Preparation and Management of Medical Emergencies

Medical Emergency Prep

By Stanley Malamed, D.D.S.

Editor's Note: This article is the second of a two-part series on medical emergencies.

Part 2 of this series of articles on developing a culture of safety regarding medical emergencies (MEs) focuses on the incidence of MEs and their prevention.

For part 1, please visit Medical emergencies in the dental office.

This Q/A identifies commonly asked questions and outlines practical steps dentists and dental professionals can take to prepare the dental office and staff for managing MEs that might arise.

How can we prepare the office to successfully manage medical emergencies that may occur?

There are four basic steps that need to be implemented to adequately prepare a dental office and its staff to recognize and manage MEs. These are:

  1. Basic life-support training
  2. Create an office "emergency-trained team"
  3. Maintain access to emergency medical services (EMS)
  4. Make certain there is availability to emergency drugs and equipment

The General Dental Council in the United Kingdom has established comprehensive standards for all dental offices for preparation for MEs.1-3

The abridged nine point summary below outlines standards that should serve as building blocks for a dental office’s emergency preparedness in the United States and elsewhere.

  1. All dental practices should have a process for medical risk assessment of their patients.
  2. All dental practitioners and dental care professionals should adopt the PCABD (Positioning – Circulation – Airway – Breathing – Definitive Care) approach to emergency management.
  3. Specific emergency drugs and items of emergency medical equipment should be immediately available in all dental surgery premises.
  4. All clinical areas should have immediate access to an automated external defibrillator (AED).
  5. Dental practitioners and dental care professionals should all undergo training in cardiopulmonary resuscitation (CPR), basic airway management and the use of an AED.
  6. There should be regular practice and scenario-based exercises using simulated emergencies.
  7. Dental practices should have a plan in place for summoning medical assistance in an emergency. In the United States, emergency medical services are accessed by calling 911.
  8. Staff skills should be updated annually.
  9. Audit of all medical emergencies should take place.

Though not mandated in the United States, every dental office should seek to achieve the standards listed above.




Basic life-support training

Most state dental regulatory bodies require a currently valid CPR (basic life support for Healthcare Providers) card for a dentist to renew their license. Increasingly, this mandate also includes dental hygienists, and in some states, dental assistants.

I have long believed that ALL dental office personnel – chairside and front office – be required to be trained in CPR. Further, it is strongly recommended that in order to maintain the ability to effectively manage MEs (1) training be repeated annually (most CPR cards are valid for 2 years), and (2) the CPR course be taken in the doctor’s dental office, as opposed to a large convention center hall with perhaps 50 to 100 participants. Numerous studies have proven than CPR skills rapidly deteriorate (within 90 days) following completion of the training course. 4-5

The ability of all office personnel to implement the steps of basic life support (PCABD) represents the single most important step in office preparation.

Office emergency team

Being prepared before a medical emergency occurs requires that all members of the dental office staff be cognizant of their role as a part of the office "emergency response team."

Though most dental facilities will have multiple employees (doctors, hygienists, front office, and chairside), the basic emergency team described below is comprised of a three-person team.

Member #1: The first person at the scene of the ME:

  • Stay with the "victim"
  • Call for help (activate the office emergency team)
  • Administer whichever steps of basic life support are necessary (PCABD)

Member #2: On hearing the call for help:

  • Obtain the emergency drug kit, oxygen and AED, and bring them to the site of the emergency.

Member #3 – includes all remaining members of the office staff:

  • Prepare emergency drugs for administration.
  • If requested, make the telephone call for emergency medical services (911).
  • If EMS is called, wait outside the building to escort emergency personnel directly to site of emergency.
  • If in a multistory building, keep elevator available on the lobby floor.

When the dentist arrives at the scene of the emergency, the doctor becomes the leader of the team, directing the actions of other team members.

Emergency Medical Services (EMS)

In North America, the EMS telephone number is 911.

Many medical emergencies occurring in the dental office environment can be efficiently managed by the dentist and their staff. Syncope (loss of consciousness), the most frequent dental office emergency,6-10 commonly develops in teenage to young adult male patients during local anesthetic administration. 11 Proper positioning for the local anesthetic injection – supine – prevents or minimizes the occurrence of syncope, while repositioning the syncopal patient to the supine position increases blood flow to their brain with consciousness returning quickly (usually within 10 seconds). Additional medical assistance is rarely required. With other emergency situations, such as bronchospasm (e.g., asthma) and angina pectoris, the patient (victim) can tell their dentist if EMS activation is warranted.

WHEN to activate EMS: The preceding paragraph described three situations (syncope, bronchospasm, angina) in which EMS is not usually required. However, in any emergency where the dentist is uncomfortable (e.g., unable to diagnose the emergency; can diagnose the emergency but is uncomfortable managing it; or is told by the patient to call an ambulance) EMS should be summoned immediately.

Essentials of the 911 call. When calling 911 you will be asked the following questions:12

  • What is the address of the emergency?
  • What is the phone number you are calling from?
  • What is your name?
  • Tell me exactly what happened.
  • How old is the patient?
  • Is the patient conscious?
  • Is the patient breathing?
  • Is anyone providing assistance?

