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Management of Medical Emergencies: Assessment, Analysis, and Associated Dental Management Guidelines

MEDICAL EMERGENCIES OVERVIEW, FACTS, AND TOOLS

Every practitioner is aware that at one time or another, medical emergencies can happen. With proper assessment and care, however, the emergency can be successfully triaged and optimally managed. Prevention of medical emergencies is the key, and every effort should be made to assess each patient thoroughly prior to dental treatment. Steps should be incorporated to prevent emergencies from happening, and this section discusses and details how to deal with these emergencies.

Prevention of Medical Emergencies

Preventive measures implemented to avoid medical emergencies in the dental setting include thorough assessment of the medical history, thorough physical examination, and appropriate treatment planning.

Thorough Medical History Assessment

Thorough medical history assessment should establish the following:

• The patient’s current medical status
• The current list of medications used daily or PRN (as and when needed): including all prescribed and over-the-counter (OTC) medications
• The patient’s compliance with medications
• Any history of medical or surgical complications requiring hospitalization within the past two years
• Any history of allergies, particularly to anesthetics, analgesics, antibiotics, antivirals, antifungals, and latex, which are all used or encountered in the dental setting
• Any history of corticosteroid intake, currently or within the previous two years
• Any history of experiencing adverse reactions or negative feelings about visiting a dentist, such as anxiety, fear, or avoidance
• Personal habits, alcohol intake, and “recreational” drug use

Thorough Physical Examination Assessment

A thorough physical examination should include an assessment of the following:

• General physical appearance
• Vital signs: pulse, blood pressure, respiration rate, temperature, height, and weight
• Examination of the head and neck
• Assessment of the cardiovascular system
• Assessment of the respiratory system

Assessment of the Treatment Plan

Assessment of the treatment plan should include the following:

• Assessment of the type of anesthetics, analgesics, antibiotics, antivirals, and antifungals that can be safely used during dentistry
• Assessment of whether the patient needs to be premedicated prior to dentistry
• Assessment of whether shorter appointments or appointments at least seven days apart are needed, if the patient is to be premedicated prior to dentistry using the same premedication antibiotic for all visits
• Assessment of whether the patient has presented for treatment on a full stomach; the appointment should occur only after the patient has eaten
• Assessment of whether the patient needs to bring emergency medications for all dental visits: nitroglycerin, inhalers, or sugar pills
• Assessment of whether stress management is needed prior to dentistry

Preparation or Training for Medical Emergencies

Preparation or training for medical emergencies should include the following:

• Acquire CPR certification or ACLS training
• Participate in continuing education courses in emergency medicine, annually
• Know how to access/contact the emergency medical system (EMS) for the dental office in the event of an emergency
• Conduct practice drills in the dental office, making it a team effort
• Have an automated external defibrillator (AED), oxygen tank, and an emergency kit in the dental office with updated medications; know the location and contents of the emergency kit plus how to use the medications, the AED, and how to open the oxygen tank

Emergency practice drill highlights:

• During emergency practice drills always go to where the emergency equipment is located and have participants bring the equipment to the mock-emergency site.
• Review all steps necessary in managing an actual emergency.
• Clearly remind all participants that the new American Heart Association (AHA) Health-Care Provider (HCP) basic life support (BLS) guidelines have moved away from the previous “A-B-C” (Airway-Breathing-Circulation) protocol to the new “C-A-B” (Circulation-Airway-Breathing) protocol. Remind all participants that one no longer has to “look, listen, and feel,” as these steps waste precious time and are not helpful in reviving a collapsed patient. Have participants demonstrate their CPR skills, so the information stays current.
• Run a mock emergency drill with a patient and provider, and have participants respond to the provider’s call for help. Observe if the correct provider and bystander tasks are appropriately completed as outlined. Once the drill is completed, provide feedback and correctional steps, if needed, to the provider and bystanders.
• During the drill, the first person or the provider encountering the emergency should call for help and stay to assess and assist the patient.
• The person or provider calling for help follows a structured form of communication so the information gets transmitted correctly to those providing assistance. Remember that the communication needs to be concise and organized, as this standardizes discussion among all participants.
• The person or provider encountering the emergency provides information about the emergency situation, any or all background information, and patient assessment information using the following formula:
  • Situation: Why help is needed or what the concern is.
  • Background: Information about the patient’s current code status, the course of the emergency, and the patient’s present medical history and/or present social history.
  • Assessment: The patient’s vital signs and what problems he/she is experiencing with the vital signs.
• Bystanders responding to the call for help must immediately disperse and bring in the emergency equipments including oxygen; they should assist the provider, call EMS, and direct EMS to the emergency site when they arrive.
• Recommendations will be provided by the EMS or triage team(s), who will indicate what best treatment(s) will help with the care, what additional consults or tests are needed once the patient is stable, and if the patient needs to be transferred for hospitalization.

