Medical Emergencies In Dental Practice

Weinstock, ddsPrivate Practice Limited to Oral and Maxillofacial Surgery Guilford, ConnecticutClinical InstructorOral and Maxillofacial SurgeryYale-New Haven HospitalNew Haven, Connectic

Medical Emergencies in Dental Practice

Orrett E Ogle, ddsLecturer, Mona Dental ProgramFaculty of MedicineUniversity of the West IndiesKingston, JamaicaFormer Chief of Oral and Maxillofacial Surgery

Woodhull Medical CenterBrooklyn, New York

Harry Dym, ddsChairmanDepartment of Dentistry and Oral and Maxillofacial Surgery

The Brooklyn Hospital CenterBrooklyn, New YorkClinical ProfessorDepartment of Oral and Maxillofacial SurgeryColumbia University College of Dental Medicine

New York, New York

Robert J Weinstock, ddsPrivate Practice Limited to Oral and Maxillofacial Surgery

Guilford, ConnecticutClinical InstructorOral and Maxillofacial SurgeryYale-New Haven HospitalNew Haven, Connecticut

Medical

Emergencies in Dental Practice

Quintessence Publishing Co, IncChicago, Berlin, Tokyo, London, Paris, Milan, Barcelona, Istanbul, Moscow, New Delhi, Prague, São Paulo, Seoul, and Warsaw

Library of Congress Cataloging-in-Publication Data

Names: Ogle, Orrett E., editor | Dym, H (Harry), 1938- , editor |

Weinstock, Robert J.

Title: Medical emergencies in dental practice / [edited by] Orrett E.

Ogle,

Harry Dym, Robert J Weinstock.

Other titles: Medical emergencies in dental practice (Ogle)

Description: Hanover Park, IL : Quintessence Publishing Co, Inc., [2016]

LC record available at http://lccn.loc.gov/2015038602

The authors and the publisher of this work have made every effort to provide reliable information that can be used to aid treatment in gency situations However, emergencies, by their nature, are unpredictable and involve diverse variables Furthermore, changes in treatment technique and medical protocol evolve with new developments in research and clinical experience Thus, readers are encouraged to confirm the information contained herein with other sources, and they are advised to be aware of all pertinent governmental regulations and to review relevant manufacturer information prior to use of a product Finally, it is the responsibility of practitioners to use their best judgment and clinical expertise when treating their patients Neither the authors nor the publisher of this work guarantees that the information contained herein is in every respect accurate or complete

emer-© 2016 Quintessence Publishing Co, Inc

Quintessence Publishing Co Inc

Editor: Bryn Grisham

Design: Ted Pereda

Production: Kaye Clemens

Printed in the USA

1 Pretreatment Evaluation of the Dental Patient 1

2 Essentials of an Emergency Kit 9

3 Respiratory Emergencies 15

4 Acute Chest Pain 27

5 Syncope 44

6 Allergy and Anaphylaxis 51

7 Seizures, Epilepsy, and Stroke 69

8 Nausea and Vomiting 77

9 Hemorrhagic Emergencies 85

10 Emergencies in the Pregnant Dental Patient 103

11 Hypertension and Hypotension 112

It is imperative that every dentist in clinical practice be prepared to manage medical emergencies

that may arise during patient treatment It is true that clinicians can prevent many emergencies

by conducting a thorough medical history, making appropriate alterations to dental treatment

as required, and optimally stabilizing the patient’s medical condition when possible However,

despite all efforts at prevention, emergencies will occur It is therefore necessary that dentists have

a sound knowledge base as to how to manage medical emergencies that they may encounter The

ability to initiate effective primary management is the key to minimizing morbidity and mortality

In general, medical emergencies in dental practice are perceived as infrequent, but when an

emergency does occur, it can be life threatening, so the dental staff must be prepared The

preva-lence of medical emergencies in dental offices is unknown Estimates of the frequency vary widely

One report estimated that sudden cardiac arrest occurs in 1 in 638, 960 patients while at a dental

facility and that a severe life-threatening event occurs in 1 in 30,427 treated patients.1 Another

report from the State University of New York at Buffalo College of Dentistry found the incidence

of emergencies to be 164 events per 1 million patient visits.2 A third study reported a frequency

of 1 emergency in 3.6 to 4.5 practice years.3 The American Dental Association4 has estimated that

there are about 3,000 life-threatening medical emergencies a year in US dental offices

The best way to ensure effective management of a medical emergency is to be prepared in

advance During a medical emergency, the dentist is legally responsible for keeping the patient

alive until his or her condition improves or until the patient can be transported to a facility with a

higher level of care If the practice is in an isolated area, or a location that is difficult to access (for

example, because of heavy traffic or slow elevators), the dentist will be responsible for the patient

for a longer period of time The aim of this book is to arm clinicians with information that will

prepare them to effectively manage various medical emergencies

From the beginning, we created this book with the busy clinician in mind It was our goal

to produce a reference text that would be easy to read and understand and would present

effec-tive emergency management in a succinct, organized sequence Beneficial step-by-step treatment

guidelines and algorithms outline the steps and decision-making process for each emergency

med-ical situation In addition, we identified contributors with significant experience dealing with

medical emergencies as hospital-based dental practitioners Each chapter focuses on a distinct

physiologic system and the common related emergencies that practitioners may encounter We

think this book will be an ideal clinical reference because it is accessible and presents a systematic

approach of how to manage specific medical emergencies

vii

We recommend that clinicians read through the entire book to familiarize themselves with management of common medical emergencies Because emergencies are, by definition, unpre-dictable events that can happen to anyone at any time, the dental practitioner and office staff must

be prepared to provide primary management for any medical emergency without first turning to

a book Familiarity with common medical emergencies is therefore crucial Practitioners are also encouraged to review the contents of their emergency kits and become knowledgeable about the pharmacology and use of the key drugs that should be maintained in the kit

As editors, we are very enthusiastic about this book and the information it presents We hope you will find this text to be very useful in your clinical practice

Acknowledgments

This book is the brainchild of Dr Harry Dym and Lisa Bywaters, director of publications at tessence Publishing, who saw a need for an updated text on medical emergencies in dental prac-tice We are grateful for their foresight and cannot thank Lisa Bywaters enough for initiating this project and standing by it despite the obstacles along the way Special thanks is also due to senior editor Bryn Grisham, who spent nearly 2 years diligently working with us and providing encour-agement and valuable advice Credit is also due to Kaye Clemens for her production work and excellent assistance with our images and photographs, which were not always the best We also thank all of the contributors who gave of their time and shared their knowledge Finally, we most especially thank our family members from whom we took valuable time to work on this book

Contributors

Ida Anjomshoaa, dmd

Chief Resident

Division of Oral and Maxillofacial Surgery

The Brooklyn Hospital Center

Brooklyn, New York

Golaleh Barzani, dmd

Resident

Division of Oral and Maxillofacial Surgery

The Brooklyn Hospital Center

Brooklyn, New York

George Blakey, dds

Director of Oral and Maxillofacial Surgery

Residency Program

Distinguished Associate Professor

Department of Oral and Maxillofacial Surgery

School of Dentistry

University of North Carolina

Chapel Hill, North Carolina

Carolyn Dicus Brookes, md , dmd

Assistant Professor

Department of Otolaryngology and

Communication Services

Division of Maxillofacial Surgery

Medical College of Wisconsin

Milwaukee, Wisconsin

Earl Clarkson, dds

Director

Division of Oral and Maxillofacial Surgery

Woodhull Medical Center

Brooklyn, New York

Harry Dym, dds

ChairmanDepartment of Dentistry and Oral and Maxillofacial Surgery

The Brooklyn Hospital CenterBrooklyn, New York

Clinical ProfessorDepartment of Oral and Maxillofacial SurgeryColumbia University College of Dental Medicine

New York, New York

Roger I Grannum, dds

Division of Oral and Maxillofacial SurgeryWoodhull Medical Center

Brooklyn, New York

Leslie Robin Halpern, md , dds , p d , mph

Associate Professor and Program DirectorDepartment of Oral and Maxillofacial SurgeryMeharry Medical College School of DentistryNashville, Tennessee

Curtis Holmes, dds

Chief ResidentDivision of Oral and Maxillofacial SurgeryThe Brooklyn Hospital Center

