4. Anaphylaxis, asthma, choking and syncope

The emergencies below are among those most frequently encountered, or most clinically significant, in the dental setting. Always use ABCDE assessment, call for help early, and reassess continuously.

Anaphylaxis

Recognition:

  • Rapid onset (seconds to minutes) after exposure to a trigger (e.g. latex, antibiotic, other medication).
  • Airway swelling, stridor, hoarse voice.
  • Breathing difficulty, wheeze, respiratory arrest.
  • Circulatory collapse: pale, clammy, tachycardic, hypotensive, reduced consciousness.
  • Skin changes: urticaria, flushing, angioedema (may be absent or subtle).

Immediate management:

  1. Remove the trigger where possible and call for emergency help (999/ambulance) immediately.
  2. Lie the patient flat and raise the legs (sit up only if breathing difficulty predominates); give high-flow oxygen.
  3. Give adrenaline 500 micrograms IM (1:1000) into the anterolateral thigh; repeat after 5 minutes if no improvement.
  4. Start CPR if the patient becomes unresponsive and stops breathing normally.
  5. All patients require hospital transfer and observation, even after apparent recovery.

Acute asthma attack

Recognition: increasing breathlessness, wheeze, use of accessory muscles; difficulty speaking in full sentences. In severe attacks: silent chest, cyanosis, exhaustion, reduced consciousness.

Immediate management:

  1. Sit the patient upright and reassure them; stop dental treatment.
  2. Give the patient’s own salbutamol inhaler (or the practice’s) — 4–10 puffs via a spacer, repeated as needed.
  3. Give high-flow oxygen if available and tolerated.
  4. Call for emergency help if there is no rapid improvement, if this is a severe attack, or if it is the patient’s first attack.

Choking (foreign body airway obstruction)

Recognition: sudden onset, often during a procedure, with coughing, distress, clutching the throat. Mild obstruction: patient can speak/cough effectively. Severe obstruction: unable to speak, breathe or cough; cyanosis.

Immediate management:

  1. Encourage continued coughing if the obstruction is mild.
  2. If severe and the patient is conscious: give up to 5 back blows, then up to 5 abdominal thrusts, alternating and reassessing between each set.
  3. If the patient becomes unconscious, lower them to the floor, call for emergency help and start CPR.
  4. Use suction and direct laryngoscopy/Magill forceps if trained and available for a visible, retrievable foreign body/instrument.

Vasovagal syncope (faint)

Recognition: often triggered by anxiety, pain or the sight of instruments/blood; pallor, sweating, nausea, yawning, slow pulse; brief loss of consciousness with rapid recovery on lying flat.

Immediate management:

  1. Lay the patient flat and raise the legs.
  2. Loosen tight clothing and ensure a clear airway.
  3. Give oxygen if recovery is slow.
  4. If recovery does not occur within 1–2 minutes, reassess for an alternative diagnosis (e.g. hypoglycaemia, cardiac cause) and escalate accordingly.
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