A medical emergency is an unanticipated complication that usually requires quick, focused, calm action to resolve a potentially life-threatening situation. The intent of this chapter is to present emergency scenarios focusing on simplified and logical process of managing the crisis in the dental office.
We recommend that a written policy of emergency procedures be generated and discussed on a routine basis with the staff. Emergency protocols should be practiced a minimum of four times per year. The goal of managing an emergency should be to quickly stabilize the patient.
To properly handle emergencies in the office setting, the dentist and key members of the team should review emergency protocols, identify in advance the resources and limitations of the practice, and take appropriate actions to correct or eliminate those limitations. Critical management of emergencies most likely will require quick, focused action by the dental office team. If resolution of the complication cannot be rapidly and satisfactorily addressed, calling paramedics to the office is the next key step while continually assisting the patient using basic life support techniques. Transfer to an acute care facility where critical care staff is better suited to manage the acute and long-term aspects of the complication is usually indicated once paramedics are called to the office [1
Although complications in the delivery of sedation for dental procedures are rare, emergency situations can occur that make it mandatory for certain types of equipment and medications to be readily available. An emergency cart should contain the necessary medications and equipment to resuscitate a non-breathing patient and address other conditions such as an allergic reaction, vomiting, hypoglycemia, and syncope [1
It is highly likely that 99 % of medical emergencies that may occur in a pediatric office setting can be managed using three basic interventions. A thorough understanding of each will become significant in being prepared and confident when a medical emergency arises.
The first and most important intervention in almost every situation is the delivery of oxygen. The brain, without oxygen, suffers irreparable damage within 4–6 min. Death occurs within about 8 min. In each of the emergency scenarios that follow, oxygen and its efficient delivery will be paramount to rescuing a patient in virtually every emergency situation.
The second intervention is careful attention to patient positioning to facilitate airway patency. Favorable head positioning for dental procedures may not be best for ensuring airway patency. Many times, the simple jaw thrust-head tilt maneuver taught in every basic life support course to mechanically assist the lifting of the base of the tongue away from the posterior wall of the pharynx will open the airway to allow air exchange. Also, a shoulder roll to slightly lift the upper torso and facilitate airway opening in a sedated patient will often deter an impending desaturation crisis.
The third intervention is suction, which is almost always intended to also clear the airway of fluids and foreign material. Efficient suctioning to clear the oral cavity and especially the hypopharynx of debris, blood, saliva, and foreign particles is essential in an emergency involving an airway compromise – the most likely emergency to occur in a sedated child. Dental procedures themselves always encroach on the airway and tend to create secretions. Dental instrumentation and materials should be respected as potential foreign bodies. Meticulous attention to suctioning can aid in protection against aspiration of blood, irrigation fluid, or foreign bodies without interfering with completion of dental procedures.
In each situation involving oral sedation, emergency equipment to rescue a patient should always be nearby in the operatory and ready for immediate use. Seconds will count in a serious emergency.
The American Society of Anesthesiologists guidelines for office-based anesthesia [1
] specifically address the challenges in dental offices. Procedure rooms in dental offices are usually small therefore compromising access to patients experiencing unexpected complications. Supplemental airway positioning devices that support the patient’s upper torso, neck, and head can be helpful in passively assisting airway management. Dental offices may not have backup emergency power sources; therefore, lighting, communications, and monitoring equipment must have sufficient battery backup or battery-powered resources in the event of power failure. Provisions for backup suction must also be addressed.
Before administering any medications that may compromise respiration, verification of an adequately functioning means to deliver positive pressure ventilation must be made. A bag-valve mask, knowledge and skills in its use, as well as an unlimited source of oxygen are imperative.
An E cylinder of oxygen or a similar portable source of oxygen such as a Jumbo D cylinder should be readily available. The E cylinder or similar portable oxygen reservoir-type rescue device should be available and ready to use within 10–20 s after identifying the complication requiring oxygen.
The E cylinder contains roughly 625 l of O2. A regulator that has a flow meter which controls gas flow through a “nipple” should be fitted to the cylinder. The nipple can be used to supply oxygen to a bag-valve-mask reservoir. A nasal cannula may also be attached to the nipple to provide supplemental oxygen in less critical situations. The threaded attachments on the regulator can be used to connect a high-pressure gas hose to the regulator.
Suctioning can easily be accomplished in a dental setting using a saliva ejector and a high-volume evacuation system. The saliva ejector is beneficial because it is flexible and, most importantly, it is readily available. Unfortunately, its small lumen, fragile connection to the hose assembly, and lack of a venting system limits its usefulness in an emergency that requires large amounts of efficient evacuation. Additionally, the same flexibility that allows for curvature to match the shape of the mouth to the hypopharynx becomes a weakness as this flexibility makes the saliva ejector too weak for definitive suctioning.
The high-volume evacuation is normally equipped with a “straw” or similar hard plastic extension that is both straight and incapable of being curved to go past the base of the tongue and down the pharynx without scraping the posterior wall of the pharynx. It is virtually impossible to reach the area near the vocal cords where blood and saliva collect and block the airway.
A tonsillar or Yankauer suction tip with an associated hose can be attached to the high-speed evacuation (HVE) in less than 30 s. The tip has a lumen that is approximately three times the diameter of the saliva ejector tip and is a flexible hard clear plastic that is precurved to match the curvature from the mouth to the hypopharynx. Efficient high-volume evacuation of blood, saliva, and vomitus can be accomplished with this apparatus. If clogging occurs, the tip can be vented to dramatically reduce the negative pressure at the tip, and debris can be much more easily removed from the intake openings. The tip is smooth and rounded so to not damage the pharyngeal mucosa. It is specifically designed to evacuate this area.
In the emergency scenarios that follow, suctioning an otherwise patent airway should always be considered. If the mouth, pharynx, hypopharynx, and trachea are correctly aligned to facilitate air exchange but the “pipeline” is clogged with saliva, water, blood, and debris, ventilation will be compromised.
Additional devices such as the oropharyngeal and the nasopharyngeal airways are useful adjuncts for keeping the base of the tongue from collapsing against the posterior wall of the pharynx and bypassing large tonsils and redundant tissue. These adjuncts create and maintain airway patency. When employed, these devices allow less restricted, less labored spontaneous breathing or permit much more efficient exchange of air when using assisted ventilation using a bag-valve mask.