Prevention is the most important phase of treating medical emergencies, despite all the efforts of prevention emergencies will still occur. An emergency is a medical condition that requires immediate treatment. Emergencies do occur in the dental offices. A survey of 4,000dentists conducted by Fast and others revealed an incidence of 7. 5 emergencies per dentist over a 10 year period. Here are three steps to prevent medical emergencies in the dental office: Medical History, Patient Evaluation, and Staff Training and Preparation. A patient’s medical history is very important in the office.
The medical history questionnaire given to all patients on their first visit is helpful in preventing emergencies in the office. It list some questions such as; Is the patient under the care of a physician? , Is the patient pregnant? , and so on. There is also another helpful tip for the medical history evaluation and it is called the Medical History Algorithm. I find it very neat to learn this. The Medical History Algorithm is really basic it gives the word SAMPLE an acronym. The meaning of the word SAMPLE is S-symptoms, A- allergies, M- medication, P- Previous History, L- last incident, and E- events leading to the problem.
Patient evaluation is very simple. We as dental assistants should automatically know to record vitals before the dentist completes the dental exam and as they are leaving the office take a visual inspection of the patient. Staff training and preparation is very important in the office. Staff must have the knowledge to identify and correctly manage each emergency. They should also have easy access to emergency equipment and drugs and have coordination of office personnel. The basic principle of managing all medical emergencies is BLS (Basic Life Support) and make sure that the staff remember the ABC’s.
Most importantly we should document everything that goes on in an emergency in the dental office. Airway obstruction is caused by a foreign body obstructed in the throat of the patient. Other causes could be blood, vomit, water, saliva in the mouth, and most commonly the tongue. The symptoms of airway obstruction are grasping for breath, patient may grab at throat and/or the patient may panic. If there is partial obstruction the patient may snore, gurgle, wheeze, and/or start crowing. However, if there is total obstruction there won’t be any noise coming from the patient at all.
When treating airway obstruction staff should know the proper techniques of the Heimlich Maneuver and CPR. In some cases of airway obstruction caused by a foreign body that can’t be dislodged it may be necessary to perform a surgical airway procedure but this procedure should only be done to adults due to the position of vocal chords in children. Only trained personnel should perform this procedure if there is a delay in the arrival of EMS. During hyperventilation a patient will be dizzy, shaking, trembling, have cold clammy hands, and have uncontrolled over-breathing.
In this case the patients respiration will increase to 25-30/minute. The patient will also have an increase in blood pressure and increase in heart rate. Hyperventilation can be managed. First the staff must discontinue treatment and remove all objects from the patient’s mouth. Next position the patient upright and assess airway. Reassure the patient and try to calm them. Have the patient breathe slowly into a paper bag or mask 6-10 time/minute. Most importantly the staff should monitor the patient’s vitals. Last, determine what precipitated the attack and then dismiss patient after all vitals have returned to normal.
In an asthmatic patient they will have symptoms such as: sense of suffocation, pressure or tightness in chest, expiratory/inspiratory wheezing, and expiration is prolonged and harder than inspiration. The symptoms of a severe asthma attack are; cyanosis of the nail beds, perspiration or flushing of the skin, and patient may also appear confused and agitated. In the case of an asthma attack the dental staff should discontinue treatment. Then place the patient in the easiest position for them to breath with their arms outstretched.
Make sure they take two puffs every two minutes from the albuterol inhaler. Give the patient supplemental oxygen at 10L/min. Most importantly monitor the asthmatic patients vital signs and if there aren’t any improvements call EMS. Some considerations for an asthmatic patient would be to take a good medical history prior to treatment; determine how often the patients has an asthma attack and precipitates it. Consider morning appointments and if the patient is using an inhaler have them to consider using it prior to treatment.
Before I illiterate more on what the symptoms are to acute adrenal insufficiency let me describe what AAI is first. The adrenal cortex produces over twenty-five different steroids. These steroids are broken into three groups: sex steroids, mineralocorticoids, and glucocorticoids. The primary concern in dentistry is the glucocorticoids. A physiologic dose of approximately 20mg/day of cortisol is produced; this plays a key role in the body’s ability to adapt to stress. Cortisol provides a chemical link within the cells of the body allowing regulation of vital functions including blood pressure and glucose utilization.
Cortisol production is triggered by real or threatened stress such as trauma, illness, fright, and anesthesia. In a patient with suppressed adrenal function a failure of this cortisol production eliminates the chemical link to regulate vital functions resulting in sudden shock and possibly death. Suppressed adrenal function or Adrenal Failure is classified as either Primary (Addison’s disease caused by TB, Bacteria, Carcinoma, and Amyloidosis) or Secondary (caused by Pituitary disorder, hypothalamic disorders, or Steroid Therapy).
Steroid therapy suppresses the function of the adrenal cortex reducing the production of natural cortisol. Due to this suppression, patients who have been on long term steroid therapy lose their ability to respond to stress. If these patients are stressed symptoms of acute adrenal insufficiency may occur. Now that we both have an understanding on what AAI is here are some of the symptoms: mental confusion, muscle weakness, fatigue, nausea/vomiting, intense pain in abdomen, lower back, and/or legs, hypoglycemia, and an increase in their heart while their blood pressure decreases.
Just like all other serious ailments that the patients have this to can be managed. The office staff should discontinue treatment and remove all objects from the patient’s mouth, initiate BLS and activate EMS. Staff should also monitor vital signs, give oxygen at 5-10L/minute and give Hydrocortisone 100mg IV or IM if available over 30 seconds. If patient is stable then the dose should be reduced to 50mg every 6 hours. For the patients with a history of glucocorticoid therapy the staff should use stress reduction protocols. These are the medical emergencies that could occur in the dental office.