Introduction Preparation Incidences of emergency occur in dental office Emergencies occur in dental office Emergency drugs Dosage form of drugs Emergency equipment Additional emergency drugs Steps to be taken in emergency treatment Syncope Reference
Although rare, medical emergencies do occur in the dental office. While the majority of medical emergencies occur in adult patients, pediatric medical emergencies can occur too. Pediatric medical emergencies occur quickly without warning and with possible severe consequences due to the child’s under-developed physiology coupled with small oxygen reserves. Successful resolution of the emergency requires early recognition of the problem and swift definitive treatment.
Adequate preparation for emergencies reduces the possibility of an emergency occurring and further complications if it does occur. Preparation steps include: • Taking and reviewing a comprehensive medical and dental history. • Providing minimum basic life support (BLS) training for providers and staff. • Advanced Cardiac Life Support (ACLS) or Pediatric Advanced Life Support (PALS) training especially for those administering sedation and general anesthesia. • Initiation and coordination of an office emergency team. • Organizing an emergency drug kit and equipment. • Retraining on a regular basis.
*Syncope Mild and anaphylactic allergic reactions Acute asthmatic attack Local aesthetic and vasoconstrictor toxicity Hypoglycaemia and hyperglycemias Seizures Respiratory distress Cardiac arrest
Emergency drugs may be divided into two categories. The first category is drugs that are essential and should be part of every emergency drug kit. The second category consists of drugs that are useful but are optional depending on the practitioner’s training in emergency medical procedures and whether sedation and general anesthesia are used for behavior and anxiety management.
Epinephrinerepresents the most important drug in the emergency kit. Though (hopefully) rarely used, it must be available for administration as soon as possible in the event of an anaphylactic reaction
Epinephrine (adrenaline) administered rapidly in anaphylaxis has a number of properties that act to save lives in this situation: (1) epinephrine is a potent bronchodilator, reversing bronchospasm (frequently seen in anaphylaxis); (2) it elevates blood pressure and stimulates the myocardium, increasing heart rate, both of which counteract the vasodilation common in anaphylaxis; (3) additionally, in the event of edema formation, epinephrine prevents any further edema from developing that, if intraoral, could lead to airway obstruction or occlusion.
Indication: Anaphylaxis Dose: 0.3 mg IM q5 minutes until patient recovers or help arrives on scene to take over management. Contraindication: There are no contraindications to epinephrine administration in anaphylaxis. Recommendation: Minimally one (preferably two) preloaded, self-injecting syringe, plus two 1-mL ampules of epinephrine 1:1,000.
A histamine-blocker is also administered in the allergic reaction. Its primary indication is the very common non-life- threatening allergy (itching, hives, rash). A histamine-blocker is also administered in anaphylaxis following epinephrine administration. Indication: Allergy Dose: 50 mg IM or IV Contraindication: There are no contraindications to diphenhydramine administration in an allergic reaction. Recommendation: Two 1-mL ampules or vials of diphenhydramine HCl (Benadryl™) 50 mg/mL.
Oxygen (O2) is the second most important drug ―in‖ the emergency kit. The ―E‖ cylinder of O2 will not physically be located in the emergency drug kit, being of considerable size, but it must be readily available for administration in any emergency situation. It is recommended that, if possible, the emergency drug kit be attached to the O2 cylinder. Indication: Almost any emergency situation. Oxygen may not make the victim better, but it will not make their condition worse Dose: As needed by victim. Contraindication: Oxygen administration is contraindicated in hyperventilation. Recommendation: One ―E‖ cylinder of oxygen with regulator and the equipment necessary to deliver
Nitroglycerin sublingual (SL) tablets or MDI (metered dose inhaler) are used in management of acute episodes of angina pectoris Indication: Chest pain of anginal origin (patient has a history of angina) or a first-ever episode of chest pain. Dose: The usual dose of nitroglycerin is one to two sublingual tablets or one to twopuffs from the MDI administered q5m. Contraindication: Signs and symptoms of low blood pressure— for example, lightheadedness, dizziness, or a systolic BP of less than 100 mm Hg. Recommendation: One MDI of nitroglycerin (Nitrolingual Spray™) or one bottle of sublingual tablets (Nitrostat™). The usual dosage form is 0.4 mg per tablet or puff.
