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911 Call Me Maybe? Response Protocols for Medical Emergencies in the Dental Setting
SCDHA Annual Symposium October 11th, 2014
Lunch and Learn
Gina H. Ormond, DMD
Learning Objectives
Review the most common medical emergencies in the
dental office.
Prepare a list of basic drugs, medicaments, and
equipment that should be in every dental office
emergency kit.
Discuss the signs, symptoms and treatment plan
algorithms for common medical emergencies in the
dental office.
Describe the role and responsibilities of the dental team
in assisting in the management of medical emergencies
in the dental office.
Specify measures available to prevent medical
emergencies from occurring in the dental office.
It is estimated that one or
two life threatening
emergencies will occur in the
lifetime practice of a general
dentist.1
..
..
The entire Dental
Team can be
included in a legal
action following an
emergency.
None of these were dental emergencies!
In 1993, Dr. Stanley Malamed reported
results from 4,307 North American dentists.
The surveys revealed that over a 10 year
period 30,608 emergencies occurred in the
dental office.2
Prevalence of Medical Emergencies 2
Least Common:
18. Thyroid storm
17. Adrenal Insufficiency
16. Cerebrovascular accident
15. Diabetic coma
14. Acute Pulmonary Edema
13. Local Anesthetic overdose
12. Myocardial Infarction
11. Anaphylactic reaction
4
25
68
109
141
204
289
304
Prevalence of Medical Emergencies 2
Most common (Top 10):
1. Syncope
2. Mild allergic reaction
3. Angina
4. Postural Hypotension
5. Seizures
6. Asthmatic Attack
7. Hyperventilation
8. Epinephrine reaction
9. Insulin Shock (Hypoglycemia)
10. Cardiac Arrest
15,407
2,583
2,552
2,475
1,595
1,392
1,326
913
890
331
Other factors to consider
In 2010 the American Medical Association reported
that the average American between the ages of 35
and 50 was currently taking SEVEN prescribed
medications.4
Aging population
Increasing use and administration of drugs in
dentistry…
1.Benzodiazepines (diazepam, midazolam)
2.Narcotics for IV sedation-meperidine
3.Nitrous Oxide sedation
Basic Emergency Equipment
Portable “E”-
cylinder
Oxygen Tank
Low Flow
Regulator
Remember Oxygen is a drug!
New studies indicate that oxygen
should be given according to patient
need.5,6
A pulse oximeter should be used to
determine the need for oxygen and
the appropriate delivery method.
Oxygen Delivery Devices
Nasal Cannula 2-6 liters/min.
Patient is breathing
SpO2 below 94%
Face Mask 8-12 liters/min.
Patient is breathing
SpO2 is 90-93%
Oxygen Delivery Devices
Non-Rebreather Mask 10-15 liters/min.
Patient is breathing
SpO2 below 90%
Bag-Valve–Mask (Ambu bag) 15 liters/min.
Patient not breathing/or needs respiratory assistance
Stethoscope and
Sphygmomanometer
Need different
sizes of BP
cuffs
Latex Free
Automated External
Defibrillator
If AED used within the
first minute of collapse
the chance of survival is
90%.
If AED used to deliver shock 10 minutes
after collapse, the chance of survival is
close to zero.7
Average time for
paramedics to arrive
at your
office…..11minutes4
Pulse Oximeter
Additional Equipment
Glucometer
Oral airways
2 (1cc) disposable syringes
with 23g 1.5 inch needle
Alcohol wipes
Penlight/Flashlight
Stopwatch
Scissors/Trauma Shears
Disposable razors
Emergency report form
2 ink pens
Blanket
Quick Reference Guide
Essential Drugs for the
Medical Emergency Kit8
Albuterol
Aspirin-2 packets
of powdered
aspirin (325 mg)
Diphenhydramine
Glucose- Tube of
gel
Essential Drugs for the
Medical Emergency Kit8
Nitroglycerin-0.4 mg/
spray or tablets
Epinephrine (1:1000)-
Two 0.3mg preloaded
self-injecting pens
(weight over 66 lbs)
and Two 0.15mg pens
(weight 33-66lbs)
Most emergency
situations can be
handled without
the use of
medication.
