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EMERGENCY
PROTOCOL
SCENARIOS
American Association of Orthodontists
Robert D. Elliott, DMD, MS
www.pedospringboard.com
©Copyright Pedo Springboard 2014
2
TABLE OF CONTENTS
I. List of Medications Page 3
II. Basic Emergency Equipment Page 5
III. Emergency Team Page 6
IV. Emergencies and Their Management Page 8
Syncope Page 9
Allergic Reactions Page 10
Hypoglycemia/ Insulin Shock Page 12
Convulsions – Seizures Page 13
Bronchospasm (Asthma) Page 14
Vomiting, Aspiration & Choking Page 15
Hypotension Page 16
Angina Pectoris (chest pain) Page 17
Myocardial Infarction & Cardiac Arrest Page 18
Hyperventilation Page 19
V. Sample Check List Forms Page 21
VI. Employee Compliance Signature Log Page 25
VII. Vital Signs Recording Sheet Page 27
VIII. Emergency Fire Exit Plan Page 28
©Copyright Pedo Springboard 2014
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I. LIST OF MEDICATIONS
ALBUTEROL (VENTOLIN/PROVENTIL) – bronchodilator
Inhaler, for asthma attacks
ANTIHYPOGLYCEMICS (cake icing, Coca-cola, sugar)
For unexplained unconsciousness and seizures of unknown origins
Glucagon, orange juice, cake icing
AMMONIA INHALANT
Syncope
Crushed between fingers and placed under nose
ATROPINE (anticholinergic agent, anti-asthmatic, bronchodilator)
Bradycardia
Bronchospasms
Dosage: .02 mg/kg every 5 minutes
BENADRYL (DIPHENHYDRAMINE) – histamine blocker
For delayed allergic reactions
Dosage: Adult: 50mg injected IM (deep)
Child: 25mg injected IM (deep)
Oral Dosage: <6 yrs: 1 teaspoon (12.5 mg)
6-12 yrs: 2 teaspoons (25 mg)
>12 yrs: 4 teaspoons (50 mg)
©Copyright Pedo Springboard 2014
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DEXAMETHASONE (steroid)
Treat airway edema (Severe Allergic Reactions, Anaphylaxis)
Dosage: .03-.15 mg/kg/day
EPINEPHRINE 1:1000 - bronchodilator
For acute allergic reactions, asthma attacks, bradycardia and cardiac
arrest
Delivered by injector stick (pre-loaded syringes 2-3 x 1ml)
Dosage: Adult: 0.3 - 0.5 mg/kg
Child: .01 mg/kg
NITROGLYCERINE - vasodilator
For chest pain of angina pectoris
Dosage: .4mg tablets (sublingual) or .4mg/spray
Note: tablets will only have a 12 day shelf life once exposed to light
and air
OXYGEN
“E” cylinder delivery tanks
to aid in breathing difficulties or as blow by
©Copyright Pedo Springboard 2014
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II. BASIC EMERGENCY EQUIPMENT
OXYGEN DELIVERY SYSTEM
Delivers positive pressure oxygen
Must maintain a patent airway
Must have an airtight seal of mask on face
Various sizes of masks
SUCTION SYSTEM AND TIPS
Tips need to be large diameter and rounded to suction vomitus and
blood (high vacuum suction)
Manual suction if power goes out
AED (portable pulse oximeter recommended)
BLOOD PRESSURE CUFF AND STETHOSCOPE
Crash Cart Supplies: www.healthfirst.com
©Copyright Pedo Springboard 2014
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III. EMERGENCY TEAM
DR. _________________________
Performs basic life support
Administers medications
FIRST CLINICAL ASSISTANT
Notifies TWO other assistants for help
Gets emergency kit
Passes drugs and equipment
Helps administer basic life support
Ventilates patient
SECOND CLINICAL ASSISTANT
Calls 911 – STAY ON THE PHONE
States the MEDICAL EMERGENCY (ie: “Respiratory
Depression”)
States “This is a DENTAL office, not a medical
office” – “there is NO physician present!”
THIRD CLINICAL ASSISTANT
Monitors vital signs
Record keeping – use “Vital Signs Recording” sheet
FOURTH CLINICAL ASSISTANT
Calls Admin via intercom and informs of
emergency/situation - CODE BLUE!
