Cathleen Terhune Alty, RDH
It can occur anytime, without warning. Teamwork and informed reactions are the key during an emergency.
It's just another Monday morning, another routine procedure. Suddenly, the patient mumbles, "I don't feel so good." His lips are pale and his forehead is sweaty. His head drops to the side - he's obviously losing consciousness. What happened? You grab the oxygen and yell for assistance. "Where is the medical kit? Call 911!"
A million scenarios race through your mind: Did I miss a warning on the health history? Did he faint? Have a seizure? A heart attack? Your adrenalin races as you check his pulse and breathing.
Medical emergencies are the last thing anyone wants to happen, but they will occur - when you least expect it. Some patients have medical conditions that could be problematic during treatment. Other patients may not have underlying medical conditions, but experience a medical emergency during treatment due to anxiety or clinician error. Medical emergencies don't happen often, but hygienists should be aware of the most common emergencies that do occur, and learn to be better prepared to deal with and prevent them when possible.
A complete medical history is the best way to prevent an emergency. Make sure the questions on the form are detailed, and that they are answered completely and updated with each visit. If you are unsure why a patient is taking a particular drug, or if a medical condition may impact dental treatment, ask the patient, the doctor, or call the patient's physician. It's always prudent to ask questions.
Next, be prepared for emergencies by knowing the location and contents of the office emergency medical kit and how to use them. Keep your emergency response skills current by attending CE courses about medical emergencies. Make sure your CPR training is up-to-date.
Develop a better sense about the patients you treat, which will help you discover those subtle clues that can indicate a problem. Constantly evaluate their current physical state while working, watching for facial cues or breathing changes. Does that faraway look in their eyes indicate daydreaming - or something else? Are they unusually calm, sweaty, or pale? Use your nose as well as your eyes. Is that alcohol on their breath or an acetone, fruity odor? Trust your intuition to know when things aren't right. If something seems strange, ask your patient questions, such as, "Are you doing OK?"
Although not an exhaustive list, here are the top 10 medical emergencies seen in a dental office.
Airway obstruction or choking occurs when air exchange is impeded or blocked. Shortness of breath or lack of breathing is the result. In the dental office, it often is the result of a dental material dropped in the mouth or inhaled. Treatment may include use of the Heimlich maneuver or abdominal thrusts, administration of oxygen, and calling for emergency medical assistance (911).
Local anesthetic reaction occurs when blood levels of anesthetic are too high or if a patient is allergic to a particular anesthetic. An overdose of anesthetic or injection inadvertently placed into a blood vessel can cause a mild to severe medical emergency.
Patients who are allergic to sulfites may have a reaction because sulfites often are in local anesthetic.
Symptoms may include apprehension, nervousness, talkativeness, dizziness, light-headedness, confusion and/or excitement. Treatment may include reassuring patient, administrating oxygen, and monitoring vital signs. If the patient does not respond well, call for medical emergency assistance (911).
Syncope or fainting result from the loss of blood flow to the brain and is the most common medical emergency condition seen in the dental office. It can affect patients of any age at any time and can indicate the presence of a more serious, underlying medical condition.
Orthostatic hypotension is the lack of blood flow to the brain due to a drop in blood pressure, usually due to a patient rising too rapidly to a seated or standing position. This can be common with the elderly and pregnant patient and often leads to syncope.
Symptoms of syncope include nausea, weakness, dizziness, cold sweat, blurring of vision and/or shortness of breath that leads to an impairment of consciousness. Treatment includes placing patient in a Trendelenburg position (head down, feet up), administration of oxygen, monitor vital signs, loosening tight-fitting clothing (especially a tight collar or tie). Slowly return the patient to a sitting position; make sure they have assistance getting home. If patient does not quickly recover or seems ill, call a medical emergency team (911).
Seizures are a sudden, uncontrolled paroxysmal discharge of the central nervous system. It is a symptom of some underlying brain disorder, whether structural, biochemical, or genetic. Seizures are classified as partial, generalized, or unilateral, depending what part of the brain is affected. Any seizures that are reoccurring are termed epilepsy. Causes may be flashing lights, stress and/or fatigue, or alcohol withdrawal.
Symptoms include confusion, loss of consciousness, behavior changes, and uncoordinated muscle contractions. Treatment may include positioning patient on his side if possible, with head extended. A soft object placed under the head to prevent injury is helpful, but do not try to place any object into a person's mouth. Monitor patient closely to ensure an open airway and administer oxygen if possible. Arrange alternate transportation for the patient.