Other Emergency Drugs
Ammonia vaporoles
Glucagon
Diazepam
Cortisone
Packaged Kit or Personalized?
Basic Action Plan
Patient assessment….Is the patient conscious or
unconscious?
Yell for Help and Call 911 if needed
Positioning- Let gravity aid in emergency
treatment
“Face is Red, Raise the
Head. Face is Pale,
Raise the Tail.”
EMS should be alerted
immediately……. Poisoning
Bleeding- Hemorrhage
Breathing- Obstruction, Anaphylaxis, Respiratory arrest
Chest pain
Basic Action Plan
P-Position
C-Circulation
A-Airway
B-Breathing
D-Definitive Treatment/ Differential Diagnosis/ Drugs
/Defibrillation
E-Evaluate Vital Signs-Respirations, Pulse, BP, SpO2, Temp
Do Not Leave
Your Patient!
Management of the Most
Common Medical Emergencies
Syncope
Allergic Reaction
Angina
Seizures
Asthma
Hyperventilation
Epinephrine reaction
Hypoglycemia
Cardiac Arrest
Syncope Signs and Symptoms:
• Diaphoresis
• Tachycardia
• Pale appearance
• Nausea
• Dizziness
• Visual disturbances
• Decreasing BP
• Dilating pupils
• Unconsciousness
Half of all Medical
Emergencies occur during or
immediately after the
administration of Local
Anesthesia
Syncope
Management: 1. Basic Life Support 2. Supine position with
feet slightly higher than the chest (Trendelenburg).
3. Ammonia inhalant (respiratory stimulant)
4. O2 administered 5. Cool rag on head and
neck 6. Monitor vitals
Allergic Reaction Signs and Symptoms:
• Urticaria (Hives)
• Pruritus (Itching)
• Erythema
• Coughing
• Bronchospasm
• Angioedema
Management:
Limited to skin:
Diphenhydramine-oral
Anaphylaxis:
911
EpiPen
Oxygen
Diphenhydramine IM
Hydrocortisone IM
Angina Signs and Symptoms:
• Substernal pressure
• Tightness
• Burning Pain
• Pain may radiate to left shoulder
Management:
• Place in comfortable position
• O2
• Nitroglycerin q 5 mins.
• Monitor vitals
• With prior history of angina administer up to 3 tabs or sublingual sprays…then activate EMS
Seizures
Signs and symptoms:
• Aura
• Epileptic Cry
• Tremors
• Tonic/Clonic convulsions
Management: • Protect head and neck • Support Airway • Oxygen for post seizure • BLS • Activate EMS if prolonged • Valium (Be Careful)
Asthma
Signs and Symptoms: • Feeling of chest congestion
• Cough
• Wheezing
• Labored breathing
• Use of accessory muscles for respiration
• Tachycardia (>120 in severe asthma)
• Nasal Flaring
• Patient sits upright and “fights” for air
Management: • Place patient in upright
sitting position
• Administer Bronchodilator (via metered-dose inhaler-MDI-) This medication is a Beta Agonist.
• Oxygen
• If severe, inject .3ml (1:1000 solution) epinephrine ( adult) S.C., I.M., or S.L.
• EMS
Hyperventilation
Signs and Symptoms: Management • Raise chair to upright
position
• Calm and reassure client
• Ask client to try to slow the rate of breathing-Hold breath for 10secs.
