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Dental Office Emergencies
Lecture 1
CO U RS E D I R EC TO R
M S . M A R I A N N E KOZ E RO, R D H , B S D H
CO N CO R D E C A R E E R CO L L EG E
L EC T U R E : F R I DAY 1 : 3 0 - 3 : 0 0
DH111
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Objectives
•Put together emergency kit & identify the basic supplies of an
emergency kit.
•Describe the use of basic emergency kit supplies.
•Properly administer Oxygen for patient emergencies.
•Discuss the emergency reference charts.
•Recognize & respond to a medical emergency in the dental office.
•Utilize the medical / dental history in planning for an emergency.
•Explain the essential components of an emergency kit in the dental
office.
Objectives
•Discuss adult & pediatric doses of essential emergency drugs.
•Describe the signs of common life's threatening emergencies in
adults.
•Differentiate between hypertensive urgency & emergency.
•Explain the various methods of oxygen administration.
•Discuss the armamentarium associated with oxygen administration.
•Explain the proper methodology for oxygen administration.
Medical Emergencies
•
Do occur in the dental office
•
1/3 of all emergencies are life threatening
•
Increasing age of population and healthcare will lead to an
increase in medical emergencies
•
Our goal as a health care professional is to recognize the signs and
symptoms of a medical emergency and manage it correctly to
prevent it from becoming a life-threatening situation.
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ASA Classification
•
Patients with higher ASA classifications have a greater risk of medical
emergency
•
ASA: American Society of Anesthesiologists
•
Pg. 3 Table 1.1
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ASA I
•
Normal, healthy patient
•
Can walk up two flights of stairs or walk two city blocks without shortness
of breath
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ASA II
•
Mild systemic disease, or risk factors for a systemic disease like
tobacco use, alcohol abuse, mild obesity.
•
Can walk up one flight of stairs or walk two city blocks, but may have
shortness of breath upon completion
 Adult onset diabetes-type II: controlled
 Controlled Epilepsy
 Controlled hypertension (Stage 1)
 Allergies
 Pregnancy
 Fearful dental patient
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ASA III
•
Severe systemic disease that limits activity but is not incapacitating.
•
Can walk up one flight of stairs or walk one city block, but must stop
during the walk due to shortness of breath
 Stable angina
 Renal Failure
 MI longer than 6 months ago – no signs or symptoms
 Well-controlled diabetes Type I
 Controlled CHF: Congestive Heart Failure
 BP > 160/100 (Stage 2)
 Morbid obesity
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ASA IV
•
Systemic disease that is
incapacitating
•
Constant threat to life
•
Unable to walk up a flight of
stairs or one city block
•
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May have shortness of breath or
distress at rest
 MI or CVA within past 6 months
 Unstable angina
 BP > 180/110
 Heart Failure
 Uncontrolled diabetes
 Uncontrolled epilepsy
 Uncontrolled thyroid condition
ASA V
•
Moribund patient not expected to survive 24 hours with or
without operation.
 Multiorgan failure
 Poorly controlled coagulopathy
 Sepsis with hemodynamic instability
Dental professionals will see ASA I, II, and III patients.
ASA IV, and V will most likely be hospitalized or bedridden.
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Most Common Dental
Emergencies
•
Syncope: 50%
•
Mild allergic reaction: 8%
•
Angina pectoris: 8%
•
Orthostatic hypotension: 8%
Most likely to occur after the administration of a local anesthetic,
extractions, or endodontics
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Prevention
•
Thorough and detailed medical history
•
ASK QUESTIONS!!!!
•
Vital signs
•
Preparing for a medical emergency
•
Knowing where the emergency kit is located in the dental office.
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Medical History
Patients may report a condition that can increase the risk of a
medical emergency
 Conditions may include:
 Heart conditions
 Asthma
 CVA
 Epilepsy
 Thyroid problems
 Diabetes
 Corticosteroid use
 Allergic Reactions
 Bleeding disorder
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Positive Response
•
Further dialogue with patient
•
Determine frequency, severity, triggers
•
May need to postpone or modify treatment
•
May need to talk to the patient’s doctor for further information
and/or clearance to treat the patient.
