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Medical Emergencies in the Oral Health Care Setting.

Course Instructions

This is a continuing education home-study course. It comes in two parts--the course and the post-test. Most state dental boards will accept the course for fulfillment of C.E. requirements toward licensure renewal. However, the course is not valid unless you take the post-test and send it in for grading. If you pass the course, you will receive a certificate of completion for submission to your state dental board or to keep on file in the event of an audit, depending on the rules in your area.

Please consult the chart on page 156 to verify if this course is approved for C.E. in your state and to learn if there are special requirements. Please note that the chart contains general information valid as of the date of publication. If you have specific questions about your license renewal requirements, or if you're not sure if the course will be accepted, please consult your state dental board.

After you have finished studying the course, please take the post-test, beginning on page 152, complete the answer sheet on page 155, and send it to ADHA, along with the processing fee, for grading.


"ER" and "Chicago Hope" have introduced many to the adrenaline filled world of emergency medicine where almost any medical dilemma can be solved in an hour, and viewers' most critical decision is which television program to watch next. Most people are fascinated with such stories, but if an emergency situation occurs in the dental office it can be frightening and there are no commercial breaks. Oral health care providers should know what to do so automatically that their actions are as precise and controlled as those of the medical personnel on television or in the movies.

In reality, while emergency situations do arise in dental hygiene practice and almost all are life threatening to a degree, only rarely does a patient die while in the dental office. Totally reliable national or even regional data describing patient deaths in the dental office or within 24 hours post treatment are not available. However, according to Frank McCarthy, a physician-dentist it would not be too farfetched to speculate that the average dentist would experience one or two deaths during a practice lifetime.[1] If one extrapolates this to dental hygiene practice, a dental hygienist might also experience a patient death as well. Statistics cannot predict exactly an individual practitioner's future experience. One can only hope to experience no emergencies or deaths. However, it is best to be prepared to prevent the preventable and deal with the unavoidable emergencies as quickly, effectively, and calmly as possible.

Today's dental patient is far different from those in the past. In the past, older dental patients were generally edentulous, but today a person over the age of 60 years is much more likely to have all or most of his or her natural teeth. An older dental patient may now require the full gamut of dental care.

Life expectancy also has risen significantly during this century. In the early 1900s, a white male could expect to live to the ripe old age of 47 years, and a white female to 48 years. Today, that same white couple could expect about 30 more years of life. The most rapidly growing segment of the United States population is those above 60 years of age even before the baby boomer generation reaches late middle age. As people age physiologically, they are usually less able to tolerate stress, a condition often inherent in dental treatment, making them more susceptible to medical emergencies. Additionally, while many older Americans appear to be in good health, they may have significant subclinical diseases, or diseases controlled by medication.

Diseases that previously killed many people at an early age, can now be successfully treated. Advances in health care have contributed not only to an increased life span, but also to greater numbers of medically compromised people of all ages.

The increasing use of drugs for a wide variety of medical conditions is another risk factor for medical emergencies. Kim Tolson, who holds a PhD in pharmacology/toxicology, stated in a recent course that more drugs are available and being prescribed than ever before. Requa-Clark, lists over 125 drugs that are classified as the latest drugs available.[2] With media advertising of prescription drugs, consumers are more aware of specific drugs and may be more likely to request them from their physicians. Additionally more drugs formerly available only by prescription are now available over the counter and are being purchased and used by many. Use of every drug carries inherent risk and many can contribute to risk of a medical emergency. Tolson also stated that a high percentage of the top 100 drugs prescribed and dispensed in U.S. community pharmacies are cardiovascular drugs, any of which can potentially cause significant untoward effects.

According to Malamed, many patients often take more than one drug.[3] Use of multiple drugs can give even greater rise to emergency situations that are related either to the pharmacological action of the drugs or to complex interactions between commonly used dental drugs and other medications taken by the patient.

The good news is that 90% of life-threatening situations are preventable.[3] If the practitioner assesses a patient's medical status and takes the precautions necessary, life-threatening emergencies may never occur. For the 10% of life-threatening situations that may occur despite the best preventive effort, oral health care practitioners should be prepared to carry out the procedures most likely to preserve the life of the affected individual.

Prevention of Emergencies

Oral health care providers must be completely familiar with each patient's medical history and current condition to provide care safely and prevent harm. The most important aspect of preventing a life-threatening emergency may just be in knowing all potential risks, taking precautionary steps, and preparing for the worst case scenario.

A thorough medical history is not only a legal and moral necessity, but can literally be the difference between life and death for some patients. At the very least, it may aid the oral health care practitioner in providing safe and effective treatment for all patients. The medical history questionnaire and interview must contain thorough and relevant questions to accurately record the patient's condition. Dental hygienists should be familiar with the questions and with the drugs being taken by each patient and the possible effects of those drugs. One of the wisest investments a clinician can make to ensure safe treatment is to acquire a concise and specific drug reference book designed for dental practitioners, such as Wynn, Meiller and Crossley's Drug Information Handbook for Dentistry or Gage and Pickett's Mosby's Dental Drug Reference.

Other patient information that may be useful in preventing emergencies can be gained from monitoring of vital signs, visual inspection, and function tests as ordered by the dentist. Specific things to look for will be addressed under each relevant condition.

One of the most critical vital signs to monitor is the blood pressure. Hypertension can result in both heart attack and stroke, and can contribute to a myriad of other problems. If at all possible, blood pressure readings should be recorded on a routine basis. In 1993, the Joint National Committee on Detection, Education and Treatment of High Blood Pressure established standards for classifying blood pressure (Table 1). Malamed described a University of Southern California (USC) physical evaluation system that combines the Joint Committee's system with the American Society of Anesthesiology Medical Risk classification system (described later) to provide an easy-to-use system that suggests the following:[3]

* If systolic is less than 140 and diastolic is less than 90, the patient should be routinely checked in six months-rated and treated as ASA I.

* If systolic is 140-159 and/or diastolic is 90-84 the patient should be rechecked for three consecutive appointments and if measurement exceeds these values -- rated and treated as ASA II.

* If systolic is 160 - 199 and/or diastolic is 95-114, the patient should be rechecked in five minutes and if still at these values, medical consultation should be done before dental therapy is initiated-rated and treated as ASA III.

* If systolic is greater than 200 and/or diastolic is greater than 115, the patient should be rechecked in five minutes and if pressure is still elevated, immediate medical consultation is indicates-rated and treated as ASA IV.