• Have client cup hands over mouth
• Instruct client to rebreathe CO2 enriched expired air
• Monitor Vitals
• Faint, lightheaded • Tightness in chest • Palpitations • Rapid breathing • Altered consciousness • Numbness, tingling
around the mouth, toes and fingers
Epinephrine Reaction
Remember Vasoconstrictors can help prevent Toxicity
Do not use with:
• Uncontrolled Hypertension
• Hyperthyroidism
Drug interactions:
• Tricyclic antidepressants
• Monoamineoxidase inhibitors (MAOI’s)
Epinephrine Reaction Signs and Symptoms: • Fear/Anxiety
• Tense/Restless
• Throbbing Headache
• Tremor
• Perspiration
• Weakness
• Pallor
• Dizziness
• Palpitations
• Respiratory Difficulty
• Elevated BP/HR
Management:
• Reassure Client
• Position Client for comfort
• BLS – if needed
• Administer Oxygen – if needed
• Monitor Vitals
• EMS – if needed
• Allow client to recover and discharge
• Usually adverse effects only last about 5-10 minutes
Hypoglycemia (Insulin Shock)
Hypoglycemia (Insulin Shock) Signs and Symptoms:
• Rapid onset, esp. if insulin dependent
• Personality change, irritability, confusion
• Cold sweat, pale, moist skin
• Nervous, trembling, weak, dizziness
• Altered consciousness, Slurred speech
• Headache
• Seizures
Management: Conscious
• administer oral carbohydrates (cake icing, orange juice, coke, glucose gel)
Unconscious
• Call 911
• Can give Transmucosal sugar, Glucagon 1mg IM, or IV 50% dextrose (50ml)
• Administer O2
• Oral carbs if consciousness is regained
• Monitor vitals until EMS arrives
Myocardial Infarction…../Cardiac Arrest Signs and Symptoms:
• Chest pain radiating to left shoulder, arms, neck and jaw.
• Nausea
• Palpitations
• Diaphoresis
• Dizziness
• Pain unrelieved by Nitroglycerin
Management:
• Activate EMS
• Administer 325mg aspirin-powder or have patient chew
• Oxygen
• Prepare for CPR
• AED
Stroke (CVA) Signs and Symptoms:
• F.A.S.T. • Face
• Arms
• Speech
• Time
• Headache
• Confusion
• Weakness/Dizziness
Management:
• Call 911
• Position-Conscious or
Unconscious
• BLS-Airway
• Oxygen
Local Anesthetic Overdose
• Remember to always aspirate!
• Do not give toxic dose!
• Predisposing factors: age, disease, pregnancy, mental state, lower weight, and genetics
Local Anesthetic Overdose
Signs and Symptoms:
• Confusion • Talkativeness • Apprehension • Excited • Headache • Lightheaded • Dizziness • Ringing in ears (tinnitus) • Flushed/chilled
• Blurred vision • Slurred speech/stutter • Muscular twitching • Tremor of face • Initial elevated
BP/HR/Resp.rate • CNS depression • Seizures • Unconsciousness
Local Anesthetic Overdose Management:
• Position client comfortably
• Administer Oxygen - if needed
• Monitor Vitals
• EMS – if needed
Preparation of Dental Team Every team member should be assigned a
role in a medical emergency
Leader:
Initiates treatment-PCAB
Determines if EMS needed
Delegates Runner
Remains with the patient
Administers Drugs
Preparation of Dental Team
Team Member 1 (Runner):
Retrieves Emergency Equipment and
Drug Kit
Alerts rest of dental team
Assists leader with BLS
Monitors Vitals
Prepares emergency drugs
Preparation of Dental Team
Team Member 2:
Calls EMS (9-1-1)
Meets the Paramedics
Records all the events on the
emergency record
The 911 Phone Call
Post by phone what to say to the 911 operator….
