by Sandra Nagel Beebe, RDH, MS
Recognition and management of medical emergencies in the dental office.
It has been a busy day in the office. You are about to escort the last patient back to your chair when the dentist, working in the next operatory, calls out, "We need some help in here!" The tone of his voice makes it clear that something is wrong. Are you prepared?
Medical emergencies in the dental office seldom occur at opportune times, but, with a little planning and forethought, you can be prepared to respond. Physiological medical emergencies, although infrequent, can occur at any time. Contributing factors that increase the likelihood of medical emergencies include an aging population seeking dental care; increased administration of drugs in the dental practice; longer dental appointments; and more individuals under medical treatment for chronic conditions.
Medical emergencies typically can be generalized as either cardiovascular or noncardiovascular. I will address the two most common - unconsciousness and altered consciousness - and general considerations for each situation. But first, it is imperative to understand the need for planning.
The time to decide "who will do what" is not during, but before the medical emergency. Staff members need to have defined roles for emergencies and thoroughly understand their specific duties. The assignment of duties should be based on abilities rather than position in the office. It is safe to assume not all health-care providers react calmly during an emergency. This is not a deprecatory statement; it's a fact. We all function differently under stressful conditions. Handling a medical emergency requires clear thinking and fast responses.
One person, typically the dentist, will be in charge of assigning emergency duties. At least one staff member - typically the hygienist - with education in anatomy, physiology, and pathology remains with the patient to help the dentist manage the emergency. Another staff member is trained in how to prepare and use the emergency equipment; another is given the responsibility for summoning rescue personnel and remains on the telephone until they arrive.
All staff members need to know the location of emergency oxygen and the drug kit. Never relocate emergency equipment without notifying all staff members! Emergency telephone numbers are posted by every telephone, and all staff members need to be trained in cardiopulmonary resuscitation (CPR) at the health-care provider level. The old adage, "Practice makes perfect" is true. Physiological emergencies can be successfully resolved if staff members are well-trained and able to respond as a team during an emergency. Practice your emergency protocol regularly. The dentist evaluates staff performance during the practice sessions.
Second in importance to treating and managing a medical emergency is the patient's physical evaluation. Before beginning any procedure, have the patient complete a written medical questionnaire that provides information on the patient's current physical condition. During the physical examination (record blood pressure, pulse, respirations, temperature, height, and weight), initiate a dialogue to ensure a thorough understanding of the patient's physical and emotional status.
Some people find visiting the dental office an extremely stressful experience; their level of stress can have a negative impact on their well-being. Stress may exacerbate pre-existing conditions such as angina pectoris, epilepsy, asthma, and anemia. Stress also may affect patients who are not medically compromised. Fear, anxiety, and pain can cause acute changes in the body's homeostasis that can lead to psychogenic emergencies such as hyperventilation and syncope. During the physical evaluation, know how to detect the characteristic signs and behaviors. If you determine that the patient is manifesting signs of distress or signifying an inablity to tolerate the procedure, the dentist can modify the treatment plan if necessary.
Your dialogue with the patient also allows you to gather additional information on what may or may not have been provided by the patient on the medical questionnaire. Instances of people deliberately failing to provide a complete medical history are, fortunately, few. However, it can and does happen. Most often, your dialogue can help you uncover unintentional omissions. If a medical emergency does occur during treatment, the physical evaluation will be critical to treating and managing the emergency.
Basic life support is the essential skill and the first procedure used in managing all emergencies. Typically, the medical emergencies reported in dental offices include unconsciousness or altered consciousness.
Unconsciousness occurs more frequently than any other condition. Vasodepressor syncope (fainting) accounts for more than 50 percent of all dental office emergencies. Syncope describes the transient loss of consciousness caused by disturbances in cerebral function. It normally is reversible and treated with these steps:
(A) Airway - maintain or establish
(B) Breathing - verify or initiate artificial ventilation
(C) Circulation - check/monitor pulse or restore heartbeat
Loss of consciousness depresses the functions of coughing, choking, swallowing, sneezing, and most important, the ability to maintain an open airway. As soon as unconsciousness is recognized, position your patient in a supine position. The head should be at the same level as the thorax, with feet slightly elevated at a 10 to 15 degree angle. Do not place your patient in the Trendelenburg position. Gravity will cause the abdominal viscera to shift superiorly into the diaphragm and may diminish the effectiveness of respiratory movement.
If your patient is pregnant and near term, do not place her in the supine position. Instead, adjust the chair to the supine position and turn her onto her right side. Placing a third-trimester patient supine may cause the gravid uterus to obstruct or diminish blood flow through the superior vena cava. Placing the patient on her right side will ensure that the gravid uterus is not directly over the vena cava.
After correctly positioning your patient, verify a patent (A) airway. In approximately 80 percent of instances of unconsciousness, there will be some anatomic airway obstruction from soft tissue. If your patient has a compromised airway, perform the head-tilt technique to establish a patent airway. Maintain the head-tilt technique until your patient resumes consciousness.
Once you have established and are maintaining an (A) airway, look, listen, and feel for (B) respirations. Your patient may be breathing normally, inadequately, or not at all. Lean over your patient, then position your ear approximately one inch from the patient's nose and mouth. Even if you see the chest rising and falling, do not assume that your patient is breathing adequately! Chest movement is only a sign your patient is trying to breathe. It does not guarantee adequacy of air exchange. Always look, listen, and feel to determine adequacy.