Table 1. Classification of Blood Pressure (BP) for Adults Age 18 Years and Older
                       Systolic BP     Diastolic BP
Category(*)            (mm Hg)(**)     (mm Hg)(**)

Normal                 <130            <85

High Normal            130-39          85-89

Stage 1 Hypertension   140-159         90-99

Stage 2 Hypertension   160-179         100-109

Stage 3 Hypertension   180-209         110-119

Stage 4 Hypertension   [is greater     [is greater
                       than or         than or
                       equal to] 210   equal to] 120

                       Recommendations for Follow-up Dental
Category(*)            Patients Based on Initial BP measurements

Normal                 Recheck at recall (within 2 years)

High Normal            Recheck at recall (within 1 year)

Stage 1 Hypertension   Recheck within 1 month; if still
                       elevated have patient evaluated by
                       physician within 1 month

Stage 2 Hypertension   Recheck within 2 weeks; if still
                       elevated have patient evaluated by
                       physician within 2 weeks

Stage 3 Hypertension   Have patient evaluated by
                       physician within 1 week

Stage 4 Hypertension   Have patient evaluated by
                       physician immediately

(*) Not taking antihypertensive drugs and not acutely ill. When systolic and diastolic pressures fall into different categories, the higher category should be selected to classify the individual's blood pressure. Isolated systolic hypertension is defined as a systolic blood pressure of 140 mm Hg or more and a diastolic blood pressure of less than 90 mm Hg.

(**) Based on the average of two or more readings taken at each of two or more visits following an initial screening. Adapted from The Fifth Report of the Joint National Committee on Detection, Education, and Treatment of High Blood Pressure. 1993.

Anxiety recognition is another important factor that can be determined by questions on the medical history, by communicating with the patient and by observing physical signs and symptoms of anxiety. Specific signs and symptoms include the following:

a. cold, sweaty palms or forehead (diaphoresis);

b. unnaturally stiff posture;

c. the individual fiddles with items in his or her hands;

d. "white-knuckle" syndrome, the person grips the hands, a chair armrest, or other object so tightly that the knuckles turn white from decreased blood circulation; and

e. more severe anxiety may be manifested by increased blood pressure and heart rate, trembling, excessive sweating, and dilated pupils.

The American Society of Anesthesiology (ASA) has provided a classification system for determining medical risk, especially for surgical patients that may be helpful in determining risk and actions to reduce risk for dental patients (Figure 1). The system is not meant to be all inclusive, but is merely a tool to help treat patients in the best possible way. The ultimate decision of whether or not to treat a particular patient, or if a decision is made to treat, the modifications or precautions necessary is most frequently made by the dentist who also assumes the bulk of the liability.

Figure 1.

American Society of Anesthesiology (ASA) Physical Status Classification System (modified to allow assignment of potential risk to dental patients)


1. normal and healthy

2. little or no anxiety

3. little or no risk


1. mild systemic disease or a healthy ASA I with extreme anxiety

2. minimal risk during treatment

3. examples: well-controlled diabetes, epilepsy, asthma, and/or hyperthyroid or hypothyroid conditions; ASA I with upper respiratory condition, pregnancy, and/or allergies


1. severe systemic disease that limits activity, but is not incapacitating

2. dental treatment indicated, but stress reduction protocol and other treatment modifications are indicated

3. examples: angina pectoris or myocardial infarction (MI) history, cerebrovascular accident (CVA) history, insulin dependent diabetes, congestive heart failure (CHF) with orthopnea and ankle edema, chronic obstructive pulmonary diseases (COPD) such as emphysema, chronic bronchitis exercise asthma


1. incapacitating disease that is a constant threat to life

2. patient poses significant risk since he/she has a medical problem that is of greater importance than the planned dental treatment. If possible, treatment should be postponed until the medical condition has improved to at least reverted back to ASA III

3. examples: unstable angina pectoris, MI, or CVA within the past 6 months, blood pressure values of 150/100 or higher, severe CHF or COPD, uncontrolled epilepsy or uncontrolled diabetes mellitus

adapted from Stanley F. Malamed's Medical Emergencies in the Dental Office

Consultation with the physician is not indicated for every patient who has a medical condition. There are many conditions for which treatment modifications are standard, but if there is any question or doubt in making the best decisions, consulting with the patient's physician or other medical or dental colleagues is recommended. A consultation or referral is simply a request for additional information and/or advice about the medical implications of oral health care treatment. A written request and reply referral is ideal, since there is no doubt about either the question or the answer. The request should be specific, concise and directly to the point. Therefore, a form may be used to standardize and simplify the written request and answer (Figure 2). If there is an immediate need for the information, an informal telephone consult may be done with a request for written follow-up documentation that can be added to the patient's chart. All details of the call should be included in the patient's written treatment progress notes. The written documentation is important for future reference and legal requirements.

Most medical emergencies that occur in the dental office can be prevented by simply using the knowledge gleaned from the health history. It should be emphasized that the clinician must routinely gather information that may help prevent an emergency. Even patients who may have been seen routinely for many years should expect to provide current health information at each appointment. A thorough and complete medical history form is of no use whatsoever unless the information it contains is updated routinely and used to implement procedures and precautions that may be necessary.

Preparation for Medical Emergencies

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

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

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

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

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

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

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

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

* exact address or location, including cross streets, landmarks, name of the building, the floor and room number;

* the telephone number from which the call is made;

* the caller's name;

* what happened;

* how many people are involved;

* the condition of the victim;

* and the care being given.

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

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

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

1. Send someone to call 911 or local emergency number when the emergency team leader feels it is necessary, or any time a life-threatening emergency becomes apparent. It is better to err on the side of caution.

2. Terminate any dental treatment in process.

3. Place the patient in the supine position unless he or she is experiencing respiratory difficulties and/or chest pain, in which case place in a semisupine or upright position.

4. Maintain the airway; administer oxygen if indicated. The individual experiencing hyperventilation is the exception since this person should not receive oxygen.

5. Establish baseline vital signs: respiration, pulse, and blood pressure.

6. Perform cardiopulmonary resuscitation, if indicated.

7. Stay calm.

8. Take whatever specific steps are necessary for the condition being experienced.

Emergencies Involving Unconsciousness

Fortunately, unconsciousness is fairly uncommon in the dental office, even though syncope (simple fainting) is reported to be the most common medical emergency encountered in dental offices. By recognizing the early manifestations of presyncope, steps can be taken to prevent a person from falling. If unconsciousness does occur, the management is essentially the same regardless of the cause.

Many cases of unconsciousness can be avoided by reducing as much stress as possible. If a person does become unconscious, one should follow the basic guidelines, or call 911 if indicated; place the victim in the supine position; maintain the airway; administer oxygen if indicated; establish baseline vital signs; perform CPR if necessary; stay calm; and take the specific steps necessary for the condition.

Stress, physical or emotional, is the most common cause of unconsciousness, or vasodepressor syncope. Most often in the dental office the cause is psychogenic--of psychological origin, such as fear, anxiety, pain, and emotional upset. It is interesting to note that good news can have the same effect as bad news. Physical or nonpsychogenic causes also can cause syncope, especially in an individual classified as ASA III or IV, but these are not the usual causes for syncope in the dental office. Nonpsychogenic causes of syncope include being upright or in a standing position; hunger; exhaustion; and being in poor physical condition or in a hot, humid, crowded environment. Children seldom experience syncope, probably because children are less likely to curb their emotions. Older adults also seldom experience syncope.