Brooklyn, New York

Brooklyn, New York

Toni M Otway, md , facog

Obstetrics and GynecologyStaten Island HospitalStaten Island, New York

Brooklyn, New York

Schenectady, New York

Schenectady, New York

Prevention is the most important aspect of preparation for medical emergencies

The dental practitioner can prevent many emergencies by conducting a thorough

medical history, making appropriate alterations to dental treatment as required, and

optimally stabilizing the patient’s medical condition when possible This chapter

will discuss pretreatment assessments that are essential to ensuring that the dentist

can provide dental treatment that is also medically appropriate for each patient

Medical Assessment

A thorough initial medical evaluation to identify correctable medical

abnormali-ties and determine the residual risk is mandatory for all patients undergoing dental

treatment The preoperative evaluation is the foundation for minimizing

undesir-able outcomes; the clinician can use the assessment to identify and mitigate risk

factors and develop a plan that will best balance the risks, benefits, and alternatives

that are available

Routine preoperative evaluation will vary among patients, depending on their

age and general health In evaluating a patient for any interventional procedure, the

dental surgeon must consider two aspects: (1) the necessary work-up that must be

performed prior to treatment and (2) whether the patient can safely undergo the

planned dental or surgical procedure

PRETREATMENT EVALUATION OF THE DENTAL PATIENT

1

Medical questionnaire

The most efficient method of obtaining the medical history is to use a medical questionnaire The form should be detailed and comprehensive (Fig 1-1) All health questions must be answered Pertinent posi-tive answers must be addressed, and certain negative answers, such as allergies or bleeding history, must

be confirmed The patient should be verbally tioned about the severity and control of the disease

ques-All medications must be noted

Any medical condition that could affect dental treatment or that could be affected by dental treat-ment should be noted on the record treatment page under a section for past medical history If the condi-tion is critical (eg, allergies or heart conditions), the external portion of the chart should be flagged with

a sticker for medical alerts or annotated in red ink

Electronic records should also be flagged using the method available in the software system

Emergency telephone numbers should be nently posted on the health questionnaire For indi-viduals with serious illness, the name and telephone number of the primary care physician should also be obtained

promi-If there are serious health issues, the health history should be updated at every visit, and any changes

in the condition should be noted in the record The health history must be dated and signed by the patient

or parent/guardian and the dentist Failure to sign the form may imply that the dentist did not review it

A detailed medical history will identify potential management problems (physiologic and pharmaceuti-cal) and allow the dental surgeon to formulate a treat-ment plan in light of the medical status A patient may present with one or multiple established medical diag-noses, which may alter how dental care is delivered

The role of the dentist is to determine how these ical problems will influence care or how dental care may affect medical treatment Medical illness may pre-dispose the patient to acute physiologic decompensa-tion under stress or failure to do well posttreatment, or

med-it may lead to drug interactions The dentist must be aware of potential results and what precautions must

be taken to minimize risks Clinicians must identify issues that should be addressed prior to treatment (eg, insulin, warfarin, or aspirin use), illnesses that may cause physiologic decompensation during treatment (eg, angina, seizure disorders, or asthma), and condi-

tions that may affect the posttreatment phase (eg, betes [infection and delayed wound healing] or aspirin use [impaired hemostasis]).1

dia-Medications

The patient’s medical record must list all drugs that the patient is currently taking The dentist should know what each drug is and why it is being used Information on drugs can be obtained very quickly from programs downloaded to smartphones or lap-top or tablet computers Some available apps are Epocrates (Athenahealth), Davis Drug Guide (Un-bound Medicine), Pocket PC drug guide (Softonic), and Drugs.com medication guide (Drugs.com).The dentist should pay special attention to side effects associated with the patient’s medications, be-cause some side effects may affect dental treatment For example, heart medications, blood pressure drugs, sedatives, muscle relaxants, and other medi-cations may contribute to bladder control problems Patients taking these drugs need to urinate frequently and will not be able to tolerate long appointments Pregabalin (Lyrica, Pfizer), thiazides, all diuretics, and carbonic anhydrase inhibitors are other drugs that will cause frequent urination and urgency.Another common medication side effect that im-pacts dental care is xerostomia More than 500 drugs can cause xerostomia Medication use is the most frequent cause of xerostomia complaints, especially among the elderly.2 Xerostomia can affect the com-fort of removable prostheses, cause angular cheilitis, and promote candidal infections

Medical consultation

Medical consultations are necessary when diagnostic medical questions are present or when the patient has medical problems that are beyond the dentist’s knowledge base The dentist should ask the consul-tant at least these basic questions:

• Is the patient in optimal condition to undergo routine dental treatment in an office setting?

• Does the patient have reversible disease?

• Where is the patient in the continuum of disease?

Home phone _ Cell phone _

Work phone Email

Date of birth Sex M □ F □

Marital status _ Occupation

Emergency contact _ Phone

If someone other than the patient is completing this form, indicate name and relationship to the

patient

1 Are you in good health? □ YES □ NO

2. Has there been any change in your general health within the past year? □ YES □ NO

3. Months since your last physical examination: _

4. Are you under the care of a physician(s)? □ YES □ NO

If yes, provide name and phone number of physician(s):

5. Have you ever had any serious illness, operation, or been hospitalized in the past? If so,

when and what was the illness or problem?

6. List all medications, including the doses that you are currently taking (include

over-the-counter medications and herbal remedies):

7. Check the appropriate box(es) if you are allergic to or had a reaction to the following:

□ Local anesthetics

□ Aspirin □ Pain medications (codeine, NSAIDs, narcotics)

□ Penicillin or other antibiotics

□ Organ transplantation (heart, kidney, lung, bone, etc)

□ Stroke

□ Diabetes

□ Kidney disease

□ High blood pressure

□ Low blood pressure

□ Asthma

□ Chronic obstructive pulmonary disease (COPD)/emphysema

PRETREATMENT EVALUATION OF THE DENTAL PATIENT

1

□ Inflammatory bowel disease (Crohn disease, ulcerative colitis)

□ Blood disease/disorder (hemophilia, anemia, sickle cell disease)

9. Have you ever had radiation treatment? □ YES □ NO

If yes, to what part of your body and when?

10. Have you ever been treated with bisphosphonates, such as Zometa, Aredia, Actonel, Fosamax, or Boniva? □ YES □ NO

11. Are you taking or have you ever taken any steroid medications? □ YES □ NO

If yes, what medication and when? _

12. Is there any other disease, condition, or problem with your health that we should know about?

13. Do you drink alcohol? □ YES □ NO If yes, how many drinks per week? _

14. Have you ever smoked cigarettes? □ YES □ NO

If yes, how many packs per day and for how many years? Year stopped smoking:

15. Do you chew tobacco? □ YES □ NO

16. Do you use recreational drugs? □ YES □ NO

Type/frequency: _

Women only: 17 Are you pregnant? □ YES □ NO 18 Are you nursing? □ YES □ NO

I have read and understood the above questions Questions I may have had about this form have been answered by the staff to my satisfaction I will not hold my dentist or any member of the staff responsible for errors or omissions that I may have made in the completion of this form.

Signature of patient or guardian Date

FOR COMPLETION BY THE DENTIST

Significant findings/alerts concerning the medical history: Dental/medical management considerations: Physician consults: Dentist’s signature Date

(Fig 1-1 cont)

Symptoms with everyday living activities,

ie, moderate limitation

Severe limitation of physical activity; inability to perform any activity without angina or angina

at rest

CLASS I CLASS II CLASS III CLASS IV

Fig 1-3 Canadian Cardiovascular Society classification of angina pectoris (Modified from the Canadian Cardiovascular Society 4

with permission.)

ASA 1 Normal healthy patient

Patient with mild systemic disease

Patient with severe systemic disease

Patient with severe systemic disease that is a constant threat to life

Moribund patient who is not expected to survive without the operation

Declared brain-dead patient whose organs are being removed for donor purpose

Added to ASA classification to denote an emergency case (eg, ASA 4E)

Simply sending a request asking a physician to

“clear a patient” for a dental procedure is likely to

yield an equally uninformative response of “patient

cleared” and must be avoided.1 Even when a

physi-cian states that a patient is medically cleared, the final

decision regarding treatment is the responsibility of

the dental surgeon A medical consultation is simply

a tool for risk assessment and is not a “green light” to

the dentist indicating that all will be well

Risk Analysis

A useful step in patient assessment is to assign an American Society of Anesthesiologists (ASA) physical status classification (Fig 1-2).1 This will inform the dental team of the degree of risk the patient’s physical ailments constitute Figure 1-3 and Table 1-1 pro-vide further classification strategies1,4 for patients who have cardiac disease Nondisease factors that are not listed in the ASA classification but that must be regarded as an additional risk are extreme age (more than 80 years), increased body mass index, and preg-nancy that is close to the estimated date of delivery.1

PRETREATMENT EVALUATION OF THE DENTAL PATIENT

1

TABLE 1-2 Approaches to patient evaluation based on medical history*

Suggested preoperative evaluation

Allergies Determine if the patient has allergies to drugs or latex.

