911 Call Me Maybe? Response Protocols for Medical Emergencies in the Dental Setting

SCDHA Annual Symposium October 11th, 2014

Lunch and Learn

Gina H. Ormond, DMD

Learning Objectives

Review the most common medical emergencies in the

dental office.

Prepare a list of basic drugs, medicaments, and

equipment that should be in every dental office

emergency kit.

Discuss the signs, symptoms and treatment plan

algorithms for common medical emergencies in the

dental office.

Describe the role and responsibilities of the dental team

in assisting in the management of medical emergencies

in the dental office.

Specify measures available to prevent medical

emergencies from occurring in the dental office.

It is estimated that one or

two life threatening

emergencies will occur in the

lifetime practice of a general

dentist.1

..

..

The entire Dental

Team can be

included in a legal

action following an

emergency.

None of these were dental emergencies!

In 1993, Dr. Stanley Malamed reported

results from 4,307 North American dentists.

The surveys revealed that over a 10 year

period 30,608 emergencies occurred in the

dental office.2

Prevalence of Medical Emergencies 2

Least Common:

18. Thyroid storm

17. Adrenal Insufficiency

16. Cerebrovascular accident

15. Diabetic coma

14. Acute Pulmonary Edema

13. Local Anesthetic overdose

12. Myocardial Infarction

11. Anaphylactic reaction

4

25

68

109

141

204

289

304

Prevalence of Medical Emergencies 2

Most common (Top 10):

1. Syncope

2. Mild allergic reaction

3. Angina

4. Postural Hypotension

5. Seizures

6. Asthmatic Attack

7. Hyperventilation

8. Epinephrine reaction

9. Insulin Shock (Hypoglycemia)

10. Cardiac Arrest

15,407

2,583

2,552

2,475

1,595

1,392

1,326

913

890

331

Other factors to consider

In 2010 the American Medical Association reported

that the average American between the ages of 35

and 50 was currently taking SEVEN prescribed

medications.4

Aging population

Increasing use and administration of drugs in

dentistry…

1.Benzodiazepines (diazepam, midazolam)

2.Narcotics for IV sedation-meperidine

3.Nitrous Oxide sedation

Basic Emergency Equipment

Portable “E”-

cylinder

Oxygen Tank

Low Flow

Regulator

Remember Oxygen is a drug!

New studies indicate that oxygen

should be given according to patient

need.5,6

A pulse oximeter should be used to

determine the need for oxygen and

the appropriate delivery method.

Oxygen Delivery Devices

Nasal Cannula 2-6 liters/min.

Patient is breathing

SpO2 below 94%

Face Mask 8-12 liters/min.

Patient is breathing

SpO2 is 90-93%

Oxygen Delivery Devices

Non-Rebreather Mask 10-15 liters/min.

Patient is breathing

SpO2 below 90%

Bag-Valve–Mask (Ambu bag) 15 liters/min.

Patient not breathing/or needs respiratory assistance

Stethoscope and

Sphygmomanometer

Need different

sizes of BP

cuffs

Latex Free

Automated External

Defibrillator

If AED used within the

first minute of collapse

the chance of survival is

90%.

If AED used to deliver shock 10 minutes

after collapse, the chance of survival is

close to zero.7

Average time for

paramedics to arrive

at your

office…..11minutes4

Pulse Oximeter

Additional Equipment

Glucometer

Oral airways

2 (1cc) disposable syringes

with 23g 1.5 inch needle

Alcohol wipes

Penlight/Flashlight

Stopwatch

Scissors/Trauma Shears

Disposable razors

Emergency report form

2 ink pens

Blanket

Quick Reference Guide

Essential Drugs for the

Medical Emergency Kit8

Albuterol

Aspirin-2 packets

of powdered

aspirin (325 mg)

Diphenhydramine

Glucose- Tube of

gel

Essential Drugs for the

Medical Emergency Kit8

Nitroglycerin-0.4 mg/

spray or tablets

Epinephrine (1:1000)-

Two 0.3mg preloaded

self-injecting pens

(weight over 66 lbs)

and Two 0.15mg pens

(weight 33-66lbs)

Most emergency

situations can be

handled without

the use of

medication.

Other Emergency Drugs

Ammonia vaporoles

Glucagon

Diazepam

Cortisone

Packaged Kit or Personalized?

Basic Action Plan

Patient assessment….Is the patient conscious or

unconscious?

Yell for Help and Call 911 if needed

Positioning- Let gravity aid in emergency

treatment

“Face is Red, Raise the

Head. Face is Pale,

Raise the Tail.”

EMS should be alerted

immediately……. Poisoning

Bleeding- Hemorrhage

Breathing- Obstruction, Anaphylaxis, Respiratory arrest

Chest pain

Basic Action Plan

P-Position

C-Circulation

A-Airway

B-Breathing

D-Definitive Treatment/ Differential Diagnosis/ Drugs

/Defibrillation

E-Evaluate Vital Signs-Respirations, Pulse, BP, SpO2, Temp

Do Not Leave

Your Patient!

