Responding to Medical Emergencies in the Dental Environment

Are you prepared for an emergency? As healthcare practitioners, you rely on your professional judgment to provide your patients with the best dental care possible. Many years of study, training and internship go into making what most people see as a traumatizing ordeal, routine for you. But how much of your training was in responding to common emergencies that will occur in your office? If the teeth are the window to our health, isn’t our health also reflected in our teeth? People who seek your services because they are not the model of good oral health may also not be the model of good medical health. How many of your patients are sick with serious diseases?

I recently visited a dental client for a CPR/AED training session. She had just taken over the practice and asked me to review the emergency equipment that was in the office. Although she meant well, she was totally unprepared. Every drug in the kit was totally expired—some by a few years, her AED was obsolete, and her oxygen tank was potentially dangerous. The dentist she bought the practice from left her with no useable emergency equipment and a wide-open window to litigation, should an emergency have occurred. Fortunately, this story ends well, but the consequences could have been catastrophic.

Preparing for an emergency can be done with a three-pronged attack: prevention, equipment, and training. We should also take a moment to remind ourselves that the most common emergencies in a dentist office include syncope, allergic reactions (possibly anaphylactoid in nature), chest pain, bronchospasm and hypoglycemia.

The best emergency to have is the one that you prevented. It is important to take the time to review the medical history and medications of your patients before they sit in your chair. Medications often clue us into the medical conditions people forgot to tell you or really don’t know they have. This information might tell you what to expect when they “open wide” for you as much as what medical emergencies you might have to be prepared to deal with. Asking follow-up questions to medical conditions might be beneficial as well. Getting a feel for just how well the insulin-diabetic has control over his/ her own blood sugar or what allergies a patient, about to receive a lidocaine injection, has will help you prevent potential problems while preparing for the worst case scenario. Don’t be afraid to think ahead and ask yourself, “What kind of medical emergency can I expect to see with this patient? What will I do when that happens”?

With respect to medications, it is important to remember that literally hundreds of new drugs come onto the market every year. It is nearly impossible to know what every medication is used for, what class of medications they belong to and which ones are now approved for use outside of their original intent. To help me in a pinch, I like to use the ePocrates app for my smartphone. I give you permission to cheat a little bit too.

When emergencies do arise, there are three pieces of equipment that you want at the patient’s side: oxygen, an emergency drug kit and an AED. I encourage you not to just take matters into your own hands. Certainly call 911 and let the paramedics and medical doctors do their jobs. Of course you probably do not have an ambulance crew at the ready in your waiting room, so there will be some things that you have to do until help arrives. Your equipment can help you provide emergency interventions and supportive care while you wait.

Oxygen can prove to be a wonder drug and should be used for patients in respiratory distress, in cases of anaphylactoid allergic reactions, for people experiencing chest pain, victims of cardiac arrest, and during the most common emergency: syncope. There are no contraindications for the short-term use of oxygen, and you can never over-do it. To deliver the oxygen to patients, every office should be stocked with a nonrebreather mask and a nasal cannula (some patients feel claustrophobic with a mask on their face) for adults. Have the same on hand in pediatric sizes, if you see children at your practice. Set your regulator to flow at 15 liters per minute (LPM) for a nonrebreather mask and 4-6 LPM for a nasal cannula. Also, think about the portability of your oxygen tank. If a patient needs oxygen in your waiting room, how will you get it there?

Your drug kit should be stocked with medications to help care for the most common emergencies. In addition to oxygen, the ADA suggests six: Aspirin, Nitroglycerine, Albuterol, Diphenhydramine, Epinephrine, and sugar. Dentists who perform conscious sedation will want to add antidotes to opiates (naloxone) and benzodizapines (flumazenil). It is most important that the dental practitioner is familiar with the medications in his/her kit, when to administer them, what route (sublingually, subcutaneously, inter-muscularly or intravenously), and what reactions or side-effects to expect. Before I give any patient a drug, I like to remember that they have four “rights”: Is the “right” patient getting the “right” drug, at the “right” dosage, by the “right” route?

It is also important that you make sure each drug is up to date and in good condition. While others might suggest assigning a staff member to this task once per month, I suggest that you do this yourself. You will be the most familiar with the medications in the kit and their administration. My suggestion is not to trust anyone else but yourself to perform these checks, as you are ultimately responsible for all medical care given in your office. To help you, many companies will provide an automatic refill program.

Most victims of sudden cardiac arrest go into ventricular fibrillation or ventricular tachycardia. Both of these disrhythmias may be corrected by quick defibrillation. For this reason, the New York State Dental Society pushed for it to be law that every dental office have an AED. Keeping your AED centrally located in the office will ensure rapid deployment to patients in your exam rooms as well as the waiting area. Make sure your AED pads are always within their expiration and that the battery is still good. Check your AED unit at least once per month. If the company you bought the AED from has a maintenance / reminder program, let them help you decide when it is best to replace batteries and pads. Place a numbered plastic seal on the zippers of the bag so that you are sure who checked the AED last.

All the equipment and prevention in the world is meaningless without training. EpiPens don’t administer themselves, and patients in cardiac arrest need CPR until the AED arrives. Having an emergency in your office may be one of the scariest moments of your career. How you handle that moment will be determined by how much you have prepared. EVERYONE in the office should have CPR and AED training and dentists and nurses should have periodic refreshers on the emergency drugs and oxygen they may have to administer. Dentists and their staffs who perform conscious sedation should also be trained in Advanced Cardiac Life Support (ACLS). Hold frequent drills in your office so that everyone knows what their role will be during the emergency. Seek help from a rescue professional to help you think of different scenarios and how to handle them.

Dental offices are not immune to a variety of medical emergencies. It is imperative to take steps that may help prevent potential medical distresses, have equipment and medications ready to administer in case of extremis, and prepare yourself and your staff for the most common medical emergencies. Procedures should be in place to handle this crisis as well as you handle fillings.

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