The usual victim, upon entering the treatment room, sees a syringe that might be there for him, experiences fear and may not let anyone know he is afraid. Because of his fear, chemicals, primarily adrenaline, are released into his blood-stream to help his body adapt to the stress resulting from his fear. This chemical release causes a reaction called the flight-or-fight response. Since the person does not flee or fight, and suppresses the response, there is no anticipated muscular activity, and the large volume of blood that was directed to the muscle pools, does not return to the heart, and results in a drop in circulating blood, including blood going to the brain. The brain is most sensitive to a lack of oxygen, and in an effort to have enough blood to keep the brain functioning, reflex bradycardia develops with a resulting decrease in blood pressure. The blood pressure falls below the level necessary to maintain consciousness, cerebral ischemia occurs and he falls to the floor unconscious.

Fainting seems rather innocuous, not much of a medical emergency at all, but if cerebral ischemia is not corrected, permanent neurologic damage or death is possible. The early Romans, masters of torture and death, used crucifixion as one of their primary forms of killing and reserved it only for the worst criminals. Crucifixion is in fact death from forcibly maintained vasodepressor syncope.

Presyncope is the period of time when the body is being affected by inadequate cerebral circulation and the resulting lack of nutrition and oxygen. Early manifestations include a pale or ashen skin color with the skin possibly cool, and/or moist ("a cold sweat").

The victim might describe a feeling of warmth in the head and neck, lightheadedness, or dizziness; and may also feel nauseated, complain of numbness or tingling in the toes and fingers, and a variety of other related symptoms. Some people say they feel bad, or that everything is going dark just before losing consciousness. Fainting can occur without warning.

Syncope is the period when the victim actually loses consciousness. Bradycardia, hypotension, and a weak, thready pulse are common. Unconsciousness results in muscular relaxation and the possibility of an obstructed or partially obstructed airway, due to a decrease in muscle tone that may cause the tongue to fall into the oropharynx. Another effect of this muscular relaxation may be fecal incontinence.

Postsyncope is a period that occurs as the victim returns to consciousness and the heart rate, pulse, and cerebral nutrition return to normal. During this time, the victim is more likely to re-experience syncope if raised from the supine position too quickly, or allowed to stand too soon after the episode. Any visually disturbing triggers such as a syringe or blood-soaked gauze should be removed from sight.

Prevention relies on using a thorough medical history to identify factors that may predispose a person to syncope, and on observing and evaluating a person to determine the anxiety level. Stress reduction methods should be used. Allowing or encouraging a person to verbalize fear is another useful step that can be taken. The clinician should also be aware of drugs being taken by a patient and their possible side effects. Fortunately treating patients while they are in the supine position prevents the development of cerebral anoxia with resultant syncope, and syncope during treatment is uncommon today. It is at other times, when the patient is upright, that syncope is most likely.

Syncope is generally self-correcting; once the person collapses, normal circulation returns. Inadequate cerebral circulation can be prevented or corrected if the person is placed in the supine position. So the first order of business, if an individual experiences presyncope or actually loses consciousness, is to position him or her in the supine position with the legs slightly elevated. Malamed suggests that, if able, the individual should also vigorously move the legs. Exceptions to the supine position rule include pregnant patients or those with respiratory difficulties and/or chest pain. A pregnant woman can be placed on her side with the legs slightly elevated to prevent further problems caused by the weight of the fetus on the vena cava. When respiratory difficulties or chest pain is present, the person should be positioned to allow ease of breathing, which is usually in a seated upright position. The second and most critical step is to maintain an open airway, making certain that the person is breathing well.

It could become necessary to perform rescue breathing and perhaps administer oxygen if indicated. However, oxygen should not be given to a person experiencing hyperventilation. The American Red Cross gives assurance that as long as a fainting victim recovers quickly, it is unnecessary to call EMS, but suggests that it be determined whether or not the episode is linked to a more serious condition.[5] After recovery, it is good to forgo additional dental therapy for the rest of the day, since a second episode is possible. The clinician should determine what triggered the episode to prevent a reoccurrence in the future. Arrangements should be made for someone to drive the victim home.

The old-fashioned remedy of asking a victim to place the head between the legs to keep from fainting is no longer advised. Bending to that extreme degree may further impede blood flow, cause even less blood to flow to the brain, and result in an even quicker loss of consciousness. Additionally, the person would be in a decidedly awkward position for airway maintenance should it become necessary.

If recovery from syncope takes longer than five minutes after positioning and/or if complete recovery does not occur in 15 to 20 minutes, another possible cause of unconsciousness should be considered and definitive management begun, including summoning EMS. One last caution when managing a simple case of syncope is for the practitioner to maintain composure, especially as the patient begins to regain consciousness. Introducing more stress could cause the victim to relapse back into unconsciousness.

Orthostatic hypotension (postural hypotension) is a disorder of the autonomic nervous system in which syncope occurs as a person abruptly assumes the upright position after being supine, or is in the standing or sitting position for an extended period of time. Malamed lists predisposing factors as:[3]

* certain drugs for which orthostatic hypotension is a side effect (some of these include antihypertensives, some classes of tranquilizers, some antidepressants, narcotics, and antiparkinsonism drugs);

* a long period of lying in bed, especially if the individual has been confined to bed for a week or longer;

* a two-to three-hour dental appointment with the patient confined in the recumbent position, especially if psychosedative drugs have been administered;

* inadequate postural reflex even in a healthy young person if he or she is forced to stand for prolonged periods of time, especially if the knees are locked;

* the first trimester of pregnancy, when a woman may experience postural hypotension on arising, but she may not experience it at any other time during the day;

* late in the third trimester of pregnancy when supine hypotensive syndrome of pregnancy can occur if the patient is allowed to lie in the supine position for as little as three to seven minutes. The cause is reduced blood flow to the brain from the weight of the uterus compressing the inferior vena cava, hindering venous return from the legs;

* venous defects in the legs causing pooling of blood in the legs;

* post-recovery after sympathectomy, a surgical procedure to reduce high blood pressure and improve circulation to the legs;

* Addison's disease (chronic adrenocortical insufficiency);

* physical exhaustion;

* fatigue;

* starvation; and

* Shy-Drager syndrome (uncommon idiopathic orthostatic hypotension, usually causing severe disability or death within five-to-10 years of onset).

A victim of orthostatic hypotension experiences a rapid loss of consciousness when there is a rapid postural change from reclining to standing or sitting upright. There are generally few or no signs or symptoms of presyncope even for patients with chronic orthostatic hypotension.

