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The successful management of a medical emergency is one of the great challenges in dentistry. This section summarizes an approach to accomplish the objective of appropriate staff preparation for medical emergencies in the dental office.1
The specific roles of team members will, in part, depend on the number within the team. One may assume that there will be at least three team members in any office—namely a dentist, a dental assistant, and a receptionist. As the office size increases, duties can be shared among more members. Team Member 1 is the team leader, but after that the other team roles often can be interchangeable. The following suggests specific roles for the team members.
Because Team Member 1 is the leader, this person is usually the dentist of the patient having the emergency. Exceptions to this can be made, taking into account individual circumstances.
This person’s role is to be in charge and lead the management of the crisis. The leader decides when to call the emergency. If in doubt, it is better to call an emergency early rather than late, bearing in mind that the “crying wolf” approach of calling help unnecessarily too often may be detrimental when it is truly needed. This person calls for assistance, positions the patient, and initiates the ABCs until the assistance arrives. The leader should remain with the patient throughout the emergency until recovery or until emergency medical services (EMS) has taken the patient away.
Being the leader requires leadership skills, which include knowing how to prioritize actions by determining what is important at any point in time relative to what actions can be deferred. Leadership skills include the ability to appear calm and in control. Although deep down inside the leader may well be worried about the events unfolding, a calm demeanor must prevail. Panic can be infectious. If the team members see their leader panicking, they may follow suit. Remaining calm and collected will help allow rational thinking and action during a stressful time.
Team Member 2 knows the location of the emergency kit, portable oxygen, and automated external defibrillator (AED), and can bring them as instructed. This person can also be assigned to be the one to check on the emergency kit on a regular basis to ensure all contents are present and within the expiration date. This person also ensures that there is sufficient oxygen remaining in the tank. Team Member 2 also assists the team leader with BLS.
Team Member 3 can fulfill various functions, including calling EMS (911) and then going out to the building’s main entrance to meet the paramedics and lead them to the site where the patient is being managed. This team member also can assist with BLS, monitor vital signs, and provide assistance in any way that is needed. This same person, or Team Member 4 if present, may prepare emergency drugs for administration and measure vital signs. One of these team members keeps a written chronological record of all events, including vital signs, timing and amount of drug administration, and patient response to treatment.
Additional team members may be other dentists or support staff members who are present in the office. Any one of them should be able to come in and relieve individual team members as required. Every team member should be able to check vital signs. In the context of a medical emergency, this means measuring heart rate, blood pressure, and respiratory rate.
An effective team not only needs to understand each other’s roles but also needs to communicate effectively. The team leader should consider using a closed-loop approach.2,3 This means that when the leader gives a message, that team member acknowledges receiving the command, which confirms that the message was heard and understood. This same model is used successfully in aviation among pilots and air-traffic controllers.
The next task should be given only after receiving a clear response back. This approach reduces the likelihood of key steps being missed through oversight, such as shouting to no one in particular “Call 911,” and everyone assumes that someone else has done it, when in fact no one has acted on this comment. An example of a correct scenario is: The team leader says, “Susan, call 911.” Susan replies, “I am going to call 911.” The team leader then listens for confirmation that, in fact, the task was performed. This happens when Susan returns and says, “I’ve called 911 and the paramedics are on their way.” Another example of a correct scenario is: the team leader states, “Jane, bring the oxygen tank.” Jane replies, “I am going to get the oxygen tank.” When she returns, acknowledgment to the team leader is given, “Oxygen tank is here,” to which the team leader responds, “Good. Now attach the bag-valve-mask.” This continues in a similar way with all team members.
An important part of effective communication is for each team member to speak clearly and directly. Good eye contact should be maintained when giving instructions. It is not appropriate to let the stress of the situation result in yelling or shouting. If any instruction is not clear, the recipient should reply asking for clarification. The best teams are comprised of members who mutually respect each other and work together in a supportive and collegial way.2 There should be an open exchange such that any team member can speak freely to any other team member, without fear or embarrassment. No one should be made to feel patronized. Any perceived dental office hierarchy should be ignored for this purpose. For example, any team member should feel comfortable making a suggestion to the team leader, in particular if it is felt that something important was missed or is being done incorrectly. The team leader should welcome any comment that could benefit the patient outcome. The team must concentrate on what is right for the patient—not who is right during the management.2
It is useful to have a planned protocol of what to say when calling 911. There are important pieces of information that should be given clearly to the dispatcher. These include a preliminary diagnosis; information on the patient with respect to age, gender, signs and symptoms; and office location.
