chapter 32 Preparation for Emergencies
Although the prevention of life-threatening emergencies is always our primary goal, potentially catastrophic situations will develop in spite of our best efforts. With proper patient evaluation before the start of any treatment, appropriate treatment modification if necessary, selection of appropriate techniques and drugs for pain and anxiety control, adherence to proper technique of drug administration, and adequate monitoring throughout the procedure, it is unlikely that serious emergency situations will arise. However, in the event that an emergency does occur, it becomes extremely important for the dental office to be properly prepared and for all office personnel to be trained to recognize and manage such situations in a prompt and effective manner. Box 32-1 summarizes the suggested preparation of the medical or dental office and staff for emergency situations.
Summary of Preparation
With all office personnel trained to recognize and manage life-threatening situations, it should be possible for each one of them to maintain the life of a victim alone or as a member of a trained emergency team. Although management of most emergencies is possible with but a single rescuer, the concerted efforts of several trained persons are more efficient. Because most dental and medical offices have numerous staff persons present during working hours, organization of a team approach to emergency management is possible.
An important factor in preparation of the medical or dental office for management of emergency situations will be the training of all office personnel, including nonchairside personnel, in their recognition and management. Training should include an annual refresher course in all aspects of emergency medicine—a course reviewing situations such as seizures, chest pain, unconsciousness, altered consciousness, drug-related emergencies, and respiratory difficulty, not simply basic life support (BLS). Such continuing education programs are available with schedules published regularly by dental organizations, such as the American Dental Association.1 In a dental office in which sedation is used, refresher courses in these techniques, including their complications, are also recommended.
Of even greater importance than the overall emergency review program is the requirement for the clinical ability to perform BLS, more commonly known as cardiopulmonary resuscitation (CPR). It is my opinion that no other preparatory step is as important as this one because training in BLS enables a rescuer to recognize an acute life-threatening situation and to know what to do. The steps of BLS require no additional equipment*: the mouth, hands, and knowledge of the rescuer are quite adequate in most cases to maintain a life. In the presence of a drug-related emergency, BLS usually proves to be the first and most important step in management. The acronym PABCD, where P is position; A is airway; B is breathing; C is circulation; and D is definitive care (D also means: Diagnosis, Drugs, Defibrillation), forms the basis of life support and management of all medical emergency situations. The Australian Resuscitation Council (ARC)’s acronym for health care providers is DRABCD, where D is danger; R is response; and D is defibrillation.2
The dentist should mandate that all office personnel remain proficient in BLS techniques after receiving their initial course. There is a rapid decline in CPR skills following an initial BLS training program. Within 6 months of completing a provider-level training program, the average person loses approximately 60% of his or her ability to perform adequate BLS.3 In a clinical experiment, only 4 of 30 postdoctoral dentists (graduate students), who had been retrained in BLS within the previous 4 months, were able to perform adequate one-person CPR on a mannequin for 1 minute.4 Maintaining proficiency is important because even when BLS is performed perfectly (a rarely achieved goal), the delivery of oxygenated blood to the victim’s brain is only 25% to 33% of normal.5 Faulty CPR technique leads to diminished cerebral blood flow and to a decreased likelihood of survival with or without permanent neurologic damage.
If a dentist, assistant, or hygienist was in a dental office with only one other person present and was the victim of cardiac arrest, this second person would be the only one available to provide BLS. Making certain that all personnel are proficient in BLS thus becomes the single most important step in ensuring that medical emergencies are managed efficiently and effectively.
Advanced cardiovascular life support (ACLS) involves the use of adjunctive equipment and drugs to further stabilize and manage a victim of cardiac arrest or other serious cardiac rhythm disturbance. The ACLS course includes training and evaluation in techniques of venipuncture and endotracheal intubation, interpretation of electrocardiograph (ECG) rhythms, and management of cardiac dysrhythmias through drug therapy and defibrillation.