Complications and emergencies

therefore be exercised when considering sedation for patients

with a history of epilepsy. Fits can also occur in patients who
lose consciousness for any other reason, especially those who
faint and who are not immediately placed in a supine position.
Acute chest pain
Acute chest pain is usually caused by stable angina but the
possibility of an acute coronary syndrome (unstable angina
or myocardial infarction) should always be considered.
Stable angina results from myocardial ischaemia caused by
narrowing of the coronary arteries. The demands of the heart
increase during exercise, stress or hypertension and it is these
situations which are most likely to precipitate an angina attack.
Patients with dental anxiety undergoing sedation are more at
risk. The features of an angina attack are a severe retrosternal
pain radiating down the left arm and a regular pulse. Sublingual
glyceryl trinitrate spray (0.4mg), should be administered, the
airway should be maintained and oxygen given. If there is no
relief in three minutes, the possibility of unstable angina or
myocardial infarction should be considered.
Unstable angina is caused by fissuring of atheromatous
plaques and subsequent platelet accumulation in a coronary
artery. This results in varying degrees of occlusion of the
affected artery. In myocardial infarction there is complete
occlusion of a coronary artery, leading to sudden ischaemia
and irreversible damage to part of the heart muscle. In
myocardial infarction the patient will have severe crushing,
retrosternal chest pain, which will not be relieved by use of
glyceryl trinitrate. They will be pale and cyanosed, breathless
and may vomit. The pulse will be weak and irregular. The
patient should be allowed to find the most comfortable
position to minimise the pain and this will usually be in the
seated position. Patients should not be reclined unless they
lose consciousness, since this increases the venous return
and hence the cardiac output, thereby making more demands
on the oxygen-starved myocardium. Nitrous oxide 50% with
oxygen 50% (if available) should be administered to relieve
pain and anxiety. Soluble aspirin (300mg) should be given
orally and the emergency services should be summoned. The
patient must be closely monitored for any deterioration,
particularly cardiac arrest, in which case cardiopulmonary
resuscitation should be initiated.
Asthma
Asthma is a very common condition which varies considerably
in severity. An acute asthma attack may be precipitated by

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