Management of these patients is the same as for other unconscious patients, except that after the victim regains consciousness, postural changes from supine to upright should be made very slowly with two or three stops over several minutes. If at any time the patient feels dizzy or lightheaded, raising the chair should be stopped until the sensation has passed. Once again, the victim should be driven home by someone else, especially if there is no prior history of orthostatic hypotension, or if the condition was a result of drugs administered while undergoing dental treatment. A patient with chronic orthostatic hypotension, or with the condition as a result of prescribed medication, may be allowed to drive home if he has recovered sufficiently. Any patient who has no previous history of orthostatic hypotension should be referred for medical care unless the cause is readily apparent, like standing for a long period of time with the knees locked.

Acute adrenal insufficiency is less common but can also cause unconsciousness. Such a person is however, in the most immediate danger of dying. The adrenal gland produces aldosterone and cortisol hormones that allow the body to adapt to stress and are vital to survival. When there is a lack of these hormones, the body is less able to adapt to stressful situations, and this causes symptoms of adrenal insufficiency. Acute adrenal insufficiency can lead to death as a result of peripheral vascular collapse (shock) and ventricular asystole (cardiac arrest).

The major predisposing factor in all cases of adrenal insufficiency is lack of glucocorticosteroid hormones. Insufficiency can result from sudden withdrawal of steroids from a patient who has primary adrenal insufficiency, or sudden withdrawal of steroids from a patient with normal adrenal cortices but with a secondary insufficiency. Administration of exogenous glucocorticosteroids is the most common cause of adrenal insufficiency. Little and Falace state that many patients taking steroids require supplemental steroids in the presence of illness, infection, surgery, or extreme stress. Susceptible patients should receive exogenous glucocorticosteroid coverage before, during and after stressful situations and care should be taken to reduce stress as much as possible. Little and Falace also advise that when treating patients with a history of steroid use, it is better to "overtreat" with additional steroids than to risk acute adrenal crisis because over short periods of time, increased amounts of steroids are safe.[6] According to Malamed, a person who has taken exogenous glucocorticosteroid hormones may not recover normal adrenal function for nine months to two years, and a patient who falls under the Rule of Twos is the most susceptible.[3]

Clinical manifestations of acute adrenal insufficiency that should be considered very serious, especially in a susceptible individual include mental confusion, muscle weakness, intense pain in the abdomen, lower back and legs, signs of hypoglycemia, extreme fatigue, and episodes of syncope. A person with acute adrenal insufficiency may progress into coma and death, so immediate attention is critical.

Management of a conscious patient follows the basic guidelines for treatment of medical emergency with the addition of administering oxygen and glucocorticosteroid from the patient's emergency kit, if available, or from the office emergency kit, if it is included. Medical assistance should be summoned immediately and basic life support provided. Airway maintenance and oxygen are required in virtually all cases and transfer to the hospital is most likely necessary.

Respiratory Emergencies

Since the human body has a constant need for oxygen, there are not many things as upsetting as hearing someone trying desperately to get a breath of air or it seems as though the next breath will never come. It is without doubt even more frightening to be the one gasping for that breath. Some people have conditions such as asthma, emphysema or bronchitis that are a constant threat. However, respiratory difficulties can be triggered by a number of medical problems that are exacerbated by physiological or psychological stress, and even healthy patients can find themselves gasping from hyperventilation brought on by psychological stress.

Recognition of a person at risk, or an extremely anxious healthy person, is very important. Once again, the medical history and attempt to reduce stress as much as possible are the keys to preventing episodes of respiratory distress.

Recognizing the signs and symptoms of respiratory distress allows prompt action that can help solve or alleviate the problem and prevent other emergencies. Besides the obvious unusual noises, such as gasping or wheezing, the person may breathe much faster or more slowly than normal, or breathing may be deeper or more shallow. Skin appearance and temperature are other indications of respiratory difficulty; initially, the skin may be moist and flushed; later, it may be pale, ashen, or cyanotic and feel cool to the touch. The person may verbally express lightheadedness, pain and tightness in the chest, paresthesia (numbness and tingling) of the hands, feet and/or lips. The difficulty being experienced, along with feelings of suffocation, may quite understandably cause fear and apprehension -- stress -- that can in turn cause the problem to worsen.

The two most common causes of respiratory difficulty are hyperventilation and airway obstruction that may occur with vasodepressor syncope. Breathing emergencies can result from other causes such as obstructed airway, asthma, heart failure, myocardial infarction, allergic reactions, inhaling or ingesting toxic substances, cerebrovascular accident (CVA, stroke) and less commonly, drug overdose reaction. Croup, a childhood viral infection and epiglottitis, another childhood illness of bacterial origin, also may cause respiratory distress in children.

The most common respiratory medical emergency in the dental office is Hyperventilation, which is almost always caused by unexpressed extreme anxiety. Hyperventilation occurs when respiration is increased in depth or frequency, most commonly occurring in individuals 15 - 40 years of age who are especially tense and nervous. There are conditions other than stress that can induce hyperventilation, such as head injury, severe bleeding, and hyperglycemia associated with diabetes mellitus. Regardless of the cause, hyperventilation is one of the easiest medical emergencies to correct.

The patient is usually unaware of overbreathing, but may feel unable to take in enough air, or that he or she is suffocating. The person also may experience the subjective feeling of tightness in the chest, globus hystericus (a "lump" in the throat), and lightheadedness or giddiness that in turn can cause even more apprehension. Increased apprehension causes more overbreathing, which then increases symptoms by exacerbating chemical changes, causing more apprehension, and a vicious circle is established.

The goal for treatment of hyperventilation is to break that circle before later clinical manifestations occur such as tingling and paresthesia of hands, feet and perioral area; muscular twitching; carpopedal tetany (a syndrome characterized by flexion of ankle joints, muscular twitching, muscular cramps, and convulsions); and unconsciousness.

Management of this emergency includes positioning the patient in an upright position for comfort; removing any materials from the mouth; and loosening binding clothing, such as a tight collar, belt, or tie. One may calm the patient by offering reassurance of regaining control of breathing. The person should be asked to breathe slowly, only at about four to six breaths per minute. Often, this alone will correct the problem. If this does not work, or if the victim is unable to slow the breathing, rebreathing exhaled air slowly into the cupped hands, into a small paper bag, or into a full face mask from the oxygen delivery unit may help. When the person rebreathes exhaled air, the carbon dioxide necessary to control breathing is replenished. If all these efforts fail, EMS should be called immediately. The airway should be kept open and breathing monitored until EMS personnel arrive and take over. Under no circumstances should oxygen be administered.

Asthma is a disease caused by increased responsiveness of the tracheobronchial tree to various stimuli, which results in bronchospasm, bronchial wall edema, and hypersecretion of mucous glands. Asthma is most frequently seen in children and in twice as many boys as girls. It affects six to eight million Americans, and the frequency and severity of the disease seems to be increasing. Asthma is a killer, with a 100% increase in asthma deaths for children between the ages of 10 and 14.3

A characteristic sign of asthma is wheezing, described as hoarse, whistling sounds on exhalation due to air trapped in the lungs. The typical patient is generally free of symptoms except during acute episodes. Individuals diagnosed with asthma control the frequency of attacks with medications that stop the muscle spasm and open the airway, making breathing easier.

