Medical Emergencies in Dental Practice

Medical Emergencies in Dental Practice

Orrett E. Ogle, DDS

Lecturer, Mona Dental Program

Faculty of Medicine

University of the West Indies

Kingston, Jamaica

Former Chief of Oral and Maxillofacial Surgery

Woodhull Medical Center

Brooklyn, New York

Harry Dym, DDS

Chairman

Department of Dentistry and Oral and Maxillofacial Surgery
The Brooklyn Hospital Center

Brooklyn, New York

Clinical Professor

Department of Oral and Maxillofacial Surgery
Columbia University College of Dental Medicine
New York, New York

Robert J. Weinstock, DDS

Private Practice Limited to Oral and Maxillofacial Surgery
Guilford, Connecticut

Clinical Instructor

Oral and Maxillofacial Surgery
Yale-New Haven Hospital
New Haven, Connecticut

Library of Congress Cataloging-in-Publication Data

Names: Ogle, Orrett E., editor. | Dym, H. (Harry), 1938- , editor. |

  Weinstock, Robert J.

Title: Medical emergencies in dental practice / [edited by] Orrett E. Ogle,

  Harry Dym, Robert J. Weinstock.

Other titles: Medical emergencies in dental practice (Ogle)
Description: Hanover Park, IL : Quintessence Publishing Co, Inc., [2016]
|

  Includes bibliographical references.

Identifiers: LCCN 2015038602 | ISBN 9780867155693 | eISBN 9780867159110
Subjects: | MESH: Dentistry. | Emergency Treatment--methods. | Critical

  Care--methods. | Emergencies.

Classification: LCC RK51.5 | NLM WU 105 | DDC 617.6/026--dc23
LC record available at http://lccn.loc.gov/2015038602

The authors and the publisher of this work have made every effort to provide reliable information that can be used to aid treatment in emergency situations. However, emergencies, by their nature, are unpredictable and involve diverse variables. Furthermore, changes in treatment technique and medical protocol evolve with new developments in research and clinical experience. Thus, readers are encouraged to confirm the information contained herein with other sources, and they are advised to be aware of all pertinent governmental regulations and to review relevant manufacturer information prior to use of a product. Finally, it is the responsibility of practitioners to use their best judgment and clinical expertise when treating their patients. Neither the authors nor the publisher of this work guarantees that the information contained herein is in every respect accurate or complete.

© 2016 Quintessence Publishing Co, Inc

Quintessence Publishing Co Inc
4350 Chandler Drive
Hanover Park, IL 60133
www.quintpub.com

All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

Editor: Bryn Grisham
Design: Ted Pereda
Production: Kaye Clemens

Contents

Preface

Contributors

  1  Pretreatment Evaluation of the Dental Patient

  2  Essentials of an Emergency Kit

  3  Respiratory Emergencies

  4  Acute Chest Pain

  5  Syncope

  6  Allergy and Anaphylaxis

  7  Seizures, Epilepsy, and Stroke

  8  Nausea and Vomiting

  9  Hemorrhagic Emergencies

10  Emergencies in the Pregnant Dental Patient

11  Hypertension and Hypotension

12  TMJ Emergencies

13  Diabetic Emergencies

14  Malignant Hyperthermia

15  Thyroid Crisis

16  Local Anesthesia Emergencies

17  Adrenal Crisis

18  Basic Life Support

Index

Preface

It is imperative that every dentist in clinical practice be prepared to manage medical emergencies that may arise during patient treatment. It is true that clinicians can prevent many emergencies by conducting a thorough medical history, making appropriate alterations to dental treatment as required, and optimally stabilizing the patient’s medical condition when possible. However, despite all efforts at prevention, emergencies will occur. It is therefore necessary that dentists have a sound knowledge base as to how to manage medical emergencies that they may encounter. The ability to initiate effective primary management is the key to minimizing morbidity and mortality.

In general, medical emergencies in dental practice are perceived as infrequent, but when an emergency does occur, it can be life threatening, so the dental staff must be prepared. The prevalence of medical emergencies in dental offices is unknown. Estimates of the frequency vary widely. One report estimated that sudden cardiac arrest occurs in 1 in 638, 960 patients while at a dental facility and that a severe life-threatening event occurs in 1 in 30,427 treated patients.¹ Another report from the State University of New York at Buffalo College of Dentistry found the incidence of emergencies to be 164 events per 1 million patient visits.² A third study reported a frequency of 1 emergency in 3.6 to 4.5 practice years.³ The American Dental Association⁴ has estimated that there are about 3,000 life-threatening medical emergencies a year in US dental offices.

