Dental Update - Two Eyes, Two Fingers, Two Minutes: Making It Easier to Recognize and Manage Medical Emergencies in Dental Practice Part 1: The Modified Dental Early Warning Score (M-DEWS2)

Abstract

Medical emergencies can happen at any time and in any place, including the dental practice setting. Recognizing the patient who is becoming unwell and remembering how to manage such emergencies can be quite daunting, especially for those who do not do so on a regular basis. The present paper describes the development of an observation recording sheet (M-DEWS2), including an escalation protocol and quick medication reference table for dealing with the common medical emergencies that may occur in the dental setting. A second paper will review how to manage and treat the eight common medical emergencies using treatment algorithms in conjunction with the M-DEWS2 tool.

CPD/Clinical Relevance: All members of the dental team must possess an up-to-date knowledge of dealing with medical emergencies and managing such situations.

Article

A patient may collapse or suffer a medical emergency in any dental clinic at any time whether or not they have undergone treatment. Whilst thankfully this is a relatively rare occurrence, it is imperative that the dental team is equipped to manage such an event if or when it occurs. This presents challenges in that rarely used information is difficult to retain and therefore apply competently should the need arise. From educational theory and practice, it is known that retention rates of information learned decreases with time.¹ For this reason, the General Dental Council (GDC) highly recommend that, as part of the minimum enhanced continuing professional development (eCPD) requirements, their registrants should complete 10 hours of medical emergency and cardio-pulmonary resuscitation (CPR) training in each 5 yearly eCPD cycle with a further recommendation that at least 2 hours should be carried out in each year.^2,3

Although it is acknowledged that, in many cases, practitioners may opt to call for the emergency services to attend the casualty in a practice, the importance of the early recognition of the deteriorating patient in both pre-hospital and in-hospital settings has become appreciated in recent times.⁴ This has led to an increased awareness and emphasis on early diagnosis as, the sooner the deteriorating patient can be identified, the quicker appropriate treatment may be instigated, thereby improving the potential outcome for the patient. It is imperative that all members of the dental team are competent in recognizing the signs and symptoms of the common medical emergencies so that appropriate treatment can be provided, including the administration of any medications.

In an attempt to address the importance of early diagnosis, and to provide an aide mémoire to assist the dental team in the recognition and treatment of patients who may become acutely unwell whilst in the dental setting, the Modified Dental Early Warning Scoring (M-DEWS2) sheet was conceived and developed by the lead author.

Development of M-DEWS2

The recognition of any deterioration in the condition of a patient is the most important component of managing any potential medical emergency. It is known that, in the hospital environment, between 50% and 80% of patients who deteriorate will have shown observable signs and symptoms of worsening prior to collapse.⁵ Within hospitals, the routine use of observation recording sheets, such as the National Early Warning System (NEWS),⁶ can assist in the recognition of such changes, so ensuring that appropriate treatment is provided and, if necessary, referral to an appropriate level of care is done in a timely fashion.

These same signs and symptoms of deterioration in a patient will be present in both the hospital and dental clinic settings. The Modified Dental Early Warning System (M-DEWS2) was therefore created to assist dental professionals in the extra-hospital environment. It comprises a single sheet of A4-sized paper consisting of three main sections which follow the standard ABCDE and systematic approach to dealing with an unwell patient (Table 1).⁷ The advantage of using such a tool is that, even if the dental team member is unsure as to what is wrong with the patient, the recorded observations and the resultant M-DEWS2 score indicate any potential deterioration of the patient and whether escalation to a more advanced level of medical care is required. In addition, the other two sections of the M-DEWS2 sheet provide useful information to help recognize and treat a potentially unwell patient in the dental care setting.

How to use the M-DEWS2 sheet

The M-DEWS2 sheet is pictured in Table 1 and is composed of three main sections:

The observable patient parameters, resulting M-DEWS2 score and recording grid;

The escalation protocol and the medications available in the dental practice for use in a medical emergency;

Individual role allocations for the dental team in the event of a medical emergency.

Table 1. Modified Dental Early Warning System 2 (M-DEWS2) sheet.

In order to identify the patient who may be unwell and at risk of deteriorating, the use of the coloured modified dental early warning score in Section 1 provides the dental care professional with the normal patient observations (white column) along with deteriorating observations (yellow, orange and red columns). Each column is associated with a score of 0, 1, 2 or 3, respectively. The clinical observations are then recorded along with the appropriate score in the grid on the right-hand side of the sheet. Once all the observations have been documented so that the totalled scores give an overall M-DEWS2 score, the assessor can then use this score in conjunction with the escalation protocol in Section 2 to indicate the probable clinical management.