Status asthmaticus, defined as persistent exacerbation of asthma, is the life-threatening condition that occurs when an asthmatic attack does not respond to therapy. Status asthmaticus manifests the same symptoms as any acute asthmatic episode and may occur in any asthmatic patient, but manifestations of the episode continue for a prolonged time, even with treatment. As a result of continuing effects of the acute episode, the person experiences extreme fatigue, dehydration, severe hypoxia (oxygen deprivation) which in turn causes cyanosis, peripheral vascular shock, and drug intoxication from intensive therapy.

Prevention of asthma attack includes using information from the health history to determine factors that may trigger an episode so that steps can be taken to minimize risk. Reduction of stress is important since psychological and physiological stress may precipitate an acute attack in susceptible individuals.

Management of an acute asthmatic episode includes positioning the patient in the most comfortable position, which is usually sitting with arms thrown forward, and administering a bronchodilator. Most asthmatic patients carry their own bronchodilator. Often taking these two steps is the only treatment necessary to terminate the episode. Dental therapy should be discontinued for the day and rescheduled. The patient may be discharged when fully recovered. However, if the episode continues, oxygen should be administered and EMS called immediately.

Heart failure and acute pulmonary edema also can cause respiratory distress. Heart failure is a pathologic state in which abnormal cardiac function is responsible for failure of the heart to pump the volume of blood necessary to meet requirements of tissue metabolism. Heart failure can develop in pulmonary circulation (left heart failure), systemic circulation (right heart failure), or both (congestive heart failure). All pose a significant risk during dental therapy, especially in both psychologically and physiologically stressful situations, which can provoke an acute episode.

A person with left heart failure may exhibit weakness and undue fatigue; dyspnea and tachypnea (abnormally rapid respiration); cough with expectoration; and orthopnea, a condition in which the person can only breath in an upright or seated position. Such a person could not tolerate reclining during dental treatment. Right heart failure is characterized by systemic venous congestion evidenced first by signs of peripheral edema. Right heart failure is usually caused by left heart failure, so symptoms are similar, with the addition of cyanosis and cold skin, especially in extremities, due to decreased blood flow. The patient with right heart failure also may exhibit anorexia, nausea and vomiting, headache, and irritability.

The patient with heart failure is at risk for acute pulmonary edema, a sudden, rapid passage of fluid through membranes from the pulmonary capillary bed into the alveolar spaces of the lungs, usually precipitated by psychological or physiological stress. Signs and symptoms include a rapid onset of severe orthopnea (feelings of suffocation and anxiety) which further increase breathing rate and difficulty. The person may notice a sense of heaviness in the chest, and may exhibit tachypnea, pallor, sweating, cyanosis, and frothy pink sputum (blood tinged saliva and mucous filled with air bubbles).

Management of acute pulmonary edema includes positioning the conscious person in an upright position, and the unconscious person in the supine position. EMS should be activated immediately, the patient calmed as much as possible, vital signs monitored, and basic life support provided. High concentrated oxygen should be administered via nasal cannula, if available. Malamed notes that since the sufferer feels like he is suffocating, a facemask would be uncomfortable. A vasodilator may also be administered until EMS arrives.

A "bloodless phlebotomy" to remove blood from circulation and alleviate symptoms of respiratory distress is a further step that can be taken especially if the patient is in extreme distress and EMS is not immediately present. A tourniquet and/or blood pressure cuff is firmly applied to three extremities, about six inches below the groin and four inches below the shoulder. The constricting strap should be tight enough to be less than systolic blood pressure, but greater than diastolic pressure. For example, if one's blood pressure were 120/80, then 100 would be less than the systolic pressure, but more than diastolic. The purpose of this degree of pressure is for the blood flow to be reduced, but loose enough for the arterial pulse to still be palpable distal to the tourniquet. Every 15 to 20 minutes one tourniquet is removed and placed on the free extremity.

The person who has experienced acute pulmonary edema must be hospitalized. Later dental treatment with appropriate stress reduction should be carried out after consultation with the person's physician.

Additional Emergency Situations

Cerebrovascular accident (CVA, stroke, cerebral apoplexy) is the destruction of brain tissue as a result of intracerebral hemorrhage that can result from a ruptured blood vessel, thrombosis, embolism, or vascular insufficiency. CVA is most common in males aged 60 - 69 years, except for embolism, which commonly occurs from 20 to 70 years of age, usually after age 40. A transient ischemic attack (TIA) is a mini-stroke," or a "temporary stroke" during which signs and symptoms usually last less than eight hours, while some last only 1560 minutes and others less than 24 hours and may signal impending stroke. Intracranial hemorrhage accounts for about 10% of all CVAs, but has the highest mortality rate. Intracranial hemorrhage is usually caused by rupture of an arterial aneurysm.

Sudden unilateral weakness and numbness, or paralysis of the face, arm, or leg are primary symptoms of stroke. The victim may have difficulty speaking or being understood when speaking. Difficulty breathing and swallowing, loss of bowel or bladder control, blurred or dimmed vision with the pupils of the eyes being of unequal size also may be signs. Clinical manifestations of CVA due to hemorrhage also may include a sudden violent headache, nausea and vomiting, chills and sweating, dizziness, and vertigo that may progress to unconsciousness. Unconsciousness in a stroke victim is associated with a grim prognosis with a very high mortality rate.

EMS should be called immediately, vital signs monitored, oxygen admin istered, and BLS provided, as indicated by the patient's condition. The unconscious CVA victim should be positioned in the supine position. If the blood pressure is markedly elevated, the head and chest should be elevated slightly. If available and possible, an IV line should be established using 5% dextrose solution. TIA, symptoms may be gone by the time EMS arrives, but the person may be hospitalized or should at least seek medical attention, especially if there has been no previous history of CVA.

Previously, stroke almost always resulted in irreversible brain damage but new drugs and treatments can now limit the damage. Most treatments for stroke are time sensitive, so it is critical that EMS be summoned as soon as stroke is suspected.

Seizure, a sudden episode of uncontrolled electrical activity in the brain, can be caused by injury, disease, fever (especially in young children), infection, poisoning or often for unknown reasons. When irregular electrical activity of the brain occurs, a sudden discharge of electrical energy can result. A seizure can be described as an episode of altered consciousness, motor activity, and/or sensory phenomena. The area of the brain where the aberration occurs determines the type of seizure experienced. The symptoms of a seizure may be as benign as a momentary break in the stream of thought and activity or may include tingling or twitching of an area of the body, and perhaps hallucinations, intense fear, or feelings of deja vu. If overstimulation of brain nerve cells continues and spreads throughout the brain, the individual may lose consciousness and progress to bilateral jerks of the extremities, involuntary sustained muscular contraction (tonic convulsions) and alternating contraction and relaxation of muscles (clonic convulsions).

