The aim of this article is to serve as a reminder of the responsibilities of GDC registrants in respect to medical emergencies, to inform the reader of how to perform basic life support in Adults and the use of an Automated, External Defibrillator.
What is the responsibility of the dental team?
GDC registrants have a duty to keep skills and knowledge up to date to ensure patients have the best possible treatment and care (General Dental Council, 2012). Dental care professionals should keep up to date with training in medical emergencies and how to deal one should it arise. The dental team may be faced with a medical emergency at any time and it is vital that the whole team are aware of how to deal with this and their responsibilities in such a situation. As well as refreshing the theory in basic life support it is also important to carry out practical refresher training on a regular basis and it can be useful to play out scenarios as part of team briefings in the dental surgery, to help ensure the team is aware of their role should the scenario occur in this setting. The GDC advise Dental Care Professionals to carry out 10 hours CPD on medical emergencies per 5 year cycle.
Adult Basic Life Support according to the Resuscitation Council
Firstly make sure the victim, any bystanders, and you are safe.
Check the victim for a response by gently shaking their shoulders; ask loudly ‘Are you all right?’
If they respond, leave them in the position in which you found them provided there is no further potential danger. Try to find out what is wrong with them and get help if needed, keep reassessing them regularly.
If they don’t respond, shout for help. Turn the victim onto their back and then open their airway by placing your hand on their forehead gently tilting the head back, with the fingertips of the other hand place them under the point of the victim's chin and lift the chin to open the airway.
Keeping the airway open, look, listen, and feel for normal breathing.
Look for chest movement.
Listen at the victim's mouth for breath sounds.
Feel for air on your cheek.
Look, listen, and feel for no more than 10 seconds to determine if the victim is breathing normally. If you have any doubt whether breathing is normal, act as if it is not normal. In the first few minutes after cardiac arrest, a victim may be barely breathing, or taking infrequent, noisy, gasps. This is often termed agonal breathing and must not be confused with normal breathing. If they are breathing normally, turn them into the recovery position.
There are several variations of the recovery position, each with its own advantages. No single position is perfect for all victims. The position should be stable with no pressure on the chest to impair breathing.
The Resuscitation council UK (2010) recommends the following sequence of actions to place a victim in the recovery position:
10 steps to the recovery position
- Remove the victim’s glasses, if present.
- Kneel beside the victim and make sure that both his legs are straight.
- Place the arm nearest to you out at right angles to his body, elbow bent with the hand palm-up.
- Bring the far arm across the chest, and hold the back of the hand against the victim’s cheek nearest to you.
- With your other hand, grasp the far leg just above the knee and pull it up, keeping the foot on the ground.
- Keeping his hand pressed against his cheek, pull on the far leg to roll the victim towards you on to his side.
- Adjust the upper leg so that both the hip and knee are bent at right angles.
- Tilt the head back to make sure that the airway remains open.
- If necessary, adjust the hand under the cheek to keep the head tilted and facing downwards to allow liquid material to drain from the mouth.
- Check breathing regularly.
NOTE: If the victim has to be kept in the recovery position for more than 30 min turn him to the opposite side to relieve the pressure on the lower arm.
Summon help from the ambulance service by mobile phone. If this is not possible, send a bystander. Leave the victim only if no other way of obtaining help is possible. Continue to assess that breathing remains normal. If there is any doubt about the presence of normal breathing, start CPR.
What if they are not breathing or not breathing normally?
Ask someone to call for an ambulance and bring an AED if available. If you are on your own, use your mobile phone to call for an ambulance. Leave the victim only when no other option exists for getting help.
Start chest compressions:
- Kneel by the side of the victim.
- Place the heel of one hand in the centre of the victim’s chest (which is the lower half of the victim’s sternum (breastbone).
- Place the heel of your other hand on top of the first hand.
- Interlock the fingers of your hands and ensure that pressure is not applied over the victim's ribs. Do not apply any pressure over the upper abdomen or the bottom end of the sternum.