The best way to ensure effective management of a medical emergency is to be prepared in advance. During a medical emergency, the dentist is legally responsible for keeping the patient alive until his or her condition improves or until the patient can be transported to a facility with a higher level of care. If the practice is in an isolated area, or a location that is difficult to access (for example, because of heavy traffic or slow elevators), the dentist will be responsible for the patient for a longer period of time. The aim of this book is to arm clinicians with information that will prepare them to effectively manage various medical emergencies.

From the beginning, we created this book with the busy clinician in mind. It was our goal to produce a reference text that would be easy to read and understand and would present effective emergency management in a succinct, organized sequence. Beneficial step-by-step treatment guidelines and algorithms outline the steps and decision-making process for each emergency medical situation. In addition, we identified contributors with significant experience dealing with medical emergencies as hospital-based dental practitioners. Each chapter focuses on a distinct physiologic system and the common related emergencies that practitioners may encounter. We think this book will be an ideal clinical reference because it is accessible and presents a systematic approach of how to manage specific medical emergencies.

We recommend that clinicians read through the entire book to familiarize themselves with management of common medical emergencies. Because emergencies are, by definition, unpredictable events that can happen to anyone at any time, the dental practitioner and office staff must be prepared to provide primary management for any medical emergency without first turning to a book. Familiarity with common medical emergencies is therefore crucial. Practitioners are also encouraged to review the contents of their emergency kits and become knowledgeable about the pharmacology and use of the key drugs that should be maintained in the kit.

As editors, we are very enthusiastic about this book and the information it presents. We hope you will find this text to be very useful in your clinical practice.

References

1.  Müller MP, Häansel M, Stehr SN, et al. A state-wide survey of medical emergency management in dental practices: Incidence of emergencies and training experience. Emerg Med J 2008; 25:296–300.

2.  Anders PL, Comeau RL, Hatton M, Neiders ME. The nature and frequency of medical emergencies among patients in a dental school setting. J Dent Educ 2010;74:392–396.

3.  Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great Britain. Part 1: Their prevalence over a 10-year period. Br Dent J 1999;186:72–79.

4.  Be Prepared: Medical Emergencies in the Dental Office. DentalCompare. Available at: http://www.dentalcompare.com/Featured-Articles/2225-Be-Prepared-Medical-Emergencies-in-the-Dental-Office/. Accessed 13 October 2015.

Acknowledgments

This book is the brainchild of Dr Harry Dym and Lisa Bywaters, director of publications at Quintessence Publishing, who saw a need for an updated text on medical emergencies in dental practice. We are grateful for their foresight and cannot thank Lisa Bywaters enough for initiating this project and standing by it despite the obstacles along the way. Special thanks is also due to senior editor Bryn Grisham, who spent nearly 2 years diligently working with us and providing encouragement and valuable advice. Credit is also due to Kaye Clemens for her production work and excellent assistance with our images and photographs, which were not always the best. We also thank all of the contributors who gave of their time and shared their knowledge. Finally, we most especially thank our family members from whom we took valuable time to work on this book.