Epilepsy is a condition affecting over a million U.S. citizens in which convulsive seizures are recurrent, although not all recurrent convulsions are due to epilepsy. Symptoms can vary from almost imperceptible to the dramatic loss of consciousness followed by paroxysms of tonic-clonic seizures.

Sometimes before a seizure, the person experiences an aura, which can be an unusual sensation, feeling, sound, smell, or urgent need for safety. At one time it was believed that the aura was a warning of impending seizure. However, currently the aura is thought to actually be a part of the seizure. In epilepsy, the aura can serve as a warning of impending attack and may give the patient time to lie down.

Though to a bystander seizures may seem to last a long time, most actually only last from about one to three minutes. Breathing may become irregular or even temporarily stop. The eyes may roll back until only the whites show and the body may become perfectly rigid. Fecal and urinary incontinence is not uncommon. More severe seizures may cause the victim to experience sudden and uncontrollable tonic-clonic muscular contractions that can last several minutes.

Emergency care of the person experiencing a seizure, regardless of the cause or degree of the symptoms, is to protect the victim from harm and maintain the airway should that action become necessary. Attempts to stop the seizure by restraining the individual should not be made. Likewise no attempt should be made to wedge the mouth open to prevent the victim from biting the tongue, which is rare, or "swallowing the tongue", which is impossible. Either of these actions may cause unnecessary injury to both the victim and/or to the person attempting to help. Objects in the vicinity that might cause injury should be removed to protect the person from harm. After the seizure is over, the victim should be positioned on the side to help blood and other fluids drain. The individual may be drowsy and disoriented when the seizure is over and needs to rest. Abnormal breathing sometimes experienced during the seizure will return to normal. The victim should be examined and treated for non-life-threatening injuries incurred during the seizure. Privacy and reassurance should be given. A tonic-clonic seizure is dramatic, but generally self-limiting. According to the American Red Cross, EMS does not normally need to be summoned, except when:

* seizures occur repeatedly; a seizure lasts longer than five minutes;

* the victim appears injured;

* the victim has no history of epilepsy that could have brought on the episode;

* the victim is pregnant;

* the victim is an infant or child experiencing his first febrile seizure;

* the victim is diabetic; or

* the victim does not regain consciousness immediately after the seizure.

Diabetic emergencies are the result of diabetes mellitus, a chronic disorder of carbohydrate metabolism in which insufficient insulin is produced or insulin is not used effectively. Insulin, the hormone produced in the pancreas, helps to regulate the amount of circulating glucose in the blood. Since cells receive nutrition from glucose, without the proper balance of sugar and insulin, they can be damaged or starve and the body will not be able to maintain homeostasis. Diabetes is marked by hyperglycemia (excess glucose in the blood) and glycosuria. Diabetes mellitus affects approximately five million people in the U.S., with about 80% over 45 years of age. The emergency conditions associated with diabetes include hypoglycemia, the most acutely life-threatening, and the slower onset hyperglycemia.

Type I, insulin - dependent diabetes mellitus (IDDM), represents about five percent of all cases of diabetes. It is more common in adolescents, but can occur in adults, especially if it occurs in a non-obese person or late in life. In this form virtually no insulin is produced. Type II, non-insulin-dependent diabetes mellitus (NIDDM) is mostly seen in adults but may occur in some children. In NIDDM, circulating endogenous insulin blood levels are present, but may be in lower than normal or inadequate amounts during times of increased need. Persons with NIDDM do not require exogenous insulin therapy.

Hyperglycemia, a medical emergency of diabetes mellitus, is precipitated by factors that increase the body's need for insulin. Hyperglycemia is not acutely life threatening, but if uncorrected may lead to diabetic ketoacidosis and coma; life-threatening conditions. The most common causes of these emergency conditions are ignorance about the disease or neglect of therapy. Dental therapy is a potential threat since stress increases insulin needs, which in turn can precipitate hyperglycemia even in a person who is normally well controlled. Also, simply having a dental appointment may cause the person to alter normal eating habits which could create an insulin imbalance. Malamed suggests that after extensive dental treatment, the patient should be instructed to check blood glucose levels at least four times a day for several days, and make dosage adjustments. If there are questions either from the oral health care professional or the patient, the physician should be consulted.[3]

Clinical manifestations of hyperglycemia depend on the severity of the condition and the length of time the patient has had the disease. The classic trio of "polys", polydipsia (excessive thirst), polyphagia (excessive hunger), and polyuria (excessive urination), especially with marked weight loss may have been evident for a day or two before the hyperglycemic episode. Some other possible symptoms include itching, frequently about the genitals, marked fatigue, weight loss, headache, blurred vision, abdominal pain, constipation, nausea and vomiting, dyspnea, and mental stupor. Over time, if diabetic hyperglycemia is not treated, the person can progress to physical weakness, fruity-sweet acetone breath, florid (bright red) face, and hot dry skin. Respiration is deep and rapid, tachycardia and hypotension are noted, diabetic coma may ensue and permanent disability or death may result.

Management of the conscious possibly hyperglycemic patient consists of recognizing the condition and referring the patient to a physician for evaluation and treatment. No dental therapy should be performed while diabetic hyperglycemia is suspected. EMS should be called immediately for the unconscious patient. The patient should be placed in the supine position and basic life support begun.

Hypoglycemia, usually a result of exogenous insulin therapy, is an acute life-threatening condition. It can result from an insulin overdosage or failure to maintain normal food intake, usually by delaying or omitting meals. It is generally manifested in patients receiving insulin therapy, but has also been seen in patients treated with oral hypoglycemic agents, although the condition is less acute in such cases. Although somewhat rare, it is also possible in a person who does not have diabetes.

Hypoglycemia is a true immediate life-threatening condition with acute onset and may rapidly progress to loss of consciousness. The first manifestations of hypoglycemia are the result of diminished cerebral function resulting from a lack of nutrition to brain cells. Symptoms include decreased spontaneity of conversation, inability to perform simple calculations, lethargy, incoherence, uncooperativeness, and mood changes. A person experiencing diabetic hypoglycemia is sometimes mistaken as being drunk or on drugs. Other symptoms may include hunger, nausea, increased gastric motility (growling stomach), sweating, tachycardia, piloerection (hair feels as if it is standing on end) and cold and wet skin.

If symptoms are permitted to progress without corrective action, the person may lose consciousness and experience seizures.

Prompt recognition of a diabetes-related emergency is crucial. The most telling differentiation between hyperglycemia and hypoglycemia is that the hyperglycemic person has a hot and dry appearance and acetone odor; the hypoglycemic person has cold, wet appearance and bizarre behavior.

Malamed emphasizes that any diabetic patient who behaves in a bizarre manner or who loses consciousness should be managed as if he were hypoglycemic until proved otherwise since this condition is an IMMEDIATE THREAT TO LIFE.

