FAINTING (VASOVAGAL SYNCOPE): CASE REPORTS L HARDWICK1
Introduction ABSTRACT The paper presents four examples of patients fainting. Although we all undergo yearly CPD updates, until you experience a medical emergency, you can never truly be ready for one. Prim Dent J. 2013; 3(1) 65-66
KEY LEARNING OUTCOMES • How to diagnose syncope (fainting) • How to treat syncope (fainting)
I have seen several patients faint in general practice in the last 12 months. When I experienced my first medical emergency, I found it difficult to be sure that the patient was definitely fainting and was assisted by senior members of the team. Having now witnessed a number of patients fainting, I have seen that they mainly follow the same pattern.
About fainting A faint, otherwise known as vasovagal syncope, is the most common medical emergency that can occur in general dental practice, with a reported prevalence of 1.9 cases per dentist per year.1 Fainting is caused by a lack of oxygen to the brain, leading to a loss of consciousness.2 Patients could present with the following symptoms: • Feeling faint/dizzy/light-headed • Becoming pale • Feeling cold and clammy • Feeling/being sick • Becoming unconscious1
Treatment • • • •
Lie the patient flat Raise the patient’s legs Give 15 litres of oxygen per minute If the patient becomes unresponsive, check for signs of life and start cardiopulmonary resuscitation in the absence of normal breathing or signs of life
Usually a higher proportion of females suffer from syncope.3 In the last 12 months I have been present at four episodes of fainting, affecting two male patients and two female patients. I have included these as case reports.
two appointments proceeded without incident. During the third appointment, several fillings were completed and a retained root of the UR3 was removed without problems. The patient wished to see the root of the tooth. After this, while going through post-operative instructions the patient blacked out, her eyes rolled backwards, and she exhibited jerking movements. We reclined the chair and the patient came round. We gave 15 litres of oxygen per minute and a glucose drink; with this, the patient quickly recovered.
Case 1 A new female patient, CB, aged 43, who was fit and well, attended the practice for a course of treatment and four appointments were made. The first
Case 2 AB is a 46 year old female who is anaemic, has low blood pressure and a gluten intolerance, and takes iron tablets. She accompanied her adult daughter
Case Reports
1
Lauren Hardwick
Specialist Registrar Orthodontics, London
VOL 3 NO 1 FEBRUARY 2014
Feeling light-headed or dizzy often precedes loss of consciousness
65
Caption here? FAINTING: CASE REPORTS
Always take into account any pre-existing medical conditions, as in Case 4 round, I gave her a glucose drink. She still appeared grey so I transferred her to the dental chair and my nurse called for assistance. I reclined AB, with her feet raised. She then fainted again and took a while to come round so I gave her some glucose gel. When she felt better, she was raised to a sitting position; however, she started to get pins and needles in her extremities, which moved towards her head, as she was hyperventilating. At this point, I was becoming concerned and I called in my practice principal, thinking that I should call an ambulance. He checked her oxygen saturation, which was 95%, and her blood pressure, which was 128/84.