A bronchodilator is necessary in management of the acute asthmatic attack (bronchospasm). Though epinephrine is an excellent bronchodilator ,its administration in asthma is relegated to that of a back up to albuterol in the event that drug is ineffective in terminating the bronchospasm (eg, status asthmaticus). Albuterol is an effective bronchodilator (as is epinephrine) that does not normally produce any significant undesirable stimulation of the cardiovascular system (eg, increased BP and heart rate) as occurs when epinephrine is used.
Indication: Bronchospasm (acute asthmatic attack). Dose: As needed by victim. Usually one to two puffs per dose Contraindication: There are no contraindications to albuterol MDI in acute episodes of bronchospasm. Recommendation: One albuterol MDI (ProAir™, Proventil™, Ventolin™). A spacer should be available to aid in administration from the albuterol MDI in children
Aspirin is a thrombolytic drug used to limit enlargement of the blood clot occurring in a coronary artery during a myocardial infarction and has been associated with decreased mortality rates in a number of clinical trials. One adult, non-enteric, coated aspirin tablet is chewed and swallowed. Indication: Suspected myocardial infarction Dose: One 325-mg non-enteric, coated aspirin tablet, chewed and swallowed along with 8 ounces of water. Contraindication: Aspirin should not be administered to persons who are known to be allergic to it or have active gastrointestinal hemorrhage. Recommendation: One or two packets of chewable 325-mg non- enteric, coated aspirin.
Several forms of ―sugar‖ should be available in the dental office for prevention or management of hypoglycemia (low blood sugar). A 12-ounce bottle of orange juice or a non-diet cola beverage may be kept in the office refrigerator; however, it is strongly recommended that a ―medical‖ form also be available as all too often the juice or soft drink is missing when needed.
Indication: The administration of ―sugar‖ represents definitive management of hypoglycemia. Though most apt to be noted in type-1 diabetics, low blood sugar can happen to anyone, not uncommonly to healthy but dental- phobic men. Dose: One 12-ounce bottle of orange juice or non-diet soft drink, or one tube of glucose gel. Contraindication: Depressed consciousness or unconsciousness. Never place any liquid or gel into the mouth of an unconscious person. Recommendation: One tube of glucose gel (InstaGlucose™) and one 12-ounce bottle of either orange juice or non-diet soft drink.
Automated external defibrillator Oxygen delivery devices Bag-valve-mask (BVM) device (eg, ―Ambu- Bag‖) Magill intubation forceps Syringes for injectable drug administration (eg, two 3-mL plastic disposable syringes with 18- or 20-gauge needle) Pulse oximeter and blood pressure Suctioning equipment monitor
The AED should be a mandatory item of dental office equipment. Implementation of basic life support (P-C-A-B) in sudden cardiac arrest will be ineffective without early defibrillation
Oxygen delivery devices are the devices used for delivery the oxygen in emergency cases. Devices like nasal cannula, non- rebreather mask standard oxygen mask
A bag valve mask, abbreviated to BVM and sometimes known by the proprietary name Ambu bag, is a hand-held device used to provide positive pressure ventilation to a patient who is not breathing or who is breathing inadequately. The device is used extensively in the operating room to ventilate an anaesthetised patient in the minutes before a mechanical ventilator is attached. The device is self- filling with air, although additional oxygen (O2) can be added.
– Although usually available in the treatment room, a portable suction unit is useful for suctioning fluids and vomit if the emergency occurs in another area of the office (waiting room)
While pulse oximeters are usually found in dental offices where sedation and general anesthesia is administered to patients, they are useful in monitoring the effectiveness of CPR efforts. The pulse oximeter monitors the patient’s pulse rate and the percent oxygenation of the blood. This frees up a staff member during an emergency from manually monitoring the patient with a stethoscope or digitally. More upscale models also provide blood pressure monitoring
Magillforceps, angled forceps used to guide a tracheal tube into the larynx or a nasogastric tube into the esophagus under direct vision. It is also used to place pharyngeal packs and remove foreign bodies.
