For more on this topic, go to www.dentaleconomics.com and search using the following key words: emergency medicine, basic life support, training, Dr. Stanley F. Malamed.
Abstract
Medical emergencies can and do occur, not only in your dental office but any place and at any time. The entire staff and designated in–office emergency team must be trained, and emergency equipment and drugs must be available and current. The best way to handle an emergency is to start by being prepared.
Introduction
A heart attack occurs every 20 seconds. About 25% of those who have heart attacks do not realize they are having them.
Imagine you are treating a patient, stop treatment to ask her a question, and find that she is unresponsive. You quickly ask someone to tell the receptionist to call 911 and to bring you the oxygen tank. The oxygen tank finally arrives about 10 minutes later, but it is almost empty. You eventually get another oxygen tank from an assistant, but it has no tubing, so there is another delay in getting the patient oxygen. The paramedics finally arrive, but it is too late — the patient is dead.
Were you prepared? You had the oxygen tank, the emergency kit, and CPR training. You may have thought you were prepared — until the patient died. Emergencies are rare in dental offices. Nonetheless, we must be prepared to manage medical emergencies when they do occur.
Preparation
Your office must be prepared to deal with medical emergencies. You must find out from patients any medical conditions or medications they are or have been taking. The entire staff must be trained, a designated in–office emergency team must also be trained, and emergency equipment and drugs must be available and current. Without all these, you will not be prepared to handle medical emergencies.
Training the entire staff — basic life support (CPR) training
Every single person who works in the dental office should receive CPR training. This is the most important step in preparing for or managing a medical emergency. Most states that require dentists and hygienists be trained in CPR for licensure mandate CPR recertification every two years — this is not adequate to be able to properly perform CPR. It is recommended that basic life support training be provided in the dental office annually.
The in–office emergency team
The emergency team should ideally consist of at least three people, at a minimum two. The dentist is the team leader as soon as he or she arrives on the scene. Do not leave the patient alone during a medical emergency unless absolutely necessary. The duties of team members are found in Table 1.
Calling for help
Knowing when to seek medical assistance and not hesitating to do so are crucial. Never hesitate — it is better to call than to attempt to handle the emergency yourself only to discover you cannot and it is too late. If you think that you need help, get it. If you do not know what is going on or are concerned about the situation, call for help. When in doubt, call for help. The most logical thing to do is to call 911, Emergency Medical Services (EMS). Their job is to save lives. The dentist is legally responsible to keep the victim alive until he or she either recovers or until someone who is better trained arrives on the scene to take over. If a team member calls 911 and EMS takes six minutes to arrive, then the dentist is responsible for keeping the person alive for those six minutes. If your office is in an isolated area, you may be responsible for the patient for a longer period of time. If so, basic training will be important for you; however, more advanced training may be necessary. Do not assume if you work in a medical–dental building that you can call one of the physicians down the hallway for help — usually that is not the case, as they are not specialists in emergency medicine. Therefore, the recommendation is to always call 911.
Emergency equipment
Oxygen tank — Having an oxygen cylinder is important — oxygen is the second–most important drug in emergency medicine. Oxygen should be available in an “E” cylinder, which is about three feet high and contains enough oxygen to ventilate a nonbreathing adult for approximately 30 minutes. Ensure that all staff members know where the oxygen cylinder and emergency kit are kept and that they are readily accessible. The oxygen cylinder should be checked regularly to make sure there is sufficient oxygen in the tank and that all tubing and equipment is present and functioning.
Pocket mask — A pocket mask is a face mask that is folded in on itself. When opened, it becomes the same type of face mask used in general anesthesia to maintain the airway of an unconscious person. By holding the mask on properly and putting your mouth onto the mask, you can ventilate a person with 16% oxygen.
Automated External Defibrillator (AED) — The AED is a small lightweight device that monitors a person's heart rhythm and talks a first responder through very simple steps to defibrillate the patient. Defibrillation is very important and is carried out by placing electrode pads on the torso that recognize a sudden cardiac arrest. For every minute that elapses until the time a heart attack patient is successfully defibrillated together with basic life support (BLS), the survival rate has been estimated to decrease 10%. At one minute the survival rate is 90%, and by 10 minutes, 0%.