Ideally, the dental office should have a written plan that describes the expected roles of the various team members. Staff meetings should take place where an effort is made to review these roles and ensure that everyone is clear about his or her individual assignments. There should be opportunities to provide practice by arranging emergency simulation or drills. The EMS number should be posted if it is other than 911.
The final decision regarding the exact roles of each team member will be determined by a number of factors, including the individual dentist’s and staff member’s training and ability.
Daniel Becker, DDS
Chest Pain
The acute onset of chest discomfort is frightening to both the patient and the dental team. The patient’s discomfort may be the result of gastrointestinal reflux, bronchospasm, or other noncardiac conditions. For safety’s sake, it should be presumed related to coronary artery disease. In this case the condition is labeled angina pectoris. The event may represent an episode of stable angina or a more serious event labeled acute coronary syndrome. To understand this difference, a basic understanding of the pathogenesis of coronary artery disease must be appreciated.
Ischemic heart disease is a condition in which coronary perfusion is inadequate for myocardial oxygen requirements. The fundamental defect is stenosis of the coronary arteries due to atherosclerosis and for this reason the condition is also referred to as coronary artery disease.
Atherosclerosis produces a narrowing, or stenosis, of the coronary arteries. The condition is not acutely life-threatening as long as the lesion remains stable and does not rupture. The patient may experience chest pain if cardiac stress suddenly increases because the coronary “supply” is outweighed by myocardial oxygen demand. These episodes of chest pain are regarded as stable angina and can be precipitated by the stress of dental treatment. The angina will dissipate when the cardiac stress is reduced.
A more serious consequence occurs when atherosclerotic lesions become unstable and rupture producing the so-called ACS. In this case, coronary perfusion becomes even further compromised. Added to the pre-existing stenosis, debris from fractured atherosclerotic plaques obstructs coronary flow more severely, and the subsequent chest pain is described as unstable angina. This form of angina can occur at rest or with stress and may evolve to thrombosis with total occlusion of a coronary vessel. If this occurs, myocardial cells will begin the process of necrosis, defined as myocardial infarction. Therefore, ACS is produced by unstable atherosclerotic lesions and manifests as either unstable angina or myocardial infarction.
Stable angina reflects a stable atherosclerotic lesion producing a constant degree of stenosis. Pain occurs when myocardial oxygen demand becomes excessive due to exertion or stress. In contrast, ACS occurs when the atherosclerotic lesion becomes unstable and ruptures. After disruption of a vulnerable plaque, patients experience ischemic discomfort (unstable angina) resulting from a more severe reduction of flow through the affected coronary artery.
The dental team can do little to improve coronary blood flow. Patient management must be devoted to reducing cardiac stress and subsequent myocardial oxygen requirement, which hopefully will render the compromised coronary perfusion adequate. When a patient experiences chest pain, perform a complete primary assessment that includes not only blood pressure and heart rate, but also hemoglobin saturation via pulse oximetry if available. This will ensure that adequate oxygenation is present. Regardless of these results, supplemental oxygen should be provided via nasal cannula (4 L/minute) or nasal hood (6 L/minute). Any benefit of supplemental oxygenation has not been established for patients who sustain normal hemoglobin saturation on room air, but short-term administration has no adverse effects. Comforting the patient may reduce stress-induced increases in heart rate and blood pressure. If pain persists, a single tablet of nitroglycerin (0.4-mg tablet) should be administered sublingually. Nitroglycerin dilates systemic veins and reduces venous return, ie, preload. This reduction in diastolic wall tension or stress may also allow improved coronary perfusion, especially in the subendocardial regions. Nitroglycerin can be repeated every 5 minutes until symptoms improve or side effects such as hypotension or reflex tachycardia occur. Hypotension is particularly troublesome because it could compromise coronary perfusion further, and reflex tachycardia increases myocardial oxygen demand. Although reclined patients are not likely to experience these problems, blood pressure and pulse should be assessed before administering each subsequent dose of nitroglycerin.