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Preparation for Medical Emergencies in the
Dental Office
•
Well-equipped medical emergency kit with O2 tank and AED (Automated
External Defibrillator) recommended
•
Current CPR (Cardiopulmonary resuscitation) training
•
Attendance at CE courses on medical emergencies
•
In-office simulated medical emergencies
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Management of Medical
Emergency : R.E.P.A.I.R.
•
R- Recognize signs and symptoms
•
E- Evaluate patients level of consciousness
•
P- Positioning patient
•
A- Activate ABC of CPR
•
I- Implement emergency protocol for specific emergency
•
R- Refer patient to healthcare professional
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Emergency Team Structure
•
P1 – person in whose operatory emergency is occurring
 Stays with patient
 Performs emergency procedure: CPR
P2 – next most available person
 Assists P1
 Responsible for vital signs and administers O2
 Records events and informs P1 of time elapsed since medication
delivered
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Emergency Team Structure
•
P3 – next available person
 Retrieves emergency kit
 Prepares emergency drugs for P1
•
Office receptionist
 Makes all necessary phone calls
Pg 5. Table 1.2
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Conclusion
•
Taking and recording accurate medical history
•
Recording vitals: getting a baseline
•
Preparation in event of emergency with current CPR, emergency drills,
continuing education
•
Skill in using the emergency dental kit including oxygen
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Emergency Kit
•
Use drugs familiar with
•
Custom designed
•
Readily available for use
•
Mobile
•
Easily accessible O2
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Emergency Kit
Simple and includes only materials with which the dental team is
familiar and will use
Consider location
◦ Urban setting with quick EMS response time – less
components
◦ Rural setting – full complement of products
◦ Are we in an urban or rural setting and why?
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Essential Drugs
Oxygen –Inhaled, used in
respiratory distress,
cardiac disease.
Do not use in
hyperventilation!!
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Oxygen Administration
•
Needed when breathing is inadequate for keeping the blood saturated
with oxygen
•
In dental office usually supplied by portable O2 tank
 Green in color
 Several parts
• Cylinder
• Regulator
• Flow meter
Parts of O2 Tank
Regulator
•
Regulator
~Reducing valve
and flow meter
Flow meter
joined
~Allows for safe
release of
O2 outlet
pressurized O2
~Must be turned on
Reducing
valve
Parts of O2 Tank
• Flow meter
 Dial that allows operator to determine
amount of O2 delivered
 Measured in liters/minute
 Amount determined by condition being
treated and oxygen delivery device
Types of Delivery Devices in Dental
Office
•
Bag mask
~Two rescuers recommended
~During ventilation should see
chest rise – if not, reposition
head to open airway and/or
bag mask
Nasal cannula
Non-rebreathing face mask
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Essential Drugs
•
Epinephrine
 Anaphylaxis: severe allergic reaction
• Counteracts major physiological events in anaphylaxis
• Reduces hypotension, bronchospasm, laryngeal edema,
prevents additional release of histamine and other
chemical mediators
• Rapid onset and short duration; vasodilator
• Adult dosage - .3 mg of 1:1,000 concentration for
intramuscular and intralingual injections
• Pediatric dosage - .15 mg of 1:1,000 concentration
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Essential Drugs
Epinephrine
◦ Severe asthma attack if
albuterol doesn’t work
◦ Should not use with
ischemic heart disease
or severe hypertension
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Essential Drugs
Nitroglycerine
◦ Angina pectoris, MI or CHF
◦ Dilates coronary blood vessels
◦ Rapid onset
◦ Tablet and spray form
◦ Tablets become impotent or useless if exposed to light or air
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Essential Drugs
 Nitroglycerine
 Administer sublingually
 Administer at 5 minute intervals – up
to 3 doses
 Should not administer if systolic BP <
90 mmHg
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Essential Drugs
Diphenhydramine or Chlorpheneramine
◦ Mile, non-life threatening allergic reactions with respiratory
symptoms
◦ Oral histamine blocker
◦ Chlorpheneramine – 10 mg or Diphenhydramine 25 – 50 mg
for adults
◦ Pediatric dosage- 1 mg/kg of body weight and should not
exceed the adult dosage.