Drug kit
Drug therapy is always secondary to basic life support (BLS). Apart from oxygen used in BLS, there are six drugs in a bare–bones basic emergency kit, two injectable and four noninjectable.
Injectable drugs
Epinephrine — Epinephrine is the single most important drug in emergency medicine and is used when an anaphylactic reaction occurs. Anaphylaxis is a life–threatening allergic reaction. Epinephrine is dosed in a 1:1000 (0.3 mg) concentration and must be available in a preloaded syringe. The faster the patient receives epinephrine, the greater the chance of survival. It is very common to need more than one dose. Therefore, in addition to the preloaded syringe, the emergency kit should contain a minimum of two or three 1 ml glass ampoules of epinephrine 1:1000. There is no medical contraindication to the use of epinephrine in an anaphylactic reaction.
Diphenhydramine (Benadryl) — Histamine blockers are used in the management of non–life–threatening allergic reactions as well as in anaphylactic reactions after epinephrine has saved the person's life. Diphenhydramine (Benadryl) is the histamine blocker most commonly found in emergency drug kits. There are no contraindications to the administration of a histamine blocker during a medical emergency. As there is no urgency in giving the histamine blocker, it is not recommended to preload a syringe.
Noninjectable drugs
Nitroglycerin — Nitroglycerin, a vasodilator, should be included in the drug kit. Patients who have angina will bring their nitroglycerin with them, usually in tablet form. It is strongly recommended that the emergency drug kit contain Nitrolingual Spray. This is sprayed onto the patient's tongue for the translingual application of nitroglycerin. It is as effective as tablets, and has a much longer shelf life. One spray equals one sublingual tablet. There are two contraindications to the administration of nitroglycerin:
- A patient suffering from chest pain who is exhibiting signs of a drop in blood pressure (e.g., feels faint or dizzy).
- A patient who has chest pain and has taken an erectile dysfunction drug, such as Viagra, within the previous 24 hours. Viagra and nitroglycerin both lower blood pressure; if a patient takes both drugs within a 24–hour period, it can lead to an unsafe drop in blood pressure.
Bronchodilator — A bronchodilator is used to treat an acute asthmatic attack. Patients with asthma will bring their own medication to the office and should use their own inhalers if necessary. The office needs a bronchodilator in the emergency kit in case an asthmatic does not bring medication or a patient with no history of asthma goes into bronchospasm. The most commonly used drug in the U.S. is albuterol (ProAir), in an inhaler. The patient places the inhaler into the mouth and compresses the spray vial to express the bronchodilator while inhaling, then slowly exhales to disperse it in the bronchii. Bronchospasm will usually resolve within 30 seconds to one minute.
Glucose (Sugar) — Hypoglycemia, or low blood sugar, is a very common emergency in the dental office and is easily managed with sugar, which can be made available either in a tube (InstaGlucose) or as a bottle of orange juice or a nondiet soft drink.
Aspirin — Aspirin is part of the prehospital treatment for suspected heart attack victims. One aspirin tablet (325 mg) chewed and swallowed is recommended in any patient who is suffering chest pain for the first time. There are three contraindications to the administration of aspirin:
- A patient with an allergy to aspirin
- A patient with a bleeding disorder of any type
- A patient with a gastric or peptic ulcer
There are no substitutes for aspirin in this particular situation.
Secondary drugs
Aromatic ammonia — Aromatic ammonia is used to manage a patient who is fainting or has fainted. Ammonia vaporole is crushed between your fingers and held under the patient's nose. The noxious odor stimulates movement, which increases blood flow to the patient's brain if the person is in a supine position. In addition to ammonia being in the emergency kit, one or two vaporoles should be taped to a wall or cabinet within arm's reach in every treatment room.