The actual need and timing for activation of EMS transport are not well-established. The package inserts for nitroglycerin formulations instruct patients to access EMS when three doses of nitroglycerin over a period of 15 to 20 minutes fail to relieve symptoms. Pollack and Braunwald4 have suggested that EMS transport is indicated after administration of three doses of nitroglycerin over a 15- to 20-minute period for stable angina, but only one dose if angina is deemed unstable. Current American Heart Association guidelines5 address only suspected ACS (unstable angina or myocardial infarction) and encourage immediate EMS transport. They do not address stable angina. However, it may be impossible for the dental team to ascertain if the condition represents a stable or unstable event, and personal judgment must be used regarding subsequent action. For a patient with pre-existing coronary disease, chest pain provoked by a particularly stressful intervention may well represent a typical episode of stable angina. In this case, the patient will respond nicely after a primary assessment or a single dose of nitroglycerin and could very well be sent home after the dental treatment is completed. In contrast, the patient having no prior history of angina—or one that requires more than a single dose to relieve symptoms—should be transported to an emergency department for further evaluation. In all cases, it is professionally courteous to inform the patient’s primary physician as soon as possible.
The most feared sequel to an ACS is a lethal cardiac arrhythmia leading to cardiac arrest. If this occurs, the office team should administer cardiopulmonary resuscitation (CPR) as instructed in all healthcare-provider basic life support (BLS) courses. Ventilation should be performed using a bag-valve-mask device (eg, Ambu-Bag) attached to a 100% oxygen source. Chest compressions must be rapid (100/minute) with pauses after 30 compressions to allow for two adequate ventilations. There is little excuse for the entire office staff not being certified in BLS at the healthcare-provider level on an annual basis.
Early cardiac arrest is due to ventricular tachycardia or fibrillation and definitive treatment requires electrical defibrillation as soon as it is available. The beneficial role of CPR likely rests in its modest influence on coronary perfusion, which may sustain electrical activity until defibrillation is available. Supporting this concept are data illustrating greatest success when CPR is initiated immediately and is followed by defibrillation within 5 to 8 minutes of cardiac arrest. For offices equipped with AEDs, the device should be turned on and dictated instructions followed. While waiting for EMS to arrive, opioid increment may be considered if there is IV access.
Kenneth L. Reed, DMD
Allergy and Anaphylaxis
Of all medical emergencies that can and do occur in dental offices, allergy-related emergencies are actually quite common. As a matter of fact, based on data from Malamed, a “mild allergic reaction” was the second most common medical emergency seen in dental offices behind only syncope (fainting).6 Additionally, “anaphylaxis,” or severe allergic reaction, was the 11th most common medical emergency seen in dental offices. The most common allergen in the dental environment today, of course, is latex.7 Penicillin is the most common cause of drug-induced anaphylaxis.8 Patients will always have allergies to penicillin and the penicillin-like drugs (amoxicillin, Augmentin®, etc) and other drugs and agents prescribed, administered and dispensed in dental offices. It should be noted here that a true allergic reaction to an injected local anesthetic in dentistry has an incidence that approaches zero. It simply does not occur to any measurable degree.9
If the allergic reaction presents as itching, hives, or a rash as the only signs and symptoms, the allergy may be considered mild (non-life–threatening). However, if the patient experiences cardiovascular and/or respiratory embarrassment, which are normally seen as dizziness or loss of consciousness due to an inadequate blood pressure and/or inadequate blood flow to the brain (cardiovascular issues), or difficulty in breathing (respiratory issues), the dental professional must treat the allergy as a life-threatening situation.10
Allergic reactions occurring many minutes to many hours after exposure to the allergen may be termed “delayed onset” while those that occur within a few seconds to a few minutes after contact with the allergen are termed “immediate onset.” As a general rule, the faster the signs and/or symptoms occur, the more severe the allergy typically will be.
Mild Allergy
If the allergy is mild (that is, itching, hives, and/or rash only) and the patient remains conscious, he or she should be made comfortable. There are two main positions that we may choose to place patients in as they are experiencing a medical emergency. If the patient remains conscious, we want to make them comfortable. These patients may wish to sit upright or be reclined. Either is acceptable. If the patient loses consciousness, the patient is placed supine (flat). Almost all medical emergencies where loss of consciousness occurs share the same cause, low blood pressure in the brain. Making the patient supine will increase blood pressure in the brain and allow the patient to regain consciousness in most cases.
Also, the conscious patient who is talking has verified that the airway is patent, he or she is breathing, and cardiovascular function is adequate to maintain consciousness. We have just verified the A–B–C steps of CPR. Even though the revised CPR guidelines call for C–A–B, for medical emergencies occurring in dental offices, A–B–C is still appropriate.