Asthma Emotional factors may trigger an attack Evaluate wheezing and do not initiate dental treatment if the

patient is wheezing Have a rescue inhaler available Do not prescribe NSAIDs or aspirin for pain.

Cerebrovascular disease

Evaluate the patient’s blood pressure Do not undertake elective oral surgery within 9 months of the cerebrovascular accident Stroke patients usually take anticoagulation therapy Review the method of anticoagulation and obtain the most recent INR from the patient’s physician.

Chronic obstructive pulmonary disease

Only the most severe respiratory compromise is a contraindication to routine outpatient dental or oral and maxillofacial surgical care with local anesthesia Determine the patient’s functional capacity (should

be able to walk one or two blocks on level ground at 2 to 3 mph and climb a flight of stairs) Do not perform long or extensive surgical procedures and do not administer 100% oxygen.

Coagulopathy Consult a hematologist for individuals with definitively diagnosed coagulopathies In the absence of a

history of bleeding diathesis, abnormal bleeding following exodontia is rare, and obtaining prothrombin time or partial thromboplastin time is not indicated

Coronary artery disease

Stratify the patient’s condition based on symptoms and the exercise capacity by the history Determine the patient’s functional capacity (should be able to walk one or two blocks on level ground at 2 to 3 mph; climb a flight of stairs; and do light housework) Patients that can perform these functions are at low risk for cardiac decompensation during oral surgery (see Table 1-1).

Diabetes mellitus

Diabetes is only associated with higher perioperative risks in vascular surgery and coronary artery bypass grafting Dental treatment poses no problem for patients with well-controlled diabetes Review symptoms such as excessive thirst, nocturia, malaise, and hunger to assess the level of control.

Epilepsy Patients with well-controlled epilepsy are no different from the average patient Review the patient’s

compliance with therapy.

TABLE 1-1 Cardiac stratification*

Heart disease to be treated

in a hospital setting

Heart disease that may be treated

in an office setting

Myocardial infarction

Angina pectoris Unstable or severe (Class III or IV) † Mild (Class I or II) †

Heart failure Decompensated heart failure (Class III or IV;

ejection fraction < 30%) Compensated or prior heart failure (Class I or II)

Other Significant arrhythmias Low functional capacity (eg, inability to walk

three city blocks)

Dental Treatment Strategy

Delay surgery if possible; consult with cardiologist Determine the patient’s functional capacity

*Modified from Petranker et al 1 with permission.

† See Fig 1-2.

Suggested preoperative evaluation

Hypertension For stages 2 and 3, delay nonemergency treatment until blood pressure can be controlled For these

patients, only emergency procedures (eg, treatment of infection) should be performed.

Stage 1 (140–159/80–99 mm Hg): Minimal risk of cardiac complications.

Stage 2 (160–179/100–109 mm Hg): Moderate risk of cardiac complications.

Stage 3 (>180/>110 mm Hg): High risk of cardiac complications.

Liver disease Screen for hepatitis B and C Treatment for hepatitis C with Harvoni (Gilead Sciences) does not produce

any significant side effects Patients taking interferon for hepatitis C virus will be anemic and easily fatigued, and their platelet counts may be low Chronic severe liver disease may increase the INR Check the history of ethanol usage.

Medication The medication history will indicate what conditions the patient is being treated for and the severity of

those conditions Avoid drug interactions.

Renal

insufficiency

Consult with a nephrologist if the patient’s history is inadequate Compensated renal disease is not

a contraindication to in-office oral surgery, and simple tooth extraction under local anesthesia is generally not a problem For patients undergoing dialysis, perform oral surgery on a nondialysis day

to avoid problems with anticoagulation In an emergency, treat the patient more than 4 hours after dialysis Do not use penicillin with potassium (penicillin VK), because potassium is difficult to eliminate

by dialysis and may cause changes in the patient’s electrocardiogram.

* Modified from Petranker et al 1 with permission

NSAID, nonsteroidal anti-inflammatory drug; INR, international normalized ratio.

The dental practitioner must emphasize risk

reduc-tion strategies and find a balance between the risks

and benefits of performing an oral procedure The

risk-benefit ratio must always stay in the patient’s

favor The clinician should also consider alternative

approaches and when it is appropriate not to perform

any intervention

The first step in risk mitigation is to ensure that

the patient is in as healthy a condition as

pos-sible Table 1-2 outlines an approach for

evaluat-ing patients dependevaluat-ing on the answers provided in

the medical history.1 Disease that can be reversed,

should be.1 Patients at risk for cardiovascular disease

who are not currently under medical care should

be evaluated by an internal medicine specialist for

disease and managed medically before dental

treat-ment is initiated At-risk patients include elderly

patients; patients with long-standing diabetes,

hy-pertension, or dyslipidemia; and patients with a

history of smoking, previous myocardial infarction,

or angina Figure 1-4 presents an algorithm for treament evaluation and classification of the dental patient to determine when to continue with routine dental care, modify treatment, or refer for medical consultation

pre-Conclusion

The dentist can prevent many emergencies by pleting a thorough pretreatment assessment to iden-tify the risks associated with treatment for each pa-tient The assessment begins with a medical history questionnaire, including an investigation of all medi-cations the patient is taking When necessary, the patient’s physician or medical specialists should be consulted prior to treatment Classifying the patient’s health enables the dentist to alter the treatment plan

com-as required and optimally stabilize the patient’s cal condition prior to dental treatment

medi-(Table 1-2 cont)

PRETREATMENT EVALUATION OF THE DENTAL PATIENT

1

References

1 Petranker S, Nikoyan L, Ogle OE Preoperative ation of the surgical patient Dent Clin North Am 2012;56:163–181.

evalu-2 Porter SR, Scully C, Hegarty AM An update of the ology and management of xerostomia Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:28–46.

eti-3 American Society of Anesthesiologists ASA physical status classification system Last approved October

15, 2014 information/asa-physical-status-classification-system Accessed March 3, 2015

http://www.asahq.org/resources/clinical-4 Canadian Cardiovascular Society Grading of gina pectoris http://www.ccs.ca/images/Guidelines/ Guidelines_POS_Library/Ang_Gui_1976.pdf Accessed March 13, 2015.

an-Fig 1-4 Algorithm for pretreatment evaluation and classification of the dental patient MI, myocardial infarction; UA, unstable angina; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease.

*At-risk conditions

• Uncontrolled hypertension

• MI in last 9 months or UA

• CHF with exercise tolerance

of less than two flights of stairs

• Cerebrovascual accident in last 6 months

• COPD with exercise tolerance of less than two flights of stairs

Modify dental care

If disease is poorly controlled or risk factors are significant*

If ASA 2, 3, 4

Take blood pressure and pulse;

perform full head and neck exam

1 Patient completes medical history form

2 Dentist reviews medical history

If ASA 1 ASA class (see Fig 1-2)Assign patient an

If disease is controlled and risk factors are minimal

Expand medical history and evaluate for disease control and risk factors

Curtis Holmes, dds

Harry Dym, dds

Opening a private dental office can be a complicated task for a new general

den-tist Aside from the known clinical responsibilities, the practitioner faces

numer-ous nonclinical areas of concern, including patient billing, accounting, insurance,

infection control, and appointment scheduling A critical area that is often

over-looked is preparation for a medical emergency

Medical emergencies are unexpected and infrequent, but dentists are expected to

have the ability to diagnose and treat medical emergencies Dentists are often held

legally responsible for any unfavorable outcomes resulting from mismanagement

of those medical emergencies The ability and preparation of the clinician and

staff to respond to an emergency play a key role in potential outcomes Therefore

strategic planning for the management of medical emergencies in the dental office

should be forefront in the mind of professionals starting a new office In

addi-tion, established practitioners must ensure that the office remains ready to respond

promptly and efficiently to such events

Considering that dentists treat numerous patients who are taking multiple

medi-cations for underlying medical conditions and the fact that the dental office can be

a stressful environment for some patients, it is not surprising that medical

emer-gencies may arise Some of the commonly encountered medical emeremer-gencies in

the dental office include adverse drug reactions, altered mental status, shortness

of breath, chest pain, diabetic complications, and seizures This chapter focuses

solely on the policies, equipment, and personnel needed to prepare for

manage-ment of emergencies, should they occur Diagnosis and managemanage-ment of specific

medical emergencies are covered in subsequent chapters Detailed discussion of the

pharmacology of the drugs used, the techniques, and the underlying physiology is

readily available elsewhere.1,2

Essentials of an

Emergency Kit

ESSENTIALS OF AN EMERGENCY KIT

2

Staff Preparation

To successfully prepare for medical emergencies, dental professionals must formulate policies and an emergency protocol The core of the emergency plan

is having the dental office team certified and pared to provide basic life support and seek emergen-

pre-cy medical services in an efficient and timely manner

All office personnel should have specific ties in the event of an emergency Front office staff should have emergency telephone numbers read-ily available Establishing a code word that informs the staff of an emergency and elicits the appropriate emergency response is beneficial.3

responsibili-Mock emergencies should be performed regularly

so that the staff will respond appropriately should the need arise It is recommended that the mock emergencies be unannounced and occur quarterly or semiannually

