EMERGENCY PREPARATION

Many chronic medical conditions, such as asthma, congestive heart failure, coronary artery disease, and cerebrovascular disease, may become acute medical emergencies when exacerbated by the stress of the dental appointment. Stress, anxiety, fear, and phobia may cause other minor stress-related emergencies, such as syncopal episodes and hyperventilation syndrome. A thorough preoperative evaluation, meticulous detail to achieving profound local anesthesia in a safe manner, consideration of nonpharmacologic stress reduction protocols, and the use of pharmacologic sedative techniques to minimize pain, fear, and anxiety help reduce this risk.

Preoperative evaluation includes the use of a medical history questionnaire, oral history, review of systems, physical examination, vital signs, and appropriate laboratory tests and consultations. This evaluation should determine the risk/benefit ratio of the contemplated procedure, what drugs should be used or avoided, the potential for a medical emergency, and the type of monitoring best suited for the particular patient.

EMERGENCY PREPAREDNESS

Although almost any medical emergency can occur during the course of dental treatment—which means that dental personnel must be prepared to provide effective basic life support (BLS) and seek emergency medical services in a timely manner—dentists must be able to diagnose and treat common medical problems (e.g., syncope or hyperventilation syndrome) definitively and respond effectively to certain less common (or even rare) but potentially life-threatening emergencies, especially emergencies that may arise as a result of dental treatment (e.g., anaphylactic reaction to an administered drug).⁹ These emergencies are listed in Box 54-1.

Many factors determine the degree of preparedness for medical emergencies needed in a specific dental practice, but all dental offices must be ready at some minimal level.³⁰ The use of local anesthesia is an indication for the dentist to be prepared to handle medical emergencies, as evidenced by the following language in product literature approved by the U.S. Food and Drug Administration: “Dental practitioners who employ local anesthetic agents should be well versed in diagnosis and management of emergencies that may arise from their use. Resuscitative equipment, oxygen and other emergency drugs should be immediately available for immediate use.”⁶ An overall emergency preparedness plan, as outlined in Box 54-2, is essential for every dental practice. Implicit in Box 54-2 is the necessity to develop a team approach in preparing for and responding to medical emergencies in the dental office, with each staff member (receptionist, dental auxiliary, dental hygienist, and dentist) responsible for a specific role.

Preparedness must be individually tailored according to the type of patient treated (e.g., young, healthy patients in an orthodontic practice versus medically compromised patients in a periodontal practice), location (an urban setting where emergency help is close at hand versus a rural location where there may be a significant delay until help arrives), and training (whether the dentist and staff are capable of performing advanced emergency procedures and protocols). Although a comprehensive guide to the pathophysiologic characteristics, prevention, diagnosis, and management of specific medical emergencies is beyond the scope of this chapter, several sources for this purpose are listed in the general references. In practices where sedation or general anesthesia is administered, advanced emergency training and equipment are required and often promulgated by state dental practice acts.

EMERGENCY DRUGS

Although many medical emergencies may be properly treated without the use of drugs, every dental office must contain an emergency kit with drugs appropriate to the training of the individual dentist, the patient being treated, and the type of procedures being performed.^2,18 No drug can take the place of a properly trained health professional and support staff in diagnosing and treating emergencies. Nevertheless, the design and purchase of an appropriate emergency kit often play an integral role in dictating the course and outcome of emergency treatment.

Besides determining which drugs should be included in an emergency kit, the dentist must understand that he or she must maintain the knowledge base to use them. In the midst of a medical emergency, with the patient by definition in an acutely abnormal or even critical situation, there is no time to begin reading labels, leafing through emergency texts, or administering drugs as suggested by a brochure in the emergency kit. In addition, there is a significant difference between the theoretic knowledge of how to treat an emergency and being able to put such cognitive skills to practical use. Constant review and training keeps the dental team sharp. Regular continuing education in medical emergencies, review of new advances in pharmacology, certification and recertification in BLS and advanced cardiac life support (ACLS), and emergency drills are the best methods to prepare for emergencies.

Many states mandate certification in BLS for dental licensure, and in offices that use deep sedation/general anesthesia, training in ACLS is a standard of care. Without prompt attention to the ABCDs (airway, breathing, circulation, defibrillation) of cardiopulmonary resuscitation (CPR), drugs are of little value. The advent of automatic external defibrillators has made early defibrillation an integral part of the BLS “chain of survival” for the treatment of cardiac arrest. Since January 1998, health care provider CPR courses conducted by the American Heart Association include a mandated module on automatic external defibrillator application and use.⁷ Some states have begun to mandate the presence of an automatic external defibrillator in general dental offices.

The role of drugs and the type of intervention that should be attempted by a dentist during a medical emergency are controversial issues. If any consequence of dental treatment is foreseeable and results in harm, liability may be imposed.⁴¹ Emergency drugs are generally powerful, rapidly acting compounds. The correct approach to the use of drugs in any medical emergency should be essentially supportive and conservative. In a review covering the use over a 2-year period of 8500 emergency drug systems purchased by dentists, a 0.75% incidence of use was reported.⁴⁷

Emergency kits either can be organized by the individual practitioner or can be purchased commercially. Many dentists are uncomfortable choosing and purchasing individual drugs for their emergency kits, and the purchase of a high-quality, commercially available emergency drug kit modified for dentistry can provide consistent drug availability (i.e., periodic drug updating) in an organized fashion.

There is a general tendency to overequip basic dental emergency kits with drugs that are beyond the needs and expertise of many general dentists. The drugs placed in an office emergency kit should include only drugs familiar to the dentist. Only one agent should be included for each particular need. The fewer drugs in an emergency kit, the easier it is to know their proper use, especially during an emergency.³⁷ Many authors, state boards of dental registration, commercial vendors, and professional groups have suggested the composition of dental medical emergency kits.³² The composition of these kits varies greatly and depends on the training and philosophy of emergency care of the creator, whether the kit is dental specific, and whether sedation or anesthesia is used. The definitive pharmacologic features of these drugs are discussed in other chapters.