Medical Emergencies in the dental office

These are a few of the top medical emergencies that occur in the dental office, their symptoms, and the action the dental staff should take:

1. Syncopy (fainting)

Syncopy is by far the most common medical emergency in dentistry that affects the patient. (Fortunately, it is also the one most easy to manage), said Dr. Stanley Malamed, professor of anesthesia and medicine at the University of Southern California in Los Angeles.

The reason it’s so common, Dr. Malamed said, is because of patient fear…and it occurs most often as the doctor administers the local anesthetic injection to the patient.

Symptom: Loss of consciousness. “You’re giving the patient an injection, their mouth will close, and they are no longer responsive,” Dr. Malamed said.

What to do: The doctor or hygienist should lay the person in a supine (mostly flat) position. Such an action, Dr. Malamed said, “increases the blood supply to the brain, the blood supplies oxygen, and once you lay the patient in this position, the patient normally will recover consciousness within 10 seconds.”

2. Severe anaphylactic reaction

Common, and requires immediate attention, Dr. Malamed stressed.

Symptoms: Difficulty breathing, or loss of consciousness often caused by low blood pressure.

What to do: The doctor should administer the drug epinephrine immediately (see “Basic medical emergency kit”). “If you don’t administer the dose as fast as possible, the likelihood is they are going to die. Although epinephrine saves lives, it’s got to be given right away…there’s no time for thinking about it,” Dr. Malamed said.

3. Cardiac arrest

Cardiac arrest is the abrupt stoppage of normal circulation, which in turn can result in a myocardial infarction (heart attack) or in brain injury if symptoms are prolonged without treatment.

Symptoms: Loss of consciousness, stoppage of normal breathing.

What to do: The doctor or staff member should administer basic life support (CPR), and also should use an automatic external defibrillator (AED), if necessary (see “Why keep a defibrillator in the office?”)

4. Myocardial infarction (heart attack)

Symptoms: For men, they include chest pain, shortness of breath, nausea, vomiting, palpitations, sweating, and anxiety (a sense of impending doom). Women often experience fewer typical symptoms than men, and these may include shortness of breath, weakness, indigestion and fatigue.

What to do: Administer oxygen, aspirin, and nitroglycerin; also use an AED.

Teamwork counts

The best way to handle medical emergencies is to be prepared before they happen, and to have a few practice runs, suggested Dr. Stanley Malamed, professor of anesthesia and medicine at the University of Southern California in Los Angeles. An emergency team should consist of at least two-but preferably, three-people. It is important to train all staff members-from the receptionist to the hygienist to the doctor-in all roles, should a staff absence occur.

One way to organize the team is on a monthly basis. For the month of August, the role of staff member #2 could be one person’s job; for the role of September, it could be another person’s job.

Everyone should know all jobs and what to do, Dr. Malamed said. And, more than one person per month can be assigned duties in the same role-for example, there may be more than one staff member who is assigned some of the duties of staff member #3, below.

It is equally important to keep emergency medical equipment in an unlocked location that everyone knows about and is easily accessible to all staff.

• Staff member #1: The first person at the scene of an emergency, this member should be trained in CPR. This person will stay with the victim and not leave them alone.

• Staff member #2: When there’s an emergency, this person first gets the medical equipment (including emergency oxygen cylinder, oxygen, emergency drug kit, and the AED), and brings this equipment to the scene of the emergency with them. This person also yells for help (may use a code word), to alert others on the staff.

• Staff member #3: Calls 911, and follows any instruction from the doctor, including monitoring vital signs (blood pressure, heart rate), assisting with basic life support, holding the elevator in the lobby while waiting for EMS to arrive, preparing emergency drugs for administration, and keeping a written time line record during the emergency.

The doctor is in charge, and is responsible for what’s happening to the patient. The doctor doesn’t have to physically minister to the patient, but can instead delegate any task. For example, in cases where a drug needs to be administered to the patient, the doctor can have a staff member prepare the drug for the doctor to administer.

Bottom line: Everybody on the staff needs to be interchangeable and able to carry out any of the tasks without panic.

Basic medical emergency kit

A dental office first aid kit doesn’t need to be elaborate, with numerous items. In fact, Dr. Stanley Malamed, professor of anesthesia and medicine at the University of Southern California in Los Angeles, recommends that a basic kit should contain just these seven items:

>> Injectable pharmaceuticals

• Epinephrine in a 1/1,000 concentration, in a pre-loaded syringe to treat an anaphylactic reaction

• Diphenhydramine (Benadryl) to treat itching, hives, rashes

>> Non-injectable pharmaceuticals

• Oxygen E-cylinder for oxygen delivery to the patient

• Nitroglycerin spray for use in patients with anginal chest pain

• Bronchodilator for asthmatic patients

• Some form of sugar (such as juice or candy) for diabetic patients

• Aspirin for mild myocardial infarction

Dr. Malamed noted the kit and its contents have changed over the years, from as few as four drugs to as many as 15 drugs. However, the seven drugs above have been the standard recommended for about a decade; this number of drugs has changed as medical knowledge has evolved over the years.

Perhaps the most important point, Dr. Malamed stressed, is that no matter the kit size, the dentist is legally obligated to be able to identify and know how to use every item included in it.
“If there’s a drug you’re not trained to use, don’t have it in your kit,” he advised.

Why keep an AED in the dental office?

Should an AED be included in the office? Most definitely, said Dr. Stanley Malamed, professor of anesthesia and medicine at the University of Southern California in Los Angeles.

“Think of it this way: The most likely person in your office to have a sudden cardiac arrest is probably the doctor; therefore, think of it as a life insurance policy for the doctor,” he said.
Malamed said according to statistics, when a person suffers a sudden cardiac arrest out-of hospital, chances of survival are based upon the amount of time between the victim collapsing and the time of defibrillation.

He noted that for every minute a person is in cardiac arrest and is not defibrillated, the victim loses approximately a 10% chance of survival.

“The mathematics-if it takes 10% off survival per minute, and it takes paramedics 10 minutes to arrive-it means that you’re down to a zero percent chance to live.”

“I would want an AED in my office and hopefully, never, ever use it; but if I happen to be a victim and I have one, I have a much better chance of surviving.”

Since 2000, the training for using AEDs and administering CPR (basic life support) have been given together. Nonetheless, only one state (Florida) requires the dentist to have an AED in the office (effective February 2006).

Still, Dr. Malamed cautioned doctors that where they decide to purchase an AED is important. Buying on the Internet from a medical supplies “super site” and not directly from the AED manufacturer may result in a problem if the doctor wants to receive training on how to properly use the AED. Dr. Malamed noted some manufacturers will not come to the dental office to demonstrate operation of their equipment, if that equipment was not purchased directly from the manufacturer. So research the product and the company before you buy.