Dentistry is a surgical specialty that is often associated with high levels of patient anxiety. These factors combine to produce a situation that may be conducive to the development of medical emergencies, especially those that are induced or aggravated by stress. Additionally, highly vasoactive drugs—local anesthetics and vasoconstrictors—are used for almost all dental procedures. All drugs, whether local anesthetics, antibiotics, sedatives, or analgesics, also carry the potential for producing acute, life-threatening reactions from toxicity or allergy.
As opposed to most other areas of dental practice, the practitioner is not routinely called upon to manage medical emergencies, and this can lead to uneasiness when faced with a medical crisis in the dental office. It should be appreciated that the main role of the dentist in the management of medical emergencies is to stabilize the patient until transfer to Emergency Medical Services (EMS) personnel for transport to an appropriate medical facility for definitive diagnosis and treatment. The accurate diagnosis of the medical condition often, in fact, requires hours to days to determine in the hospital setting. Ideally, prevention of medical emergencies is preferred. The primary responsibilities of the dentist in the area of medical emergencies, therefore, fall into the area of prevention, preparation, basic life support, basic emergency medicine procedures, and procurement of help and transport.
Arguably, the most important aspect of dealing with medical emergencies is preventing their occurrence. Prevention of medical emergencies can generally be accomplished, as much as possible, through an appropriate medical history and physical examination, medical consultation (when indicated), and vigilant patient monitoring.
A thorough knowledge of all existing medical conditions, physical or psychological, that may predispose the patient to development of a medical complication will help prevent the vast majority of emergency situations. This knowledge is gained through the medical history and physical examination as well as an assessment of the patient’s psychological outlook to dental treatment. The medical history is generally obtained via a written questionnaire, which is completed by the patient or parent. Many standardized forms are available, but they may require modification for pediatric dental practice. These forms should include questions pertaining to any present or past medical conditions, allergies or adverse drug reactions, hospitalizations and surgeries, medications, and so forth. Questions regarding dental concerns as well as past dental treatment are frequently included. The dentist reviews this form, notes positive findings, and conducts a brief interview with the patient to clarify any positive responses and expand on the questionnaire. It must be emphasized that clarifications and further explanations of positive findings should also be written by the dentist on the record to document that these questions were thoroughly investigated. For instance, if the parent or patient circles “asthma” on the past medical history, the dentist needs significantly more information than the mere fact that the patient currently has or has had asthma in the past. The dentist should further document the frequency and severity of the asthma attacks, what causes them, how they are managed, whether or not past episodes were ever so severe that treatment was emergently needed in the hospital or emergency room, when the last attack occurred, and finally whether the patient is breathing easily today. Based on the assessment of these documented clarifications, the dentist may feel comfortable providing the needed dental treatment at that appointment or may decide to postpone treatment until the patient is medically optimized by their physician.
The physical examination should include baseline vital signs (blood pressure, pulse rate and rhythm, respiratory rate and character), a thorough head and neck examination, and observation of general appearance (gait, mental status, skin tone and color, etc.). Further physical evaluation should be dictated by the dentist’s training and expertise. If a practitioner intends to use moderate sedation techniques that may depress the patient’s cardiovascular or respiratory function, it is recommended that the practitioner possess supplemental skills in physical examination such as lung auscultation to assess basic breathing abnormalities as well as airway assessment.
A thorough history and physical examination will help make the dentist aware of any preexisting conditions that may potentially lead to a medical emergency. In general, conditions involving the cardiac, pulmonary, and endocrine systems are of greatest concern regarding potential medical emergencies. Patients with a history of seizures also warrant special consideration. This knowledge should allow the development of a treatment protocol for the patient that will decrease the likelihood of a serious medical event. This may involve the use of minimal or moderate sedation for stress-induced conditions (e.g., cardiac arrhythmias, asthmatic attacks, or epileptic seizures), proper timing of appointments, infective endocarditis prophylaxis, assistance of an office-based dental or medical anesthesiologist during the procedure, or use of a hospital operating room, if necessary.