While many dental professionals who infrequently perform an ABCDE assessment may be unsure how to proceed, completing the structured M-DEWS2 sheet can help to identify patients who may require further assistance and possible medical emergency treatment in the dental clinic or a referral to hospital.

The phrase ‘Two Eyes, Two Fingers and Two Minutes’ is another simple way of remembering how to complete the patient assessment, in as much as with two eyes the respiratory rate may be counted, two eyes can also observe the pulse oximeter reading and two fingers can determine the pulse rate. The cognitive function of the clinician can then assess the conscious level of the patient, all in a two-minute timeframe. These observations may be recorded on the M-DEWS2 sheet, so gaining longitudinal information to help assess deterioration of the condition of the patient and to provide a medico-legal record to be included in the clinical notes of the patient.

If a patient becomes unwell whilst in a dental clinic, a rapid ABCDE assessment of the patient should be completed, with the findings recorded on the M-DEWS2 chart in the ‘Act’ table on the right-hand side of the page (Table 2). The easiest way for this to be carried out is for one member of the dental team to read out and record each parameter whilst a second colleague takes the physical observations.

Table 2. Observational parameters and recording of scores table.

As can be seen in the observation grid on the left-hand side of Table 2, the score received depends on the range of the parameter being measured. If the patient's observations are in the white column then this is within normal range and the score is 0. Similarly, if the recorded score is in either the yellow, orange or red column then it would score 1, 2 or 3, respectively. Whilst most practitioners will be used to measuring many of the parameters on the sheet, when measuring the conscious level in the primary survey it is advised to use the ACVPU assessment. With A (Alert) scoring 0, while any altered level of consciousness from the patient's normal, ie C (acute confusion), V (responds to voice), P (responds to pain), U (unresponsive), is given a score of 3.

After all the recordings and scores have been entered onto the sheet, the scores are then totalled and inserted into the box at the foot of the page. This total score is then used in conjunction with the escalation protocol (Table 3). This is included to guide the clinician when a patient becomes unwell whilst in the dental setting. There are 4 categories based on the total M-DEWS2 score:

A score of 0 indicates that all observations are within normal parameters. However, the clinician should continue to monitor the patient if there are still concerns as to his/her condition.

A score of between 1 and 4 indicates that there is a change from the normal ranges which could potentially require further medical management. The patient should be reassessed every 5 minutes and, if after 20 minutes there is no improvement, then the situation should be escalated and medical assistance sought. This could be through a general medical practitioner (GP/GMP) with whom the dental clinic has an agreement or by calling the emergency services.

A score of 5 or 6, or a score of 3 in one single parameter, should be viewed as concerning and there is a high possibility that the patient will need to be assessed by medical professionals. The M-DEWS2 score should be repeated every 5 minutes and, if there is no improvement after 10 minutes, the emergency services should be contacted if not done so already.

A score of 7 or more should be particularly worrying and could mean that the patient is, or could become, very unwell very quickly. The first thing which should be done is that all the observations should be repeated to confirm that the M-DEWS2 score is the same. If it is and the patient has signs and symptoms of being unwell then the emergency services should be summoned so that the patient can be medically assessed and treated as a matter of urgency.

Table 3. The escalation protocol based on the M-DEWS2 score which gives guidance as to the appropriate management of the patient.

Escalation Protocol based on M-DEWS 2
M-DEWS 2 Score	Clinical Response
0	Continue to monitor the patient if you still have concerns that they may deteriorate
1-4	Reassess and monitor every 5 minutes – if no further improvement after 20 minutes escalate and call for local GP assistance (if pre-arranged)
5, 6 or a score of 3 in any single one	Potentially needs to be assessed by medical professionals – Reassure and monitor every 5 minutes, if no improvement after 10 minutes call 999 for emergency services assessment
≥ 7	Reassess to confirm the M-DEWS 2 score, then call 999 for emergency assessment by medical professionals

If at any stage in the observation and recording process or if there is documented medical history of a pre-existing condition, such as asthma, angina, hypoglycaemia, then treatment may be indicated and instigated. If the patient is unable to self-medicate, then it may be necessary to use the medicines available in the emergency drug kit. All the emergency drugs kept in the dental clinic and the medical conditions that they are used to treat can be found in the middle section of the M-DEWS2 sheet (Table 4) as an aide mémoire should they need to be administered.

Table 4. Table listing the medications available in the emergency drug kit available in each dental clinic with the associated common medical emergencies.

