Office preparation and your medical emergency kit what you should know.
The Medical Emergency Protocol
This protocol should assign responsibility for certain tasks to each member of the dental team. The dentist should be the team leader, directing the activities of all team members. The team leader could also be the dental hygienist, especially in an emergency involving his or her patient or involving the dentist. Assigning individual responsibilities to staff and simulating those emergencies will prevent chaos and save valuable time. All dental staff should have Basic Life Support (BLS) certification. The receptionist needs to be prepared to recognize emergencies that occur in the waiting room. She or he can also activate emergency medical services (EMS) and direct patients away from the site of an emergency.
Staff roles should include weekly checking of the emergency cart, mobilizing the cart in the event of an emergency, obtaining and monitoring the vital signs of the person experiencing the emergency, and record keeping. It is very important to schedule biannual mock emergency drills to keep the office prepared. The treatment of the following emergencies should be practiced:
1. Airway obstruction
2. Angina pectoris
3. Myocardial infarction
4. Unstable hypertension
8. Severe allergic reaction
10. Cerebral vascular accident (CVA)
Documentation of those drills is a must! This should be documented in your medical emergency procedure manual.
It is also very important that your office facilities and equipment be adaptable for the management of medical emergencies, and you need to evaluate them.
There should be enough room between the cabinetry and the dental chair to place a patient on the floor to perform CPR.
The dental chair needs to be evaluated. Can the dental chair be lowered enough to perform CPR? How soft is the chair? You need a hard surface to perform CPR on. Since most chairs are soft, you need to have a board made that can fit between the patient and the chair. It may be a good idea to practice CPR on your dental chair using a manikin.
Good lighting is important for evaluating the airway, and it is important to have a flashlight available with extra batteries in case there is a power failure.
High-speed suction with a yankeur suction tip is the right equipment to have for clearing an airway. Since power failures or equipment failures are possible, backup suction is needed. You can purchase a battery-powered suction or a hand-pump type as a backup (Figure 1).
An E cylinder with an Ambu bag to deliver positive pressure oxygen is an important piece of equipment to have available. Even if you have oxygen in the operatory, occasionally emergencies can occur in the waiting room or hallway (Figure 2).
It is important to document treatment of the medical emergency. The treatment record should include drugs used, vital signs, and when 911 was called. An example can be found at www.emergencyActionGuide.com. Documentation of emergency drills and review of the emergency drills and emergency kit should be maintained by the team leader. (1)
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The Emergency Kit
The Council on Dental Therapeutics of the American Dental Association issued a report on the emergency drug kit in 2002. The report stated, "All dental offices should maintain at least the basic recommended emergency equipment and drugs. The content and design of these kits should be based upon each practitioner's training and individual requirements." (4)
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Even though there are commercially available kits, none fits the needs of all practitioners. When constructing an emergency kit, you must take into consideration the practitioners' training and the type of anesthesia used in the office (Figure 3). If the practitioner cannot gain intravenous (IV) access, IV drugs in a kit will not be helpful. The drugs needed for offices that perform conscious sedation or deep sedation are different from those needed in offices that perform local anesthesia and nitrous oxide administration.
In a dental office that uses only local anesthesia and nitrous oxide, I believe in the Keep It Simple System (KISS). This kit should contain the basic injectable medication, non-injectable medication and equipment. (3) The basic drugs should include:
1. Epinephrine 1:1000 injectable
2. Oxygen with positive pressure administration ability
3. Nitroglycerin (sublingual or spray) vasodilator
7. Histamine blocker
8. Aromatic ammonic
The basic equipment should include:
1. Oxygen delivery system
4. Magill forceps
5. Oral and nasal airway - artificial airways
Since automatic external defibrillator (AED) training is part of BLS training, I feel that having an AED in the office is definitely needed. I highly recommend making your own medical emergency kit and using a label maker to post dosages for adult and children inside the container or on the drug itself. It is possible for a practitioner to forget the correct drug dosage during an actual medical emergency. (2)
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Basic Emergency Kit
This is the drug of choice for a severe allergic reaction and acute asthmatic attacks. The principle effects of this drug are bronchodilation, vasoconstriction and increased heart rate, excitability and contractility. This should not be used on patients with ischemic heart disease or significant tachycardia. Epinephrine can be supplied via an auto-injector and ampules of 1:1000 concentration. The dosage for an adult is 0.3 mg. Remember if you are treating children, you will need a pediatric size auto-injector (Figure 4).
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Even though there are commercially available kits, none fits the needs of all practitioners.