It is important to remain on the line until the 911 dispatcher has told you to hang up.

Emergency drugs and equipment

It is essential that drugs and equipment for the management of medical emergencies be readily available in every dental office facility. In the United States two states – Massachusetts13 and West Virginia14 have such requirements for all dental offices. In dental practices where sedation is employed (oral, parenteral, general anesthesia) state regulatory agencies require the doctor to receive a ‘permit’ for that level of sedation after demonstrating their education and proficiency in that technique. A required list of emergency drugs and equipment accompanies the issuing of the permit.15

Many dentists do not employ sedation (aside from inhalation sedation with N2O-O2), however most do use local anesthetics. For these dentists a list of basic emergency drugs and equipment follows:

Drugs: The Basic Eight

Injectable:

  • Epinephrine
  • Histamine-blocker

Non-injectable:

  • Bronchodilator:
    • Albuterol metered-dose inhaler (MDI)
  • Vasodilator:
    • Nitroglycerin sublingual tablets
  • Thrombolytic:
  • Aspirin (powdered, chewable, tablets)
  • Sugar:
    • Orange juice, non-diet soft drink, Glutose, Insta-glucose
  • Opioid antagonist:
    • Naloxone nasal spray
  • Oxygen
    • “E” cylinder with appropriate delivery system

Equipment:

Face masks for ventilation and/or delivery of oxygen

Health care providers are required to ventilate a non-breathing (apneic) person. A barrier-device, such as a face mask is strongly recommended. It is important for dental office personnel to be trained to properly to utilize this device.

My recommendation is that prior to your next BLS training program a face mask ("pocket" mask) be purchased for each staff member. Training in its use will be a component of the BLS-healthcare provider program.

Automated external defibrillator (AED)

It is my opinion that an AED is an absolutely essential item of emergency preparedness equipment. 16,17

The occurrence of cardiac arrest in the dental office environment is low, however, it does occur. 18-19 Though prompt implementation of the PCABD steps of basic life support is important, it is D, defibrillation – as quickly as possible – that significantly increases a victim’s chance of long-term survival. 20-22

A complete listing of recommended drugs and equipment, doses and indications, is available from https://info.healthfirst.com/en-us/emergency-medication.23


Management of all medical emergencies

The PCABD algorithm is employed in the management of all medical emergencies. Only those steps necessary for a given patients management are employed.

P – Position the victim:

Conscious (responds to stimulation):

In a conscious person, any position in which they are comfortable is appropriate. Persons with difficulty breathing (e.g., asthmatics) or chest discomfort (e.g., angina, myocardial infarction) will usually prefer to sit up.

Unconscious (lack of response to sensory stimulation):

An insufficient flow of blood to the brain is the most common cause of unconsciousness in humans (e.g., syncope [fainting]). Placing the unconscious person into a supine position with their feet elevated slightly significantly increases cerebral blood flow. The dental chair is ideally suited for this position. Syncopal episodes commonly result in a prompt (~10 seconds) return of consciousness with proper positioning.

In a conscious person who can speak, CABD is assessed as being (at least minimally) okay and need not be implemented.

However, for the unconscious person, each step must be assessed and implemented if needed.

C – Assess circulation:

Palpate the carotid pulse for not more than 10 seconds.

If no pulse: immediately (1) begin CAB, (2) procure the AED, and (3) activate 911.

If a palpable pulse is present, continue to assess A and B.

A – Assess airway:

As the tongue is the major cause of airway obstruction in an unconscious person, head tilt – chin lift is implemented.

B – Assess breathing:

Look, listen, and feel, by placing your ear close to the victim’s mouth and nose. Feeling air being exhaled is the only sign that air is being exchanged by the victim. Seeing the victim’s chest rise and fall does not mean that they are successfully exchanging air.

If the victim is not breathing, then rescue breathing – using a face mask – is started.

D – Definitive care:

D: Diagnosis

D: Drugs

D: defibrillation

If a diagnosis can be made, and if appropriate drugs are available, they are administered. If the diagnosis is cardiac arrest, then defibrillation – as quickly as possible – is indicated.

If a diagnosis cannot be made, then emergency medical services (911) should be activated immediately.

A chart describing management of common medical emergencies is available from https://info.healthfirst.com/en-us/medical-emergency-quick-guide.24

Conclusion

Medical emergencies can – and do – occur in the dental office. We have reviewed the four steps necessary to prepare the dental office and staff to promptly recognize and to effectively manage those that do arise.


References
  1. General Dental Council. The First Five Years: A Framework for Undergraduate Dental Education. 2nd ed. London: GDC; 2002.
  2. Resuscitation Council UK. Medical Emergencies and Resuscitation: Standards for Clinical Practice and Training for Dental Practitioners and Dental Care Professionals in General Dental Practice. London: Resuscitation Council; 2006 (revised 2012). https://www.adam-aspire.co.uk/wp-content/uploads/2011/02/resuscitation-guidelines.pdf. Accessed 21 May 2023
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  17. Malamed SF. Automated external defibrillators, Part 2. Application. Dent Today. 2003 Jul;22(7):109-112, 114. PMID: 12901057.
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