2
Medical Emergencies
In the past, oral health-care practitioners might have expected to encounter one life-threatening situation among their patients during years of practice. With advances in medicine, and the prevalence of dental disease in a geriatric patient population, the clinician may now be called on more often to provide dental care to medically and/or pharmacologically compromised patients. Being ill-prepared for such eventualities is inexcusable. Being the subject of public censure or accused of negligence in the office is an agony best prevented. Assessment of the patient and recognition of actual or potential problems are imperative in initiating proper treatment and/or summoning proper help. A system of patient classification adopted by the American Society of Anesthesiologists (Table 2-1), with the primary purpose of quickly and easily placing each patient in an appropriate risk category, can provide guidelines for the course of patient management. This classification must be made during the physical evaluation of the patient before any dental treatment is initiated.
Consequently, oral health-care providers must be able to recognize high-risk patients and initiate immediate correction of life-threatening problems. Although there are a number of techniques available for maintaining life in emergency situations, many require sophisticated devices and valuable time that the patient simply may not have. Oral health-care providers must know how to sustain life with no more than their hands, their breath, a few basic supplies and therapeutic agents, and a great deal of common sense.
Table 2-1 Risk Status Classification for Dental Patients
| Risk Status | Definition | Approach |
|---|---|---|
| I | No overt systemic condition(s) | Routine office care |
| May require sedation | ||
| II | Moderate systemic condition(s) | Routine office care |
| Medically stable | Appropriate minor modifications | |
| III | Severe systemic condition(s) | Emergency care |
| Medically fragile | Medical consult | |
| Limited activity | Modified office care | |
| Not debilitating | ||
| IV | Debilitating systemic conditions | Emergency care |
| Constant threat to life | Medical consult | |
| Care in a hospital environment | ||
| V | Morbid patient | Maintain basic life support |
| Not expected to live |
Source: Adapted from Anesthesiology 1963;24:111.
Emergency Steps
The basic emergency procedures include five fundamental steps that should be taken immediately in every emergency as appropriate:
| Step 1 | Discontinue treatment and assess consciousness |
| Step 2 | Be sure that the patient has an unobstructed airway |
| Step 3 | Check the pulse rate and its character |
| Step 4 | Check the blood pressure |
| Step 5 | Monitor the rate and character of respiration |
If the patient becomes unconscious, proceed to cardiopulmonary resuscitation, Steps 6a-h.
Specific emergencies will require the additional steps listed under the emergency situation.
STEP 1
Discontinue treatment and assess consciousness
Shake the patient gently and ask, “Are you all right?” The patient may have fainted or may just be sleeping. Gently shaking the patient and asking, “Are you all right?” are usually enough to revive or awaken the patient in such cases.
| Note: | The clinician should also inspect the pupils of the eyes to see if they are reactive to light and if they are both equal in size and reaction. The pupils may be constricted, as in drug overdose; unequal, as in stroke; or dilated, as in shock and unconsciousness. The unconscious patient has to be protected from airway obstruction caused by the tongue. If the patient is unconscious, proceed immediately to Step 6. |
Cardiopulmonary Resuscitation
STEP 6a
Position the patient
The unconscious patient must be positioned correctly for further assessment and care. Place the patient in an extended supine (face-up) position on a fixed, level, hard surface to allow for efficient compression of the chest should external cardiac compression be necessary.
| Note: | A patient in late pregnancy, who may experience supine hypotensive syndrome when lying on her back, should be placed on her left side (left lateral position) to place the weight of the fetus away from the easily compressible vena cava on the patient’s right side. |
Vasovagal Syncope (Fainting)
Brief Overview
Syncope is characterized by a sudden and brief loss of consciousness. The cause is reversible disturbances in cerebral function resulting from decreased cerebral blood flow. Vasovagal syncope is the result of emotional excitation of the parasympathetic nerves to the heart and of the vasodilator nerves of skeletal muscles. The result is reduced heart rate, reduced arterial pressure, and reduced blood flow to the brain. Factors that provoke syncope include pain, anxiety, and heat. Syncope may also result from cardiac or vascular problems or other causes.
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