Contributors

Ida Anjomshoaa, DMD

Chief Resident

Division of Oral and Maxillofacial Surgery

The Brooklyn Hospital Center

Brooklyn, New York

Golaleh Barzani, DMD

Resident

Division of Oral and Maxillofacial Surgery

The Brooklyn Hospital Center

Brooklyn, New York

George Blakey, DDS

Director of Oral and Maxillofacial Surgery Residency Program

Distinguished Associate Professor

Department of Oral and Maxillofacial Surgery

School of Dentistry

University of North Carolina

Chapel Hill, North Carolina

Carolyn Dicus Brookes, MD, DMD

Assistant Professor

Department of Otolaryngology and Communication Services

Division of Maxillofacial Surgery

Medical College of Wisconsin

Milwaukee, Wisconsin

Earl Clarkson, DDS

Director

Division of Oral and Maxillofacial Surgery

Woodhull Medical Center

Brooklyn, New York

Harry Dym, DDS

Chairman

Department of Dentistry and Oral and Maxillofacial Surgery

The Brooklyn Hospital Center

Brooklyn, New York

Clinical Professor

Department of Oral and Maxillofacial Surgery

Columbia University College of Dental Medicine

New York, New York

Roger I. Grannum, DDS

Division of Oral and Maxillofacial Surgery

Woodhull Medical Center

Brooklyn, New York

Leslie Robin Halpern, MD, DDS, PhD, MPH

Associate Professor and Program Director

Department of Oral and Maxillofacial Surgery

Meharry Medical College School of Dentistry

Nashville, Tennessee

Curtis Holmes, DDS

Chief Resident

Division of Oral and Maxillofacial Surgery

The Brooklyn Hospital Center

Brooklyn, New York

Ghazal Mahjoubi, DMD

Private Practice Limited to Oral and Maxillofacial Surgery

New York, New York

Stanley E. Matthews, DDS, MS

Private Practice Limited to Oral and Maxillofacial Surgery

Bellerose Village, New York

Levon Nikoyan, DDS

Private Practice Limited to Oral and Maxillofacial Surgery

Bellerose Village, New York

Orrett E. Ogle, DDS

Lecturer, Mona Dental Program

Faculty of Medicine

University of the West Indies

Kingston, Jamaica

Former Chief of Oral and Maxillofacial Surgery

Woodhull Medical Center

Brooklyn, New York

Toni M. Otway, MD, FACOG

Obstetrics and Gynecology

Staten Island Hospital

Staten Island, New York

Garry Shnayder, DDS

Private Practice Limited to Oral and Maxillofacial Surgery

Brooklyn, New York

Avichai Stern, DDS

Attending Surgeon

Division of Oral and Maxillofacial Surgery

The Brooklyn Hospital Center

Brooklyn, New York

David R. Telles, DDS

Private Practice Limited to Oral and Maxillofacial Surgery

Huntington Beach, California

Robert J. Weinstock, DDS

Private Practice Limited to Oral and Maxillofacial Surgery

Guilford, Connecticut

Clinical Instructor

Oral and Maxillofacial Surgery

Yale-New Haven Hospital

New Haven, Connecticut

Adam Weiss, DDS

Private Practice Limited to Oral and Maxillofacial Surgery

Clifton Park, New York

Attending Surgeon

Department of Oral and Maxillofacial Surgery

Ellis Hospital

Schenectady, New York

Stephanie Weiss, MD, DDS

Private Practice Limited to Oral and Maxillofacial Surgery

Gloversville, New York

Attending Surgeon

Department of Oral and Maxillofacial Surgery

Ellis Hospital

Schenectady, New York

1

Pretreatment Evaluation of the Dental Patient

Orrett E. Ogle, DDS

Prevention is the most important aspect of preparation for medical emergencies. The dental practitioner can prevent many emergencies by conducting a thorough medical history, making appropriate alterations to dental treatment as required, and optimally stabilizing the patient’s medical condition when possible. This chapter will discuss pretreatment assessments that are essential to ensuring that the dentist can provide dental treatment that is also medically appropriate for each patient.

Medical Assessment

A thorough initial medical evaluation to identify correctable medical abnormalities and determine the residual risk is mandatory for all patients undergoing dental treatment. The preoperative evaluation is the foundation for minimizing undesirable outcomes; the clinician can use the assessment to identify and mitigate risk factors and develop a plan that will best balance the risks, benefits, and alternatives that are available.

Routine preoperative evaluation will vary among patients, depending on their age and general health. In evaluating a patient for any interventional procedure, the dental surgeon must consider two aspects: (1) the necessary work-up that must be performed prior to treatment and (2) whether the patient can safely undergo the planned dental or surgical procedure.

Medical questionnaire

The most efficient method of obtaining the medical history is to use a medical questionnaire. The form should be detailed and comprehensive (Fig 1-1). All health questions must be answered. Pertinent positive answers must be addressed, and certain negative answers, such as allergies or bleeding history, must be confirmed. The patient should be verbally questioned about the severity and control of the disease. All medications must be noted.

Fig 1-1 Sample of long medical history form. NSAIDs, nonsteroidal anti-inflammatory drugs.

Any medical condition that could affect dental treatment or that could be affected by dental treatment should be noted on the record treatment page under a section for past medical history. If the condition is critical (eg, allergies or heart conditions), the external portion of the chart should be flagged with a sticker for medical alerts or annotated in red ink. Electronic records should also be flagged using the method available in the software system.

Emergency telephone numbers should be prominently posted on the health questionnaire. For individuals with serious illness, the name and telephone number of the primary care physician should also be obtained.

If there are serious health issues, the health history should be updated at every visit, and any changes in the condition should be noted in the record. The health history must be dated and signed by the patient or parent/guardian and the dentist. Failure to sign the form may imply that the dentist did not review it.