Common Medications Used During Medical Emergencies

The following medications are used in a medical emergency (list given in alphabetical order):

• Aminophylline (250mg/10mL): In addition to aminophylline, metaproterenol (Alupent) or albuterol (Proventil) are the most common inhalers found in emergency drug kits. The patient places either inhaler into the mouth and compresses the spray vial to express the bronchodilator while inhaling. Then the patient slowly exhales to disperse the medication in the bronchi. Bronchospasm usually resolves within 30 seconds to one minute of inhaler use.
• Aromatic ammonia: The white wrap turns pink when ammonia vapors form after the vaporole is crushed or cracked open.
• Aspirin: Uncoated 81mg and 325mg tablets. Aspirin is part of the prehospital treatment for suspected heart attack victims. Two 81mg tablets or one 325mg aspirin tablet chewed and swallowed is recommended in any patient who is suffering chest pain for the first time. Ensure that the patient has no allergy to aspirin, no underlying bleeding disorders, and no history of peptic ulceration.
• Cimetidine (Tagamet): H2 blocker: 300mg IV/IM/PO.
• Dextrose (D50W): 50mL, 50% dextrose.
• Diazepam (Valium): 5mg/mL vial. Newer kits also contain Midazolam (Versed) in 1mg/mL or 5mg/mL vials.
• Diphenhydramine (Benadryl): H1 blocker: 50mg/mL. Diphenhydramine (Benadryl) is the histamine blocker most commonly found in emergency drug kits and it is used in the management of allergic reactions that are not life threatening and in the management of acute anaphylactic reactions, after epinephrine has been used.
• Epinephrine: 1:10,000: Administer 0.3mg IV slowly in a hypotensive patient. Only an emergency room physician or emergency personnel responding to the emergency should administer this.
• Epinephrine: 1:1,000 dilution: Administer 0.3–0.5mL SC/IM. Epinephrine is dosed in a 1:1000 (0.3 mg) concentration and must be available in a preloaded syringe. The faster the patient gets epinephrine during an acute anaphylactic reaction, the greater is the chance of survival. It is not uncommon to need more than one dose. Therefore, in addition to the preloaded syringe, the emergency kit should contain 1 mL cartridges of epinephrine 1:1000.
• Famotidine (Pepcid): H2 blocker: 20mg IV/PO.
• Glucagon: 1mg injected IM in the deltoid muscle.
• Glucose: Oral glucose.
• Hydrocortisone sodium succinate (Solu-Cortef): 100–200mg IV/IM.
• Lidocaine.
• Morphine sulfate.
• Naloxone (Narcan): 0.4mg IV.
• Nitroglycerine (NTG) tablet: 0.3mg sublingual (SL). This is given every five minutes up to a maximum of three tablets after confirming, each time, that the systolic BP is maintaining above 115 mmHg. Some emergency kits may have nitroglycerine lingual spray instead of nitroglycerine tablets. It is actually better to have nitroglycerine lingual spray in the emergency kit instead of nitroglycerine tablets, as it has a longer shelf life compared to NTG tablets. The nitroglycerine is sprayed onto the patient’s tongue and it is as effective as the NTG tablets. The potency of one spray is equal to the potency of one sublingual tablet (0.3mg/tablet).