Blood glucose disorders include diabetic patients who are untreated or have forgotten to eat or take their insulin. Hyperglycemia results from too much sugar in the blood and not enough insulin to metabolize it (for example, a diabetic who forgot to take insulin.)
Symptoms have a slow onset: increased thirst, nausea, acetone odor to breath, hot, dry skin. Treatment includes having patient take insulin.
Hypoglycemia is from too much insulin (e.g.: diabetic who took insulin and forgot to eat. Symptoms have a rapid onset: anxiety, sweat, pallor, headache, patient may appear intoxicated. Treatment is to get glucose into the body rapidly (orange juice, frosting in tube, etc.).
Hyperventilation is abnormal, rapid breathing that decreases carbon dioxide levels in the blood; it is often caused by anxiety. It can lead to decreased blood flow to the brain, and in rare cases, syncope.
Symptoms may include rapid pulse, numbness or tingling of fingers, pale skin around the lips, and dizziness. The treatment includes sitting the patient upright, and reassurance. Giving the patient a bag to breathe into may be helpful in some cases. Frequent occurrences may indicate the need for a mild sedative prior to dental treatment.
Asthma is a chronic lung disease characterized by coughing, chest tightness, shortness of breath, and wheezing. According to the Asthma and Allergy Foundation of America, 12 million people have asthma. The prevalence of asthma has been increasing since the 1980s across all age, gender, and racial groups. It is most prevalent among children and African Americans.
Asthma can be triggered by allergens, infections, cold weather, smoke and air pollution, strong odors from chemical products, strong emotions, medications, and exercise. General instructions for an asthma attack may include use of bronchodilators or anti-inflammatory drugs. Further medical assistance may be needed if the patient does not quickly respond to prescribed asthma medication.
Fluoride overdose can occur, mainly in children, who ingest too much fluoride. Causes are inadequate suction during fluoride treatment, too much product applied, or an unsupervised child ingesting directly from fluoride container.
Symptoms of acute fluoride toxicity include cramps, vomiting, and diarrhea. Treatment includes inducing vomiting, calling poison control, and 911 for medical assistance.
Chest pain could result from many conditions, including angina, heart attack, or anxiety. Symptoms include pain or tightness in chest, pain radiating to extremities, mandible or face, nausea, feeling of dread, pallor, and numbness.
Treatment includes reassurance, administration of oxygen, and call for emergency medical assistance. If patient has angina and is carrying nitroglycerin, administer nitroglycerine and wait for patient response. Call for emergency medical assistance for evaluation if there is no change in symptoms.
Allergic reactions can occur in any person at any age with no warning or prior history. Allergic reactions in patients can range from mild (hives, contact dermatitis) to severe and life-threatening (anaphylactic shock) that require swift and immediate medical attention.
Contact dermatitis is a skin sensitivity or allergy, often caused by latex gloves, topical anesthetic, acrylic, or other dental materials. Symptoms include hives, redness, rash, swelling, tissue sloughing, itching, or a burning sensation. The reaction may be delayed several hours before symptoms appear, sometimes after the patient has left the office. Treatment may include rinsing affected area, use of topical ointment or cream (Benadryl), and ice.
Hives (urticaria) are itchy, white-centered, raised wheals often produced by foods or drugs against which the patient has antibodies. They also can be caused by emotions, exercise, and exposure to heat or cold. They tend to quickly appear and disappear.
Anaphylaxis is an acute, unpredictable allergy event with a sudden onset that can lead to complete circulatory collapse. In dentistry, subcutaneous or intramuscular injections of anesthetics or antibiotics are often the culprit. Symptoms may include swelling of tongue, lips or larynx, wheezing, asthma, hives, rapid pulse, profound decrease in blood pressure, and/or abdominal pain. General instructions include placing patient in recumbent position, monitoring of vital signs, maintaining airway, and administering oxygen and epinephrine and/or other drugs. Call 911 for emergency medical assistance.
When a patient experiences a medical crisis, there is no better time to show teamwork and fast, informed action. Once the crisis has passed, be sure to take detailed notes for the chart entry in case the patient's physician, or possibly, an attorney needs further information. Record the incident, treatment, people involved or who witnessed the episode, a timetable of events, vital signs taken before, during, and after, plus any other details you have while the incident is fresh in your memory.
Additional resources for information include:
•American Academy of Allergy, Asthma and Immunology: www.aaaai.org
•The Anaphylaxis Campaign: www.anaphylaxis.org
•American College of Physicians-American Society of Internal Medicine: www.acponline.org
Cathleen Terhune Alty, RDH, is a frequent RDH contributor based in Clarkston, Mich.