Emergency Procedures in the Dental Office



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Indian Health Service Oral Health Program Guide


Emergency Procedures in the Dental Office

Dental officers in the Indian Health Service (IHS) should be aware that urgent or emergent medical and dental situations may arise in their clinics. It is their responsibility to ensure that they themselves and their dental staffs are well-prepared to cope efficiently, quickly, and appropriately on such occasions. Preparation and training must take place well in advance so that when action is needed in potentially life-threatening situations appropriate action will be taken.

Equipment for providing supplemental oxygen to hypoxic patients should be available in all IHS, Tribal, and Urban (I/T/U) Indian dental clinics. This equipment should provide capabilities for forced respiration through the use of a rubber reservoir bag and a face mask that can produce an air-tight seal around the patient’s nose and mouth. An ambu-bag is ideal for such purposes. Portable oxygen machines or nitrous oxide/oxygen machines can also be easily adapted to provide such capabilities.

All dental staff should be trained in cardiopulmonary resuscitation and maintain current certification. Courses may be obtained through local American Red Cross units to assist in meeting certification requirements.



Emergency Care Equipment and Drugs Recommended for I/T/U Indian Dental Clinics

Each dental clinic should have a plainly marked and readily available emergency drug kit containing the following basic diagnostic and treatment equipment and drugs for emergency use, as recommended by the IHS Oral Surgery Consultant:

Basic Equipment and Drugs:


  • Ambu-bag: various sizes (or oxygen machine with bag-valve-mask device for assisting in ventilation procedures for the patients)

  • Sphygmomanometer: automated and manual, various sizes (blood pressure cuff)

  • Stethoscope

  • Molt or McKesson mouth props (or taped stack of 8 to 10 wooden tongue depressors for use as a mouth prop)

  • 13-gauge sterile needles (2) (to use in providing emergency airway at cricothyroid space)

  • Adult-sized and child-sized oropharyngeal airways (1 each)

  • 1/2" or 3/4" wide tape (adhesive, autoclave, paper, or “Scotch”)

  • Tubex syringes (2) or Luer lock syringes with 22-gauge needles

  • Alcohol sponges (in foil wrappers to keep them moist)

  • Band-aids (6)

  • Sterile 2" ×2" gauze packets (12)

  • Sterile 2cc. disposable syringes (4) with 18 and 21 gauge needles

Drugs:

  1. Oxygen: minimum 1 (one) E cylinder for 30 minutes of 8-10L/min

  2. Epinephrine: Tubex syringe cartridges with sterile protected needle attached (6) or 1:1000 in unit dose vials (1 mg/ml) or IV fluids (aqueous) 1:1000 in 1 ml for use IM or subcutaneous

  3. Benadryl (50 mg/ml) ampule (3)

  4. Nitroglycerine tablets (0.15mg) for angina pectoris and 1 bottle of metered translingual spray 0.4mg/dose)

  5. Aspirin: Antiplatlet: 3-4 baby chewable aspirin (162mg)

  6. Alupent (Albuterol) inhaler for treatment of acute asthma via metered dose inhaler (asthma patients should have their own inhalers in their possession when receiving dental treatment)

  7. Ammonia inhalant (4)

  8. Antihypoglycemic: non-injectable ( fruit juice, glucostat, soda, granulated sugar)

The rationale behind the preceding list of critical items is that the emergency kit should contain only those items that the dentist knows how to use. In a real emergency, the IV is not the number one tool for treating the emergency. The dentist should focus on doing those things that will increase the patient’s chance for a good outcome once the emergency room staff arrives, and should let them start the IV and give the drugs, if possible.

If a crash cart and medical staff are not available in the facility (such as in stand-alone dental clinics without a medical clinic nearby), or if intravenous sedation is being performed in the dental clinic, additional equipment and drugs should be present. A dentist working in such a clinic should plan ahead very carefully for the possibility of a medical emergency, such as considering the likely response time for a 911 call. Advanced training in the treatment of medical emergencies is also strongly recommended, so that he/she will be able to use the following drugs and equipment if necessary:



Additional items for clinics without a crash cart:

  • Rubber tourniquets (2)

  • Sterile 25-gauge x 5/8" length, and 22-gauge x 1 5/8" length needles (3)

  • Intravenous infusion set

  • IV tubing (2)

  • 1000 cc. of normal saline for hypotension

  • 500 cc. of 5% Dextrose and water for piggyback meds or IV fluids

  • Versed 5mls in 5mg/ml dosage or Meperidine (Demerol) in 50 mg. Tubex cartridges with sterile protected needle attached (3) or Talwin 50 mg. ampule