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Essential Drugs
 Diphenhydramine or Chlorpheneramine
 Intramuscular histamine blocker
 Diphenhydramine 25 – 50 mg or
Chlorpheneramine 10 – 20 mg
 Pediatric dose is 1 mg/kg of body weight and
should not exceed adult dose
 Chlorpheneramine does not
cause as much drowsiness
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 Albuterol
 Asthma attack or
bronchospasm
 Inhaler
 Dilation of bronchioles
with minimal
cardiovascular effects
 Quick onset – 30 to 60
minutes
 Long duration of
action – 4 to 6 hours
 Adult dose 2 sprays
 Pediatric dose 1
spray
 Can repeat dose if
necessary
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Essential Drugs
Figure 2.7 Albuterol inhaler
Essential Drugs
Aspirin
◦ Reduces overall mortality from (MI)
◦ Prevents progression of cardiac ischemia to
cardiac injury or cardiac tissue death
◦ Recommended dose 162 mg – 325 mg: 2 - 4 baby
aspirin (81 mg each)
◦ Check medical history for allergy
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Essential Drugs
Oral Carbohydrate- (Glucose)
◦
◦
◦
◦
◦
for conscious patients
Hypoglycemia
Not actually a drug, but inclusion necessary
Paste or tablets do not require refrigeration
ALWAYS ask diabetic patients if they ate before their visit and look for
hypoglycemic signs
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Supplemental Drugs
• Glucagon
 Unconscious
hypoglycemic patient
 Administered IM
 Adult dose – 1 mg
 Pediatric dose–0.5 mg
Supplemental Drugs
 Atropine
 Hypotension
 Increases heart rate which
may also increase BP
 Recommended dosage – 0.5
mg/ml IM
 3 mg maximum
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Supplemental Drugs
Corticosteroid
 Prevention of recurrence of anaphylaxis
 Adrenal crisis
 100 mg hydrocortisone drug of choice for dental
office emergency kit
 Reduce histamine release
 Slow onset > 1 hour
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Supplemental Drugs
Injectable Benzodiazepine
◦
◦
◦
◦
Prolonged seizures or hyperventilation
Skeletal muscle relaxation – anticonvulsant
Lorazepam drug of choice
4 mg IM
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Additional Items
BP cuff and stethoscope
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Additional Items
Thermometer with sleeves: to check for fever
Perioretriever: a magnetized device for the removal of
broken instrument tips.
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Additional Items
Pocket mask with one-way valve
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Additional Items
Syringes: to deliver IM drugs
Bandaids and sterile gauze: for minor cuts and burns
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Additional Items
Ice pack: for burns or bruises
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Additional Items
AED : automated external defibrillator
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Case Scenario 1
Your 1:00 p.m. oral prophylaxis patient is John Brown, a 79-year-old male
retired service salesman for an automobile dealership. He is in fair
health, having suffered from a previous myocardial infarction four years
ago. You take his vital signs (pulse, respiration, and blood pressure) and
find the following readings:
Pulse: 102 beats per minute
Respiration: 22 per minute and
exaggerated
Blood pressure: 150/98 mmHg
What can you conclude from these vital signs?
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Vital Signs
 Accurate taking and recording of vital signs is essential to
comprehensive patient care.
 Baseline vital signs are needed for comparison during medical
emergency to determine severity.
 Vital signs – determine the body’s ability to pump blood and breathe
– also determine health status of patient.
 An elevated temperature may indicate the presence of infection.
 Vital signs and health history are used to determine a patient’s health
before providing dental treatment.**
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Vital Signs
Pulse
Respiration
Blood pressure
Temperature
TAKE AT EVERY
APPOINTMENT!!
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From the moment patient walks in, start to evaluate their health:
 Gait
 Eyes
 Speech
 Skin color
 Weight gain/loss
•
It is okay to ask “Are you feeling okay today?”
Vital Signs
•
Baseline pulse, respiration, temperature and blood pressure essential.
•
Irregular vital signs can be an indication of a medical emergency.
•
Hypertensive (high BP) or hypotensive (low BP) Patients are more likely
to experience various medical emergencies.
