Preparation for Medical Emergencies

The dental hygienist takes or updates the patient medical history, asking all the appropriate follow-up questions and recording vital signs. The physician is consulted when a question about a particular patient's status arises. The dental hygienist observes the patient carefully for signs of undetected medical problems and for signs of stress and anxiety. The appointment is planned using all medical information gathered. After every possible precaution has been taken, stress and anxiety management techniques are used and patient rapport is established. Despite all the best preventive efforts, a medical emergency can still occur, so it is critical that the entire office be prepared for any emergency that may arise. There may be an instance where an individual must maintain the life of the victim alone, and everything should be prepared for that eventuality. Therefore, every person in the office should be trained in basic life support (BLS). Having the necessary equipment and drugs, as well as a staff that responds appropriately, can mean the difference between a person's survival and death. Malamed suggests an accessible emergency kit, staff training, a team approach, and practice drills to keep the facility ready for any medical emergency.3

The emergency kit should consist of current medications likely to be needed for an emergency, an oxygen source, resuscitation mask or face shield and other devices, depending upon the type of practice. It is not necessary for the dental office to have the drugs, equipment and skill found in an emergency room, but it is necessary to have available all equipment that a reasonably prudent person would be expected to need and use in the type of practice carried out in a particular facility. McCarthy suggests that unless one is knowledgeable and skilled with various drugs and techniques, emergency efforts should be as basic as possible.1 The goal is for a living person to enter into the emergency medical system as quickly as possible. He suggests that overpreparation without experience may lead to treatment failure; the outcome may be the opposite of what the practitioner hoped to provide. The emergency kit need not be complicated since drugs are not necessary for immediate treatment of most emergencies. Malamed advises, that when one is in doubt, never medicate.3 One should remember that the primary management of all medical emergencies is BLS.

All oral health care personnel should know the location and contents of the emergency kit. Emergency drugs and equipment should be checked regularly for availablity and current date. The kit should be inspected routinely to verify that the equipment is functioning properly and that outdated drugs are replaced. The kit should be stored in an easy to access, convenient location.

Emergency kit drugs should include only what the dentist and staff are familiar with and able to employ. Epinephrine and an antihistamine injectable drugs are considered basic for most dental facilities. Oxygen and a vasodilator such as nitroglycerin spray are essential non-injectable drugs. A ready source of carbohydrate for treatment of hypoglycemic episodes also should be available. Equipment considered essential includes an oxygen delivery system, syringes with 18-to 21-gauge needles, suction and suction tips, and tourniquets (if intravenous drugs may be administered). Other emergency equipment may be added depending on the special training, knowledge, and expertise of the caregiver.

Training should consist of initial medical emergency education with periodic refreshers in medical emergency procedures and current certification in basic life support, including cardiopulmonary resuscitation. To be able to assist an individual in an emergency situation, one must first recognize an emergency has occurred, or is occurring, able to provide appropriate care until professional medical help arrives and be confident enough to take the steps necessary, calmly and automatically, so that appropriate decisions and other actions can be accomplished.

The team approach involves having assigned roles and backup roles in the event of an emergency. Dental facilities vary in how emergency duties are delegated based on the knowledge and strengths of the staff, but each person should fully understand his or her specific duties and responsibilities. Malamed suggests that, generally, two or three individuals should comprise the emergency team, with each having predefined responsibilities.3 The team leader bears responsibility for the actions of the team, initiates basic life support, and remains with the victim throughout the emergency unless relieved by another team member. The team leader is usually, but not always, the dentist. A second team member might assist with BLS as needed, monitor vital signs, be responsible for retrieving the emergency kit and oxygen, and prepare drug(s) for administration. A third team member may also assist with BLS, summon emergency medical services (EMS), and maintain a written record as events occur, including times. This written record will serve as an accurate record to assist EMS personnel and to reconstruct events if it becomes necessary at a later time. All personnel should be capable of joining the team at any point.

Some additional team duties suggested by Chernega, include notifying the dentist of the emergency, retrieving a hard backboard if cardiopulmonary resuscitation is required, or placing the victim on the floor, and assisting in preparation of drugs for administration.4

Updated emergency phone numbers should be posted in a prominent location close to the telephone. When making the phone call to activate EMS, the American Red Cross instructs the individual making the call to be prepared to give the following information:5

• exact address or location, including cross streets, landmarks, name of the building, the floor and room number;
• the telephone number from which the call is made;
• the caller's name;
• what happened;
• how many people are involved;
• the condition of the victim;
• and the care being given.

The caller should not hang up until instructed to do so by the dispatcher taking the call. Once the call is completed, the caller should report back to those caring for the victim. It is also advisable, especially if the facility is in a large office building or complex, for someone to wait outside the building to help guide EMS personnel to the emergency site.

Once everyone in the facility understands and can carry out their emergency responsibilities, emergency practice drills should be held to maintain readiness. An emergency situation can be simulated with drills, which should be unannounced. These will help each person know exactly what to do, and can help everyone automatically respond appropriately.

When a medical emergency or potential medical emergency occurs and is recognized, certain routine steps should be undertaken. Management for specific medical emergencies follows. Learning these is the first step in handling any emergency situation.

1. Send someone to call 911 or local emergency number when the emergency team leader feels it is necessary, or any time a life-threatening emergency becomes apparent. It is better to err on the side of caution.
   
   
2. Terminate any dental treatment in process.
   
   
3. Place the patient in the supine position unless he or she is experiencing respiratory difficulties and/or chest pain, in which case place in a semi-supine or upright position.
   
   
4. Maintain the airway; administer oxygen if indicated. The individual experiencing hyperventilation is the exception since this person should not receive oxygen.
   
   
5. Establish baseline vital signs: respiration, pulse, and blood pressure.
   
   
6. Perform cardiopulmonary resuscitation, if indicated.
   
   
7. Stay calm.
   
   
8. Take whatever specific steps are necessary for the condition being experienced.