Office Equipment

Dental offices should be prepared and equipped to provide basic airway management to a patient in need (Fig 2-1) Oxygen is a key component in a medical emergency, and office personnel should be able to ad-minister 100% oxygen through a portable source (E cylinder; see Fig 2-2) The office should have devices that allow supplemental oxygen administration to both the conscious and unconscious patient Oxygen can be delivered via a nasal cannula, face mask, or face mask with reservoir Nasopharyngeal and oro-pharyngeal airway devices can be useful adjuncts to overcome airway obstruction (see Fig 2-3) Dental professionals must frequently check to ascertain the status of the oxygen tank, even if multiple backup tanks are present.3

Equipment that allows the monitoring and ment of a patient’s vital signs is useful to have Ideally,

assess-Basic emergency armamentarium

(all offices) Additional equipment (advanced)

• Bag-valve-mask device with oxygen reservoir

• Portable oxygen system (E cylinder size; Fig 2-2)

• Nasopharyngeal and oropharyngeal airways (Fig 2-3)

• Automated external defibrillator (Fig 2-4)

• Sphygmomanometer (child- and adult-sized cuffs)

• Yankauer suction tip

• Normal saline 0.9% (1,000-mL bags)

Fig 2-1 Emergency equipment for the dental office.

Fig 2-2 Type E oxygen cylinder. Fig 2-3 Nasopharyngeal and oropharyngeal

airways.

Emergency Drugs

a stethoscope and sphygmomanometer (with child-

and adult-sized cuffs) should be considered basic

emergency equipment in the dental office If possible,

automated vital sign monitors can be used to assess

heart rate, blood pressure, and oxygen saturation

An automated external defibrillator (AED) should

be present in the office (see Fig 2-4) The AED

elimi-nates the need for training in rhythm recognition

but it does require that the dentist and key staff be

trained in its use by participating in the American

Heart Association’s basic life support course

If the office personnel have advanced training,

pro-vide intravenous sedation, or are proficient in

veni-puncture, a few other items should be a part of the

emergency armamentarium (see Fig 2-1) Offices with

this level of training should have tourniquets, alcohol

gauze, angiocatheters, and an assortment of syringes

and needles Intravenous fluids (normal saline 0.9%

and dextrose 50% in water) should also be available.3The emergency kit, like the oxygen tanks, should

be checked and updated regularly

Emergency Drugs

In addition to the armamentarium previously cated, general dentists and dental specialists should develop an emergency kit stocked with key resus-citation drugs (Box 2-1 and Fig 2-6) Those offices providing intravenous sedation will certainly have more comprehensive emergency drugs available

indi-Emergency medications should be checked regularly, and replacement drugs should be ordered before the expiration dates approach

Fig 2-4 Automated external brillator. Fig 2-5 Magill forceps and

defi-laryngoscope.

Fig 2-6 Emergency drug kit.

BOX 2-1 Basic emergency drugs

ESSENTIALS OF AN EMERGENCY KIT

2

Oxygen

Hypoxemia is a common occurrence associated with many medical emergencies, making delivery

of supplemental oxygen of primary importance

Multiple routes are available for delivery of oxygen;

however, the authors believe that all offices should have a bag-valve-mask device (Ambu bag, Ambu) and a full-face mask to allow the dentist to provide positive-pressure ventilation should the need arise (Fig 2-7)

Aromatic ammonia

Syncope is a common medical emergency in the dental office Aromatic ammonia is a general arousal agent indicated for use in these situations (Fig 2-8) It should be cracked or crushed, allowing the release of

a noxious odor that stimulates the respiratory and somotor centers of the medulla This agent, in com-bination with supplemental oxygen and placing the patient in the Trendelenburg position, causes most patients to return to consciousness

va-Aspirin

It is recommended that patients experiencing chest pain suggestive of ischemia or any other symptoms

of an acute myocardial infarction (heart attack) chew

an aspirin A non–enteric-coated aspirin (325 mg), chewed for 30 seconds and then swallowed with water, is thought to have rapid and then sustained anticoagulative effects Caution should be used in ad-ministering aspirin to patients with severe bleeding disorders or allergies to aspirin

Albuterol

Bronchodilators are the lead drug groups used for the treatment of acute wheezing and bronchospasm sec-ondary to asthma attack Selective β2-agonists cause bronchial smooth muscle relaxation Albuterol is the most selective of the β2-agonists, and it is available in

a metered dose inhaler Albuterol also has fewer side effects than other bronchodilators

Glucose

Some preparation of oral hypoglycemic agents should

be present in the office to increase blood glucose els in patients suffering from hypoglycemia Offices should store a simple sugar source such as fruit juice, cola, or candy for the conscious patient Oral for-mulations of glucose should never be administered if the patient is unconscious, because of the potential risk of aspiration If the patient cannot swallow and the dentist has or can obtain intravenous access, dex-trose 50% in water should be administered by any intravenous route (Fig 2-9) Alternatively, injectable glucagon is available (Fig 2-10)

lev-Nitroglycerine

Nitroglycerine is a vasodilator recommended for relief

of acute chest pain in patients who have a past tory of angina It is also used in patients with undi-agnosed angina with symptoms of myocardial infarc-tion Nitroglycerin is available in many forms, but in the dental office setting the 0.4-mg metered aerosol and sublingual tablet are most often used The aerosol form does not require special storage and has a longer

his-Fig 2-7 Bag-valve-mask device. Fig 2-8 Ammonia ampule.

shelf life than the tablet form, which requires storage

in light-resistant containers Common side effects of

nitroglycerin are headaches, dizziness, and flushing

Nitroglycerine should not be administered to patients

taking drugs prescribed for erectile dysfunction

Epinephrine

Epinephrine is a sympathomimetic drug that acts on

α-adrenergic and β-adrenergic receptors The

pri-mary effects of epinephrine include bronchodilation,

vasoconstriction, increased heart rate, myocardial

contractility, and cerebral blood flow, along with

sta-bilization of mast cells (involved in severe allergic

re-actions.) The effects make epinephrine useful during

severe bronchospasm, cardiac arrest, and anaphylaxis

Diphenhydramine

Diphenhydramine is a histamine blocker used to

reverse the effects of mild or delayed-onset allergic

reactions It is available in oral and parenteral forms

Injectable drugs

Dentists with advanced training and specialists

pro-viding intravenous sedation should maintain

supple-mental injectable drugs with the other emergency

medications present in the office Supplemental

in-jectable drugs include, but are not limited to,

anal-gesics, anticholinergics, anticonvulsants,

antihyper-tensives, corticosteroids, vasopressors, and reversal

agents The speed of drug action is increased when

drugs are injected into the vascular system During a

medical emergency, it may be difficult to obtain travenous access, and either intramuscular or intraos-seous routes of administration may be beneficial

in-Each of these routes of administration requires skill, and therefore which route to use is at the dentist’s discretion

Protocol Tips

The emergency kit and medications, along with gen, should be placed in an area that is readily ac-cessible to personnel in the event of an emergency (Box 2-2) Table 2-1 lists common emergency medi-cal situations and the drug or device from the emer-gency kit that should be used

oxy-Fig 2-9 Dextrose 50%

in water emergency kit. Fig 2-10 Glucagon kit for treatment of low blood sugar.

Protocol Tips

BOX 2-2 Tips for rendering emergency care

• Hold frequent (semiannual or quarterly) emergency drills in which every staff member’s role is detailed.