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Normal Pulse Rates
•Babies to age 1: 80-120 BPM
•Children 1 to 10 yrs: 70-130 BPM
•Children age 10+ and adults: 60-100 BPM
•Well-conditioned athletes: 40-60 BPM
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Pulse
 Bradycardia – less than 60 BPM
 May be caused by sleep, certain drugs, fasting, or disease.**
 May cause lightheadedness, dizziness, chest pain, syncope, circulatory collapse.
 Treated with atropine to increase heart rate.
 If patient often experiences bradycardia may need a medical referral for an
implantable pacemaker.
 Should also assess rhythm and strength.
 Rhythm – relation of one pulse to another as measured by regularity of action.
 Irregular pulse could be a sign of arrhythmia.
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Respiration
External respiration
 Process by which O2 and CO2
exchanged
 O2 taken in and CO2
eliminated via lungs
Internal respiration
 Use of O2
 Production of CO2
 Exchange between cells
 Involuntary
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Respiration Rate
• Tachypnea – abnormally fast rate > 20 breaths/min
• Often seen in hyperventilation (discussed in
separate chapter)
• Bradypnea – slow rate < 12 breaths/min
• Often seen in syncope
• Apnea – absence of breathing
• If continues results in respiratory arrest
• Cannot sustain life as brain requires O2
• O2 deprivation of 10 minutes or longer leads to
coma or death
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Respiration
Process
◦ Immediately following pulse so patient is unaware and is not
controlling breathing
◦ Move patient’s arm over stomach and continue as if
monitoring pulse rate
◦ Count number of times patient’s chest rises in 30 seconds,
multiply by 2
◦ If respiration is irregular count respirations for 60 seconds
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Respiration
◦Abnormal patterns
◦ Biot’s – periods of shallow breathing, alternating with
apnea (pt’s with neurological problems, head trauma,
brain abscesses and heat stroke)
◦ Cheyne-Stokes – increased rate and depth alternating
with apnea
◦ Often seen in heart failure and drug overdose
◦ Kussmaul – increased depth and rate > 20
◦ Often seen in hyperventilation, diabetic
ketoacidosis, or renal failure
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Temperature
Measure of heat associated
with metabolism of body
Normal 98.6° F (37.5° C) +/- 1
degree
Body temp of 99.5 considered
elevated**
In clinic, patient’s with a temp
of 100.4 will be dismissed.
Wait 15 minutes to take temp
if patient has been eating,
smoking or drinking
something hot.**
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Temperature
Pyrexia/fever – abnormal elevation in body temp
◦ Infection
◦ Neurological disease
◦ Malignancy
◦ CHF: Congestive Heart Failure
◦ Trauma
◦ Drugs
◦ Convulsions or delirium may occur with extremely high fevers
◦ Exercise**
◦ Ingestion of hot food or drink**
◦ Smoking**
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Temperature
Hypothermia
• reduced body
temperature
• Shivering
• Cool skin
• Pallor
Etiologies
• Starvation**
• Shock**
• Illness
• Trauma
• Malnutrition
• Medications
• Should refer to MD
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Factors Affecting Blood Pressure
Blood pressure depends on: heart’s contractile force, peripheral vascular
resistance, and vascular volume.**
Blood vessel resistance
◦ Reduced elasticity of vessels (atherosclerosis) increases
BP
Age
◦ Elderly higher BP due to atherosclerosis
Gender
◦ Men and postmenopausal women, higher BP
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Factors Affecting Blood Pressure
 Blood volume
 Additional blood (transfusion) increases BP
 Reduction in blood (hemorrhage) decreases BP
 Blood viscosity
 Increased thickness causes heart to contract
more forcefully thus increasing BP
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Factors Affecting Blood Pressure
Blood pressure depends on: heart’s contractile force, peripheral vascular
resistance, and vascular volume.**
Blood vessel resistance
◦ Reduced elasticity of vessels (atherosclerosis) increases
BP
Age
◦ Elderly higher BP due to atherosclerosis
Gender
◦ Men and postmenopausal women, higher BP
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Blood Pressure Risks
Higher diastolic readings in people 50 or
younger at risk for heart attacks, strokes
(CVAs), and kidney failure.
Higher systolic readings in people 50 and
over can be at risk for hypertension, stokes
(CVAs), heart attacks (MI), heart failure,
kidney damage, blindness, and other
conditions.