If any questions arise regarding the management of a medically compromised child, it is highly desirable to consult with the patient’s physician for further information to aid the dentist in forming a patient management plan and, in some cases, for guidance. After obtaining all of the pertinent medical information from the primary care physician and/or medical specialists, in most instances, the outdated concept of obtaining “medical clearance” from a medical consultant before initiation of a dental procedure has now been superseded by requesting the consultant’s statement that “the patient is in optimal condition for the planned procedure.”
The level of monitoring that is necessary to treat a pediatric dental patient safely will vary, depending on the procedure to be provided, the patient’s underlying medical condition, and the patient management technique being used. Patient monitoring involves the observation of physiologic parameters over time to detect any change and to intervene, if necessary, before a potentially dangerous situation develops. The dentist should always monitor (observe) the general appearance of the patient, including the level of consciousness, level of comfort, muscle tone, color of the skin and mucosa, and respiratory pattern. For the majority of healthy patients being treated with local anesthesia alone or with minimal sedation as defined by the American Dental Association, this is all the monitoring that is necessary.
When moderate sedation is used, and especially in children in whom a much narrower margin of safety often exists because of smaller degrees of respiratory and cardiovascular reserve, additional monitoring should be routinely employed. This will include continual monitoring of blood pressure, usually via an automated blood pressure cuff, continuous monitoring of oxygenation and pulse rate via pulse oximetry, and continuous monitoring of ventilation, either with a pretracheal/precordial stethoscope (Figure 10-1; see also Figure 8-5) or a capnograph. These measures are particularly important for patients with whom continual verbal contact is difficult or undesirable. (See Chapter 8 for a detailed discussion of monitoring during sedation.) Presedation and discharge vital signs, including pulse rate, respiratory rate, and blood pressure should always be obtained unless prevented by the lack of patient cooperation.
FIGURE 10-1 Use of a precordial stethoscope.
Whenever deep sedation or general anesthesia is used, more sophisticated monitoring is essential. The vast majority of pediatric dentists are not trained in these advanced pain and anxiety control techniques, which should only be used by appropriately trained dentists and physicians in the dental office.
As previously stated, it cannot be expected that the practicing dentist will be able to diagnose and manage every possible medical emergency. However, it is possible to anticipate with some certainty which emergency situations are most likely to arise in the dental office, as well as those that have the greatest potential to cause patient morbidity or mortality, and be well prepared to deal with them. Examples include syncope, hyperventilation, seizures, hypoglycemia, acute asthmatic attack, allergic reactions, and airway obstruction. Certainly, any emergency situation that might logically occur as a direct result of medications or techniques being used must not only be anticipated and well understood; the dentist must also be prepared to quickly carry out an action plan to manage the situation. Examples include local anesthetic toxicity reactions and respiratory depression secondary to sedation. Personal preparation for the dentist should include, as a minimum, a working knowledge of the signs, symptoms, course, and therapy for common treatable conditions. Training in basic life support at the health care provider level (BLS-HCP, colloquially referred to as cardiopulmonary resuscitation [CPR]) should be considered the foundation of emergency medical management in the dental office regardless of whether this is required for dental licensure. Intramuscular (IM) injection techniques will be the most common method of emergency drug delivery, when needed. The deltoid region of the upper arm and the vastus lateralis region of the thigh are commonly employed sites. When needed because of lack of patient cooperation, injection can be performed through the patient’s clothes. If moderate sedation techniques are to be used, pediatric advanced life support (PALS) or advanced cardiac life support (ACLS) training may be desirable. However, it is appreciated that most dentists, including pediatric dentists, are generally not experienced and competent in emergently obtaining intravenous or intraosseous access, using intravenous medications, or performing endotracheal intubation. Therefore a course focusing on emergency airway management, such as the American Dental Association’s Recognition and Management of Complications During Minimal and Moderate Sedation course, is likely more beneficial.