Admin team member will go outside and wait for
EMS to arrive
Make sure EMS is escorted to office and room
where emergency is being managed
©Copyright Pedo Springboard 2014
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EMERGENCY ROAD MAP
R ecognition
Unconsciousness
Altered consciousness
Respiratory difficulty
Seizure
Drug related emergency
Chest pain
1. Discontinue treatment
2. Assess level of consciousness
3. Position patient accordingly
4. Suction if needed
A ssess Consciousness
1. ALERT – is patient aware of surroundings?
2. VERBAL – can patient respond to questions?
3. PAIN – does patient react to peripheral pain?
4. UNRESPONSIVE to verbal command or pain – CALL 911!
P osition - If Unconscious:
1. Place patient in supine position
2. Elevate feet slightly above head
3. P-CAB’s if needed
R eassess patient
©Copyright Pedo Springboard 2014
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IV. EMERGENCIES AND THEIR
MANAGEMENT
TABLE OF CONTENTS
Syncope Page 9
Allergic Reactions Page 10
Hypoglycemia/ Insulin Shock Page 12
Convulsions – Seizures Page 13
Bronchospasm (Asthma) Page 14
Vomiting, Aspiration & Choking Page 15
Hypotension Page 16
Angina Pectoris (chest pain) Page 17
Myocardial Infarction & Cardiac Arrest Page 18
Hyperventilation Page 19
©Copyright Pedo Springboard 2014
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SYNCOPE
50% of all dental emergencies produced by a sudden drop
in blood pressure which decreases oxygen supply to brain.
Dizziness associate with fainting
Patient feels warm, is pale, sweaty, nauseous and tachycardic
Patient may feel nauseous for next 24 hours
MANAGEMENT
1. Position patient in supine position
2. Elevate legs
3. Administer oxygen
1. Administer ammonia inhalant
If no recovery in SECONDS, call 911!
5. Observe for one hour – should not leave office alone
©Copyright Pedo Springboard 2014
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ALLERGIC REACTIONS
A hypersensitive state acquired through exposure to an allergen or re-
exposure that produces a heightened capacity to react.
Reactions can be mild, delayed (up to 48 hrs.), immediate and/or life
threatening
15% of all adverse drug reactions are immunologic or true allergies
N20/02 has never been known to elicit an allergic response
A good thorough history is crucial!
TYPES OF RESPONSES:
SKIN REACTIONS – symptoms include urticaria (smooth, elevated
patches of skin with itchiness), erythema and angioedema
RESPIRATORY REACTIONS – symptoms include bronchospasm, local
edema of larynx leading to airway obstruction
ANAPHYLAXIS – the most acute and life threatening! Death can
occur in minutes! Patient symptoms include nausea, itchiness, flushing,
hives on face and chest, vomiting, cramps.
Respiratory symptoms then follow – tightness in chest,
coughing, wheezing.
Cardiovascular symptoms follow – pallor, light headiness,
palpitations, tachycardia, hypotension, arrhythmias, loss of
consciousness, and finally cardiac arrest. This is known as
anaphylactic shock.
©Copyright Pedo Springboard 2014
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SKIN REACTIONS
1. Administer an antihistamine or benadryl
a. Child under 6yo: 1.2tsp to 1 tsp (12.5mg per tsp)
b. Child (6-12 yrs): 1-2tsp (12.5mg per tsp)
c. Child over 12 - Adult (>60kg): 2-4 tsp (12.5mg per tsp)
2. Continue with oral benadryl for 3-5 days prescribed before leaving
3. Refer to an allergist/consult with a physician
If severe reaction:
1. Epinephrine IM or SC Note: onset of action for IM is 10 minutes (peaks at
30 min); oral takes 60 minutes and is not effective
2. Call 911 or have medical consultation before discharge
RESPIRATORY REACTIONS
1. Refer to Bronchospasm section
2. Laryngeal Edema –
a. place patient in supine position and elevate
legs
b. administer epinephrine IM from preloaded syringe
0.3-0.5 mg/kg ADULT
0.01 mg/kg CHILD (up to .3mg)
c. maintain patent airway
GENERALIZED ANAPHYLAXIS
1. Call 911
2. Supine position
3. Institute BLS
a. monitor and record vital signs
b. administer O2
c. CPR
4. Administer epinephrine 1:1000 concentration sub Q
0.3-0.5 mg/kg ADULT
.01 mg/kg CHILD
5. Administer benadryl (diphenhydramine) IM in front of upper leg
50mg ADULT
25mg CHILD (approx. 1cc)
6. Should see resolution in minutes
7. Administer second dose, if necessary
8. When stable, give benadryl IM in front of upper leg to decrease chance of
recurrence
9. Contact MD for consultation of admission to hospital for monitoring
©Copyright Pedo Springboard 2014
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HYPOGLYCEMIA / INSULIN SHOCK
Low blood sugar
Associated with Type I Diabetes (Insulin Dependent Diabetes
Mellitus)
Will see mental confusion, mild muscle tremor, diaphoresis, cold
feeling and tachycardia
Usually seen when patient doesn’t eat prior to appointment
If patient must be fasting then insulin should be adjusted per
physician
If blood sugar falls too low, seizures and loss of consciousness follow
MANAGEMENT
1. End procedure
2. Make patient comfortable
3. Check blood glucose (<60 is a problem for a child)
Infant normal 50-80 mg/dL
Child 1-16yo 60-100 mg/dL
>16yo normal 74-106 mg/dL
4. Give patient sugar (cake icing, orange juice, candy)
4. Maintain patent airway
5. Check and record vitals:
Blood pressure
Respiration rate
Pulse
INSULIN SHOCK
If unconscious:
2. call 911
3. Administer 100% oxygen
4. Administer cake icing mucosally by placing under maxillary lip
and continue oxygen delivery
5. Alternatively administer 50% Dextrose intravenously
©Copyright Pedo Springboard 2014
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CONVULSIONS - SEIZURES
Seen commonly in epileptics but can be elicited by stress, overdose of
local anesthetic or intravascular injection of local anesthetic.