A detailed medical history will identify potential management problems (physiologic and pharmaceutical) and allow the dental surgeon to formulate a treatment plan in light of the medical status. A patient may present with one or multiple established medical diagnoses, which may alter how dental care is delivered. The role of the dentist is to determine how these medical problems will influence care or how dental care may affect medical treatment. Medical illness may predispose the patient to acute physiologic decompensation under stress or failure to do well posttreatment, or it may lead to drug interactions. The dentist must be aware of potential results and what precautions must be taken to minimize risks. Clinicians must identify issues that should be addressed prior to treatment (eg, insulin, warfarin, or aspirin use), illnesses that may cause physiologic decompensation during treatment (eg, angina, seizure disorders, or asthma), and conditions that may affect the posttreatment phase (eg, diabetes [infection and delayed wound healing] or aspirin use [impaired hemostasis]).¹

Medications

The patient’s medical record must list all drugs that the patient is currently taking. The dentist should know what each drug is and why it is being used. Information on drugs can be obtained very quickly from programs downloaded to smartphones or laptop or tablet computers. Some available apps are Epocrates (Athenahealth), Davis Drug Guide (Unbound Medicine), Pocket PC drug guide (Softonic), and Drugs.com medication guide (Drugs.com).

The dentist should pay special attention to side effects associated with the patient’s medications, because some side effects may affect dental treatment. For example, heart medications, blood pressure drugs, sedatives, muscle relaxants, and other medications may contribute to bladder control problems. Patients taking these drugs need to urinate frequently and will not be able to tolerate long appointments. Pregabalin (Lyrica, Pfizer), thiazides, all diuretics, and carbonic anhydrase inhibitors are other drugs that will cause frequent urination and urgency.

Another common medication side effect that impacts dental care is xerostomia. More than 500 drugs can cause xerostomia. Medication use is the most frequent cause of xerostomia complaints, especially among the elderly.² Xerostomia can affect the comfort of removable prostheses, cause angular cheilitis, and promote candidal infections.

Medical consultation

Medical consultations are necessary when diagnostic medical questions are present or when the patient has medical problems that are beyond the dentist’s knowledge base. The dentist should ask the consultant at least these basic questions:

• Is the patient in optimal condition to undergo routine dental treatment in an office setting?

• Does the patient have reversible disease?

• Where is the patient in the continuum of disease?

Simply sending a request asking a physician to “clear a patient” for a dental procedure is likely to yield an equally uninformative response of “patient cleared” and must be avoided.¹ Even when a physician states that a patient is medically cleared, the final decision regarding treatment is the responsibility of the dental surgeon. A medical consultation is simply a tool for risk assessment and is not a “green light” to the dentist indicating that all will be well.

Risk Analysis

A useful step in patient assessment is to assign an American Society of Anesthesiologists (ASA) physical status classification (Fig 1-2).¹ This will inform the dental team of the degree of risk the patient’s physical ailments constitute. Figure 1-3 and Table 1-1 provide further classification strategies^1,4 for patients who have cardiac disease. Nondisease factors that are not listed in the ASA classification but that must be regarded as an additional risk are extreme age (more than 80 years), increased body mass index, and pregnancy that is close to the estimated date of delivery.¹

Fig 1-2 ASA classification of physical status. (Reprinted from the ASA³ with permission.)

Fig 1-3 Canadian Cardiovascular Society classification of angina pectoris. (Modified from the Canadian Cardiovascular Society⁴ with permission.)

*Modified from Petranker et al¹ with permission.

^†See Fig 1-2.

The dental practitioner must emphasize risk reduction strategies and find a balance between the risks and benefits of performing an oral procedure. The risk-benefit ratio must always stay in the patient’s favor. The clinician should also consider alternative approaches and when it is appropriate not to perform any intervention.

The first step in risk mitigation is to ensure that the patient is in as healthy a condition as possible. Table 1-2 outlines an approach for evaluating patients depending on the answers provided in the medical history.¹ Disease that can be reversed, should be.¹ Patients at risk for cardiovascular disease who are not currently under medical care should be evaluated by an internal medicine specialist for disease and managed medically before dental treatment is initiated. At-risk patients include elderly patients; patients with long-standing diabetes, hypertension, or dyslipidemia; and patients with a history of smoking, previous myocardial infarction, or angina. Figure 1-4 presents an algorithm for pre-treament evaluation and classification of the dental patient to determine when to continue with routine dental care, modify treatment, or refer for medical consultation.

*Modified from Petranker et al¹ with permission.

  NSAID, nonsteroidal anti-inflammatory drug; INR, international normalized ratio.

