called a non rebreed mask, is that you must make sure that you fill up the reservoir bag. So you might see a lot of medical programs like Casualty@Holby City , where they leave a flat bag on a patient’s chest. And actually then you’re not getting the proper oxygenation through the reservoir bag. So put your finger over the valve, make sure it fills up with the oxygen before you pop it on their face. 

[Jaz]
Okay.

[Rachel]
Because that’s a really key thing with non-rebreather masks. 

[Jaz]
I think the next time you’re here I think these kind of things that we’d like to see and do. 

[Rachel]
So click on. 

[Jaz]
Yeah, exactly. So that makes it very useful. So while we’re on the topic of oxygen, what are the different conditions? So moving, stepping slightly away from anaphylaxis, we’ll come back down to anaphylaxis. But what are all the different medical emergencies that we may see as a dentist that require oxygen? 

[Rachel]
So probably the most common one would be asthma. So patients could come in you can get patients who manage their asthma really well, or you can get patients that even just a bit of pollen can trigger off their asthma. Or the fact that they’ve walked here or something or ran here. And patients might come in feeling a bit wheezy, short of breath. They might tell you that their asthmatic, you’d hopefully know with an adult, whether they’re asthmatic or not, they should know. And severe asthmatics would need, or a sort of, we call it an asthma attack, but if somebody is suffering with their asthma, they might need oxygen because actually their oxygen saturations will drop. So that’s one of them– 

[Jaz]
Which actually reminded me should we be– because there’s a lot of people, lot of practice have got those oxygen, sat–

[Rachel]
I’m sure you did have one. Yeah. But they could be wrong. But yeah–, 

[Jaz]
I feel like it’s so cheap.

[Rachel]
They are cheap. COVID made them a lot more accessible, didn’t they? So, yeah, I mean, I think they’re really helpful. Obviously, if your patient is peripherally shut down, the peripheral or cold, or you know, there’s not enough blood going to them, then they’re not, it’s not going to give you an accurate figure. So you just need to be mindful that obviously it’s not the be all and end all, but they give you a good indicator of, and it should be above 94%.

[Jaz]
Yeah, but if they’ve got anaphylaxis, we know the guidelines are oxygen, so–

[Rachel]
Correct. 

[Jaz]
Asthma.

[Rachel]
Just give it anything. 

[Jaz]
Oxygen– 

[Rachel]
Asthma, if they’re their sort of severe life-threatening asthma, you need to give them oxygen, obviously cardiac arrest, but that’s again, a bit of a given. We could continue down the lines of all the respiratory burden and how far you want to go. 

But patients with COPD that are really struggling, so chronic obstructive pulmonary disorder, if they’re really severe, they may need oxygen. But we’re also very cautious with those. Yeah. But they can’t have too much oxygen because they retain it or retain the carbon dioxide. 

[Jaz]
Are there any medical motives that we see as dentists that actually oxygen is contraindicated? Because, you know what, I’ll be, I’ll be honest with you, because I’m thinking like when post comes to serve. I’m like trying to remember everything. I’m like, oxygen probably sounds a good idea. You know, a lot of people might just say, just get the oxygen anyway, kind of thing. Could we be doing more harm? 

[Rachel]
The only thing really is chronic obstruct pulmonary.

[Jaz]
Very niche. 

[Rachel]
Yeah, very niche. And actually the rule is really, is that you always treat hypoxia first before hypocapnia. So you must treat their oxygen levels before anything else. So I can’t really think of a reason not to give it. With heart attacks, myocardial infarctions, they say that as long as the saturations are above 94%, you can hold off oxygen. Whereas they used to say, give everybody oxygen. That was having a— 

[Jaz]
That was my thought. Yeah.

[Rachel]
But actually. If in doubt give it because it’s better to give than to make somebody hypoxic essentially. But in hospital we would measure their saturation levels and we would titrate it against making sure they’re above 94%. But no, I can’t think of anything that you are going to really—

[Jaz]
Because I remember listening to you when you come every and most times you say, grab the oxygen. it makes sense. So it’s good to know that, and it’s reassuring. But back to our anaphylaxis, fake scenario, I’ve given the upper outer. Zoe, my nurse got the oxygen. We put it on, we’ve filled up the reservoir bag. Good. Okay. You’ve shown us or describe it to us exactly the three step process. So the gray thingy, the gray lid–

[Rachel]
The gray cap, pull that down. Turn the auction, the black controller, turn that to on and then stick the oxygen, you know, tubing onto it turn it on three steps. 