Medications Available in the Dental Practice (suggested drugs which may be considered in a medical emergency)
Drug or Medication Available	Asthma	Acute MI	Angina	Hypo-Glycaemia	Anaphylaxis	Stroke* Brain Attack	Seizures
Oxygen (high flow 10-15 l/min) via non-rebreather mask	Yes	If < 94%	lf < 94%	Yes	Yes	If < 94%	Yes
Salbutamol inhaler via 2 puff technique and repeated	Yes				Yes
Glyceryl Trinitrate (GTN) 2 puffs under tongue		Yes	Yes
Aspirin 300 mg (crushed or chewed)		Yes
Oral glucose solution / tablets, gel or 4 jelly babies (approx. 15-20g)				Yes		<4 *
Glucagon injection 1mg (should be kept in the fridge)				Yes		<2 *
Adrenaline 0.5mg (1:1000) Inject 0.5ml intramuscularly					Yes
Midazolam 10 mg/ml buccal (as per local protocol)							Yes ^‡

* *In suspected stroke complete a FAST assessment and check blood glucose (if < 4 mmol give glucose as above)

The final section of the sheet is the Medical Emergency Role Allocation (Table 5), which was included in the sheet so that, in the event of an emergency, the various key roles and tasks can be allocated in a calm and efficient manner rather than trying to remember all the different roles when it is already a stressful situation. While the medical emergency role allocation box indicates six roles, in some cases there may be fewer staff available to assist, so this should be used as a guide only and is not a definitive list.

Table 5. Medical Emergency Role Allocation table denoting the role of each member of the dental team should a medical emergency occur.

Medical Emergency Role Allocation
Team Leader	Initiate initial assessment / confirm M-DEWS 2 then stand back and oversee treatment and resuscitation. Give clear and calm directions	Scribe/Observations	Ensure that observations are recorded on M-DEWS 2 as per time scale and document any treatments initiated and the time
Team Member 1	Get emergency drug box, oxygen and AED and prepare to give oxygen via appropriate method	Receptionist	Ensure that emergency services have been called and that someone is outside to meet them
Team Member 2	Assist in the preparation of emergency drugs and provide treatment as requested	Possible Other	Ensure that other patients are advised that there is a situation which is currently being dealt with

Case studies illustrating how to use the M-DEWS2 sheet

Whilst at first glance the M-DEWS2 sheet looks complicated, it is in fact very easy to use. In order to demonstrate its usage, two example scenarios are now presented.

Example 1

Mrs EW is a 63-year-old retired female who has been a patient of the dental practice for many years and is known to be nervous and anxious when attending for treatment. Today, as the procedure begins, she suddenly starts sweating and appears confused with slurring of her speech. The emergency medical kit is summoned and a rapid ABCDE assessment is performed and an M-DEWS2 sheet is completed. This is shown in Table 6. As can be seen, Mrs EW has an M-DEWS2 score of 6. This is comprised of 1, due to her low oxygen saturation levels (SpO₂) of 95%, 3 to account for her lethargy and confusion, and 2 because of a low blood sugar level of 3.0 mmol.

Table 6. Initial M-DEWS2 assessment and score of Mrs EW's condition.

The escalation protocol should be referred to for a score of 6 which indicates that the patient potentially needs to be seen by medical professionals. Any identified problems should be treated and the patient reassessed every 5 minutes. If no improvement is seen in the condition of the patient after 10 minutes, then consideration should be given to enlisting the help of the emergency services. (Table 7).

Table 7. Escalation protocol and recommended treatment for Mrs EW.

Given the presentation and blood sugar measurement, it is suspected that the patient is having a hypoglycaemic episode. Using the medication/treatment grid and her recorded observations, oral glucose in the form of 15–20 g of dextrose tablets/solution/gel or 4 Jelly Babies^® (Maynards Bassetts, Sheffield, UK) should be given. Additionally, as she is hypoxic, oxygen should be given at 15 l/min via a non-rebreather mask and titrated to maintain the oxygen saturation at above 96%.

After approximately five minutes another ABCDE assessment is performed and documented on the sheet in the Time + 5 column. The reassessment of the patient is as follows (Table 8). As can be seen from both the observations and recordings, Mrs EW's M-DEWS2 score has decreased from 6 to 2 and is predominantly due to the use of oxygen to reverse the initial hypoxia. This has now improved, with her oxygen saturation level increasing to 97%, meaning that the oxygen can be reduced to 10 l/min and then turned off if saturations remain more than 96%. The glucose given has increased the blood sugar to 4.5 mmol, so all the parameters are improving. Her M-DEWS2 score of 2, when referred to the escalation protocol, indicates that the patient should be reassessed and monitored after a further 5 minutes. Similarly, after a further 5 minutes has elapsed, the assessment is once again completed and documented in the Time +10 column (Table 9).

Table 8. M-DEWS2 reassessment and score of Mrs EW's condition at 5 minutes.

Table 9. M-DEWS2 reassessment and score of Edna Woodrough's condition at 10 minutes.