Management of the Most

Common Medical Emergencies

Syncope

Allergic Reaction

Angina

Seizures

Asthma

Hyperventilation

Epinephrine reaction

Hypoglycemia

Cardiac Arrest

Syncope Signs and Symptoms:

• Diaphoresis

• Tachycardia

• Pale appearance

• Nausea

• Dizziness

• Visual disturbances

• Decreasing BP

• Dilating pupils

• Unconsciousness

Half of all Medical

Emergencies occur during or

immediately after the

administration of Local

Anesthesia

Syncope

Management: 1. Basic Life Support 2. Supine position with

feet slightly higher than the chest (Trendelenburg).

3. Ammonia inhalant (respiratory stimulant)

4. O2 administered 5. Cool rag on head and

neck 6. Monitor vitals

Allergic Reaction Signs and Symptoms:

• Urticaria (Hives)

• Pruritus (Itching)

• Erythema

• Coughing

• Bronchospasm

• Angioedema

Management:

Limited to skin:

Diphenhydramine-oral

Anaphylaxis:

911

EpiPen

Oxygen

Diphenhydramine IM

Hydrocortisone IM

Angina Signs and Symptoms:

• Substernal pressure

• Tightness

• Burning Pain

• Pain may radiate to left shoulder

Management:

• Place in comfortable position

• O2

• Nitroglycerin q 5 mins.

• Monitor vitals

• With prior history of angina administer up to 3 tabs or sublingual sprays…then activate EMS

Seizures

Signs and symptoms:

• Aura

• Epileptic Cry

• Tremors

• Tonic/Clonic convulsions

Management: • Protect head and neck • Support Airway • Oxygen for post seizure • BLS • Activate EMS if prolonged • Valium (Be Careful)

Asthma

Signs and Symptoms: • Feeling of chest congestion

• Cough

• Wheezing

• Labored breathing

• Use of accessory muscles for respiration

• Tachycardia (>120 in severe asthma)

• Nasal Flaring

• Patient sits upright and “fights” for air

Management: • Place patient in upright

sitting position

• Administer Bronchodilator (via metered-dose inhaler-MDI-) This medication is a Beta Agonist.

• Oxygen

• If severe, inject .3ml (1:1000 solution) epinephrine ( adult) S.C., I.M., or S.L.

• EMS

Hyperventilation

Signs and Symptoms: Management • Raise chair to upright

position

• Calm and reassure client

• Ask client to try to slow the rate of breathing-Hold breath for 10secs.

• Have client cup hands over mouth

• Instruct client to rebreathe CO2 enriched expired air

• Monitor Vitals

• Faint, lightheaded • Tightness in chest • Palpitations • Rapid breathing • Altered consciousness • Numbness, tingling

around the mouth, toes and fingers

Epinephrine Reaction

Remember Vasoconstrictors can help prevent Toxicity

Do not use with:

• Uncontrolled Hypertension

• Hyperthyroidism

Drug interactions:

• Tricyclic antidepressants

• Monoamineoxidase inhibitors (MAOI’s)

Epinephrine Reaction Signs and Symptoms: • Fear/Anxiety

• Tense/Restless

• Throbbing Headache

• Tremor

• Perspiration

• Weakness

• Pallor

• Dizziness

• Palpitations

• Respiratory Difficulty

• Elevated BP/HR

Management:

• Reassure Client

• Position Client for comfort

• BLS – if needed

• Administer Oxygen – if needed

• Monitor Vitals

• EMS – if needed

• Allow client to recover and discharge

• Usually adverse effects only last about 5-10 minutes

Hypoglycemia (Insulin Shock)

Hypoglycemia (Insulin Shock) Signs and Symptoms:

• Rapid onset, esp. if insulin dependent

• Personality change, irritability, confusion

• Cold sweat, pale, moist skin

• Nervous, trembling, weak, dizziness

• Altered consciousness, Slurred speech

• Headache

• Seizures

Management: Conscious

• administer oral carbohydrates (cake icing, orange juice, coke, glucose gel)

Unconscious

• Call 911

• Can give Transmucosal sugar, Glucagon 1mg IM, or IV 50% dextrose (50ml)

• Administer O2

• Oral carbs if consciousness is regained

• Monitor vitals until EMS arrives

Myocardial Infarction…../Cardiac Arrest Signs and Symptoms:

• Chest pain radiating to left shoulder, arms, neck and jaw.

• Nausea

• Palpitations

• Diaphoresis

• Dizziness

• Pain unrelieved by Nitroglycerin

Management:

• Activate EMS

• Administer 325mg aspirin-powder or have patient chew

• Oxygen

• Prepare for CPR

• AED

Stroke (CVA) Signs and Symptoms:

• F.A.S.T. • Face

• Arms

• Speech

• Time

• Headache

• Confusion

• Weakness/Dizziness

Management:

• Call 911

• Position-Conscious or

Unconscious

• BLS-Airway

• Oxygen

Local Anesthetic Overdose

• Remember to always aspirate!

• Do not give toxic dose!

