Emergencies in a public health dental program



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EMERGENCIES IN A PUBLIC HEALTH DENTAL PROGRAM
General Information:

LHDs must be able to respond to a range of medical emergencies, potentially violent or abusive situations, and facility or natural/weather related emergencies. Staff must be familiar with emergency supplies and equipment and trained in their use, as appropriate.


Procedures for non-medical emergencies such as fire, tornadoes/severe weather conditions, earthquakes, and bomb threats shall be addressed in the LHD’s Emergency Evacuation and Fire Prevention Control Procedures Plan. Training is to occur on at least an annual basis. For further information, refer to the Administrative Reference, Vol. I, Section VIII-LHD Operations for LHDs. (Also see the Disaster Recovery and Response Plan Manual).

MEDICAL EMERGENCIES IN A PREVENTIVE DENTAL SETTING

LHDs should be prepared for medical emergencies, particularly, life-threatening drug reactions. Established procedures, adequate and properly maintained equipment, and appropriately trained staff are essential.


In general, in a public health setting/health department clinic or satellite, the following is adhered to:


  • All physicians, clinicians, nurses and dental hygienists should be certified in CPR

  • All staff should be offered the opportunity to participate in CPR training

  • At a minimum, all staff must know their role in an emergency situation.

  • All staff should have access to the Poison Control phone number, 1-800-222-1222, and it should be posted in a prominent place.

Emergencies in a public health setting for dental hygiene usually are not the severity seen in other medical/health services settings. The following protocols are for those that are more commonly seen in a dental hygiene setting in a school or clinic:


Diabetic Mellitus and Related Episodes

Allergies

Anaphylaxis

Asthma


Seizures

Syncope


Aspirated or Ingested Objects During a Dental Visit

DIABETES MELLITUS

HYPERGLYCEMIA AND HYPOGLYCEMIA
Definition: The most common endocrine disease. It is a group of diseases marked by high levels of blood glucose resulting from defects in insulin production, insulin action or both.
Symptoms and Signs may include:
Hyperglycemia High Blood Sugar

•Bright red color in the face, hot & dry skin, Signs of dehydration, Respirations are deep and rapid

•Breath is fruity, with a sweet smell of acetone

•Rapid Heart Rate with a BP lower than normal


Hypoglycemia Low Blood Sugar

•Diminished Cerebral Function

•Changes in mood

•Decreased spontaneity

•Hunger & Nausea
More Severe Stage

•Sweating, Tachycardia, Piloerection, Increased anxiety, Bizarre behavioral problems

•Belligerence, poor judgment, uncooperativeness
Later Severe Stage

•Unconsciousness, Seizure activity, Hypotension, Hypothermia


MANAGEMENT
Conscious patient for hyperglycemia:

1. Do not do any dental treatment.

2. Patient needs to contact medical provider and be seen immediately.
Unconscious patient for hyperglycemia:

1. Recognize problem – lack of response to sensory stimulation

2. Discontinue dental treatment

3. Position patient in supine position with feet elevated

4. Access and perform basic life support as needed

5. Summon Emergency medical service


Conscious patient with hypoglycemia:

1. Recognize problem – altered consciousness

2. Stop dental treatment

3. Position patient comfortably

4. Access & Perform basic life support as needed

5. Administer Oral Carbohydrates – i.e. orange juice, soda (4-6 oz. of soda or water with

2-4 tsp. of added sugar).

6. Permit patient to recover. Observe the patient for one hour.

7. Seek medical assistance if recovery is not complete.
Unconsciousness patient with hypoglycemia:

1. Recognize problem – lack of response to sensory stimulation

2. Call 911 or activate EMS

3. Stop dental treatment

4. Position patient in supine position with feet elevated

5. Access and perform basic life support as needed

6. Monitor vital signs every 5 minutes

7. Administer Oxygen

8. Allow patient to recover and discharge per medical recommendations
NEVER LEAVE PATIENT ALONE
Source: Medical Emergencies in the Dental Office; Malamed, Stanley F.

ALLERGIES
Definition: A hypersensitive state acquired through exposure to a particular allergen, reexposure

to which produces a heightened capacity to react.