Office personnel should be familiar with their role in the recognition and management of common medical emergencies. If moderate sedation is provided, it is desirable and often required that all office clinical staff members be certified in BLS-HCP. A team approach to medical emergencies will provide for organized management of emergency situations. Each staff member should have a preassigned role in case of an emergency so that emergency equipment, medications, and oxygen will be brought (and maintained) by assigned persons, and all tasks will be performed in an organized fashion. Fortunately, because medical emergencies occur relatively rarely in the dental office, it is desirable to regularly run mock medical emergency drills to keep the team protocol running smoothly and to reduce panic in an actual emergency.
Another essential component of office preparation for medical emergencies involves securing backup medical assistance in advance. This involves having the current telephone number for activating EMS, which is usually 911. If the dentist is in a rural area that does not have access to EMS through 911, the dentist should have the telephone numbers of the nearest rescue squads and emergency room facilities conveniently displayed where they will be immediately available. The dentist should arrange in advance to have paramedics versus basic emergency medical technicians respond to dental office medical emergencies whenever available. When feasible, arrangements should be made with a physician whose office is nearby for immediate assistance should an emergency arise. Such a relationship must be prearranged, not assumed.
Realizing that basic life support until EMS transport arrives is the foundation of medical management in most situations, it should be apparent that very little equipment is necessary to deal with medical emergencies. When discussing the presence of any emergency equipment where pediatric patients are to be treated, it should be appreciated that appropriate sized equipment will be necessary, potentially for infant to adolescent sized patients; it is the dentist’s responsibility to ensure that the correctly sized equipment is available. Oxygen is the primary emergency drug in the dental office, which requires specialized equipment for its administration. An oxygen source capable of delivering greater than 90% oxygen at flows of 10 L/min for a minimum of 1 hour is ideal. This means that an “E” cylinder is the minimum size required. Since pediatric dental patients only very rarely suffer myocardial infarction and cardiac arrest as the initiating medical event, and because drug-induced respiratory depression and loss of a patent airway during unconsciousness is much more likely to occur, the initial primary goal of basic life support is establishment and maintenance of proper respiratory function. Hypoxemia (low oxygen content in the arterial blood) is the final common pathway leading to morbidity and mortality in the majority of severe pediatric medical emergency situations. Adequate oxygenation is more easily ensured by the administration of supplemental oxygen. If the patient is adequately breathing spontaneously, oxygen may be delivered by way of a facemask, nasal mask, or nasal cannula prongs. Ideally, a non-rebreather facemask should be available as this delivers the highest concentration of oxygen to the spontaneously breathing patient for the most serious medical emergencies. However, should the patient cease breathing during an emergency situation, positive pressure ventilation will be necessary. Although mouth-to-mouth ventilation, or preferably mouth-to-mask ventilation, is possible, this delivers only about 16% oxygen from the rescuer’s lungs and is not ideal, but certainly better than no ventilation in a patient who is not breathing. Therefore a positive-pressure oxygen delivery system (bag-valve-mask device) that can be connected to a high-flow oxygen source is also considered essential equipment to deliver oxygen to the apneic patient (Figure 10-2). As an alternative for those trained in its use, a Robertshaw demand valve device or similar oxygen-powered positive pressure breathing apparatus can also be considered. The bag-valve-mask device, face masks, and oxygen cylinder should all be together in one central location in the office.
A high-volume suction device is another piece of equipment that is considered essential for the management of medical emergencies. Emergency situations, especially those involving an obtunded patient, often induce vomiting. The aspiration of vomitus can be disastrous. This can usually be minimized or prevented by proper patient positioning and suctioning. Of course, most dental offices contain high-volume suction equipment for restorative dentistry purposes. A Yankauer type of suction configured to be connected to the dental high-volume evacuation dental suction unit would be ideal to suction the mouth and pharynx (Figure 10-3).
Other emergency equipment items that are needed include syringes and needles for intramuscular drug administration. Oropharyngeal and nasopharyngeal airways are highly desirable. For those dentists with advanced anesthesia training, the armamentarium for establishing intravenous access and advanced airway equipment, such as laryngeal mask airways and other emergency airway devices, can be employed. Lastly, availability of an automated external defibrillator (AED) capable of electrical the/>