• Predisposing factors: age, disease, pregnancy, mental state, lower weight, and genetics

Local Anesthetic Overdose

Signs and Symptoms:

• Confusion • Talkativeness • Apprehension • Excited • Headache • Lightheaded • Dizziness • Ringing in ears (tinnitus) • Flushed/chilled

• Blurred vision • Slurred speech/stutter • Muscular twitching • Tremor of face • Initial elevated

BP/HR/Resp.rate • CNS depression • Seizures • Unconsciousness

Local Anesthetic Overdose Management:

• Position client comfortably

• Administer Oxygen - if needed

• Monitor Vitals

• EMS – if needed

Preparation of Dental Team Every team member should be assigned a

role in a medical emergency

Leader:

Initiates treatment-PCAB

Determines if EMS needed

Delegates Runner

Remains with the patient

Administers Drugs

Preparation of Dental Team

Team Member 1 (Runner):

Retrieves Emergency Equipment and

Drug Kit

Alerts rest of dental team

Assists leader with BLS

Monitors Vitals

Prepares emergency drugs

Preparation of Dental Team

Team Member 2:

Calls EMS (9-1-1)

Meets the Paramedics

Records all the events on the

emergency record

The 911 Phone Call

Post by phone what to say to the 911 operator….

1. State your name and the name of the

dentist’s practice and location

2. Give patient’s symptoms and status.. (patient is

conscious, unconscious, alert…)

3. State that a team member will meet the

paramedics at the office entrance

4. Stay on the phone

5. Tell the team leader that EMS is on the way

Midlands Technical College Dental Clinic

Emergency Treatment Record

Person’s Name: ___________________________Date:____________Time:__________

Allergies: __________________________________

List of Medications taken prior to emergency: __________________________________

Time Blood

Pressure

Pulse Respirations O2

Flow

L/Min

Medications

Administered

Medication

Dosage

Medication

Route

(IM, SL,

PO, IV)

EMS 911 called at (time):_______________EMS called by (whom):________________

EMS arrived at (time):_______________________

Disposition of person when released from MTC and transported from site: ____________

________________________________________________________________________

Person released to: ________________________________________________________

Person taken to what hospital: _______________________________________________

Faculty, students, and people present: _________________________________________

________________________________________________________________________

EMS personnel: __________________________________________________________

Signature of person recording events: ________________________

Other Significant treatment information: _______________________________________

________________________________________________________________________

GHO 8/09

Preparation of Dental Team

Prepare office by role playing

emergencies. “Practice Drills”

Cross-Train Team Members

Set schedule to check the

emergency equipment and

drugs

Current CPR certification

Prevention

Never treat a stranger Review health history and update

90% of all medical emergencies can

be prevented. The Health History is

our best tool to prevent medical

emergencies.

Prevention Obtain vitals

Modify treatment

Use stress reduction

protocols

1. Explain Procedures

2. Medications

3. Adequate Pain Control

Legal Considerations

Review State Dental Practice Acts

S.C. Code of Laws Title 40 Chapter 15:

Dental Hygienists practicing under general

supervision must maintain professional liability

insurance.

S.C. Licensure:

Current CPR status

CE

Legal Considerations

The standard of care can be defined as “what the reasonable, prudent person

with the same level of training and experience would have done in the same

or similar circumstances”.

What must be proven in malpractice litigation14

Duty to Act

Act of omission or commission

Patient was actually injured in some way- emotional and economic

Failure to act reasonably was cause of the patient’s injuries

Additional Prevention

Eyewear for Patient http://www.dentistryiq.com/articles/2014/08/jenn-

s-vision-a-true-lesson-in-best-practices.html

Questions?

Thank you!!

gormond@midlandstech.edu

Bibliography

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office medical emergencies. J. Dent Educ. 54:10 (1990):623-5.

2. Malamed S. F., Managing medical emergencies. J Amer Dent

Assoc.1993;124:40-53.

3. Fast, T.B., Martin, M.D., and Ellis, T.M. Emergency preparedness: A

survey of dental practitioners. J Amer Dent Assoc. 112 (1986):499-500.

4. Goodson, C. How prepared are you for a Medical Emergency?

Dentaltown March 2013:103-108.

5. www.jems.com/print/22676 “EMS Education Overlooks Challenges of

Oxygen Therapy”

6. O’Connor RE, et al. Acute Coronary Syndrome:2010 American Heart

Association Guidelines for Cardiopulmonary Resuscitation and

Emergency Cardiovascular Care. Circulation 122:S787-817,2010.

7. Biron Leiseca,C. Dental Office Medical Emergencies. Continuing

Education Course, Amelia Island, Florida, November 2013

www.DHmethEd.com.

Bibliography

8. Malamed, S.F., Emergency Management 101. Dimensions of Dental

Hygiene.2014;12 (1):39-41.

9. Jennings,D.,Chernega, J.B. Emergency Guide for Dental Auxiliaries,

4th ed., Delmar Publishers Inc., Albany, NY, 2013.

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11. Haas, Daniel A. J Amer Dent Assoc, May 2010 Emergency Supplement,

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12. Meiller, T., et al. Dental Office Medical Emergencies: A Manual of

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Emergencies in the Dental Office” www.dentalcare.com Crest Oral –B

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15. Patton, L., The ADA Practical Guide to Patients with Medical

Conditions. 1st ed.,Wiley-Blackwell,2012.