[Jaz]
And so nice little dial fifteens, the max. 

[Rachel]
Correct. 

[Jaz]
Take it there and then put it on the patient. 

[Rachel]
And how long is it going to last, roughly? 

[Jaz]
Ooh. Oh, I love this. For some reason 40 minutes came from my head. 

[Rachel]
So not exactly, but between sort of 15 to 20 minutes on 15 liters.

[Jaz]
Okay. 

[Rachel]
So it runs out pretty quick. 

[Jaz]
Yeah, it does. 

[Rachel]
And one of the practices that I taught at did run out. They had an asthmatic and this was more GP so don’t freak out. But yeah, as GP practices run out of oxygen and they have to wheel their patient across the road to the care home to plug them into the wall oxygen. So it’s a bit of a lesson that they then bought a massive cylinder, but you guys aren’t using it as much as GP surgeries are, so that’s fine. 

[Jaz]
Okay, so you get 20 minutes on that. But a patient who’s got oxygen, we’ve given one dose. How do you know– are we looking for complete resolution or if they’re feeling a bit better? Okay, we’re good. And at what point should the ambulance be caught?

[Rachel]
Straight away because you’ve given adrenaline and actually you can get rebound anaphylaxis. So you could actually feel you could get another rebound in an hour. 

[Jaz]
So as a team, like one person get the auction, or another person get the adrenaline can reception, please call 999. 

[Rachel]
Correct. 

[Jaz]
And say we suspend anaphylaxis. And then, oh, away you go. 

[Rachel]
Yeah. And I guess. It very much is a clinician decision. If your patient is much better, then no. Do you need to give another one after five minutes? No. But if you are kind of umming and arring and they still look pretty gray and they still say that their breathing doesn’t feel gray–

[Jaz]
It means pretty good stuff. Right. 

[Rachel]
It’s good stuff. And also, you know, we’re not going to cause much harm with adrenaline. So if we gave it and they didn’t necessarily need it, they’re going to feel like they’ve got a bit of a fluttery heart rate. But I thought dentists gave adrenaline anyway for– 

[Jaz]
Yeah. With an anesthetic. And it’s quite often when we go in a vessel, they feel straightened out. I’ve had it by myself before I’ve had an injection in my lower incisor region. And my heart sight racing straight away because it was injected into my vessel and that’s fine. 

[Rachel]
Just get them to run around the block a few times and they’ll burn it off. The good thing is it’s got such a short half life that if you gave it and you weren’t quite sure, it’s going to wear off very quickly. So I guess it does go back to a little bit of what you’ve got, the picture you’ve got in front of you, IE the patient. And do you think that they could benefit from another dose? Just to keep that breathing going, just to keep their blood pressure steady. If I was in doubt and I thought, actually, I’m not sure, I’d give another dose just to make sure.

[Jaz]
Do I remember correctly that at some point in the guidelines it had hydrocortisone?

[Rachel]
Yep. So in the previous

[Jaz]
Or anti tomine as well? 

[Rachel]
Yep. There was amine and hydrocortisone. Now it’s a bit of a gray area because they removed it from the initial algorithm in 2021. That doesn’t mean that we don’t give it, it just means that it’s not part of your initial management. 

So when you are presented with a patient with anaphylaxis, say you are having one right now, what I don’t want is someone saying, quit, go and get the Piriton because the Piriton isn’t going to vasoconstrict and bronchodilate, it’s going to help with the source of all the helping with the background allergy, but it’s not going to save your life.

So by removing it from the initial algorithm and putting it in sort of refractory anaphylaxis, it stops people running for the wrong drug–

[Jaz]
Wrong priority-

[Rachel]
And it makes you prioritize the adrenaline a lot more. 