Disposable syringes are used mainly for injecting the drug
Additional Drugs Other ―emergency‖ drugs, considered as secondary (for use by doctors specifically trained in their administration [eg, ACLS]) include: Aromatic ammonia vaporoles (smelling salts) Analgesics (injectable), eg, morphine Anticholinergics (injectable), eg, atropine Anticonvulsants (injectable), eg, midazolam Antihypertensives (injectable), eg, metoprolol Antihypoglycemics (injectable), eg, dextrose 50% Corticosteroids (injectable), eg, hydrocortisone Na succinate
The following steps are taken for all emergencies: Discontinue dental treatment Activate the office emergency system Call for assistance The oxygen and emergency drug kit is brought to the site of the emergency Attend to the patient Position the patient to ensure an open and unobstructed airway Monitor vital signs Support respiration and circulation
Syncope is the most common emergency seen indental offices (50% to 60% of all emergencies). Syncope occurs as a result of a ―fight or flight‖ response and the absence of patient muscular movement, leading to a transient loss of consciousness. It is most common in young adults, most commonly between the ages of 16 to 35 years and in men more than women, probably as a result of being told to ―Take it like a man‖ during a stressful situation. Pediatric patients rarely develop syncope because they donot hide their fears and readily react emotionally and physically during a stressful situation. If a pediatric patient or an adult older than 40 years exhibits syncope without predisposing factors, they should be sent for medical consultation.
Predisposing factors for syncope can be divided into two categories, psychogenic or non- psychogenic factors. Psychogenic factors include: Fright Anxiety (due to the anticipation of discomfort or the fee) Stress Receipt of unwelcome news (treatment or the treatment fee) Sudden and unanticipated pain (injection or during treatment) The sight of blood (gauze, dental instruments)
Non-psychogenic factors include: Sitting in an upright position (especially during the injection) or immobility while standing resulting in blood pooling in the peripheral extremities, decreasing the flow of blood to the brain. Hunger from dieting or missed meals resulting in decreased glucose supply to the brain. Exhaustion Poor physical condition Hot, humid environments
In the early stage the patient: Expresses feeling warm Exhibits loss of color with an ashen-grayskin tone Perspires heavily Reports ―feeling bad‖ or ―feeling faint‖ Reports feeling nauseous Exhibits slightly lower blood pressure and TachycardiaIn the late stage the patient exhibits:• Pupillary dilation• Yawning• Hyperpnea• Cold extremities• Hypotension• Bradycardia• Visual disturbances• Dizziness• Loss of consciousness
The first step in the management of syncope is prevention. This is accomplished by: • Taking a thorough medical and dental history to identify any predisposing factors that might contribute to syncope, i.e., previous history of syncope, a fear of dental treatment due to previous traumatic dental experiences or pain, and hypoglycemia. • Patients, especially those that are anxious, should eat a light meal prior to treatment to maintain a stable blood glucose level during stressful treatment. • Patients should be treated in a supine or semi- supine position (30-45 degrees), especially during the injection. • Consider the use of anxiety techniques such a premedication and nitrous oxide anxiolysis.
Discontinue treatment Assess the level of consciousness: Evaluate the patient’s lack of response to sensory stimulation. Activate the office emergency system: Call for help and have oxygen and the emergency drug kit brought to the site of the emergency. Position the patient: The patient should be in a supine position with the feet elevated slightly. Assess airway and circulation: Assess the patient’s breathing and airway patency and adjust the head and jaw position accordingly; monitor the pulse and blood pressure. Provide definitive care:*Administer oxygen *Monitor vital signs* Administer aromatic ammonia ampoules.*Crush the ampule between the fingers and position it under the patient’s nose. The irritating fumes stimulate movement of the extremities and aids in blood return from the peripheral areas to the heart and brain.• Postsyncopal management: If recovery occurs in less than 15 minutes, postpone further dentaltreatment. If recovery is delayed by more than 15 minutes, contact emergency medical serviceswhile continuing definitive care until arrival of trained emergency care providers.• Determine precipitating factors: Determine the cause of the syncope (anxiety, the sight ofblood, unexpected pain, hypoglycemia, etc.).
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