From the documented scores, it can be seen that the patient is much improved from her initial state and is now scoring 0, as the oxygen has been discontinued due to SpO₂ being maintained above 96%. Similarly, with the blood sugars rising to within normal range, the patient's confusion has resolved and she is now alert and apologizing for causing a fuss.

Example 2

Mr DT is a 38-year-old male who works for an oil company based both in the UK and the USA. He is a relatively new patient to the practice, having recently moved to the area due to work commitments. He has just sat in the dental chair when he complains of a sudden shortness of breath. As this has happened quite suddenly, the medical emergency kit is brought into the surgery and a rapid ABCDE assessment is performed and an M-DEWS2 sheet is completed as shown in Table 10.

Table 10. Initial M-DEWS2 assessment and score of Mr DT's condition.

This initial assessment has indicated an M-DEWS2 score of 1 (SpO₂ of 95%) and, whilst it is not known what the patient's normal oxygen saturation level is, it is slightly decreased for an otherwise heathy patient. Using the escalation protocol, a score of 1 indicates that there should be a reassessment and re-evaluation of the M-DEWS2 score after 5 minutes and, if no improvement after 20 minutes, then consideration should be given to further escalation. The assessment and completion of the M-DEWS2 at Time +5 minutes can be seen in Table 11.

Table 11. M-DEWS2 assessment and score of Mr DT's condition at 5 minutes.

From this assessment, while the M-DEWS2 score remains at 1, there have been a few subtle but possibly potentially significant increases to some of the parameters. The respiratory rate has slightly increased, as has the heart rate, while at the same time the SpO₂ has slightly decreased from the initial reading. Given this decrease, it was decided to provide oxygen at 15 l/min via a non-rebreather mask and a further assessment made after 5 minutes. The reassessment and completion of the M-DEWS2 chart at Time +10 minutes is shown in Table 12. From this Time + 10 minutes assessment it can now be seen that there has been some significant deterioration to Mr DT, as the M-DEWS2 score has greatly increased from 1 to 7. His respiratory rate continues to rise and his oxygen saturation level continues to decrease, despite the delivery of high flow oxygen. It can also be observed that, though it remains within the normal range, his pulse rate has increased from the initial recording and is a further potential sign that he is becoming increasingly unwell, with an M-DEWS2 score of 7 (Table 13).

Table 12. M-DEWS2 assessment and score of Mr DT's condition at 10 minutes.

Table 13. Escalation protocol and recommended medical treatment fo Mr DT at the 10 minute mark.

The escalation protocol now indicates that a potential clinical emergency may be occurring and the patient may need to be urgently assessed by medical professionals. However, before the emergency services are called, a reassessment is performed to confirm that no errors have been made in the recording. The figures for this reassessment are illustrated in Table 14. Unfortunately, the reassessment confirms the increased M-DEWS2 score and, indeed, shows that there has been a further deterioration in the patient's condition from 7 to 9. The oxygenation continues to remain very low at 91% and, despite the delivery of high flow oxygen, the respiratory rate continues to rise and his pulse has now increased outside of normal range. The dental team may not know what exactly is wrong with the patient but what is certain is that he is becoming acutely unwell and needs to be seen urgently by medical professionals for further investigations and treatment in hospital.

Table 14. M-DEWS2 assessment and score of Mr DT's condition at 15 minutes.

Conclusion

The M-DEWS2 scoring system was developed to facilitate the early assessment of the medically deteriorating patient, whilst providing the necessary information in an easy to assimilate form which can be used should a medical emergency occur in the dental clinic setting. Most importantly, the completion of the Medical Observation Sheet is a record of the condition of the patient as it is happening. It may be an invaluable source of information and as a hand-over tool for the use of the paramedics or medical professionals to explain what has happened in the pre-hospital setting.

The two illustrated examples demonstrate how the M-DEWS2 tool can be used to help in identifying both the deterioration and improvement in the condition of a patient who may become unwell while in the dental practice setting. Completing and recording both the actual observations and the resulting score assists in seeing changes in the clinical status of the patients. The subsequent use of the escalation protocol empowers dental healthcare professionals to be proactive in appropriately channelling unwell patients to a more appropriate clinical setting, such as hospital, while the medication and treatment grid reminds the provider of the management of specific medical emergencies. To this end, a series of seven medical emergency treatment algorithms for dental practices was developed to be used in tandem with the M-DEWS2 Observation Sheet and will be discussed in the second paper.

Who's to blame?

The Adult Orthodontic– Restorative Interface. Part 1: Concepts of Treatment and Presenting Challenges

References

Two Eyes, Two Fingers, Two Minutes: Making It Easier to Recognize and Manage Medical Emergencies in Dental Practice Part 1: The Modified Dental Early Warning Score (M-DEWS2)

Authors

Jerry Morse

Stephen J Bonsor