Emergency Equipment and Adjuncts

Emergency equipment and adjuncts should consist of the following:

• Artificial airways: oropharyngeal and nasopharyngeal airways.
• Airway adjuncts: endotracheal tubes and laryngoscope.
• Ambu-bag: self-inflating, bag-valve mask that provides 100% oxygen.
• Syringes.
• Tourniquets.

Oropharyngeal Airways

Measure from lips to the angle of jaw to determine the size of oropharyngeal airway needed. Insert the airway inverted and turn it upright as you reach the back of the tongue. This holds the tongue off the throat. Oropharyngeal airways are tolerated only by the unconscious patient without a gag reflex.

Cricothyrotomy Needle

A thirteen-gauge cricothyrotomy needle is occasionally inserted to access the airway at a point below an upper airway obstruction. This is done by inserting the wide-bore needle through the cricothyroid membrane. This form of care should be provided only by emergency personnel.

Endotracheal Intubation

A cuffed tube is passed through the vocal cords utilizing direct laryngoscopy, and the tube is placed in the trachea.

Oxygen

With a nasal cannula you can give 1–6L/min of oxygen. This provides the patient with 24–44% oxygen. Through a simple mask you can deliver 40–60% oxygen, and a non-rebreather mask can deliver 90–100% oxygen.

The Basics of Support: Airway, Breathing, and Circulation (The ABCs)

The new American Heart Association (AHA) Health-Care Provider (HCP) basic life support (BLS) guidelines have moved away from the previous “A-B-C” (Airway-Breathing-Circulation) protocol to the new, “C-A-B” (Circulation-Airway-Breathing) protocol. One no longer has to “look, listen, and feel” as these steps waste precious time and are not helpful in reviving a collapsed patient. This should be followed by reassessment of the patient’s status, use of medications, and transfer to the hospital if needed, for definitive therapy.

CLASSIFICATION OF MEDICAL EMERGENCIES

It is always best to classify medical emergencies according to the patient’s presenting symptoms. Once you focus on the specific presenting symptoms you are able to triage and implement the proper care for the patient immediately.

Syncope Attack

Multiple factors can cause syncope, but some factors can cause syncope more commonly than others:

• Common Causes: The more common causes of syncope attacks are vasovagal syncope, orthostatic hypotension, hyperventilation syndrome, and hypoglycemic reaction or coma.
• Less Common Causes: The less common causes of syncope are transient ischemic attack (TIAs), cerebrovascular accident (CVA/stroke), cardiac arrest, hyperglycemia, and acute adrenal insufficiency.

Chest Pains

Chest pains can occur with angina, myocardial infarction, or hyperventilation. Angina can be stable angina/angina of effort, unstable angina, acute coronary insufficiency (preinfarction angina), and atypical/coronary artery spasm/Prinzmetal’s angina.

Respiratory Distress

Respiratory distress can occur from foreign body obstruction, asthma, or hyperventilation.

Adverse Drug Reactions

Adverse drug reactions can be associated with anaphylaxis/allergy, local anesthetic, and/or epinephrine overdose.

Seizures

Seizures can be due to grand mal epilepsy, hypoglycemia, or hyperventilation.

VASOVAGAL SYNCOPE

Vasovagal Syncope Predisposing Factors

Predisposing factors for vasovagal syncope include anxiety, fear, and sight of blood; hot and humid surroundings; upright position without movement; prolonged motionless standing for a period of time; and age (patients in their teens to early forties). Males are more often affected than females.

Vasovagal Prodrome Stage

There is a definite prodrome stage when the patient feels that a collapse is imminent: This is the fright and flight response. It lasts for ten seconds to a few minutes. Anxiety, tachycardia, perspiration, light-headedness, and blurred vision are commonly experienced.