(DB) for her appointment. AB is also a patient of the practice, although she had only attended once. AB’s daughter required root canal treatment, but wished further clarification on this. Because DB usually sees my practice principal, I performed a thorough examination and we had a long discussion about her treatment plan. Towards the end of this, AB said she wanted to sit down. After a few minutes, she said she was feeling very hot and on examination she had turned grey and clammy. I opened the window and my nurse brought her a glucose drink. I then helped her with the drink, whereupon her eyes rolled back and she lost consciousness causing the glucose drink to spill over her. I quickly removed the plastic cup. We gave AB oxygen at 15 litres per minute and moved her chin back; however, because she was not in a dental chair, I was unable to recline her properly. When she came
66
He slowly raised the chair and she was monitored for the next 15 to 20 minutes. During this time, AB explained that she was menstruating, had been working in the sun for long hours doing hard work as a gardener and did not eat a lot. She also admitted to not having felt right over the last month. I advised her to see her GP at her earliest convenience. By now, her colouring had returned to normal and she felt happy to go home. During this time, we had phoned her husband and arranged for him to collect her. Later on, AB returned to the practice and said she was attending the hospital for investigation. Case 3 OM (male, 52 years of age) is a regular attender who suffers from arthritis and takes methotrexate for this. He felt faint following a root canal treatment dressing
REFERENCES 2 1
Wilson MH, McArdle NS, Fitzpatrick JJ, Stassen LFA. Medical emergencies in dental practice. J Irish Dent
of the LR5. After appearing pale, clammy and faint, we reclined the chair and he came to relatively quickly. On sitting him up, we gave the patient a glucose drink and he quickly recovered. Case 4 SM is a 28 year old male who suffers from asthma and hayfever. He was a new patient and had two appointments booked for restorative treatment. During his second appointment, at 2pm, he felt hot after an ID block. It transpired that he had only eaten a slice of toast early in the morning. My nurse went to get him a glucose drink. While she was gone, the patient fainted, his eyes rolled backwards and he lost consciousness. I reclined the chair, raised his feet, and gave him oxygen. Once he was better, I gave him glucose. After this, he recovered quickly and wished the treatment to be completed.
Summary With the exception of Case 2, all patients had an uneventful recovery. It is important to know what is normal and what is abnormal in order to gain help when required. In combination with good training in basic life support and medical emergencies, relevant experience makes assessing patients’ conditions easier. However, until you experience a medical emergency, you never fully know what to expect: it is not like in a simulation when you know the emergency will occur and what it will be. Medical emergencies can look very similar, but as long as you take a deep breath, check for signs of life first and have a systematic checklist in your head, you should be able to diagnose and treat syncope.
Assoc. 2009;55:134-43. Resuscitation Council UK. Resuscitation Guidelines 2010 (online). Accessed (2013 Oct 20) via: www.resus.org.uk/
3
Ganzeboom KS, Colman N, Reitsma JB, Shen WK, Wieling W. Prevalence and triggers of syncope in medical students. Am J Cardiol. 2003;91:1006-8.
P R I M A R Y D E N TA L J O U R N A L
Introduction ABSTRACT The paper presents four examples of patients fainting. Although we all undergo yearly CPD updates, until you experience a medical emergency, you can never truly be ready for one. Prim Dent J. 2013; 3(1) 65-66
KEY LEARNING OUTCOMES • How to diagnose syncope (fainting) • How to treat syncope (fainting)
I have seen several patients faint in general practice in the last 12 months. When I experienced my first medical emergency, I found it difficult to be sure that the patient was definitely fainting and was assisted by senior members of the team. Having now witnessed a number of patients fainting, I have seen that they mainly follow the same pattern.
About fainting A faint, otherwise known as vasovagal syncope, is the most common medical emergency that can occur in general dental practice, with a reported prevalence of 1.9 cases per dentist per year.1 Fainting is caused by a lack of oxygen to the brain, leading to a loss of consciousness.2 Patients could present with the following symptoms: • Feeling faint/dizzy/light-headed • Becoming pale • Feeling cold and clammy • Feeling/being sick • Becoming unconscious1
Treatment • • • •
Lie the patient flat Raise the patient’s legs Give 15 litres of oxygen per minute If the patient becomes unresponsive, check for signs of life and start cardiopulmonary resuscitation in the absence of normal breathing or signs of life
Usually a higher proportion of females suffer from syncope.3 In the last 12 months I have been present at four episodes of fainting, affecting two male patients and two female patients. I have included these as case reports.
two appointments proceeded without incident. During the third appointment, several fillings were completed and a retained root of the UR3 was removed without problems. The patient wished to see the root of the tooth. After this, while going through post-operative instructions the patient blacked out, her eyes rolled backwards, and she exhibited jerking movements. We reclined the chair and the patient came round. We gave 15 litres of oxygen per minute and a glucose drink; with this, the patient quickly recovered.