Severe Allergy
Anaphylaxis is an acute life-threatening systemic reaction with varied mechanisms and clinical presentations.15 Immediate discontinuation of the offending drug(s) and early administration of epinephrine are the cornerstones of treatment. Epinephrine is the drug of choice in the treatment of anaphylaxis, because its alpha-1 effects help to support the blood pressure while its beta-2 effects provide bronchial smooth-muscle relaxation.11 Absorption is more rapid and plasma levels are higher in patients who receive epinephrine intramuscularly in the thigh with an autoinjector.12 Intramuscular injection into the thigh is also superior to intramuscular or subcutaneous injection into the arm.13 No established dosage or regimen for intravenous epinephrine in anaphylaxis is recognized. Because of the risk for potentially lethal arrhythmias, epinephrine should be administered intravenously only during cardiac arrest or to profoundly hypotensive subjects who have failed to respond to intravenous volume replacement and several injected doses of epinephrine.8
If the allergy is severe, the patient has lost, or soon will lose, consciousness. The dentist should place the patient in a supine position, open the airway, and evaluate breathing. Often, breathing is spontaneous and adequate. If the patient is not breathing, the dental professional must administer positive pressure oxygen via a bag–valve–mask device. If the patient has lost consciousness, his or her cerebral blood pressure is too low. Another dental staff also must contact EMS as the patient requires additional treatment in the hospital’s emergency department. The appropriate pharmacologic management for anaphylaxis in an outpatient setting is outlined in Table 1.
Conclusion
Knowing how to react in situations in which patients have medical emergencies can be the difference between life and death. The dental team that is well-prepared is a patient’s best ally.
These articles originally appeared in Inside Dentistry, March 2011.
About the Authors
Daniel A. Haas, DDS, PhD
Associate Dean Clinical Sciences, Faculty of Dentistry
Professor and Head of Dental Anesthesia, Faculty of Dentistry
Professor, Department of Pharmacology Faculty of Medicine
University of Toronto
Toronto, Ontario, Canada
Daniel Becker, DDS
Associate Director of Education BLS and ACLS Instructor
General Practice Residency American Heart Association
Miami Valley Hospital
Dayton, Ohio
Kenneth L. Reed, DMD
Assistant Director, Advanced Education in General Dentistry
Attending Dentist in Anesthesia, Graduate Pediatric Dentistry
Attending Dentist, Dental Anesthesiology
Lutheran Medical Center
Brooklyn, New York
Clinical Associate Professor
Endodontics, Oral and Maxillofacial Surgery and Orthodontics
The Herman Ostrow School of Dentistry of the University of Southern California
Los Angeles, California
Associate Professor in Residence
University of Nevada Las Vegas
School of Dental Medicine
Las Vegas, Nevada
References
1. Haas DA. Preparing dental office staff members for emergencies. Developing a basic action plan. J Am Dent Assoc. 2010;141:8S-13S.
2. American Heart Association. Part 3. Effective Resuscitation Team Dynamics. In: Advanced Cardiac Life Support Professional Provider Manual. 2006;11-17.
3. Gaba DM, Fish KJ, Howard SK. Principles of anesthesia crisis resource management. In: Crisis Management in Anesthesiology. Philadelphia: Churchill Livingston; 1994;31-52.
4. Pollack CV Jr, Braunwald E. 2007 update to the ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: implications for emergency department practice. Ann Emerg Med. 2008;51(5):591-606.
5. O’Connor RE, Brady W, Brooks SC, et al. Part 10: Acute Coronary Syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(Suppl 3):S787-S817.
6. Malamed SF. Managing medical emergencies. J Am Dent Assoc. 1993;124(8):40-53.
7. Desai SV. Natural rubber latex allergy and dental practice. N Z Dent J. 2007;103(4):101-107.
8. Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of anaphylaxis: An updated practice parameter. J Allergy Clin Immunol. 2005;115(3 Suppl 2):S483-S523.
9. Malamed SF. Medical Emergencies in the Dental Office. 6th ed. St. Louis, MO: Mosby; 2007.
10. Reed KL. Basic management of medical emergencies: recognizing a patient’s distress. J Am Dent Assoc. 2010;141(5 Suppl 1):20S-24S.
11. Hepner DL, Castells MC. Anaphylaxis during the perioperative period. Anesth Analg 2003;97(5):1381-1395.
12. Simons FER, Roberts JR, Gu X, Simons KJ. Epinephrine absorption in children with a history of anaphylaxis. J Allergy Clin Immunol. 1998;101:33-37.
13. Simons FER, Gu X, Simons KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol. 2001;108:871-873.