A cooperative patient with signs and symptoms of hypoglycemia should be given oral carbohydrates, such as sugar or sugared drink. Recovery is usually rapid and dramatic. When a person does not respond to carbohydrates or will not cooperate, EMS should be called. If available, a parenteral carbohydrate, such as glucagon or IV dextrose solution should be given, the patient monitored, and BLS provided as indicated. For unconscious patients, EMS should be summoned immediately and BLS provided. Definitive management includes the administration of CHO by the most effective method possible, but liquids should never be given.

Myocardial infarction (MI) or heart attack occurs when there is deficient arterial blood supply to a portion of the myocardium resulting in deprivation of oxygen and nutrition to the cells of the heart muscle. The lack of oxygen and nutrition for a long enough period of time can cause cellular necrosis. Angina pectoris occurs when there is a temporary insufficient supply of oxygen to the heart muscle. Angina pectoris and myocardial infarction both cause chest pain. The primary differentiating symptoms are in the type of pain experienced and duration of symptoms.

Mild exercise, stress and/or anxiety increase the demand for oxygen and precipitate episodes of angina pectoris. The victim may describe the pain as a squeezing, as heaviness, or a dull ache that lasts only from one to 10 minutes. A person with angina pain generally has had a previous diagnosis of angina pectoris. These individuals usually carry nitroglycerin to relieve the symptoms of an acute attack by widening the arteries and allowing more blood to flow to the myocardium. Also, ceasing the physical activity or other provoking stimulus to reduce the added need for oxygen to the heart may also shorten the episode. Vital signs are generally normal during an anginal episode.

A person experiencing an anginal episode should be placed in a comfortable position and given their own vasodilator, either nitroglycerin tablet under the tongue, or nitrolingual spray. Oxygen also may be administered. The symptoms should be relieved within two to three minutes. After the episode passes, it is best to let the patient rest before continuing dental treatment or reschedule for another day to continue. If the pain is not relieved, oxygen should be provided and the person assisted in taking a second dose of nitroglycerin. After waiting another two to three minutes, a third dose may be administered if necessary. No more than three sprays or three tablets should be administered within a 15-minute period. If pain is not relieved in the known angina pectoris patient within 10 minutes, the American Heart Association recommends that emergency care be sought immediately.

MI is of longer duration than angina and is characterized by more intense pain. The pain has been described as ranging from discomfort to a crushing s. ubsternal pain that can radiate to the shoulder, arm, neck, or jaw. Resting, changing position, or taking nitroglycerin does not relieve the pain. Often the victim has dyspnea, is short of breath, and/or breathes noisily and faster than normal. The skin may be pale, ashen, or cyanotic, and there may be sweating. Some victims may be nauseated and may vomit.

Since MI can lead to cardiac arrest, immediate recognition and action are critical. Once a heart attack victim goes into cardiac arrest, the chances of survival decrease. Most deaths from MI occur within the first two hours after the signs and symptoms occur. EMS should be summoned immediately if there is any reason to suspect heart attack. The person should be assisted to rest as comfortably as possible. Vital signs should be monitored and preparation to give CPR begun, in case the person goes into cardiac arrest.

Anaphylaxis is an acute life-threatening severe allergic reaction. It can result from contact with drugs, foods, or chemicals, or from the bite or sting of insects to which the person is allergic. The symptoms may initially include skin reactions such as swelling, redness, rash, or hives; then progress to respiratory distress from swollen air passages and eventually to life-threatening shock.

The primary response following contact with the allergen should be to observe the person carefully for signs of allergic reaction. At the first sign of respiratory difficulty, EMS should be summoned. The person should be assisted to a position that allows easier breathing and if available, epinephrine should be given. Many severely allergic patients carry their own anaphylaxis emergency kit, but dental facilities should keep epinephrine in the emergency kit. The patient should be monitored and BLS begun as warranted.


Regardless of how well one is trained, or how frequently he or she has to deal with life and death situations, some degree of doubt or fear is normal when confronted with an emergency. When someone's life is at risk, emergency help is vital and cannot wait. Following the basic rules for providing basic life support, or at the very least remembering to call 911, may save a life. According to the American Red Cross: "The worst thing to do is nothing."[5]

In most states Good Samaritan laws give legal protection to those who provide emergency care as long as the victim is not being charged for the emergency care and the person providing the care does not exceed the scope of their training for medical emergencies. Individuals who provide care in an oral health care facility have an obligation to provide a higher level of emergency care than one would expect in a grocery store or other nonmedical facility.

Management of a medical emergency is an ethical, moral, legal, and professional obligation owed by oral health care personnel to any patient who enters the dental office. An emergency can occur not only to dental patients, but also to oral health care personnel themselves, to relatives or friends who accompany patients, or to individuals who enter the dental office for other reasons. The best policy is to prevent what can be prevented and be prepared for what cannot be prevented. The information in this paper is not all-inclusive. Readers are urged to seek other sources of information about managing medical emergencies, and to always, always keep CPR certification up-to-date.

CREDITS 2 hours

COURSE GOALS: The purpose of this continuing education course is to provide an overview/review of the prevention, recognition, and management of the medical emergencies most likely to occur in the dental office. Each potential emergency includes a brief synopsis of the pathophysiology, signs and symptoms, and emergency treatment of the condition.


Upon completion of this continuing education course, the learner will be able to:

* Discuss why there is need for dental hygiene practitioners to know how to prevent medical emergencies and what to do should they arise.

* Identify precautionary steps that may prevent medical emergencies from occuring.

* Describe how dental hygiene practitioners and the dental office can be prepared in the event a medical emergency arises.

* List information that should be provided in the event EMS must be summoned.

* Delineate immediate and common management steps to be taken for most emergency situations.

* Provide a brief pathophysiology, signs and symptoms, and prevention and emergency procedures for the following specific conditions:

* Vasodepressor syncope

* Orthostatic hypotension

* Acute adrenal insufficiency

* Hyperventilation

* Asthma

* Heart failure and acute pulmonary edema

* Cerebrovascular accident

* Seizure

* Hyperglycemia

* Myocardial infarction

* Angina pectoris

* Anaphylaxis


Rule of Twos

Adrenocortical suppression should be suspected if a patient has received glucocorticosteroid therapy:

* in a dose of 20 mg or more of cortisone or its equivalent daily

* for a continuous period of two weeks or longer orally or parenteral

* within two years of dental therapy

If there is any possibility that loss of consciousness is in any way related to a deficiency of glucocortcosteroids, the immediate administration of 100 mg of hydrocortisone succinate may prove to be a life-saving procedure.


Suggested Readings

* American Medical Association: Home Medical Encyclopedia. New York, Random House, 1989.

* Braun R J, Cutilli B J: Manual of Emergency Medical Treatment for the Dental Team. Baltimore, Williams & Wilkins. 1999.