Case 1 A new female patient, CB, aged 43, who was fit and well, attended the practice for a course of treatment and four appointments were made. The first
Case 2 AB is a 46 year old female who is anaemic, has low blood pressure and a gluten intolerance, and takes iron tablets. She accompanied her adult daughter
Case Reports
1
Lauren Hardwick
Specialist Registrar Orthodontics, London
VOL 3 NO 1 FEBRUARY 2014
Feeling light-headed or dizzy often precedes loss of consciousness
65
Caption here? FAINTING: CASE REPORTS
Always take into account any pre-existing medical conditions, as in Case 4 round, I gave her a glucose drink. She still appeared grey so I transferred her to the dental chair and my nurse called for assistance. I reclined AB, with her feet raised. She then fainted again and took a while to come round so I gave her some glucose gel. When she felt better, she was raised to a sitting position; however, she started to get pins and needles in her extremities, which moved towards her head, as she was hyperventilating. At this point, I was becoming concerned and I called in my practice principal, thinking that I should call an ambulance. He checked her oxygen saturation, which was 95%, and her blood pressure, which was 128/84.
(DB) for her appointment. AB is also a patient of the practice, although she had only attended once. AB’s daughter required root canal treatment, but wished further clarification on this. Because DB usually sees my practice principal, I performed a thorough examination and we had a long discussion about her treatment plan. Towards the end of this, AB said she wanted to sit down. After a few minutes, she said she was feeling very hot and on examination she had turned grey and clammy. I opened the window and my nurse brought her a glucose drink. I then helped her with the drink, whereupon her eyes rolled back and she lost consciousness causing the glucose drink to spill over her. I quickly removed the plastic cup. We gave AB oxygen at 15 litres per minute and moved her chin back; however, because she was not in a dental chair, I was unable to recline her properly. When she came
66
He slowly raised the chair and she was monitored for the next 15 to 20 minutes. During this time, AB explained that she was menstruating, had been working in the sun for long hours doing hard work as a gardener and did not eat a lot. She also admitted to not having felt right over the last month. I advised her to see her GP at her earliest convenience. By now, her colouring had returned to normal and she felt happy to go home. During this time, we had phoned her husband and arranged for him to collect her. Later on, AB returned to the practice and said she was attending the hospital for investigation. Case 3 OM (male, 52 years of age) is a regular attender who suffers from arthritis and takes methotrexate for this. He felt faint following a root canal treatment dressing
REFERENCES 2 1
Wilson MH, McArdle NS, Fitzpatrick JJ, Stassen LFA. Medical emergencies in dental practice. J Irish Dent
of the LR5. After appearing pale, clammy and faint, we reclined the chair and he came to relatively quickly. On sitting him up, we gave the patient a glucose drink and he quickly recovered. Case 4 SM is a 28 year old male who suffers from asthma and hayfever. He was a new patient and had two appointments booked for restorative treatment. During his second appointment, at 2pm, he felt hot after an ID block. It transpired that he had only eaten a slice of toast early in the morning. My nurse went to get him a glucose drink. While she was gone, the patient fainted, his eyes rolled backwards and he lost consciousness. I reclined the chair, raised his feet, and gave him oxygen. Once he was better, I gave him glucose. After this, he recovered quickly and wished the treatment to be completed.
Summary With the exception of Case 2, all patients had an uneventful recovery. It is important to know what is normal and what is abnormal in order to gain help when required. In combination with good training in basic life support and medical emergencies, relevant experience makes assessing patients’ conditions easier. However, until you experience a medical emergency, you never fully know what to expect: it is not like in a simulation when you know the emergency will occur and what it will be. Medical emergencies can look very similar, but as long as you take a deep breath, check for signs of life first and have a systematic checklist in your head, you should be able to diagnose and treat syncope.
Assoc. 2009;55:134-43. Resuscitation Council UK. Resuscitation Guidelines 2010 (online). Accessed (2013 Oct 20) via: www.resus.org.uk/
3
Ganzeboom KS, Colman N, Reitsma JB, Shen WK, Wieling W. Prevalence and triggers of syncope in medical students. Am J Cardiol. 2003;91:1006-8.
P R I M A R Y D E N TA L J O U R N A L