1. State your name and the name of the
dentist’s practice and location
2. Give patient’s symptoms and status.. (patient is
conscious, unconscious, alert…)
3. State that a team member will meet the
paramedics at the office entrance
4. Stay on the phone
5. Tell the team leader that EMS is on the way
Midlands Technical College Dental Clinic
Emergency Treatment Record
Person’s Name: ___________________________Date:____________Time:__________
Allergies: __________________________________
List of Medications taken prior to emergency: __________________________________
Time Blood
Pressure
Pulse Respirations O2
Flow
L/Min
Medications
Administered
Medication
Dosage
Medication
Route
(IM, SL,
PO, IV)
EMS 911 called at (time):_______________EMS called by (whom):________________
EMS arrived at (time):_______________________
Disposition of person when released from MTC and transported from site: ____________
________________________________________________________________________
Person released to: ________________________________________________________
Person taken to what hospital: _______________________________________________
Faculty, students, and people present: _________________________________________
________________________________________________________________________
EMS personnel: __________________________________________________________
Signature of person recording events: ________________________
Other Significant treatment information: _______________________________________
________________________________________________________________________
GHO 8/09
Preparation of Dental Team
Prepare office by role playing
emergencies. “Practice Drills”
Cross-Train Team Members
Set schedule to check the
emergency equipment and
drugs
Current CPR certification
Prevention
Never treat a stranger Review health history and update
90% of all medical emergencies can
be prevented. The Health History is
our best tool to prevent medical
emergencies.
Prevention Obtain vitals
Modify treatment
Use stress reduction
protocols
1. Explain Procedures
2. Medications
3. Adequate Pain Control
Legal Considerations
Review State Dental Practice Acts
S.C. Code of Laws Title 40 Chapter 15:
Dental Hygienists practicing under general
supervision must maintain professional liability
insurance.
S.C. Licensure:
Current CPR status
CE
Legal Considerations
The standard of care can be defined as “what the reasonable, prudent person
with the same level of training and experience would have done in the same
or similar circumstances”.
What must be proven in malpractice litigation14
Duty to Act
Act of omission or commission
Patient was actually injured in some way- emotional and economic
Failure to act reasonably was cause of the patient’s injuries
Additional Prevention
Eyewear for Patient http://www.dentistryiq.com/articles/2014/08/jenn-
s-vision-a-true-lesson-in-best-practices.html
Questions?
Thank you!!
gormond@midlandstech.edu
Bibliography
1. Theisen, F. C., Feil, P. H., and Schultz, R. Self perceptions of skill in
office medical emergencies. J. Dent Educ. 54:10 (1990):623-5.
2. Malamed S. F., Managing medical emergencies. J Amer Dent
Assoc.1993;124:40-53.
3. Fast, T.B., Martin, M.D., and Ellis, T.M. Emergency preparedness: A
survey of dental practitioners. J Amer Dent Assoc. 112 (1986):499-500.
4. Goodson, C. How prepared are you for a Medical Emergency?
Dentaltown March 2013:103-108.
5. www.jems.com/print/22676 “EMS Education Overlooks Challenges of
Oxygen Therapy”
6. O’Connor RE, et al. Acute Coronary Syndrome:2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. Circulation 122:S787-817,2010.
7. Biron Leiseca,C. Dental Office Medical Emergencies. Continuing
Education Course, Amelia Island, Florida, November 2013
www.DHmethEd.com.
Bibliography
8. Malamed, S.F., Emergency Management 101. Dimensions of Dental
Hygiene.2014;12 (1):39-41.
9. Jennings,D.,Chernega, J.B. Emergency Guide for Dental Auxiliaries,
4th ed., Delmar Publishers Inc., Albany, NY, 2013.
10. Grimes, E. Medical Emergencies: Essentials for the Dental
Professional. Pearson Education, Upper Saddle River, NJ, 2009.
11. Haas, Daniel A. J Amer Dent Assoc, May 2010 Emergency Supplement,
Vol. 141, p8-13, 6p
12. Meiller, T., et al. Dental Office Medical Emergencies: A Manual of
Office Response Protocols, 5th ed. Lexi-Comp Company, 2013.
13. Malamed, S.F. Medical Emergencies in the Dental Office, 6th ed., St.
Louis: Mosby-Year Book, Inc., 2007.
14. Protzman, S., Clark, J., Leeuw, W. “Management of Medical
Emergencies in the Dental Office” www.dentalcare.com Crest Oral –B
Continuing Ed. Course, revised Jan. 24, 2012.
15. Patton, L., The ADA Practical Guide to Patients with Medical
Conditions. 1st ed.,Wiley-Blackwell,2012.
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