Fig 1-4 Algorithm for pretreatment evaluation and classification of the dental patient. MI, myocardial infarction; UA, unstable angina; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease.

Conclusion

The dentist can prevent many emergencies by completing a thorough pretreatment assessment to identify the risks associated with treatment for each patient. The assessment begins with a medical history questionnaire, including an investigation of all medications the patient is taking. When necessary, the patient’s physician or medical specialists should be consulted prior to treatment. Classifying the patient’s health enables the dentist to alter the treatment plan as required and optimally stabilize the patient’s medical condition prior to dental treatment.

References

1.  Petranker S, Nikoyan L, Ogle OE. Preoperative evaluation of the surgical patient. Dent Clin North Am 2012;56:163–181.

2.  Porter SR, Scully C, Hegarty AM. An update of the etiology and management of xerostomia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:28–46.

3.  American Society of Anesthesiologists. ASA physical status classification system. Last approved October 15, 2014. http://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system. Accessed March 3, 2015.

4.  Canadian Cardiovascular Society. Grading of angina pectoris. http://www.ccs.ca/images/Guidelines/Guidelines_POS_Library/Ang_Gui_1976.pdf. Accessed March 13, 2015.

2

Essentials of an Emergency Kit

Curtis Holmes, DDS
Harry Dym, DDS

Opening a private dental office can be a complicated task for a new general dentist. Aside from the known clinical responsibilities, the practitioner faces numerous nonclinical areas of concern, including patient billing, accounting, insurance, infection control, and appointment scheduling. A critical area that is often overlooked is preparation for a medical emergency.

Medical emergencies are unexpected and infrequent, but dentists are expected to have the ability to diagnose and treat medical emergencies. Dentists are often held legally responsible for any unfavorable outcomes resulting from mismanagement of those medical emergencies. The ability and preparation of the clinician and staff to respond to an emergency play a key role in potential outcomes. Therefore strategic planning for the management of medical emergencies in the dental office should be forefront in the mind of professionals starting a new office. In addition, established practitioners must ensure that the office remains ready to respond promptly and efficiently to such events.

Considering that dentists treat numerous patients who are taking multiple medications for underlying medical conditions and the fact that the dental office can be a stressful environment for some patients, it is not surprising that medical emergencies may arise. Some of the commonly encountered medical emergencies in the dental office include adverse drug reactions, altered mental status, shortness of breath, chest pain, diabetic complications, and seizures. This chapter focuses solely on the policies, equipment, and personnel needed to prepare for management of emergencies, should they occur. Diagnosis and management of specific medical emergencies are covered in subsequent chapters. Detailed discussion of the pharmacology of the drugs used, the techniques, and the underlying physiology is readily available elsewhere.^1,2

Staff Preparation

To successfully prepare for medical emergencies, dental professionals must formulate policies and an emergency protocol. The core of the emergency plan is having the dental office team certified and prepared to provide basic life support and seek emergency medical services in an efficient and timely manner. All office personnel should have specific responsibilities in the event of an emergency. Front office staff should have emergency telephone numbers readily available. Establishing a code word that informs the staff of an emergency and elicits the appropriate emergency response is beneficial.³

Mock emergencies should be performed regularly so that the staff will respond appropriately should the need arise. It is recommended that the mock emergencies be unannounced and occur quarterly or semiannually.

Office Equipment

Dental offices should be prepared and equipped to provide basic airway management to a patient in need (Fig 2-1). Oxygen is a key component in a medical emergency, and office personnel should be able to administer 100% oxygen through a portable source (E cylinder; see Fig 2-2). The office should have devices that allow supplemental oxygen administration to both the conscious and unconscious patient. Oxygen can be delivered via a nasal cannula, face mask, or face mask with reservoir. Nasopharyngeal and oropharyngeal airway devices can be useful adjuncts to overcome airway obstruction (see Fig 2-3). Dental professionals must frequently check to ascertain the status of the oxygen tank, even if multiple backup tanks are present.³

Fig 2-1 Emergency equipment for the dental office.

Fig 2-2 Type E oxygen cylinder.

Fig 2-3 Nasopharyngeal and oropharyngeal airways.

Equipment that allows the monitoring and assessment of a patient’s vital signs is useful to have. Ideally, a stethoscope and sphygmomanometer (with child- and adult-sized cuffs) should be considered basic emergency equipment in the dental office. If possible, automated vital sign monitors can be used to assess heart rate, blood pressure, and oxygen saturation.

An automated external defibrillator (AED) should be present in the office (see Fig 2-4). The AED eliminates the need for training in rhythm recognition but it does require that the dentist and key staff be trained in its use by participating in the American Heart Association’s basic life support course.

