Recognition of medical emergencies begins at the first sign or symptom. Dentist needs to focus on what is happening with a patient minute by minute. Treatment should consist minimally of basic life support and monitoring of vital signs.
Recognition of medical emergencies begins at the first sign or symptom. Dentist needs to focus on what is happening with a patient minute by minute. Treatment should consist minimally of basic life support and monitoring of vital signs.
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Recognition of medical emergencies begins at the first sign or symptom. Dentist needs to focus on what is happening with a patient minute by minute. Treatment should consist minimally of basic life support and monitoring of vital signs.
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symptom.1 Familiarity with the patient’s medical profile aids immensely in recognition; knowing what to expect and what to look for promotes a faster response. The dentist needs to focus on what is happening with a ABSTRACT Background and Overview. Medical emergencies can happen in the dental office, possibly threatening a patient’s life and hindering the delivery of dental care. Early recogni- tion of medical emergencies begins at the first sign of symp- patient minute by minute because distrac- toms. The basic algorithm for management of all medical tions slow response time. emergencies is this: position (P), airway (A), breathing (B), By performing a simple visual inspection circulation (C) and definitive treatment, differential diag- of the patient, the dentist can determine if nosis, drugs, defibrillation (D). The dentist places an uncon- he or she has various diseases such as obe- scious patient in a supine position and comfortably positions sity, a history of cerebrovascular accident a conscious patient. The dentist then assesses airway, (CVA) (stroke), Parkinson disease, jaundice, breathing and circulation and, when necessary, supports the exophthalmos, breathing difficulties and patient’s vital functions. Drug therapy always is secondary to heart failure (orthopnea). basic life support (that is, PABCD). When treatment is indicated, the dentist Conclusions and Clinical Implications. Prompt should proceed without hesitation. Often, recognition and efficient management of medical emergencies management of medical emergencies in the by a well-prepared dental team can increase the likelihood of dental office is limited to supporting a satisfactory outcome. The basic algorithm for managing patients’ vital functions until emergency medical emergencies is designed to ensure that the patient’s medical services (EMS) arrives. This is brain receives a constant supply of blood containing oxygen. especially true in the case of major mor- Key Words. Medical emergencies; basic life support; bidity such as myocardial infarction or CVA. seizures; hypoglycemia; chest pain; angina pectoris; acute Treatment should consist minimally of basic myocardial infarction; bronchospasm; syncope; allergy. life support and monitoring of vital signs.2 JADA 2010;141(5 suppl):20S-24S. The dentist never should administer poorly understood medications. Dr. Reed is an associate professor in residence, School of Dental Medicine, University of An emergency management plan, as Nevada, Las Vegas; assistant director, Advanced Education in General Dentistry, Arizona described by Haas3 in this supplement and Region, Lutheran Medical Center, Brooklyn, N.Y.; and a clinical associate professor, Endodontics, Oral and Maxillofacial Surgery and Orthodontics, the Herman Ostrow School by Peskin and Siegelman,4 is of paramount of Dentistry of USC, Los Angeles. Address reprint requests to Dr. Reed, 4700 W. Flying importance. The dental team’s ultimate goal Diamond, Tucson, Ariz. 85742, e-mail “kr@klrdmd.com”.