Vasovagal Syncope Stage Vital Signs

Bradycardia with hypotension is the classic finding on physical examination. This is the only syncope where a drop in the blood pressure (BP) is associated with bradycardia and not tachycardia. Tonic-clonic activity may occur.

Vasovagal Postsyncope Stage

Recovery occurs within a few seconds. There may be some headache, dizziness, nausea, vomiting, pallor, and perspiration that may persist for a few minutes to a few hours. The patient may try to sit up on recovery. Discourage this from happening.

There is no postsyncope confusion. Confusion could occur if the patient falls during the emergency and knocks his/her head. This should prompt you to activate the emergency medical system (EMS) and transfer the patient to the nearest emergency room (ER) for evaluation of a head injury.

Vasovagal Syncope Treatment

Immediately put the patient in a supine position. Crack open a vial of ammonia (smelling salts), and hold it away from your face to prevent you from inhaling the vapors! The white covering of the vial turns pink once the ammonia vapors are released. Next, lean forward and have the patient inhale the vapors. The patient will immediately start showing movement. Reassure the patient on recovery. Assess the clarity of the mental status by having the patient respond to some common-knowledge questions. Observe for 30–60 minutes with the patient lying down.

Vasovagal Syncope and Suggested Additional Steps of Care

During an emergency always monitor the pulse using one of the most accessible arteries: radial, brachial (in children), or carotid. Use the following guidelines to get an instant perception of the blood pressure level:

Steps to Interrupt a Vasovagal Syncope Attack

Occasionally you will find yourself facing a patient who has denied anxiety and the need for stress management during an initial medical history assessment visit. Now, when you are ready to inject the local anesthetic, you may find this patient clenching the sides of the dental chair and looking quite pale.

Immediately stop the treatment, reassure the patient, and put the chair in a horizontal or slight head-down position. Have the patient open and close the fists and perform bicycling movements with the legs. This will move the blood from the extremities and toward the heart. Stress management should always be provided for future visits in patients who have experienced vasovagal syncope in the dental setting.

ORTHOSTATIC HYPOTENSION

Orthostatic Hypotension Predisposing Factors

Normally when a person stands up from a sitting or lying-down position, the vasoconstriction response maintains the cerebral blood flow. An elderly patient is more likely to experience orthostatic hypotension (OH), because in the elderly patient, the erect vasoconstrictor action upon standing is slow in onset. Patients on antihypertension, antidepression, and anti–Parkinson’s disease drugs often experience orthostatic hypotension as a side effect of the medications. OH can also occur due to increased vasodilation right after IV sedation or nitroglycerine use and it is more common in diabetics with autonomic neuropathy.

Orthostatic Hypotension Prodrome Stage

There is no prodrome stage with OH and the patient feels normal prior to the syncope.

Orthostatic Hypotension Syncope Stage Vital Signs

The syncope occurs with rapid change from a lying-down position to an upright position. There is a precipitous drop in the blood pressure. The pulse is normal or slightly elevated from baseline values. The patient regains consciousness when becoming horizontal as circulation to the brain is maintained.

Orthostatic Hypotension Pretreatment Diagnosis

In a suspect case for orthostatic hypotension, monitor the BP and pulse in a lying-down and immediate upright position. You can diagnose OH if the systolic blood pressure (SBP) drops by 20–30 mmHg or the diastolic blood pressure (DBP) drops by 10–15 mmHg upon standing and the pulse rate increases by 10–15 beats/min.

Orthostatic Hypotension Prevention Strategy

At the end of the appointment have the patient sit upright in the dental chair for a few minutes and then assist the patient out of the chair. Steady the patient until the patient feels stable standing upright.

HYPERVENTILATION SYNDROME

Hyperventilation Syndrome Predisposing Factors

Anxiety and fear are the most common predisposing factors.

Hyperventilation Syndrome Pathophysiology and Clinical Features

Rapid and deep breathing occurs because of severe anxiety and fear. This rapid breathing causes a washout of CO2 and the PCO2 goes below normal (35–45 mmHg). The PO2 stays in the normal range. Generalized vascul/>