  • Ephedrine Sulfate 50 mg. ampule for use as a vasopressor to treat hypotension

  • Solu-Cortef (100 mg. vial) for use as an anti-inflammatory agent

  • Narcan (1 ml. ampule) to counteract narcotic depression

  • Amyl nitrite inhalant (3) for coronary artery dilatation

  • Valium (10 mg. vial) IV/IM for convulsions

  • Glucagon (1 mg. IM) for hypoglycemia

  • Glucose 50% (25 mg. in 55 cc vial) for hypoglycemia

  • Aminophyllin (500 mg. vial) mix 500 cc D5W for acute asthma

  • Atropine (1 mg. ampule) for bradycardia

  • Automatic External Defibrillators (AEDs) are becoming the standard of care in the private sector, and have been mandated by some states. All stand-alone dental clinics should consider having one on hand.

Emergencies in the Dental Office

Syncope (Mild Neurogenic Shock)

Early Symptoms: Ashen gray(pallor), cold perspiration, nausea, lightheadedness, restlessness (anxiety), talkativeness, tachycardia.

Late Symptoms: Depressed medullary function, papillary dilation, low blood pressure, convulsive movements, bradycardia (rapid, thready, or slow, weak pulse), shallow, slow respirations, unconsciousness.

Prevention: Minimize hypoglycemic risk (advise a light meal), adequate emotional evaluation; barbiturate or tranquilizer premedication; aspiration when giving injection.

Treatment:

  1. Monitor vital signs

  2. Supine position (lower head slightly, elevate legs and arms (pregnancy–roll to side)

  3. Oxygen 8–10 l minute

  4. Spirits of ammonia

  5. Cold packs to forehead

  6. Monitor vital signs.

  7. Reassure patient

Hyperventilation Syndrome (Neurogenic)

Symptoms: Hyperventilation (rapid and shallow breathing); apnea; lightheadedness; paresthesia of hands and feet; sometimes carpo-pedal spasm, tension anxiety, chest pain, dry mouth, syncope may develop.

Prevention: Adequate evaluation; premedication; “vocal anesthesia.” Stress reduction protocol (confidence, early and short appointments, profound anesthesia).

Treatment:

  1. Terminate procedure

  2. Sit upright

  3. Quiet reassurance

  4. Instruct patient to take slow deep breaths with hands cupped over mouth of use bag valve mask (BVM) with patient holding the mask

Allergic Reaction

Mild (slow onset)



Symptoms: Rash; hives; itching; rhinitis

Prevention: Adequate medical history; sensitivity test

Treatment: Benedryl 25-50mg oral or IM follow-up with 50 mg PO every 6 hours for 2 days

Toxic (Severe) Reaction (rapid onset)



Symptoms: Rapid onset swelling; asthma; bronchospasm; angioneurotic edema; shock; cardiovascular collapse. CNS stimulation—CNS depression

Stimulation: vital signs elevated; apprehensive, excitation, convulsions

Depression: vital signs depressed; lethargy, unconsciousness

Prevention: Adequate medical history; aspiration when injecting; do not approach toxic limit

Treatment:

  1. Activate (call) EMS

  2. Oxygen

  3. Epinephrine 0.3–0.5mg 1:1000 subcutaneously. Note: contraindicated in presence of severe hypertension

  4. If ACLS trained: IV Valium 5–10 mg. for convulsions

  5. If ACLS trained ephedrine sulfate 10–25 mg IM or IV

  6. Supportive therapy for depression

Idiosyncrasy

Symptoms: Same as toxic reaction

Prevention: Same as toxic reaction

Types: 1) Local anesthetics—most stimulate, then depress; lidocaine, Carbocaine, and monocaine depress; 2) Barbiturates—CNS stimulation; 3) Epinephrine—tremor, stimulation

Coronary Insufficiency (Angina Pectoris)

Symptoms: Severe precordial or substernal pain which may radiate to left arm; pain described as tight or choking; may have headache; duration of pain only a few minutes.

Prevention: Adequate history; premedication; prophylactic nitroglycerine.

Treatment:

  1. Place in a semi-reclined position

  2. Monitor and record Vital signs

  3. Oxygen

  4. 0.3 mg. nitroglycerine sublingually, x 3 if needed

  5. Keep patient quiet

  6. If in doubt of Angina Pectoris: ACTIVATE EMS

Anaphylactic Shock

Symptoms: Sudden circulatory and respiratory collapse; cyanosis; bronchospasm; weak pulse; spasms; dyspnea; vomiting; headache; coughing.

Treatment: Activate EMS. Epinephrine (0.5-1.0 ml 1:1000) IV or SC; oxygen therapy; CPR as necessary.