Symptoms and Signs may include:
Allergic skin reactions are the most common sensitization reactions to drug administration.

Rash, localized swelling, whelps, itching, and angioedema are common symptoms.


MANAGEMENT
Skin reaction – delayed (more than one hour)

1. Observe and record affected area

2. Medical consultation with patient’s physician

3. Inform legal representative, if patient is a minor


Skin reaction - immediate (less than one hour)

1. Monitor & Record vital signs-heart rate & rhythm, BP, respirations every 5 minutes.

2. Observe the patient for one hour for signs of recurrence.

3. Medical consultation with patient’s physician, if respiratory or cardiovascular

involvement occurs. Pt. should be transported to ER.
Respiratory reaction - bronchial constriction

1. Terminate dental procedures.

2. Place the patient in a position of comfort.

3. Observe the patient. If patient not improving call 911.

4. Medical consultation with patient’s physician
Respiratory reaction – laryngeal edema

1. Call 911 or activate EMS.

2. Place the patient in a position of comfort.

3. Maintain airway.


NEVER LEAVE PATIENT ALONE
Source: Medical Emergencies in the Dental Office; Malamed, Stanley F.

ANAPHYLAXIS
Definition: An acute systemic allergic reaction resulting in respiratory difficulty and cardiovascular collapse. This condition may occur rapidly reaching maximum intensity in 5-30 minutes after onset.
Symptoms and Signs:
Phase 1: Skin

•Intense itching with generalized warmth & tingling of the face, mouth, upper chest, palms, soles or the site of the antigenic exposure.

•Increased mucous secretion
Phase 1: GI/GU

•Abdominal cramps

•Nausea and vomiting

•Diarrhea

•Incontinence, pelvic pain, headache, sense of impending doom, decrease in level of consciousness
Phase 2: Respiratory

•Dyspnea


•Cyanosis

•Laryngeal edema


Phase 3: Cardiovascular

•Pallor


•Light-headedness

•Palpitation

•Hypotension

•Cardiac Dysrhythmias

•Tachycardia

•Loss of consciousness

•Cardiac arrest
MANAGEMENT

1. Call 911 or activate EMS.

2. Place the patient in a position of comfort.

3. Maintain the airway and do CPR if necessary.

4. Monitor and record vital signs.
NEVER LEAVE PATIENT ALONE
Source: Medical Emergencies in the Dental Office; Malamed, Stanley F.

ASTHMA
Definition: A chronic inflammatory disorder that is characterized by reversible obstruction of the

airway.
Symptoms and Signs

•History of asthma

•Feeling of chest congestion

•Spells of coughing with or without sputum production

•Wheezing, Dyspnea

•Slow, labored breathing, nasal flaring

•Patient wants to sit or stand

•Chest tightness

•Anxiety and apprehension, Agitation

•Tachypnea, increase in BP, Heart Rate, Diaphoresis

•Somnolence

•Confusion

•Cyanosis

•Supra--clavicular and Intercostal Retraction
MANAGEMENT
1. Recognize problem (Respiratory distress, wheezing)

2. Stop dental treatment

3. Position patient upright.

4. Assess & perform basic life support as needed

5. Administer bronchodilator via inhalation (patient’s personal inhaler only)

6. If the episode continues, Activate EMS (911)

7. If the episode stops after administration of the bronchodilator, dental care can be

continued or rescheduled depending upon the patient, then discharge patient.

8. Observe the patient for signs of status asthmatics:

•Mental confusion

•Extreme fatigue

•Cyanosis

•Heavy perspiration
NEVER LEAVE PATIENT ALONE
Source: Medical Emergencies in the Dental Office; Malamed, Stanley F.

SEIZURES
Definition: A recurrent paroxysmal disorder of cerebral function marked by sudden, brief attacks

of altered consciousness, motor activity or sensory phenomena.