- Position yourself vertically above the victim's chest and, with your arms straight, press down on the sternum 5 - 6 cm.
- After each compression, release all the pressure on the chest without losing contact between your hands and the sternum. Repeat at a rate of 100 - 120 min-1 .
- Compression and release should take an equal amount of time.
Continue with chest compressions and rescue breaths in a ratio of 30:2. Stop to recheck the victim only if he starts to show signs of regaining consciousness, such as coughing, opening his eyes, speaking, or moving purposefully AND starts to breathe normally; otherwise do not interrupt resuscitation.
If the initial rescue breath of each sequence does not make the chest rise as in normal breathing, then, before your next attempt:
Check the victim's mouth and remove any visible obstruction.
Recheck that there is adequate head tilt and chin lift.
Do not attempt more than two breaths each time before returning to chest compressions.
If there is more than one rescuer present, another should take over CPR about every 1-2 min to prevent fatigue. Ensure the minimum of delay during the changeover of rescuers, and do not interrupt chest compressions. Continue until the ambulance arrives.
Automated External Defibrillator
An Automated External Defibrillator (AED) is a safe, reliable,computerised device that can analyse a heart rhythm enable a non-medically qualified rescuer to safely deliver a live saving shock to the victim of a cardiac arrest. Automated External Defibrillators (AEDs) will reduce mortality from cardiac arrest caused by ventricular fibrillation and pulseless ventricular tachycardia. The widespread deployment of such devices throughout the UK and the Department of Health’s ‘Public Access Defibrillation’ programme has ensured that such machines are now readily available and in common use.
According to guidance for dental practices (The Resuscitation Council, 2012) all clinical areas should have immediate access to resuscitation drugs, equipment for airway management and an automated external defibrillator (AED). Staff must be familiar with the location of all resuscitation equipment within their working area. The provision of an AED enables all dental staff to attempt defibrillation safely after relatively little training and their use is therefore recommended. These defibrillators should have recording facilities and standardised consumables, e.g., self-adhesive electrode pads, connecting cables. Adult AEDs can safely be used on children over 8 years old. Some machines have paediatric pads or a mode that permits them to be ‘attenuated’ to make them more suitable for use in children between 1 and 8 years of age. These modifications should be considered for practices that regularly treat children. In cardiac arrest situations when paediatric pads or attenuation are not available, a standard adult AED may be used in a child over 1 year old. Staff should be familiar with the device in use on their premises and its mode of operation.
Sequence of actions when using an automated external defibrillator
The following sequence applies to the use of both semi-automatic and automatic AEDs in a victim who is found to be unconscious and not breathing normally.
Follow the adult BLS sequence as described above. Do not delay starting CPR unless the AED is available immediately. If more than one rescuer is present, continue CPR while the AED is switched on. If you are alone, stop CPR and switch on the AED.
Placement of AED pads
Place one AED pad to the right of the sternum (breast bone), below the clavicle (collar bone). Place the other pad in the left mid-axillary line, approximately over the position of the V6 ECG electrode. It is important that this pad is placed sufficiently laterally and that it is clear of any breast tissue.
Although most AED pads are labelled left and right, or carry a picture of their correct placement, it does not matter if their positions are reversed. If this happens ‘in error’, the pads should not be removed and replaced because this wastes time and they may not adhere adequately when re-attached.
The victim’s chest must be sufficiently exposed to enable correct pad placement. Chest hair will prevent the pads adhering to the skin and will interfere with electrical contact. Shave the chest only if the hair is excessive, and even then spend as little time as possible on this. Do not delay defibrillation if a razor is not immediately available.
For dental professionals working with the public it is vital to keep up to date with the latest advice on basic life support. A medical emergency could happen at any time and dental professionals have a responsibility of care for the patients they are treating. AED’s are an important tool in basic life support and can help increase the chances of survival when used as part of BLS. Ensuring the dental team have up to date knowledge and training could save a patient’s life.