Anaphylaxis: an update for dental practitioners

This summary is based on the article published in the Australian Dental Journal: Anaphylaxis: an update for dental practitioners (June 2014)

NG Maher, J de Looze, GR Hoffman

Context

Anaphylaxis is an acutely presenting life-threatening medical emergency.

Purpose of the Update

This paper reviews the terminology and pathophysiology of anaphylaxis, and describes the recognition and initial management of anaphylaxis for dentists. Dentists should be able to administer intramuscular adrenaline during anaphylaxis at the appropriate dose. The role of further medical care is also explained.

Key Messages

Anaphylaxis symptoms arise rapidly, and can progress to life-threatening airway obstruction and convulsions, which may result in death within minutes. (1)

For a diagnosis of anaphylaxis, there should be an acute onset (minutes to hours) of two or more of: skin-mucosal involvement; respiratory compromise; hypotension and associated symptoms; and persistent gastrointestinal symptoms. 

Recognition and early treatment of anaphylaxis is crucial. Assessment is undertaken according to the basic tenets applied to any medical emergency with a consideration of the airway, breathing, circulation, and disability (level of consciousness). (2) This should be accompanied by cutaneous examination and review of gastrointestinal symptoms if anaphylaxis is suspected. (2)

In the event of suspected anaphylaxis, the dentist should immediately cease their procedure, clear the airway of any materials and remove any contact of likely triggering agent from the patient. The patient should then be positioned supinely with leg elevation. If breathing is difficult, the patient may be allowed to sit, maintaining leg elevation.

Adrenaline administration is the next step. This is the most important treatment in anaphylaxis and should be given by the dentist without hesitation. (2)

Repeat administrations of adrenaline should be given every five minutes if symptoms are persisting. (2) Given the risk of potentially fatal arrhythmias, intravenous (IV) use of adrenaline is reserved for patients who are profoundly hypotensive, refractory to several doses of IM adrenaline or who are in cardiorespiratory arrest. (2)

At this stage, if not already done by another staff member, retrieval via ambulance to a medical facility should be arranged by contacting the relevant emergency number.

Supplemental oxygen should then be delivered, ideally via a one-way valve face mask with oxygen running.

Finally, while these therapies are being considered, airway management may necessitate endotracheal intubation or cricothyroidotomy. (2) Medical observation should be continued for at least four hours after the event. (3)

References

1. Freeman TM. Anaphylaxis: diagnosis and treatment. Prim Care 1998;25:809–817.
2. Lieberman P, Nicklas RA, Oppenheimer J, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol 2010;126:477–480.e471-442.
3. Australasian Society of Clinical Immunology and Allergy. First aid treatment for anaphylaxis. Balgowlah: ASCIA, 2012. URL: ‘http://www.allergy.org.au/images/stories/anaphylaxis/2012/ASC IA_First_Aid_for_Anaphylaxis_19Feb2012.pdf’. Accessed 12 May 2013.

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