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4 Classifications of BP Levels in Adults
Category
Systolic
Diastolic
Normal
<120
And
<80
Prehypertension
120 – 139
Or
80 - 89
Stage 1
Hypertension
140 – 159
Or
90 - 99
Stage 2
Hypertension
>160
Or
> 100
High Blood
Pressure
Case Scenario 1 Conclusion
•John Brown’s vital signs are significantly elevated. His pulse is 102.
Normal pulse range is 60-90 beats/min. His respirations are 22 and
exaggerated, whereas the normal RR is 12-20. His BP places him in stage
1 hypertension range. Taken in combination, this individual should be
referred to his physician for an examination prior to treatment.
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Case Scenario 2
Your 2:00 p.m. patient, Harry Fredericks, is a 62-year-old male postal
worker and is new to your practice. His history indicates daily intake of
hypertension medications, but he states that he does not like to take
them due to the side effects. Other than the hypertension, his medical
history is negative.
You take his blood pressure and find that it is 188/112 mmHg. His pulse
rate is 86 and his respiration rate is 16. What is the medical significance
of the information stated by the patient and the recorded blood
pressure?
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Hypertensive Emergency/Crisis**
 Symptoms – similar to MI or CVA – difficult to determine exact
emergency
– Sudden increase in BP >
180/110 often
as high as
220/140
– Dyspnea (labored breathing)
– Chest pain
– Dysarthria (difficulty
speaking)
– Weakness
–
–
–
–
–
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Altered consciousness
Visual loss
Seizures
Nausea/vomiting
Eventually coma
Hypertensive Emergency/Crisis
•
Treatment
 Treat quickly to reduce the blood pressure to prevent further
end organ damage like acute MI, aortic dissection, or CVA.
 Treating hypertension secondary
 Seat patient upright
 Contact EMS
 Monitor vital signs
 Administer O2 4-6L/minute
 In hospital setting pt given vasodilators, nitroglycerin.
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Case Scenario 2 Conclusion
•Harry Fredericks indicated that he has a history of hypertension, but is
noncompliant in the use of antihypertensives. His extremely high BP
and lack of any other form of target end organ damage should indicate
to the clinician that he is most likely suffering from hypertensive
urgency; however, the final determination on the diagnosis will be
performed in the emergency department. The clinician retook Harry’s
BP and determined it to be significantly elevated at 186-110mmHg.
Harry was seated upright, and EMS was contacted. Oxygen was
administered via nasal cannula at 4L/minute. Harry was treated in the
emergency room for hypertensive urgency and was given Captropril, an
angiotensin-converting enzyme inhibitor. He was administered the drug
orally, and within 30 minutes his BP had returned to a reasonable range.
After this experience Harry was convinced that his hypertension was a
serious concern and he took his antihypertensive medication as
prescribed.
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Hypotension
 Abnormal condition in which BP is not
adequate for perfusion and oxygenation of
body tissues
 Usually reduction in baseline systolic or
diastolic BP of 15 – 20 mmHg
 Often caused by medications (antihypertensive)
 Can lead to shock due to the sudden blood
pressure reduction.
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Hypotension
Treatment
◦Position supine with feet raised
◦Assess airway
◦Administer O2 4-6L/minute
◦Monitor vital signs
◦If no improvement, contact EMS
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Orthostatic Hypotension
•
Postural hypotension
•
Sudden drop in BP due to change in body position
•
Usually from supine to sitting or standing
•
Dizziness or loss of consciousness may occur
•
Etiologies
 Prolonged supine positioning
 Illness
 Medications (anti-hypertensive)
 Normally hypotensive individuals
Orthostatic Hypotension
•
Symptoms
 Dimming of vision
 Decreased hearing
 Lightheadedness
•
Treatment
 Position supine with feet raised
 Assess airway
 Administer O2 4-6L/minute
 Monitor vital signs every 5 minutes
 If no improvement, contact EMS
Board ?
If the mask becomes fogged when oxygen is delivered to a patient, it
indicates which of the following?
a. Flow meter is set too high.
b. Mask does not fit the patient correctly
c. Tank is empty, and no further oxygen is available
d. Patient has started breathing
D
`
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