review, readers should refer to one of the text- that the dentist can manage, or begin to treat, in books on the topic.5,6 This article serves as a brief the dental office. I will not address chest pain of review of some of the commonly encountered med- noncardiac origin, although it certainly is valid ical emergencies in the dental office. I examine and somewhat common in the population at large. some of these medical emergencies and their most If a patient is experiencing chest pain, he or common manifestations and lightly touch on some she will let the dentist know, so recognition of the potential treatments. problem will not be difficult. A conscious patient experiencing chest pain is free to be in any posi- RESPIRATORY DISTRESS tion that is comfortable. As stated earlier, these Respiratory distress in a dental patient may take patients often will want to sit upright. Conscious one of many forms. For example, the precipitating patients who can talk have a patent airway, are problem may be asthma, an allergic reaction, breathing and have sufficient cerebral blood flow tachypnea (hyperventilation, a pulmonary and blood pressure to retain consciousness. The embolus, acute congestive heart failure, diabetic difficulty for the dentist is the differential diag- ketoacidosis, hyperosmolar hyperglycemic nonke- nosis of chest pain.11 totic syndrome) or unconsciousness. Angina pectoris and AMI are the two most Clinicians can recognize respiratory distress in likely cardiac problems in a conscious patient who a patient through a variety of manifestations. is exhibiting chest pain in the dental office. Other Probably the most common cause of respiratory possibilities exist, but this article focuses on the distress seen in dental patients is asthma, also recognition and early treatment of these two known as acute bronchospasm.7 Patients with this common entities. If the patient had experienced type of respiratory distress typically will want to cardiac arrest, he or she would not be conscious. sit upright (position). The dentist follows this with Differential diagnosis. A differential diag- an evaluation of the patient’s airway. Is it patent? nosis of chest pain involves looking at a number By definition, conscious patients who can talk of signs and symptoms. One consideration is the have a patent airway, are breathing and have suf- patient’s history. Has he or she ever experienced ficient cerebral blood flow and blood pressure to anginal chest pain? If so, it is likely that the cur- remain conscious. Definitive treatment includes rent chest pain is angina pectoris. However, if administration of a bronchodilator. For conscious this is the patient’s first episode of chest pain, the patients, this bronchodilator commonly is dentist should treat him or her as if it were an albuterol, administered via a metered-dose AMI and have EMS transfer the patient as inhaler. If the patient loses consciousness or is uncooperative with administration of albuterol via ABBREVIATION KEY: AMI: Acute myocardial infarc- inhalation or if bronchospasm is refractory to tion. CVA: Cerebrovascular accident. EMS: Emergency administration of albuterol, telephoning EMS medical services. MONA: Morphine, oxygen, nitroglyc- (9-1-1) and administering epinephrine parenter- erin and aspirin. PABCD: Position, airway, breathing, ally (intramuscularly) are indicated. Subcuta- circulation, definitive treatment.
ence no chest pain at all (that is, silent myocar- intervention (that is, sedation). Inhalation seda- dial infarction).13 tion (nitrous oxide/oxygen) may be ideal for some Blood pressure. Blood pressure also might patients, while enteral sedation may be more indicate whether the patient is experiencing appropriate for others. Some patients benefit angina pectoris or an AMI. If the patient’s blood most from parenteral (that is, intramuscular, pressure is elevated during this episode of chest intranasal) moderate sedation and others may pain, angina more likely is the cause.10 This eleva- require general anesthesia to properly address tion may be a response to the pain being experi- their anxiety. enced. If the blood pressure falls below the Hypoglycemia. Dentists also should consider patient’s baseline value or the immediate preop- hypoglycemia in a differential diagnosis of dizzi- erative value, the dentist should consider an AMI; ness. Frequently, the patient has a history of dia- if the pump (the heart) has been injured, it is less betes. Patients with type 1 diabetes (and some efficient, resulting in a decreased cardiac output with type 2) self-administer insulin to lower a and subsequent drop in blood pressure.12(p475) high glucose level (hyperglycemia) toward the Definitive treatment. Definitive treatment upper limit of normal (120 milligrams/deciliter). for angina pectoris requires the administration of Patients with diabetes must ingest food immedi- a nitrate, commonly nitroglycerin, via sublingual ately after administering insulin to prevent the tablet or translingual or transmucosal spray. development of hypoglycemia