• Store all emergency drugs and equipment in easily accessible area.

• Perform an annual review to check for drug expiration dates and the level of the oxygen tanks.

• Develop “cheat sheets” for what procedure to follow based on the nature of the emergency.

• Have the telephone numbers of emergency personnel

or local volunteer ambulance service readily available.

• Patient emergencies can occur in the office waiting area, so have airway equipment that is mobile and easily transferable rather than fixed to a room.

ESSENTIALS OF AN EMERGENCY KIT

2

Conclusion

For a dentist, competence in handling medical gencies is just as important as proficiency in the den-tal procedures performed in the office It is essential that dental professionals and office staff have the ability to recognize a dental emergency and respond accordingly Unfamiliar challenges along with the stress of the potential consequences can potentially impair anyone in the midst of an emergency It is good practice to formulate “cheat sheets” listing the type of emergency and the appropriate actions to

emer-be taken by the doctor and staff A well-maintained emergency armamentarium, knowledge of the prop-

er equipment and medications used during a medical emergency, and proper training and emergency sim-ulations are invaluable keys to effective management

of such emergencies

References

1 Dym H Stocking the oral surgery office gency cart Oral Maxillofac Surg Clin North Am 2001;13:103–118.

emer-2 Saef SN, Bennett JD Basic principles and tion In: Bennett JD, Rosenberg MB (eds) Medical Emergencies in Dentistry Philadelphia: Saunders, 2002:3–60.

resuscita-3 Dym H Preparing the dental office for medical gencies Dent Clin North Am 2008;52:605–608.

emer-TABLE 2-1 Treatment of emergency medical situations with the emergency kit

Adrenal insufficiency

Allergic reaction Urticaria; erythema; rhinitis; conjunctivitis Antihistamine

Anaphylaxis • Marked upper airway (laryngeal) edema and bronchospasm; low

blood pressure and collapse (can cause cardiac arrest)

• Respiratory arrest leading to cardiac arrest

• Epinephrine

• Oxygen

Angina pectoris Chest pain or pressure; sweating; shortness of breath • Nitroglycerine

• Oxygen

Asthma Difficulty breathing; wheezing; coughing; shortness of breath;

Progressing crushing pain in the center and across the front of chest; shortness of breath

• Nitroglycerine

• Aspirin

• Oxygen

• Automated external defibrillator

Seizure Sudden loss of consciousness; jerking movements of the limbs;

tongue may be bitten

Oxygen

Syncope Feeling of faintness, dizziness, or lightheadedness; pallor and

sweating; loss of consciousness; slow pulse rate; low blood pressure

• Oxygen

• Vaporable aromatic ammonia

Only the most severe respiratory compromise is a contraindication to routine

out-patient dental and/or oral maxillofacial treatment with local anesthesia Such

pa-tients can be screened by the medical history and treated in consultation with their

physician Regardless, respiratory emergencies can be the most dangerous that the

dentist may encounter because they can result in rapid loss of consciousness and

death The most significant respiratory emergencies that the dentist has to manage

in the nonanesthetized patient are:

• Foreign body obstruction

• Hyperventilation

• Asthma

• Respiratory arrest

• Problems related to chronic disease such as chronic obstructive pulmonary

disease (COPD) and heart failure

In the anesthetized patient, additional respiratory emergencies would include:

• Airway obstruction

• Laryngospasm

• Bronchospasm

• Aspiration

Understanding the best precautions to prevent airway emergencies as well as

be-ing prepared to manage them is an important part of the role of clinicians and health

care providers The most important part of planning for a medical emergency is to

try to prevent one from ever occurring However, despite best efforts at prevention,

respiratory emergencies are unpredictable, and when they occur, they are dangerous

Respiratory

Emergencies

RESPIRATORY EMERGENCIES

3

Foreign Body Obstruction

Choking is the physiologic response to sudden way obstruction The obstruction may be partial or complete Choking due to inhalation of a foreign body in the dental office is most likely to occur dur-ing anterior or maxillary tooth extraction or when working with implant abutments, crowns, orthodon-tic brackets, or even endodontic instruments

air-An aspirated foreign body may lodge in one of three anatomical sites: the larynx, trachea, or bron-chus (Fig 3-1) From 80% to 90% become lodged

in the bronchi, usually in the right main bronchus because of its lesser angle of convergence compared with the left bronchus (Fig 3-2) and the location of the carina left of the midline Larger objects like teeth tend to become lodged in the larynx or trachea A large foreign body lodged in the larynx or trachea can produce complete airway obstruction When a for-eign body enters the airway of a patient during treat-ment, the patient reacts immediately with coughing

in an attempt to expel the object

As soon as a foreign body enters into the airway, the dentist should rapidly assess the severity of the obstruction With mild obstruction, the patient is able to breath, cough effectively, and speak Severe obstruction is indicated by:

• Wheezing

• Ineffective cough or no cough

• Inability to breathe or speak (Clutching the neck with the hands is considered the universal sign of choking.)

• Cyanosis (the nail beds and lips turn blue) if there is an inability to move air

• Diminishing conscious level (particularly in children)

• Unconsciousness

Management

For a mild obstruction, the dentist should instruct the patient to lean forward and continue spontane-ous coughing so that the obstructing object can come out of the mouth The dentist should not interfere with attempts by the patient to dislodge the foreign body but should stay with the patient until the for-eign body has been expelled and monitor for any deterioration in condition A spontaneous cough is more likely to expel the object and is safer than any maneuver that the dentist might perform In cases where the patient is unable to dislodge the foreign object, the patient should be referred to an otolar-yngologist for therapeutic bronchoscopy for foreign body removal

Fig 3-2 Tracheobronchial tree showing lesser angle of vergence of right main bronchus

con-Fig 3-1 Site of obstruction and clinical symptoms.

Coughing, unilateral wheezing, and decreased breath sounds

For a severe obstruction, management steps are

covered for a conscious patient in Fig 3-3 and for an

unconscious patient in Fig 3-4

Complete obstruction of the airway is a

life-threatening emergency and must be addressed

with urgency In complete airway obstruction, the

patient is unable to make sounds or breath After a

few minutes of complete airway obstruction, the

pa-tient becomes cyanotic followed by bradycardia,

hy-potension, and irreversible cardiovascular collapse If

it is impossible to open the airway with a jaw-thrust

maneuver and ventilate with a bag-valve mask, then

a surgical airway must be established immediately

In this situation, cricothyrotomy (a procedure that

involves placing a tube through an incision in the

cricothyroid membrane to establish an airway) is the

surgical intervention of choice to reestablish airflow

by fitting a 10-mL plastic syringe (with the plunger removed) and then inserting the connection piece of

a 7.0- or 7.5-mm endotracheal tube into the barrel

of the syringe

If the patient is able to stand: If the patient is unable or unwilling to stand:

1 Ask the patient to stand; it is easier to work with a standing

individual.

2 Stand behind the person and slightly to the side

3 Support the chest with one hand and lean the victim forward (so

that the obstructing object can come out of the mouth).

4 Give up to five back blows between the shoulder blades with

the heel of the hand, checking after each blow to see if the

obstruction has been relieved.

5 If unsuccessful, stand behind the victim (who is leaning forward),

put both arms around the upper abdomen, clench one fist,

grasp the fist with the other hand, and pull sharply inwards and

upwards to give up to five abdominal thrusts.

6 Continue alternating five back blows and five abdominal thrusts

until successful or the patient becomes unconscious (see Fig 3-4).

1 Incline the chair with the head down.

2 Place the patient on the left side with the right arm over the chair arm.

3 Attempt five back blows with the heel of the hand, aiming the blow upwards.

4 If unsuccessful, roll patient into a supine position and perform five abdominal thrusts

5 Continue alternating five back blows and five abdominal thrusts until successful

or the patient becomes unconscious (see Fig 3-4).

Fig 3-3 Management of a conscious patient with a severe obstruction.

Lower the patient to the floor if possible If not, raise the chair arm and place the patient in a supine position Be sure that the chair arm will not interfere with effective chest compressions.

Have an office staff member call EMS and an ambulance (9-1-1).

Begin CPR, even if a pulse is present in the unconscious choking victim.

Hyperextend the patient’s neck to bring the larynx and cricothyroid membrane into the extreme anterior position.

membrane between the cricoid and thyroid cartilages by feeling for the depression below the midline of the Adam’s apple see (Fig 3-6a).

povidone-iodine solution or with alcohol swabs.