Fig 2-4 Automated external defibrillator.

Fig 2-5 Magill forceps and laryngoscope.

If the office personnel have advanced training, provide intravenous sedation, or are proficient in venipuncture, a few other items should be a part of the emergency armamentarium (see Fig 2-1). Offices with this level of training should have tourniquets, alcohol gauze, angiocatheters, and an assortment of syringes and needles. Intravenous fluids (normal saline 0.9% and dextrose 50% in water) should also be available.³

The emergency kit, like the oxygen tanks, should be checked and updated regularly.

Emergency Drugs

In addition to the armamentarium previously indicated, general dentists and dental specialists should develop an emergency kit stocked with key resuscitation drugs (Box 2-1 and Fig 2-6). Those offices providing intravenous sedation will certainly have more comprehensive emergency drugs available. Emergency medications should be checked regularly, and replacement drugs should be ordered before the expiration dates approach.

Fig 2-6 Emergency drug kit.

Oxygen

Hypoxemia is a common occurrence associated with many medical emergencies, making delivery of supplemental oxygen of primary importance. Multiple routes are available for delivery of oxygen; however, the authors believe that all offices should have a bag-valve-mask device (Ambu bag, Ambu) and a full-face mask to allow the dentist to provide positive-pressure ventilation should the need arise (Fig 2-7).

Fig 2-7 Bag-valve-mask device.

Aromatic ammonia

Syncope is a common medical emergency in the dental office. Aromatic ammonia is a general arousal agent indicated for use in these situations (Fig 2-8). It should be cracked or crushed, allowing the release of a noxious odor that stimulates the respiratory and vasomotor centers of the medulla. This agent, in combination with supplemental oxygen and placing the patient in the Trendelenburg position, causes most patients to return to consciousness.

Fig 2-8 Ammonia ampule.

Aspirin

It is recommended that patients experiencing chest pain suggestive of ischemia or any other symptoms of an acute myocardial infarction (heart attack) chew an aspirin. A non–enteric-coated aspirin (325 mg), chewed for 30 seconds and then swallowed with water, is thought to have rapid and then sustained anticoagulative effects. Caution should be used in administering aspirin to patients with severe bleeding disorders or allergies to aspirin.

Albuterol

Bronchodilators are the lead drug groups used for the treatment of acute wheezing and bronchospasm secondary to asthma attack. Selective β2-agonists cause bronchial smooth muscle relaxation. Albuterol is the most selective of the β2-agonists, and it is available in a metered dose inhaler. Albuterol also has fewer side effects than other bronchodilators.

Glucose

Some preparation of oral hypoglycemic agents should be present in the office to increase blood glucose levels in patients suffering from hypoglycemia. Offices should store a simple sugar source such as fruit juice, cola, or candy for the conscious patient. Oral formulations of glucose should never be administered if the patient is unconscious, because of the potential risk of aspiration. If the patient cannot swallow and the dentist has or can obtain intravenous access, dextrose 50% in water should be administered by any intravenous route (Fig 2-9). Alternatively, injectable glucagon is available (Fig 2-10).

Fig 2-9 Dextrose 50% in water emergency kit.

Fig 2-10 Glucagon kit for treatment of low blood sugar.

Nitroglycerine

Nitroglycerine is a vasodilator recommended for relief of acute chest pain in patients who have a past history of angina. It is also used in patients with undiagnosed angina with symptoms of myocardial infarction. Nitroglycerin is available in many forms, but in the dental office setting the 0.4-mg metered aerosol and sublingual tablet are most often used. The aerosol form does not require special storage and has a longer shelf life than the tablet form, which requires storage in light-resistant containers. Common side effects of nitroglycerin are headaches, dizziness, and flushing. Nitroglycerine should not be administered to patients taking drugs prescribed for erectile dysfunction.

Epinephrine

Epinephrine is a sympathomimetic drug that acts on α-adrenergic and β-adrenergic receptors. The primary effects of epinephrine include bronchodilation, vasoconstriction, increased heart rate, myocardial contractility, and cerebral blood flow, along with stabilization of mast cells (involved in severe allergic reactions.) The effects make epinephrine useful during severe bronchospasm, cardiac arrest, and anaphylaxis.

Diphenhydramine

Diphenhydramine is a histamine blocker used to reverse the effects of mild or delayed-onset allergic reactions. It is available in oral and parenteral forms.