as a result of the Prehospital treatment of a patient suspected of insulin injection. The most common cause of having AMI typically involves the administration hypoglycemia in patients with type 1 diabetes is of morphine, oxygen, nitroglycerin and aspirin not eating after administering insulin. (MONA), in addition to notifying EMS. Given Patients with clinically significant hypo- that most dental offices do not have morphine, glycemia may be recognizable because they com- the dentist may substitute nitrous oxide/oxygen monly experience diaphoresis and tachycardia in a 50:50 concentration.14 and feel faint. Subsequently, they may experience mental confusion and, ultimately, the loss of con- ALTERED CONSCIOUSNESS sciousness. As long as the patient retains con- As with respiratory distress, altered conscious- sciousness, the clinician should allow him or her ness or unconsciousness may occur owing to a to remain in a comfortable position. Conscious variety of precipitating factors. Some of these patients with hypoglycemia have a patent airway, include significant hypotension from any cause, are breathing and have an adequate pulse. The hypoglycemia, CVA, illicit drug use, AMI and treatment of choice for patients with hypo- seizure. glycemia is administration of sugar. Unconscious Dizziness developing in the dental office may patients with hypoglycemia require parenteral have many origins, but low blood pressure in the administration of sugar. Absent a proficiency in brain often is the ultimate cause. The easiest and venipuncture, the dentist should activate EMS. least invasive way to increase blood flow to the Malamed5(p283) recommends that a dentist never
sciousness. Although many possible explanations with the patient is present (such as a parent, exist, the more common reasons a patient loses spouse or professional caregiver), a team member consciousness in the dental office (assuming no should bring the person into the operatory and medications have been administered) are syncope, ask him or her to evaluate the patient. He or she low glucose level, CVA and cardiac arrest. may determine that this is a typical seizure for In each of these examples of unconsciousness, the patient, in which case simple monitoring is the initial management of the emergency is the sufficient, or he or she may feel that this seizure same. The dentist should place the patient in a is unusually severe and suggest that someone supine position. If he or she has not responded contact EMS. within one minute, the clinician probably can rule out syncope. The dentist then should open the ALLERGY-RELATED EMERGENCIES airway and assess breathing (“look, listen and Allergy-related emergencies are rare but possible feel”16). If the patient is breathing, the next step is in the dental office. The most common allergen in to check his or her circulation. Does the patient the dental environment today is latex.18 An have a palpable pulse at the carotid artery allergy can be mild or severe. If the patient has (brachial artery in infants)? itching, hives, rash or a combination of these, the Patients who are breathing spontaneously and allergy may be considered mild (non–life threat- normally may be experiencing hypoglycemia or a ening). However, if the patient experiences respi- CVA, but not cardiac arrest. In cardiac arrest, the ratory or cardiovascular compromise—that is, the patient does not breathe spontaneously (agonal loss of consciousness due to difficulty in breathing breathing notwithstanding). A patient with apnea or inadequate blood pressure and blood flow to requires positive pressure ventilation with 100 the brain—the dentist should treat the allergy as percent oxygen. a life-threatening situation. Patients placed in a supine position who do not Mild allergy. If the allergy is mild (that is, respond within 30 to 60 seconds but are breathing itching, hives, rash or a combination of these) and spontaneously likely are experiencing hypo- the patient remains conscious, he or she should glycemia or a CVA. If the patient’s blood pressure be made comfortable. The conscious patient who is normal (that is, close to baseline values—part is talking has verified that the airway is patent, of assessing circulation), the problem probably is he or she is breathing and he or she has cardio- a low glucose level. If the patient’s blood pressure vascular function adequate to maintain conscious- is alarmingly high, the dentist must strongly con- ness. In this case, the dentist should administer a sider the possibility that the event is a CVA. histamine blocker, such as diphenhydramine, via intramuscular or intravenous injection. SEIZURES Severe allergy. If the allergy is severe, the Seizures are rare in dental offices, especially in patient has lost, or soon will lose, consciousness. patients who never have had them. Patients who The dentist should place the patient in a supine convulse in the dental office typically have a position, open the airway and evaluate breathing.
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