(see Fig 3-6b, yellow dotted line).

incision through the skin, use a mosquito hemostat to quickly open up the surgical site.

incision through the cricothyroid membrane

to fall into a hollow space

(see Fig 3-6b, red dotted line).

6.

Once the scalpel has passed through the membrane into the trachea, use a curved hemostat

to open a space between the cricoid and thyroid cartilages

The handle of the scalpel may also be inserted into the opening and twisted to further open the space—but be careful not to get injured by the blade.

mm through the incision into the trachea Insert the largest tube that will enter through the incision site.

the lung sounds to be sure that the tube is in the trachea and oxygen is going into the lungs

9.

Fig 3-5 Steps for performing open cricothyrotomy.

Open cricothyrotomy

Hyperventilation is a sustained abnormal increase in

breathing that can occur with anxiety or panic

Dur-ing hyperventilation, the rate of removal of carbon

dioxide from the blood is increased As the partial

pressure of carbon dioxide in the blood decreases, the

individual develops respiratory alkalosis The

respira-tory alkalosis causes constriction of the small blood vessels that supply the brain Reduced blood supply

to the brain can cause a variety of symptoms, such

as light-headedness; tingling in the lips, hands, or feet; weakness; fainting; and seizures Continuous, severe hyperventilation can cause a transient loss of consciousness, and any loss of consciousness in the dental office should be considered an emergency

Hyperventilation

Position the patient supine

with the neck extended.

cricoid cartilage, and cricothyroid membrane (see Fig 3-6a)

epinephrine 1:100,000 into the skin and through the cricothyroid membrane into the trachea to suppress the cough reflex.

3.

Use the index finger of the

nondominant hand to locate the

cricothyroid membrane Keep the

finger on the membrane.

the 14-gauge needle attached to

a syringe filled with normal saline below the finger and through the cricothyroid membrane, directing

it inferiorly at a 45-degree angle (see Fig 3-8b)

syringe as the needle is advanced

Air bubbles will appear in the fluid-filled syringe when the needle enters the trachea.

6.

Attach the syringe without the

plunger to the needle and attach

the Ambu bag via the connection

piece of an endotracheal tube

Ventilate at 15 L/minute.

chest wall and listen for breath sounds Judge the adequacy of ventilation by pulse oximetry

8.

Fig 3-7 Steps for performing a needle cricothyrotomy.

Fig 3-8 Needle cricothyrotomy (a) Connections for the Ambu

bag (b) Insertion of needle with negative pressure inserted at

a 45-degree angle.

a

b

Branches of cricothyroid artery

Thyroid cartilage

Vocal void Laryngeal

ventricle

Cricoid cartilage

Needle cricothyrotomy

RESPIRATORY EMERGENCIES

3

Anxiety over dental treatment or pain may lead to panic (a severe episodic form of anxiety), and often, the anxiety/panic and hyperventilation can become a vicious cycle The anxiety of sitting in a dental chair and the anticipation of treatment can lead to rapid breathing, and breathing rapidly can then make the individual more anxious and panicky and produce more hyperventilation with resultant symptoms The symptoms of respiratory alkalosis can be quite fright-ening, which often causes faster and deeper breath-ing, making the situation worse

If the patient begins to hyperventilate, the goal is

to raise the carbon dioxide level in the blood, which ends most of the symptoms Usually, tingling of the fingertips is one of the early warning signs that the patient is becoming alkalotic The dentist should first provide reassurance and try to help the individual get his/her breathing under control The dentist should instruct the patient to try to slow his/her breathing

by explaining that fast breathing makes them feel worse

To increase the carbon dioxide level, the level of oxygen intake needs to be decreased To accomplish this, instruct the patient to breathe through pursed lips (as if blowing out a candle) or cover his/her mouth and one nostril and breathe through the other nostril However, be careful not to excite the indi-vidual by placing a hand over his/her face

Breathing into a paper bag is a common and very simple method that can be very effective Place the bag to completely cover the mouth and nose Breath-ing into the bag eventually fills the bag with carbon dioxide Then, breathing the exhaled air from the bag back into the lungs raises the partial pressure of car-bon dioxide in the blood and brings levels back up to where they should be Once carbon dioxide levels in the blood are back to normal, the symptoms should disappear within a short period of time

to avoiding complications in the asthmatic patient

is to continuously monitor the maintenance of the anti-inflammatory and bronchodilatory (β2-agonist) regimens through the period of dental care (Box 3-1) When asthma is well controlled, there is very little additional risk for respiratory complications during dental treatment However, when it is poorly con-trolled, the risk for an attack in the dental office is always high The anxiety from anticipated treatment and pungent odors in dental offices may act as po-tential trigger agents for an asthmatic attack In addi-tion, it is important to know what agents precipitate

an attack and to try to avoid exposure to them.Finally when treating an asthmatic patient, it is important to not treat anyone who is currently or has recently experienced symptoms Be aware that even a person with seemingly mild asthma can have a severe

or even life-threatening exacerbation All acute matic attacks are serious and potentially life threaten-ing A symptomatic patient can be rescheduled after they have obtained medical care and the symptoms have abated

asth-An asthmatic should be treated with his/her rescue inhaler present, or an easily accessible emergency office inhaler should be available The inhaler should be used prophylactically in persons with chronic moderate to severe disease The best time to treat an asthmatic is in the late morning or late afternoon.2 The most com-mon time for an asthmatic attack to occur is either during or after an injection or during a stimulating dental procedure such as an extraction and induction

of or recovery from sedation or general anesthesia.3Signs and symptoms of an asthmatic attack vary from person to person and, from time to time, in any individual (Box 3-2) The attack may develop very rapidly over a few minutes, or it may take a few hours During an asthmatic attack, there is an initial short-ness of breath, coughing, and wheezing Without im-mediate care, the breathing becomes more labored, the wheezing gets louder, and the lungs tighten Gradually, the bronchioles tighten to the point where

BOX 3-1 Short-acting 𝛃2-agonists

• Albuterol/salbutamol (Ventolin, GlaxoSmithKline)

• Levalbuterol (Xopenex, Akorn)

• Metaproterenol

• Pirbuterol

• Terbutaline

there is not enough air movement to produce

wheez-ing This is called the silent chest and is a dangerous

sign—the dentist should not be fooled into

believ-ing that the condition has improved Eventually, the

patient is unable to speak and becomes cyanotic At

that stage, the patient requires aggressive treatment

in an emergency room or intensive care unit

Management

Treatment of an asthmatic attack in an office ting involves the administration of a bronchodilator (Fig 3-9) For conscious patients, the most common bronchodilator is albuterol that is administered via a metered-dose inhaler If the patient loses conscious-

set-BOX 3-2 Signs and symptoms of an asthmatic attack

• Pale, sweaty face

• Blue lips or fingernails

Asthma

1 Sit the patient upright

comfortably and loosen tight

clothing

2 If the patient has an inhaler, assist him/her in using it If the patient does not have an inhaler, use one from the office’s first aid kit.

3 Shake inhaler well after removing the cap and set up the inhaler.

4 Have the patient breathe out

completely then close his/her

mouth tightly around the inhaler

mouthpiece.

5 Give an initial puff and have the patient breath in slowly through the mouth and hold

it for 10 seconds Give a total

of four puffs, waiting about 1 minute between each puff.

6 After four puffs, wait 4 minutes and assess breathing If the person still has trouble breathing, give another set of four puffs.

7 If there is little or no

improvement, give two puffs

every 2 minutes until the

Fig 3-9 Steps for management of an acute asthmatic attack.