Adrenal Crisis

Symptoms: Sudden circulatory collapse (hypotension/syncope); pallor; sweating; headache; pain in abdomen and legs; respiratory collapse; weak pulse; nervousness early, then apathy and unconsciousness; coma; may terminate in death if not treated.

Treatment:

  1. If conscious: semi-reclined position, monitor vital signs

  2. Oxygen therapy

  3. Unconscious: Activate EMS; supine position, BLS, oxygen, Solu-Cortef 100 mg. IV

Asthma

Symptoms: Wheezing; cough; difficult respiration; cyanosis; agitation, sense of suffocation

Treatment:

  1. Alupent inhaler 1–2 puffs (use patient’s supply)

  2. Oxygen therapy

  3. Activate EMS, Epinephrine (0.5 ml 1:1000) SC

Cerebrovascular Accident

Symptoms: Sudden onset; mild dizziness to unconsciousness; varying degree of paralysis; headache; aphasia; nausea; numbness; diplopia; blindness, unilateral weakness

Treatment:

  1. Activate EMS

  2. Position patient reclined with head slightly elevated

  3. Maintain airway and provide oxygen

  4. Monitor patients vital signs

  5. Reassure patient

  6. Obtain medical help and transport rapidly

Insulin Shock

Symptoms: Hunger, nausea, sweating (skin cool and moist), nervousness; headache; mental confusion (poor judgment), dizziness; transient unconsciousness; convulsions; coma

Treatment: Give glucose orally if able; or IV dextrose (50 ml 50% sol.) or glucagon 1 mg. IV or IM

Diabetic Coma

Symptoms: Gradual loss of consciousness; face flushed; dry mouth; breath has fruity odor; headache; weakness; apathy; abdominal pain; nausea

Treatment: Recognize early course and obtain medical help; give glucose or dextrose to distinguish from insulin shock

Airway Obstruction

Symptoms: Nervousness; difficult respiration or complete blockage; paradoxical respiration; cyanosis; laryngeal stridor (harsh grating or creaking sound)

Treatment: CPR (FBAO), oxygen therapy, Heimlich abdominal thrust, if clear airway and insert oral airway if above fails, do a cricothyrotomy and give oxygen

Laryngospasm

Symptoms: Inspiratory and expiratory stridor; complete or partial blockage of airway; paradoxical respiration; cyanosis; initially rapid pulse followed by a slowing pulse rate; terminates in cardiac arrest

Treatment: 100% oxygen administered under gentle, positive pressure will sometimes break spasm; activate EMS; Succinylcholine (1/2 cc) given IV and 100% oxygen; if above is unsuccessful, give succinylcholine (3-4 cc) IV and insert endotracheal tube; administer 100% oxygen; alternate method—cricothyrotomy

Cardiopulmonary Emergency

Treatment:

  1. If unconscious: Check respirations; clear airway; insert oral or nasal airway. Activate EMS.

  2. If breathing: Give oxygen; suction airway if necessary; give aromatic spirit of ammonia. Check pulse and blood pressure.

  3. If not breathing: Establish patient airway; administer oxygen or air via mechanical device or mouth-to-mouth, mouth-to-nose, or mouth-to-airway artificial respiration. Activate EMS. Check pulse.

  4. If carotid pulse is present: Continue 12 lung inflations per minute. Check blood pressure. Activate EMS.

  5. If apparent cardiac arrest with absence of carotid pulse and dilated pupils: Activate EMS and start CPR.

References

Emergencies in the Dental Office. Needham, MA: Hoyt Laboratories. Peterson LJ, et al.

Contemporary Oral and Maxillofacial Surgery. St. Louis: The C.V. Mosby Co; 1988; pp 41-70.

Medical Emergencies in the Dental Office, 5th ed, Malamed SF, Mosby 2000

Dental Management of the Medically Compromised Patient, 6th ed, Little JW, Falace DA, Miller CS, Nelson LR, Mosby 2002

Additional Resources

Journal of the Canadian Dental Association article: http://www.cda-adc.ca/jcda/vol-65/issue-5/284.html

ADA Report on Office Emergencies and Emergency Kits: http://www.ada.org/prof/resources/pubs/jada/reports/report_emergency.pdf#search='medical%20emergencies%20in%20the%20dental%20office'

PowerPoint Presentation, Thomas Jefferson University Hospital http://www.tju.edu/omfs/research/powerpoint/medical_files/frame.htm (297 slides, broadband recommended)

AAPD Guidelines: http://www.aapd.org/media/Policies_Guidelines/RS_MedEmergencies.pdf

State of Tennessee Division of Oral Health guidelines: http://www2.state.tn.us/health/oralhealth/pdf/Section4.pdf



Chapter 5-H-

Delivery of Dental Services 2007




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