Nitroglycerine is a venous (primary) and arteriolar dilator that results in increased cardiac output and reduced left ventricular filling pressure. This is the drug of choice for chest pain due to myocardial ischemia and for severe hypertension. It comes in 1/150 mg sublingual tablets or spray. One tablet should be placed sublingually. If pain is not relieved in three to five minutes, another tablet should be given up to a maximum of three doses. If that does not relieve the pain, myocardial infarction should be suspected.
Albuterol is used to treat a severe asthmatic attack. It is a beta 2 adrenergic bronchodilator that causes relaxation of the smooth muscle of the bronchioles. It comes in a metered aerosol inhaler. The patient is given one to two sprays to relieve the bronchospasm (Figure 5).
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Glucose is used to treat hypoglycemia in a diabetic patient. Any glucose source will do and you can use a non-carbonated soft drink, cake frosting tube or a tube of viscous glucose gel.
This is indicated for patients suffering a myocardial infarction. Aspirin has antipyretic, analgesic and antiplatelet effects. It is important that the 325 mg tablet can be chewable since most tablets have an enteral coating. You would give the patient one 325 mg tablet to chew only. Do not use this with patients who are having a stroke since you do not know if the stroke is being caused by a clot or a bleed occurring in the body.
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Benadryl is used to treat an allergic reaction or as a local anesthetic in patients allergic to lidocaine. It is an H2 antagonist, which helps minimize the release of histamine. You can supply this in your kit in tablet or liquid form and injectable 50 mg/ml ampules. I recommend three to four ampules and liquid form for your emergency kit (Figure 6).
This is a respiratory stimulant used to treat respiratory depression and syncope. It comes in a silver gray vaporole and you can crush it under the nose. The harsh odor irritates the mucous membrane and stimulates the respiratory and vasomotor centers of the medulla. Since syncope is one of the most common medical emergencies, you may want to keep one in each operatory.
Basic Emergency Equipment
Oxygen Delivery System
It is important to have an E cylinder with a bag valve mask that can deliver close to 100% oxygen to the patient.
Suction and Suction Tips
High-volume suction with backup is necessary, and large-diameter, rounded suction tips are also recommended.
Proper size syringes are needed for your kit. Epinephrine needs a small tuberculin syringe for subcutaneous administration. You should have at least three 3 ml syringes and needles available for your kit.
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Magill forceps are designed to aid in nasal endotracheal intubation. These forceps can be used to retrieve objects that fall deep into the hypopharynx such as a crown or implant screwdriver (Figure 7).
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There are two types of artificial airways (oropharyngeal and nasopharyngeal) you can have available for your kit. Artificial airways help to maintain a patent airway in an unconscious or semi-unconscious patient. The oropharyngeal airway keeps the tongue off the posterior pharyngeal wall and can be used only in an unconscious patient (Figure 8). The nasopharyngeal airway can be used in a conscious patient.
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Both airways come in a variety of sizes. Artificial airways should only be part of your emergency kit if you have had training in their use (Figure 9). (3)
As you can see, your emergency medical kit does not need to be complicated but it does need to contain drugs and equipment you can easily use. A dental staff member needs to be assigned to check your emergency drug kit and equipment weekly. You don't want to be in a situation where you are treating an emergency with expired drugs. The medical emergency kit should be in an area of easy access for all dental team members.
Most medical emergencies occurring in the dental office can be prevented through thorough patient evaluation. This includes a good medical history, physical examination and baseline vital signs before dental treatment is started. Conducting biannual mock drills with the entire staff will ensure that your office is prepared to manage life-threatening situations.
(1.) Institute of Medical Emergency Preparedness: Medical Emergency book. Hattiesburg, Miss.: Institute of Medical Emergency Preparedness; 2004.
(2.) American Association of Oral and Maxillofacial Surgery: A guide for practice, monitoring and evaluation. Rosemont, Ill.: AAOMS; 1995.
(3.) Malamed S. Medical emergencies in the dental office, 6th ed. St. Louis, Miss.: Mosby Elsevier; 2007.
(4.) ADA Council on scientific Affairs report, JADA vo1.133, no. 3, pps.364-365.
Pamela L. Alberto, DMD, earned her doctorate from the University of Pennsylvania, School of Dental Medicine and her specialty certificate in Oral and Maxillofacial Surgery from the University of Medicine and Dentistry of New Jersey--University Hospital. She is currently the director of predoctoral surgery and a clinical associate professor in the Department of Oral and Maxillofacial Surgery at New Jersey Dental School. She is a fellow in the American Association of Oral and Maxillofacial Surgery, the American College of Oral and Maxillofacial Surgery and the International College of Dentistry. She is a member of the International Society of Plastics, Anesthetics and Reconstructive Surgery.