MANAGEMENT OF PETIT MAL AND PARTIAL SEIZURES

1. Recognize the problem – lack of response to sensory stimulation.

2. Position patient in supine position with feet elevated.

3. Watch the patient and prevent injury.

4. Don’t try to move the patient.

5. Never place anything in the patient’s mouth.

6. After the seizure is over, reassure patient, allow patient to recover.

7. If seizure continues, (more than 5 minutes), Call 911.

8. Perform Basic life support as needed.
MANAGEMENT OF TONIC-CLONIC SEIZURE (GRAND MAL)

1. Recognize aura.

2. Stop dental treatment.

3. Position patient in supine position with feet elevated.

4. Consider activation of EMS.

5. Assess and perform Basic life support as needed.

6. Protect patient from injury.

7. Administer oxygen & monitor vital signs.

8. Reassure patient and permit recovery.

9. Discharge patient either to hospital, to home or to physician.

A life-threatening medical emergency exists when a seizure lasts more than five minutes, when

repeated seizures occur, or if the patient begins having continuous seizures (status epilepticus). If one of these conditions is occurring, call 911 or activate EMS. The patient should be placed in a safe position as noted above.


NEVER LEAVE PATIENT ALONE
Source: Medical Emergencies in the Dental Office; Malamed, Stanley F.

SYNCOPE
Definition: Syncope is a general term referring to a sudden, transient loss of consciousness that

usually occurs secondary to a period of decreased blood flow to the brain.


PRESYNCOPAL SIGNS AND SYMPTOMS
EARLY

•The patient feels warm on the head and neck

•Loss of color; pale or ashen-gray skin tone

•Heavy perspiration

•Reports of “feeling bad” or “feeling faint”

•Nausea & Tachycardia

•Blood Pressure at baseline level or slightly lower
LATE

•Pupillary dilation

•Yawning, hyperpnea

•Cold hands and feet, hypotension

•Bradycardia

•Visual disturbances, dizziness

•Loss of consciousness
MANAGEMENT
1. Assess consciousness – lack of response to secondary stimulation.

2. Position patient on their back with feet slightly elevated.

3. Establish airway - tilt head back and lift the chin - assess breathing. If the patient is not

breathing, retilt and check again, if still not, check for an obstruction. If fluid is present in

the back of the throat, tilt the head to one side, suction the throat, and start artificial

ventilation.

4. Check for circulation

5. Loosen tight fitting clothes.

6. Monitor vital signs. (BP, pulse, and respiration)

7. Administer ammonia inhalant.

8. Consciousness should return within a few seconds to a few minutes. If not within five

minutes, another cause should be considered. Call 911 or activate EMS.


NEVER LEAVE PATIENT ALONE
Source: Medical Emergencies in the Dental Office; Malamed, Stanley F.

ASPIRATED AND INGESTED OBJECTS DURING DENTAL TREATMENT
When this occurs,

•patient should be placed in an upright position and allowed time to determine if a productive cough will force the object into the mouth, where its retrieval is possible.


•If the object cannot be found in the mouth, the patency of the patient's airway and his or her ability to breathe must be monitored. If the patient can breathe independently, the airway remains unobstructed. However, objects can be lodged in a bronchus without labored breathing or coughing.
•When the object cannot be located, contact 911 if airway obstruction is severe.
•For no or slight airway obstruction, immediately refer to the closest medical facility. When located, the object can be removed by surgical procedures such as bronchoscopy, but only by an appropriate health professional.
•In some cases, aspirated objects may become lodged in the trachea and cause partial or complete obstruction of the airway. In the latter case, the Heimlich maneuver, or in patients who are pregnant or obese, abdominal or chest thrusts must be used.
•The activation of EMS is required if these procedures cannot remove the aspirated object and oxygen via CPR or positive pressure cannot be supplied to the lungs.
Even if the object is retrieved and a normal flow of oxygen is resumed, the patient should be referred to a physician or specialist to determine if the lodged object caused any trauma to the area.
When an object has been aspirated or swallowed by a patient, it is essential that the dental staff reviews the incident to determine methods by which this incident can be avoided in the future.

NEVER LEAVE A PATIENT ALONE
Source: Submitted by Sid Brantley, DMD, as based on the article “Prevention and management of accidental foreign body ingestion and aspiration in orthodontic practice” from the Journal of Therapeutics and Clinical Risk Management. 2012; 8: 245–252 by Uday Kumar Umesan, Kui Lay Chua, and Priya Balakrishnan.


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