If your patient is breathing, maintain the airway and administer oxygen (O2). Monitor vital signs of blood pressure, heart rate (C) , and breathing. If you cannot feel or hear air exchange at the nose and mouth, begin artificial ventilation. Once the patent (A) airway is established and your patient's (B) breathing and (C) circulation are ensured, manage the patient until consciousness returns.
The easiest way to prevent vasodepressor syncope is by managing the patient correctly before the episode occurs. Psychogenic factors should be evident during the patient evaluation, and the dental team should manage the factors before beginning treatment. Although vasodepressor syncope is usually a benign condition that self-corrects with repositioning and A, B, C, it can be life-threatening. If the patient has stopped breathing, the brain can become hypoxic and cause convulsions. Vasodepressor syncope also can aggravate pre-existing conditions, and, if left untreated, can lead to life-threatening cardiopulmonary changes.
The second most frequent incidence of syncope in the dental office is caused by postural hypotension. It is a result of the baroreceptor reflex failing in response to positional changes. When you move your patient from the supine to upright position after dental treatment, stress on the cardiovascular system intensifies. When your patient was in the supine position, the force of gravity was equally distributed over the body, and blood flow from the heart to the brain was sufficient. Moving from a supine to upright position causes the heart to pump blood against the force of gravity to reach the brain to supply it with the necessary O2 and glucose to maintain function. Your patient will experience immediate decreases in systolic blood pressure of approximately 2mmHg for every inch the head is raised above the heart. This will result in an immediate drop in systolic pressure from 5mmHg to 60mmHg within a minute. Thirty to 60 seconds later, the patient will experience an equally fast rise in systolic pressure as the cardiovascular system stabilizes the blood pressure at or slightly above what was recorded in the supine position. As the patient rises from your chair, he or she will experience an increase in heart rate of approximately five to 20 beats per minute.
Normally, your patient's adaptive mechanisms compensate and the patient does not experience postural hypotension. However, if any of the body's reflex mechanisms fail, postural hypotension can occur. Management of postural hypotension is the same as that described for vasodepressor syncope. Position your patient in the supine position and check A, B, C. Postural hypotension usually can be prevented by slowly repositioning your patient in increments of 22.5 degrees, 45 degrees, 68 degrees, and finally 90 degrees, allowing time for stabilization at each position. Perform a final blood-pressure check against the baseline readings (taken before the procedure began) before allowing your patient to stand.
In most instances of unconsciousness, the age of your patient will be a good indicator in the differential diagnosis of unconsciousness. Typically, patients between the ages of 15 and 40 experience most psychogenic occurrences of vasodepressor syncope. Children younger than 14 usually are more vocal about psychogenic and physiogenic factors. If your patient is 40 years and older, you may suspect cardiovascular complications such as acute myocardial infarction, cerebrovascular accidents (CVA) or acute cardiac dysrhythmias.
The most common cause of altered consciousness in dental patients is the administration of pharmacosedation. Knowledge of pharmacology and drug interaction will minimize incidents. Administration of central nervous system (CNS) depressants invites serious consequences if a patient evaluation fails to reveal the use of other CNS depressants.
Hyperventilation in the dental setting is the most common non-pharmacological cause of altered consciousness. Most instances occur in children, young adults, and patients under 40 years of age, and psychogenic and physiogenic factors are the leading causes. Hyperventilation seldom causes vasodepressor syncope unless it is left untreated.
When altered consciousness is suspected, immediately discontinue the dental procedure. In most instances, the patient is conscious, positioning is not critical, and can be at the patient's discretion or comfort - if the blood pressure remains stable. Altered consciousness may be a sign of a serious medical problem such as cerebrovascular ischemia, cerebrovascular infarction, anaphylactic shock, thyroid gland hyperfunction or hypofunction, or diabetes mellitus. Increases in psychologic or physiologic stress during the dental appointment increases the chances for exacerbation of the medical condition. Therefore, it is extremely important that a patient with any of these medical conditions has an up-to-date medical history and evaluation before starting any treatment. The first key in the prevention or management of altered consciousness is to modify the treatment plan to minimize the risk.
If your patient exhibits signs or symptoms of altered consciousness, monitor your patient's (A) airway, (B) breathing, and (C) circulation. Record the patient's vital signs (blood pressure, heart rate, heart rhythm, and respiratory rate) in a permanent record every five minutes during the episode. Keep your patient comfortable while treating the signs and symptoms. Depending on the office's plan, management will range from basic life support to contacting advanced life-support personnel.
I strongly recommend that you take the time to brush up on your emergency skills, and ensure that all staff members know and regularly rehearse your office protocol. The time you spend practicing may well save the life of a patient.
Sandra Nagel Beebe, RDH, MS, is a clinical instructor in Health Care Professions at Southern Illinois University, Carbondale, and teaches in the dental hygiene program. She may be reached at (618) 453-7202 or by email at [email protected].Cardiovascular and noncardiovascular emergencies include eight primary areas:• Unconsciousness • Altered consciousness • Ocular • Respiratory distress • Seizures• Drug-related emergencies• Chest pain• Cardiac arrest