Management of medical emergencies
All medical emergencies are managed in basically the same way, following the PABCD protocol.
Conscious patients — Whichever position is most comfortable for the patient is the position of choice (P). If the person is breathing or talking to you, then their airway is open. Since the patient is conscious, his or her heart is beating. When the conscious patient speaks, you have assessed the person's airway (A), breathing (B), and circulation (C) just by listening to them.
You do not have to do anything for A, B, or C, in this situation.
P. Positioning patient
A. Airway
B. Breathing
C. Circulation
D. Definitive care
Unconscious patients — Unconsciousness patients should be in the supine position — horizontal with their feet elevated slightly. The most common reason for loss of consciousness is low blood pressure. In the supine position, the patient's head and heart are parallel to the floor, increasing blood flow to the brain, and the patient can still breathe adequately. Do not put an unconscious patient in a head–lower–than–heart position, as this decreases the patient's ability to breathe. Airway management, the next step, is critically important.
In unconscious patients the muscles relax, including the tongue, which falls backward into the airway due to gravity and either totally or partially obstructs the airway. Head tilt/chin lift is used to maintain the airway and is very simple to accomplish — place one hand on the patient's forehead, place two fingers under the jaw, and rotate the head back; since the tongue is attached to the mandible, it is lifted from the airway when you lift the mandible.
Next, check whether the patient is breathing (B) (air going in and out). While maintaining head tilt/chin lift, place your ear one inch away from the patient's mouth and nose, while looking at the patient's chest to see if the patient is trying to breathe.
This is a very important concept: the airway could be obstructed, but the patient would still automatically attempt to breathe with their chest moving. You need to physically feel and hear the patient's breath.
If you feel or hear air coming out of the patient's mouth and nose, the airway IS open and the person IS breathing. If the patient is not breathing, the rescuer must deliver two complete full ventilations to get oxygen to the patient's lungs and blood. Checking circulation (C) is the next step.
You need to know if the blood that now contains oxygen is circulating through the body and going to the patient's brain. Maintain the head tilt/chin lift and check the carotid artery for a pulse. It is vitally important to know how to locate the carotid artery. Missing or misdiagnosing the carotid artery can be a life–and–death mistake.
To locate the carotid artery, maintain the head tilt with one hand, place the index and middle fingers of the opposite hand on the patient's Adam's apple (thyroid cartridge), and slide them down along the neck (towards the rescuer) until the fingers fall into the groove formed by the sternocleidomastoid muscle. The carotid artery is located in that groove. Palpate the carotid pulse for not more than 10 seconds.
If the pulse is not present, start chest compressions to circulate blood, which contains oxygen, to the patient's brain to keep the patient alive.
The last step is definitive care (D). P, A, B, and C are basic life support. Definitive care is the stage where you will diagnose the problem. If a diagnosis can be made and the office has the appropriate drugs and equipment, you can treat it. If you cannot diagnose the problem, or do not feel comfortable treating it, call 911.
For CE credits, much more information, and a complete set of references go to www.ineedce.com and open the Emergency Medicine course.
Dr. Stanley F. Malamed was born and raised in Bronx, N.Y., graduating from the New York University College of Dentistry in 1969. He has authored more than 135 scientific papers and 16 chapters in various medical and dental journals and textbooks in the areas of physical evaluation, emergency medicine, local anesthesia, sedation, and general anesthesia.
Table 1. The In–Office Emergency Team
Team member 1: The person who first observes the emergency — could be any staff member. Responsible for staying with the patient, performing CPR as needed.
Team member 2: The person who will get the emergency oxygen cylinder and emergency drug kit as soon as the person hears of the emergency and bring it to the location of the patient in distress.
Team member 3: All other staff members. Handle other tasks as assigned by the dentist during the emergency. Call 911 if asked to do so. A staff member should go to the lobby of the building and wait for the ambulance to arrive and also have the elevator waiting in the lobby to save time if in a multistory building. If another staff member is available, this person stands in the background and records the patient's vital signs or what is happening.