Acute asthmatic attack

Respiratory Arrest

Apnea can come and go and be temporary or longed If the patient stops breathing but the heart

pro-is still active, the condition pro-is known as respiratory

arrest Interruption of respiration for more than 5

minutes irreversibly damages vital organs, especially the brain Unless respiratory function is rapidly re-stored, cardiac arrest almost always follows within minutes Respiratory arrest (and impaired respira-tion that can progress to respiratory arrest) can be caused by:

• Airway obstruction from a foreign body or asthma This leads to a loss of muscular tone and decreased consciousness, which allows for displacement of the posterior portion of the tongue into the oropharynx and causes upper airway obstruction or laryngospasm

• Decreased respiratory effort This arises from

an adverse drug effect (eg, alcohol, narcotics) or central nervous system depression due to severe hypoglycemia or hypotension

• Respiratory muscle weakness This presents in many neuromuscular diseases (eg, myasthenia gravis)

Before going into respiratory arrest, a patient’s breathing may be labored or erratic and he/she may become confused, agitated, and unable to speak and may gesture to indicate that she or he is having trou-ble breathing When respiratory arrest occurs, the patient becomes unconscious and cyanotic

The immediate treatment for respiratory arrest is artificial ventilation to get oxygen into the patient

The artificial ventilation must be provided until EMS arrive In addition to providing mechanical ventila-tion, treatment may involve clearing the airway and/

or establishing an alternate airway Cardiopulmonary resuscitation (CPR) may eventually be required.The following set of respiratory emergencies are related to office-based intravenous (IV) anesthesia/sedation In the anesthetized patient, respiratory emergencies include:

Management

Airway obstruction is managed by lifting the chin

or thrusting the jaw For a chin lift, the fingers of one hand are placed under the mandible and gently lifted upward to bring the chin anterior A jaw thrust moves the tongue forward with the mandible, which reduces the tongue’s ability to obstruct the airway To complete this maneuver, stand at the head of the pa-tient The middle finger of the right hand is placed at the angle of the patient’s jaw on the right The middle finger of the left hand is similarly placed at the angle

of the jaw on the left An upward pressure is applied

to elevate the mandible, which lifts the tongue from the posterior pharynx5 (Fig 3-11)

Laryngospasm

Laryngospasm is a protective reflex of the airway ten precipitated by light levels of anesthesia in combi-nation with a noxious stimulus such as blood, saliva, mucus, or foreign matter It is the body’s attempt to prevent the foreign material from entering the lar-ynx, trachea, or lungs.6 When it occurs, there is an

of-involuntary muscular contraction of the vocal cords

that suddenly blocks the flow of air into the lungs

Laryngospasm presents with increased respiratory

ef-fort along with difficulty with air exchange and often

a “crowing” sound (Box 3-3) In complete spasm, the

“crowing” sound may not be audible.6 In the fully

con-scious patient, foreign material is cleared by coughing

and swallowing In the lightly anesthetized patient, such material often precipitates laryngospasm.6The easiest way to avoid precipitation of laryngo-spasm is prevention Adequate suctioning of the oro-pharynx, use of an oral throat pack, and proper head positioning can prevent secretions, irrigation, and foreign material from initiating laryngospasm

Tonsil

Tongue Base of tongue

Hyoid Epiglottis Vocal cord Trachea Esophagus Clavicle

Pharynx

Fig 3-10 Cross section of the pharynx

Fig 3-11 Algorithm for treatment of an obstructed airway during sedation SpO2, oxygen saturation level.

If no improvement

If yes Problem resolved

Suspected airway obstruction

• Perform jaw thrust

• Administer 100% oxygen

If not

Should the spasm persist, the clinician should tinue to attempt to break the spasm by bag-valve-mask (BVM) ventilation with 100% oxygen If this fails, the next treatment should be succinylcholine via IV with oxygen administration by positive pressure The recommended dose for a partial laryngospasm is 10

con-to 20 mg IV.6 However, in patients with complete laryngospasm or a barrel-shaped chest a larger dose

of 20 to 40 mg IV may be required.6 It is often propriate to attempt the smaller dose, and if it fails immediately administer the larger dose The clinician should then assist with respirations while the patient recovers and spontaneous respiratory effort resumes

ap-Recovery from succinylcholine should take place within 4 to 6 minutes,8 although larger doses may result in more prolonged blockade The dentist must continue assisted respiration until the patient is able

to maintain adequate air exchange (Fig 3-12)

In the pediatric population, laryngospasm may cur in the absence of IV access In such cases, it is appropriate to administer 4 mg/kg of succinylcholine intramuscularly

oc-Bronchospasm

Bronchospasm must be distinguished from spasm because it can be more serious and the treat-ment is different (Table 3-1) Like laryngospasm, it tends to occur in patients under light anesthesia, but

laryngo-it is unrelated to laryngospasm Bronchospasm is a sudden constriction of the muscles in the walls of the bronchioles that causes difficulty in breathing, which can be very mild to severe It is an acute increase in airway resistance with the associated signs and symp-toms of tachypnea, wheezing, prolonged expiration, air trapping, and decreased gas exchange.2

Management

The first-line treatment of bronchospasm is tion of rapid-acting β2-adrenergic agonist (albute-rol) This can be administered through an inhaler in

inhala-an awake patient or via endotracheal tube in a patient under general anesthesia.2 Typically, patients who are undergoing IV sedation are not so obtunded that they cannot cooperate with the use of a β-agonist inhaler in conjunction with supplemental oxygen

In the majority of dental offices, IV sedation cases are typically done without intubation of the patient

In a nonintubated sedated patient who is unable to cooperate, the use of parenteral agents are the first-line treatment.6 The administration of 0.3 to 0.5 mL of epinephrine (1:1,000 solution) subcutaneously is rec-ommended under the ordinary intraoperative condi-tions in most dental offices.6 IV epinephrine should be reserved for those patients exhibiting hypotension and signs of acute anaphylactic bronchospasm A bolus of

10 to 20 µg (1:10,000 solution) is titrated according

to response in such an instance.6 A note of caution: Administration of large doses of IV epinephrine can cause dysrhythmias and hypertension and is danger-ous in a patient with a preexisting cardiac condition; it should therefore be used with care The patient should also receive supplemental oxygen (Fig 3-13)

In cases where the patient is hypoxemic despite supplemental oxygenation, the clinician should assist ventilatory efforts with 100% oxygen by BVM Should the clinician be unable to adequately oxygenate the pa-

BOX 3-3 Signs of laryngospasm

• Harsh breathing sounds

• High-pitched sounds with inspiratory stridor

• Suprasternal retraction

• Use of accessory muscles

• Paradoxic movement of chest and abdomen

• Silence as glottic aperture closes completely

TABLE 3-1 Bronchospasm versus laryngospasm

Desaturation

Fig 3-12 Algorithm for treatment of laryngospasm.

100% oxygen until patient is able to breathe unassisted

If

not

If unable to break spasm

and patient deteriorating

IV succinylcholine

20 mg OR 40 mg

Respiratory Arrest

Fig 3-13 Management steps of bronchospasm.

Provide positive-pressure oxygenation

Administer β-agonist inhaler

Administer 5 mL epinephrine in 1:10,000 solution (0.3 to 0.5 mL

RESPIRATORY EMERGENCIES

3

tient via BVM, and the patient shows sign of tion, intubation is indicated.6 The patient can then re-ceive positive-pressure ventilation with 100% oxygen

deteriora-In the intubated patient, the use of albuterol or another β-agonist inhaler can be administered either through the open end of the endotracheal tube or through an elbow added to the circuit for inhaler de-livery The typical dose is 5 to 10 puffs titrated accord-ing to therapy and heart rate response.6 The ventilato-

ry effort can be further assisted with positive-pressure ventilation and supplemental oxygen

Aspiration

Pulmonary aspiration is the inhaltion of geal or gastric contents into the larynx and lower respi-ratory tract.9 It may be entirely asymptomatic or may manifest as a clinical syndrome characterized by any combination of bronchospasm, hypoxia, cough, dys-pnea, or auscultatory abnormalities.10 Because sedation

oropharyn-in dentistry is most often performed with an opened mouth and an unprotected airway, there is a potential risk for aspiration However, the reported risk of aspi-ration pneumonitis under general anaesthesia is very low,11 and the risk is even much less under conscious sedation because protective reflexes are maintained

However, clinicians must be cautious because it has been reported that, in some patients, even a minute volume of gastric contents can lead to aspiration pneu-monitis.12 To minimize the risk of pulmonary aspira-tion of gastric contents, it is important to do a proper assessment of preprocedure fasting and limit the depth

of sedation Risk factors for aspiration include an vanced age, oversedation, and a full stomach

ad-Aspiration may manifest as coughing, wheezing, and chest discomfort It should be suspected if a patient starts coughing violently during or soon after sedation;

however, some patients may have a latent period tween the aspiration event and the onset of symptoms

be-Management

If it is believed that there is a possibility of aspiration, the patient should be supported with supplemental oxygen and both lungs auscultated If there are any abnormal sounds, such as wheezing or rhonchi, or if the oxygen saturation level (SpO2) decreases despite oxygen supplementation, the patient should be im-mediately transferred to an emergency department for further evaluation by a pulmonologist

If bronchospasm is suspected, 2 to 4 puffs of buterol should be administered If the patient is heavily sedated and cannot cooperate with the use

al-of an inhaler, 0.3 mg al-of epinephrine (1:1,000 centration) should be administered intramuscularly Intubation of the patient should be considered if hy-poxemia develops (SpO2 < 80%) despite efforts at oxygenation via a BVM device

con-References

1 Steinbacher DM, Glick M The dental patient with asthma An update and oral health considerations J

Am Dent Assoc 2001;132:1229–1239.