Usually associated with hyperventilation, hypoxia, anoxia, and
hypercarbia
Patient requires adequate ventilation
Most seizures last 2-5 minutes
MANAGEMENT
1. End procedure
2. Call 911
3. Position patient in supine position
4. Gently hold patient’s arms and legs to prevent injury (allow
controlled movement)
5. Do not place anything in patient’s mouth
6. Keep airway patent
1. Administer 100% oxygen
2. Maintain A, B, C’s!
3. Consider benzodiazepine – Valium dose (max 10mg) or
Versed dose (max 20mg)
Note: Morbidity and mortality can occur post seizure!
©Copyright Pedo Springboard 2014
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BRONCHOSPASM
(asthmatic attack)
A constriction of smooth bronchial muscle causing respiratory distress,
dyspnea, wheezing, flushing, cyanosis, perspiration, tachycardia, and
anxiety
There is a higher percentage of bronchospasm noted in
children!
MANAGEMENT
1. End Treatment immediately
2. Position patient in semi-erect position
3. Monitor with pulse oximeter
4. Initiate bronchodilation:
a. albuterol via inhaler first!
b. epinephrine .3mg, if no resolution
5. Begin oxygen delivery through nasal cannula*
6. May need positive pressure oxygen if patient starts
to desaturate.
7. MAINTAIN the AIRWAY !
*Note: Oxygen alone will NOT end bronchospasm!!
©Copyright Pedo Springboard 2014
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VOMITING and ASPIRATION
Aspirating solid material can lead to airway obstruction and death
Aspirating liquid matter can trigger laryngospasm or bronchospasm
FOREIGN-BODY AIRWAY
OBSTRUCTION
AIRWAY- AIRWAY- AIRWAY
1. Call 911
2. Position head
3. Remove foreign bodies and suction
4. Secure and evaluate adequacy of airway
5. Deliver positive pressure oxygen
ASPIRATION MANAGEMENT for CHILD or ADULT
1. Administer abdominal thrusts (child/adult)
2. Cup hands around waist standing behind patient (thumbs inward)
3. Deliver forceful and upward thrusts above bellybutton
ASPIRATION MANAGEMENT for INFANT
1. Administer back slaps and chest thrusts
If unconscious:
1. Lay flat on floor or dental chair
2. Turn face to side and perform finger sweep to remove any
debris that may have become dislodged
3. Attempt to ventilate
4. If unsuccessful, deliver 6-10 abdominal thrusts
5. Perform finger sweep again
6. Attempt to ventilate again
7. BLS and A,B,C’s as needed
8. Tracheal intubation if necessary
©Copyright Pedo Springboard 2014
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HYPOTENSION
Low blood pressure
Child’s minimal systolic blood pressure is:
70mm Hg + 2(age)
ie: 4 yr. old child = 78 mm Hg = (70 + 2(4))
Usually caused by too much premed, overdose of local anesthetic,
intravascular injection, hemorrhage, postural changes, abnormal
circulatory system, unmanaged diabetes
Patient will be restless, anxious, disoriented, cold, pale with clammy
hands and dilated pupils
MANAGEMENT
1. Know patient’s pulse and BP prior to sedation
2. End procedure
3. Call 911
4. Position patient in supine position, legs elevated
5. Nitrous oxide off, Oxygen on
6. Antidotal drugs/reversal drugs if needed
7. BLS, CAB’s if needed
©Copyright Pedo Springboard 2014
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ANGINA PECTORIS
A substernal thoracic pain due to inadequate coronary circulation
Associated with exercise, emotion or heavy meal
Patient describes tightness in chest, palpitations, faintness, dizziness
or indigestion
MANAGEMENT
4. End procedure
5. Make patient comfortable
6. Place nitroglycerin* under tongue if needed
7. Administer oxygen (100%) or oxygen (70%) and nitrous oxide(30%)
8. Place pulse oximeter on patient
9. Monitor blood pressure
10. Transfer to hospital as needed
If no resolution:
1. Consider as an acute myocardial infarction and begin ABC’s!
*Note: Nitroglycerin tablets lose their effectiveness and shelf-life once
exposed to air (12 days). Should use the sublingual nitroglycerin spray
(.4mg/spray) in emergency kit.