[Jaz]
So, which in that imagining patient I described, should I also be supplementing it with an antihistamine?

[Rachel]
Correct. Yeah. 

[Jaz]
At what point? Which order? So you’ve got I’m high oxygen, adrenaline. 

[Rachel]
Pull your patient out in terms of an airway point of view, in terms of a perret point of view because obviously if we leave this patient. You know, they could go into cardiac arrest. So try and manage that acute side of things and once you feel like you’ve got time and you’re not trying to draw up drugs and keep the patient calm and raising the legs, then you can reach for the Chlorphenamine and just make sure that their swallows okay. 

[Jaz]
And Chlorphenamine is that tablet form? Okay. 

[Rachel]
Yeah, I mean, in hospitals we can give it. 

[Jaz]
So, I mean, antihistamine, I’ve taken the past the scene, but we’re not talking about that. Right. Or-

[Rachel]
Yeah. So Chlorphenamine is Piriton, you’ve got cetirizine or loratadine. 

[Jaz]
So you can give any of those? 

[Rachel]
Yeah, you can give them. You just need to make sure they’ve got safe swallow. Because what we don’t want to be doing, if they’re swollen, we don’t want them to risk aspirating or anything. So just make sure that their swallow is safe. 

[Jaz]
Okay. Perfect. Now, when I opened up this kit and it says severe allergy, should there not be some cetirizine or something. 

[Rachel]
Yeah, it would be helpful to have like a Piriton there, but as long as we remember that the initial algorithm is anaphylaxis fluids or raise the legs, obviously we know that dentists don’t give fluids. And oxygen, so what we worry about is putting something like Piriton in there or is it, you’ll forget about the rest of it and just give, so I guess it’s up to the Dentist–

[Jaz]
It makes sense that we’ve done the important things. Okay. So I did actually find the pulse ox in there, but no sign of any cetirizine or chlorphenamine. Okay. Chlorphenamine, there’s none of that. But that’s fine because you explained why adrenaline is the most important thing. but I think it’s a good idea perhaps for it to be floating in the bag somewhere just to give–

[Rachel]
Or even in your practice, like a cupboard or something, that if you don’t have room and whatever bags you have, then you can always put it in the surgery somewhere. Because as I say, it’s not an immediate life sort of saving medication, but it does help with the aftermath of a, alternatively, you know, you should be getting an ambulance fairly quickly. So it is something the hospital can always give. 

[Jaz]
Okay, great. So that wraps up Vasovagal Syncope and anaphylaxis. We also talked about oxygen and we talked about different modes of delivery of the adrenaline. Was there anything else that we want to talk about in terms of the adrenaline itself in terms of the different, we talked about Emerade having the correct dose, but being difficult to get hold of. 

[Rachel]
Yeah. 

[Jaz]
And the EpiPen and the Jext being a smaller dose, and that makes, you know, ideally they should have two, but time is of the essence. Three–

[Rachel]
Emirate, I believe have a one 50 dose, a 300 dose, and a 500 dose, whereas I believe that Jext and EpiPen just do a 300– but don’t quote me, but I believe. Yeah. Yeah. That’s what I’ve sort of been told. 

Jaz’s Outro:
Okay, great. Well, there we have it. Guys, thank you so much for listening to our first ever series on medical emergencies, mandatory training, but hope you found the style of listening or watching this wherever you caught the episode, that it was a bit more relatable, more tangible, and more enjoyable than someone just telling you about all the drugs and, and speaking at you.

Shout out to Rachel King Harris. She did a wonderful job and is very excited to share part two with you next week. If you’ve got this far, you deserve your CE credit. Head over to protrusive.app to choose a plan that suits you and if you are just ready to actually go for it and make this your best year ever and check out all our mass classes from Verti Preps, from Resin Bonded Bridges, sectioning School and CPD for all the previous episodes. You need our Ultimate Plan. 

However, to protrusive.co.uk/ultimate. I do want to thank Team Protrusive as well for this one it would be Gian, Kriselle, Nav, Erica for the publishing, and Mari our CPD Queen who looks after you to make sure you get all your certificates. Thanks again, guys, and catch you same time. Same place next week. Bye for now.