Injectable drugs

Dentists with advanced training and specialists providing intravenous sedation should maintain supplemental injectable drugs with the other emergency medications present in the office. Supplemental injectable drugs include, but are not limited to, analgesics, anticholinergics, anticonvulsants, antihypertensives, corticosteroids, vasopressors, and reversal agents. The speed of drug action is increased when drugs are injected into the vascular system. During a medical emergency, it may be difficult to obtain intravenous access, and either intramuscular or intraosseous routes of administration may be beneficial. Each of these routes of administration requires skill, and therefore which route to use is at the dentist’s discretion.

Protocol Tips

The emergency kit and medications, along with oxygen, should be placed in an area that is readily accessible to personnel in the event of an emergency (Box 2-2). Table 2-1 lists common emergency medical situations and the drug or device from the emergency kit that should be used.

Conclusion

For a dentist, competence in handling medical emergencies is just as important as proficiency in the dental procedures performed in the office. It is essential that dental professionals and office staff have the ability to recognize a dental emergency and respond accordingly. Unfamiliar challenges along with the stress of the potential consequences can potentially impair anyone in the midst of an emergency. It is good practice to formulate “cheat sheets” listing the type of emergency and the appropriate actions to be taken by the doctor and staff. A well-maintained emergency armamentarium, knowledge of the proper equipment and medications used during a medical emergency, and proper training and emergency simulations are invaluable keys to effective management of such emergencies.

References

1.  Dym H. Stocking the oral surgery office emergency cart. Oral Maxillofac Surg Clin North Am 2001;13:103–118.

2.  Saef SN, Bennett JD. Basic principles and resuscitation. In: Bennett JD, Rosenberg MB (eds). Medical Emergencies in Dentistry. Philadelphia: Saunders, 2002:3–60.

3.  Dym H. Preparing the dental office for medical emergencies. Dent Clin North Am 2008;52:605–608.

3

Respiratory Emergencies

Orrett E. Ogle, DDS
Stephanie Weiss, MD, DDS
Adam Weiss, DDS
Harry Dym, DDS

Only the most severe respiratory compromise is a contraindication to routine outpatient dental and/or oral maxillofacial treatment with local anesthesia. Such patients can be screened by the medical history and treated in consultation with their physician. Regardless, respiratory emergencies can be the most dangerous that the dentist may encounter because they can result in rapid loss of consciousness and death. The most significant respiratory emergencies that the dentist has to manage in the nonanesthetized patient are:

• Foreign body obstruction

• Hyperventilation

• Asthma

• Respiratory arrest

• Problems related to chronic disease such as chronic obstructive pulmonary disease (COPD) and heart failure

In the anesthetized patient, additional respiratory emergencies would include:

• Airway obstruction

• Laryngospasm

• Bronchospasm

• Aspiration

Understanding the best precautions to prevent airway emergencies as well as being prepared to manage them is an important part of the role of clinicians and health care providers. The most important part of planning for a medical emergency is to try to prevent one from ever occurring. However, despite best efforts at prevention, respiratory emergencies are unpredictable, and when they occur, they are dangerous.

Foreign Body Obstruction

Choking is the physiologic response to sudden airway obstruction. The obstruction may be partial or complete. Choking due to inhalation of a foreign body in the dental office is most likely to occur during anterior or maxillary tooth extraction or when working with implant abutments, crowns, orthodontic brackets, or even endodontic instruments.

An aspirated foreign body may lodge in one of three anatomical sites: the larynx, trachea, or bronchus (Fig 3-1). From 80% to 90% become lodged in the bronchi, usually in the right main bronchus because of its lesser angle of convergence compared with the left bronchus (Fig 3-2) and the location of the carina left of the midline. Larger objects like teeth tend to become lodged in the larynx or trachea. A large foreign body lodged in the larynx or trachea can produce complete airway obstruction. When a foreign body enters the airway of a patient during treatment, the patient reacts immediately with coughing in an attempt to expel the object.

Fig 3-1 Site of obstruction and clinical symptoms.

Fig 3-2 Tracheobronchial tree showing lesser angle of convergence of right main bronchus.

As soon as a foreign body enters into the airway, the dentist should rapidly assess the severity of the obstruction. With mild obstruction, the patient is able to breath, cough effectively, and speak. Severe obstruction is indicated by:

• Wheezing.

• Ineffective cough or no cough.

• Inability to breathe or speak. (Clutching the neck with the hands is considered the universal sign of choking.)

• Cyanosis (the nail beds and lips turn blue) if there is an inability to move air.

• Diminishing conscious level (particularly in children).

• Unconsciousness.