2 Tisi GM Preoperative identification and evaluation

of the patient with lung disease Med Clin North Am 1987;71:399–412.

3 Warner MA, Divertie MB, Tinker JH Preoperative cessation of smoking and pulmonary complications

in coronary artery bypass patients Anesthesiology 1984;60:380–383.

4 Reed KL Basic management of medical cies: Recognizing a patient’s distress J Am Dent Assoc 2010;141:120S–124S.

emergen-5 Sedation Airway Management Society of terology Nurses and Associates (SGNA) http://www sgna.org/issues/sedationfactsorg/patientcare_safety/ airwaymanagement.aspx Accessed 13 May 2015.

Gastroen-6 American Association of Oral and Maxillofacial geons Complications and Emergencies In: Office of Anesthesia Evaluation Manual, 7 ed Rosemont, IL: American Association of Oral and Maxillofacial Sur- geons, 2006.

Sur-7 Hagberg C, Georgi R, Krier C Complications of managing the airway Best Pract Res Clin Anesthesiol 2005;19:641–659.

8 Anectine [package insert] Princeton, NJ: Sandoz, 2012.

9 Marik PE Aspiration pneumonitis and aspiration pneumonia N Engl J Med 2001;344:665–671.

10 Warner MA, Warner ME, Weber JG Clinical significance of pulmonary aspiration during the peri- operative period Anesthesiology 1993;78:56–62.

11 Mellin-Olsen J, Fasting S, Gisvold SE Routine erative gastric emptying is seldom indicated A study

preop-of 85,594 anaesthetics with special focus on aspiration pneumonia Acta Anaesthesiol Scand 1996;40:1184– 1188.

12 Green SM, Krauss B Pulmonary aspiration risk ing emergency department procedural sedation–An examination of the role of fasting and sedation depth Acad Emerg Med 2002;9:35–42.

Chest pain is an alarmingly common symptom with a lifetime prevalence of 20%

to 40% in the general population.1,2 According to the Centers for Disease Control

National Hospital Ambulatory Medical Care Survey,3 7 million emergency

depart-ment visits were made by patients who cited chest pain as the chief complaint;

other sources corroborate this high number.4,5 Lindsell et al6 found that roughly

20% of patients evaluated in the emergency department for chest pain had acute

coronary syndrome (ACS), so these visits often do represent a very serious event

In the outpatient dental setting, patients are exposed to significant stressors that

may precipitate episodes of chest pain.7 As with any office emergency, the

corner-stone of management is prevention (Fig 4-1)

Perhaps more important for the clinician, it is necessary to understand that chest

pain can represent anything from benign indigestion to a potentially fatal

myocar-dial infarction (MI) or aortic dissection (AD) When assessing a patient with acute

chest pain, the clinician’s primary responsibility is to quickly identify those patients

whose symptoms have life-threatening causes so that intervention may be initiated

rapidly The dental practitioner must rule out potentially fatal causes of chest pain

and, if unable to do so, refer the patient to a center that has such capabilities

To aid with this critical triage, it behooves the dental practitioner to learn some

of the attributes of various conditions that manifest as chest pain When in doubt,

activation of emergency medical services (EMS) or referral for additional

evalua-tion is always an appropriate response

ACUTE CHEST PAIN

4

Differential Diagnosis

The crucial question when the dentist is ing a patient’s chest pain is whether it represents a life-threatening process (Fig 4-2 and Box 4-1) The major life-threatening causes of chest pain include:

assess-• ACS, the most common

• AD

• Pulmonary embolism (PE)

Other life-threatening causes of chest pain that are less likely to be seen in the dental office include tension pneumothorax, pericardial tamponade, esophageal rupture, and perforated peptic ulcer dis-ease (PUD) Work-up of non–life-threatening chest pain is generally left to a patient’s primary medical provider Some of the more common causes of non–life-threatening chest pain are briefly outlined later

Before a treatment appointment, ask each patient with known angina about any changes in symptoms

to rule out UA; patients with UA are not candidates for elective dental treatment

Assess vital signs

at the beginning of appointments; patients with uncontrolled hypertension or tachycardia should be referred to a primary care provider and should not undergo elective dental treatment.

For high-risk patients, make

an effort to reduce anxiety

by creating

a low-stress environment and by obtaining excellent local anesthesia.

• Acute coronary syndrome:

• Esophageal rupture (Boerhaave syndrome)

• Perforated peptic ulcer

− Cervical disc disease

− Chest wall pain

Potentially Life-Threatening Causes of Chest Pain

distinguishing between the two can be challenging,

even for an astute and experienced clinician As in

all clinical scenarios, a directed history and physical

are paramount as they will uncover subtleties in the

clinical picture as well as the individual patient’s risk

factors Adjunctive studies—rarely available in the

general dental office—are often required to make a

definitive diagnosis

Potentially Life-Threatening

Causes of Chest Pain

Acute coronary syndrome

The most common life-threatening cause of

acute-onset chest discomfort is myocardial ischemia/

infarction Coronary artery disease (CAD) remains

the leading cause of death for both men and women

in the United States.5,8,9 Most early deaths after MI

are attributable to heart failure or arrhythmias

Indi-viduals who live beyond the initial hour have better

outcomes if their condition receives prompt

recog-nition and treatment, primarily because there is less

damage to the heart muscle and subsequent heart

function is better

ACS is a spectrum disorder that includes:

• Unstable angina (UA)

• Non–ST-elevation MI (NSTEMI)

• ST-elevation MI (STEMI) (ST elevation refers

to an electrocardiographic [ECG]

phenome-non: In STEMI, a segment on the ECG tracing

known as the ST interval is elevated in at least

two contiguous anatomical leads.)

Because UA and NSTEMI can be impossible to

distinguish on initial presentation, the most recent

American Heart Association (AHA) and

Ameri-can College of Cardiology (ACC) guidelines

re-fer to UA/NSTEMI as a single group renamed

non–ST-elevation acute coronary syndromes.8 All of

these entities represent myocardial ischemia, or an

imbalance between oxygen supply and demand All

three can present very similarly, but in NSTEMI and

STEMI, the ischemia is severe enough to cause

dam-age to the myocardium with release of cardiac

bio-markers, such as troponin T, troponin I, or creatinine

kinase-MB, into the bloodstream.10 In STEMI, the damage to the myocardium is more severe, extend-ing through the full thickness of the heart wall; in NSTEMI, the damage is only partial thickness

Management is time sensitive; outcomes of

STE-MI, in particular, are extremely dependent on time to revascularization Because distinguishing among UA, NSTEMI, and STEMI requires 12-lead electrocar-diography and medical evaluation, EMS should be activated for all patients with symptoms of ACS.8,10

Atherosclerosis

Atherosclerosis underlies most, but not all, ACS

Atherosclerosis is plaque formation, primarily fecting medium and large arteries Atherosclerosis is present to a degree in nearly everyone; it marches on progressively at a variable rate determined by genetics and individual risk factors.10

af-Atherosclerosis is initiated by injury to the vascular endothelium, which normally functions to modu-late vascular tone and to help control intravascular thrombosis Hypertension, hyperlipidemia, tobacco abuse, and diabetes mellitus can all contribute to the endothelial damage that initiates atherosclerotic changes Once the endothelium is damaged, mono-cytes and other inflammatory cells cross the damaged vessel lining Macrophages digest low-density lipo-protein; this forms foam cells Foam cell aggregation forms a fatty streak, which is the first visible lesion

in atherosclerosis The streak matures into a plaque

Eventually, the plaque enlarges enough to narrow the vessel lumen to the point of flow impairment (Fig 4-3) If the plaque ruptures, collagen and lipids are exposed to circulating blood These substances are highly thrombogenic; an intraluminal thrombus forms The initial platelet plug leads to vasoconstric-tion, so blood flow is further compromised.10

BOX 4-1 Symptoms that should prompt urgent EMS

activation

• Chest pressure/pain of new onset or increased severity versus baseline, with or without nausea, vomiting, diaphoresis, syncope

• Tearing chest pain with or without radiation to the back