©Copyright Pedo Springboard 2014
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MYOCARDIAL INFARCTION
(heart attack)
Mimics angina yet pain is more severe and prolonged.
Produced by partial or complete occlusion of blood flow through one
or more coronary arteries
Leads to necrosis of heart muscle
MANAGEMENT
1. End procedure
2. Make patient comfortable and proper positioning
3. Administer oxygen (100%) or oxygen (70%) and nitrous oxide (30%)
4. Administer pain relief – one aspirin and nitroglycerine spray under
tongue
5. Call 911
6. Monitor patient vitals
7. Prepare for CPR
CARDIAC ARREST
1) Recognize no pulse
2) Call 911
3) Initiate CPR ~ CAB’s
4) Give oxygen
5) Attach monitor/ defibrillator - determine if rhythm is shockable with defibrillator
6) If not a shockable rhythm, resume CPR
©Copyright Pedo Springboard 2014
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HYPERVENTILATION
Usually anxiety induced when patient breathes more rapidly and deeply
than usual
Toes and fingers feel cold and tingly
Patient feels lightheaded and has pain in chest
Most common in late teens to late 30’s
MANAGEMENT
1. End procedure
2. Make patient comfortable
3. Communicate with patient/continue to talk to
4. Have patient re-breath exhaled air by cupping hands – which
also helps warm them
©Copyright Pedo Springboard 2014
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WHEN TO CALL
911
1. Patient is unresponsive to verbal command or pain stimuli
2. Convulsion or seizure episode
3. Hypertension is unrelieved
4. Unconscious hypoglycemia
5. Hypotension (low blood pressure)
6. Laryngospasm
7. Myocardial Infarction
8. Syncope without recovery immediately after ammonia inhalant and
positioning
V. OFFICE CHECK LIST
SAMPLE FORMS
1. Eye Wash Inspection Station Check List
2. Oxygen Tank System Weekly Check List
3. Emergency Drug Kit Monthly Check List
©Copyright Pedo Springboard 2014
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OXYGEN TANK SYSTEM Weekly Check
Week Ending Initials Week Ending Initials
©Copyright Pedo Springboard 2014
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EMERGENCY DRUG KIT Monthly Check
Month Ending Initials Month Ending Initials
©Copyright Pedo Springboard 2014
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EMPLOYEE COMPLIANCE
SIGNATURE LOG
MONTH COMPLETED:
Employee
Signature
Date
Completed
Reviewed
Manual ()
MONTH COMPLETED:
Employee
Signature
Date
Completed
Reviewed
Manual ()
©Copyright Pedo Springboard 2014
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MONTH COMPLETED:
Employee
Signature
Date
Completed
Reviewed
Manual ()
MONTH COMPLETED:
Employee
Signature
Date
Completed
Reviewed
Manual ()
MONTH COMPLETED:
Employee
Signature
Date
Completed
Reviewed
Manual ()
VITAL SIGNS RECORDING SHEET
Patient Name: Date:
Likely Event Occurring:
Beginning time of recording: Person Recording:
START
3
min
5
min
7
min
10
min
13
min
15
min
18
min
20
Min
23
min
25
min
SaO2 (%)
Pulse (bpm)
BP (mm/Hg)
RR (bpm)
100% Oxygen Administration? No Yes – Time:______
Nitrous Oxide/Oxygen Administration? No Yes -- _____% Nitrous Oxide & _____% Oxygen
Supplemental Drug Delivery? No Yes –Name of Drug:
Amount of Drug: Time Administered:
Delivery Route: Delivered By:
Normal Vital Signs
ADULT: SaO2: 98%-99% Pulse: 60-80 bpm BP: <140/<90 RR: 14-20 bpm
ADULT RESCUE BREATHING: 1 breath / 6-8 sec. ADULT CPR: (dual) 30 comp/2 breaths
CHILD (2-6): SaO2: 98%-99% Pulse: 80-100 bpm BP: 100/66 RR: 20-30 bpm
CHILD RESUCE BREATHING: 1 breath/6-8 sec. CHILD CPR (dual): 15 compressions/2 breath (one palm only!)