Management

For a mild obstruction, the dentist should instruct the patient to lean forward and continue spontaneous coughing so that the obstructing object can come out of the mouth. The dentist should not interfere with attempts by the patient to dislodge the foreign body but should stay with the patient until the foreign body has been expelled and monitor for any deterioration in condition. A spontaneous cough is more likely to expel the object and is safer than any maneuver that the dentist might perform. In cases where the patient is unable to dislodge the foreign object, the patient should be referred to an otolaryngologist for therapeutic bronchoscopy for foreign body removal.

For a severe obstruction, management steps are covered for a conscious patient in Fig 3-3 and for an unconscious patient in Fig 3-4.

Fig 3-3 Management of a conscious patient with a severe obstruction.

Fig 3-4 Management of an unconscious patient with a severe obstruction. EMS, emergency medical services; CPR, cardiopulmonary resuscitation.

Complete obstruction of the airway is a life-threatening emergency and must be addressed with urgency. In complete airway obstruction, the patient is unable to make sounds or breath. After a few minutes of complete airway obstruction, the patient becomes cyanotic followed by bradycardia, hypotension, and irreversible cardiovascular collapse. If it is impossible to open the airway with a jaw-thrust maneuver and ventilate with a bag-valve mask, then a surgical airway must be established immediately. In this situation, cricothyrotomy (a procedure that involves placing a tube through an incision in the cricothyroid membrane to establish an airway) is the surgical intervention of choice to reestablish airflow (Figs 3-5 and 3-6).

Fig 3-5 Steps for performing open cricothyrotomy.

Fig 3-6 Open cricothyrotomy. (a) Surface anatomy. (b) Midline vertical (yellow dotted line) and horizontal incisions (red dotted line). (Courtesy of Johan Fagan.)

When an open cricothyrotomy would be too time consuming or difficult, a needle cricothyrotomy may be performed (Figs 3-7 and 3-8). This procedure is simple, fast, and relatively bloodless, and minimal surgical training is required. However, ventilation via needle cricothyrotomy only suffices for approximately 45 minutes; it does not permit adequate ventilation and leads to an accumulation of carbon dioxide. Therefore, a formal tracheostomy must be done within 45 minutes. Ventilation must be done with an Ambu bag (Ambu) since a low-pressure, self-inflating resuscitation bag would be very ineffective. The needle can be attached to the Ambu bag by fitting a 10-mL plastic syringe (with the plunger removed) and then inserting the connection piece of a 7.0- or 7.5-mm endotracheal tube into the barrel of the syringe.

Fig 3-7 Steps for performing a needle cricothyrotomy.

Fig 3-8 Needle cricothyrotomy. (a) Connections for the Ambu bag. (b) Insertion of needle with negative pressure inserted at a 45-degree angle.

Hyperventilation

Hyperventilation is a sustained abnormal increase in breathing that can occur with anxiety or panic. During hyperventilation, the rate of removal of carbon dioxide from the blood is increased. As the partial pressure of carbon dioxide in the blood decreases, the individual develops respiratory alkalosis. The respiratory alkalosis causes constriction of the small blood vessels that supply the brain. Reduced blood supply to the brain can cause a variety of symptoms, such as light-headedness; tingling in the lips, hands, or feet; weakness; fainting; and seizures. Continuous, severe hyperventilation can cause a transient loss of consciousness, and any loss of consciousness in the dental office should be considered an emergency.

Anxiety over dental treatment or pain may lead to panic (a severe episodic form of anxiety), and often, the anxiety/panic and hyperventilation can become a vicious cycle. The anxiety of sitting in a dental chair and the anticipation of treatment can lead to rapid breathing, and breathing rapidly can then make the individual more anxious and panicky and produce more hyperventilation with resultant symptoms. The symptoms of respiratory alkalosis can be quite frightening, which often causes faster and deeper breathing, making the situation worse.

If the patient begins to hyperventilate, the goal is to raise the carbon dioxide level in the blood, which ends most of the symptoms. Usually, tingling of the fingertips is one of the early warning signs that the patient is becoming alkalotic. The dentist should first provide reassurance and try to help the individual get his/her breathing under control. The dentist should instruct the patient to try to slow his/her breathing by explaining that fast breathing makes them feel worse.

To increase the carbon dioxide level, the level of oxygen intake needs to be decreased. To accomplish this, instruct the patient to breathe through pursed lips (as if blowing out a candle) or cover his/her mouth and one nostril and breathe through the other nostril. However, be careful not to excite the individual by placing a hand over his/her face.