You have just given a nerve-block local anaesthetic injection to an elderly patient who is worried about her dental visit. She did not sleep well, and has not eaten much today. Her medical history indicates she is taking oral medication to control mild diabetes, and thyroxine for hypothyroidism. Otherwise nil relevant.
As you withdraw the needle, she says she is feeling a bit strange and light headed. Her breathing appears to be normal as she says this.
What are the possible causes at this stage?
In order of probability -
Syncope (fainting, including fainting due to hypotension)
Hypoglycaemia
Partial (“Petit Mal”) epileptic seizure
Painless (“Silent”) Myocardial Infarction
You notice her airway is clear, and her breathing is shallow but regular, with a slight wheeze. While you have been doing this, your receptionist has brought in the emergency kit.
What should you do next?
Check her circulation as follows.:
- Take her pulse.
- Look at her skin colour, and the colour of the oral mucosa: Pink? Blue? Mottled? Pale?.
- Check her capillary refill time – press on her finger for 5 seconds to blanche it. The colour should normally return in 2 seconds.
- Check her pupils. Are they normal or dilated?
Her circulation appears to be mostly normal, although her pulse rate seemed a bit slow at 55 bpm, and she looked a little pale. However, while examining her you noticed her skin was clammy and cold.
What should you do next?
You should finish your assessment: “Disability” and “Exposure”. Only interrupt the assessment if you think there is an immediate life-threatening condition.
After a few minutes, the patient starts to regain consciousness. She has a clear memory of what happened and how she felt just before she became unresponsive.
What is your definitive diagnosis, and how would you continue your management today regarding her dental treatment?
The very clear memory of what happened, plus the lack of previous history, would indicate this was a syncope (faint).
If the patient appears fully recovered, and is happy to continue treatment, this can be provided, preferably in the supine position.
When the patient leaves the chair, allow her to do so slowly. Circulatory haemodynamics can be unstable for a few hours after a faint (i.e. there is a higher chance of another one later): she should be made aware of this, and preferably escorted home.
Make full notes about the incident in the patient record, and in the Practice Incident Book.
Review the episode with the whole team as part of a staff training session.
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