* Bricker SL, Langlais RP, Miller CS: Oral Diagnosis, Oral Medicine and Treatment Planning. Philadelphia, Lea & Febiger, 1994.

* Coleman G, Nelson JF: Principles of Oral Diagnosis. St. Louis, Mosby Year Book, 1993.

* Stoltenberg J: Medical History Evaluation and Management of Medical Emergencies. University of Minnesota, 1998.

* Taber's Cyclopedic Medical Dictionary, 18th ed. Philadelphia, F.A. Davis Company, 1997.

* The Fifth Report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. NIH Publication, 1993.

clip & use Key Terms


A substance that causes allergic reactions in susceptible individuals.


Severe potentially life-threatening allergic reaction. Also called anaphylactic shock.


Condition in which there is urticaria and edema in areas of skin, mucous membranes or internal organs.


Lack of oxygen in tissues (also see hypoxia).


A protein developed by the body in response to an antigen.


Any substance that, under the right conditions, can cause the formation of antibodies. Examples are toxins, bacteria, and foreign proteins, such as blood cells.


The reaction between the antigen and antibody that forms the basis of the immune response.


Cessation of breathing.


A common form of arteriosclerosis in which plaques containing cholesterol and other fats fill the intima (innermost coat) of blood vessels.


Hereditary tendency to develop an allergy.


Alternating contraction and relaxation of muscles.


State of unconsciousness from which a patient cannot be aroused by external stimuli.


Lack of orientation with respect to time, place and/or self.


Orientation with respect to time, place and self, with responsiveness of the mind to impressions made by the senses.


Spasms including involuntary muscular contraction and relaxation. (see clonic).


Mental confusion and excitement, sometimes with hallucinations and/or aimless physical activity.

diabetes mellitus

Disorder of carbohydrate metabolism due to an inability of the body to produce or utilize insulin to regulate the amount of circulating glucose. Insulin is produced in the beta cells of the islets of Langerhans in the pancreas.


A spinning sensation or a sensation that one is falling.


Difficulty breathing.


Any recurrent seizure pattern, but most commonly used to describe sudden, brief attacks of altered consciousness and convulsions.


Temporary loss of consciousness.


A condition characterized by circulating glucose in the blood in excess of physiologic need.


Increased respiratory rate or deeper than normal breathing.


Abnormally prolonged and deep breathing usually associated with acute anxiety or emotion, which causes alkalosis, and can eventually cause loss of consciousness.


A condition characterized by inadequate circulating glucose in the blood to meet physiologic need.


Diminished availability of oxygen to body tissues. Deficiency of oxygen in inspired (breathed in) air.


A seizure or sudden attack.


Insulin dependent diabetes mellitus. The patient requires exogenous insulin injections.


Non-insulin dependent diabetes mellitus.


Difficulty breathing when in any position except sitting or standing upright.


Severe itching.


Inhaling and exhaling air, which causes the taking in of oxygen by breathing in, utilization of oxygen at the tissue level and giving off carbon dioxide by breathing out.

seizure A sudden attack, a convulsion.

status asthmaticus

A sustained and severe episode of asthma that does not adequately respond to normal treatment.

status epilepticus

Repeated episodes of epileptic seizures without respite and that do not adequately respond to normal treatment.

stertorous breathing

Labored breathing with snoring sounds usually due to partially obstructed upper airway.


A transient loss of consciousness due to inadequate blood flow to the brain, a simple faint.


Abnormally rapid heart rate.


Abnormally rapid respiratory rate.


Sustained muscular contraction.


State of being unaware or without conscious experience.


Transient appearance of papules or wheals that cause intense itching, also known as hives.


Slightly elevated patch that either redder or paler than the normal skin color, or may be white in the center with a pale red periphery and cause itching.
Medical Consultation Form:




Dear Dr.--

The above named patient is seeking dental care
in our office. In order to provide the best care
possible, it is necessary that we know the following
information. The patient indicates a history of:

--cardiovascular accident
--prosthetic heart valve
--mitral valve prolapse
--renal disease
--pulmonary disease
--systematic lupus eythematous
--Marfan's syndrome
--Prescription diet drugs
(i.e. Pondimin/phenteramine combination)
--adrenal insufficiency or steriod therapy
--rheumatic heart disease
--heart murmur
--systematic-pulmonary artery shunt
--drug allergies
--hepatitis A or B (circle one)
--renal dialysis with shunts
--liver disease
--anticoagulant therapy
--prosthetic joint
--radiation therapy to head and neck
--pacemaker, type--

Treatment to be performed on this patient includes:

--oral surgical procedures including extractions
--deep scaling and root planing
--dental radiography
--endodontic treatment (root canals)
--local anesthetics (tropical and injectible)
--oral prophylaxis (to include some of epithelial tissue)

Possible consideration are:

--bleeding with trasient bacteremia
--prolonged bleeding
--pacemaker interference due to use of ultrasonic scaling devices

We are requesting a medical consultation for this patient.
Please indicate appropriate response below.

1. This patient's current medications include:--

2. This patient requires no prophylatic antibiotic premedication
regimen for the indicated procedures.--

3. This patient requires prophylactic antibiotic coverage for
the prescribed dental procedures. Please indicate regimen if
other than standard AHA regimen.--

4. This patient may not receive dental treatment at this time.

5. This patient may receive limited dental treatment at this time.

6. Comments: Please use reverse side.


Physician's Signature--

Supplementary Activities:

* Visit Procter & Gamble's Web site: for additional information. Click on Research Resources, then click on Internal Medicine. At least the following are available: Hypertension, Effects of Hypertension, Congestive Heart Failure, Diadetes, and Epilepsy.

* Visit Procter & Gamble's Web site: for additional continuing education courses. At least the following are available under Courses for Dental Hygienists: Seizure Disorders, and Asthma (under Courses for Dentists).

The Program

* Your Results

Expect to wait six-to-eight weeks for your results to be mailed.

* Credit

Continuing Education Hours: 2

If you have specific questions about the C.E. requirements in your state, or if you're not sure if the course will be accepted, please consult your state dental board. See page 156 for more details.

* Directions

After you study the course, please complete this test by checking the best answer. When you have finished, transfer your answers to the answer sheet on the right, complete the forms, detach, and submit it along with the processing fee(*) to ADHA. Only one original answer sheet per individual will be accepted--photocopies are not valid. Answers left blank will be graded as incorrect.

* Scoring

In order to receive credit, you must correctly answer 14 out of the 20 questions.

* Processing

Complete this form and mail it, along with a check or money order for the processing fee(*), made payable to:


* Questions?

Contact Wesley Blaszczynski at: 312/4408924

(*) Course processing fee varies depending on ADHA membership status

This Continuing Education Course Is Sponsored by Optiva Corporation

Post Test #02-00

1. Which of the following is a primary reason that a practicing dental hygienist can expect to encounter medical emergency during the course of his or her practice?

a. The approximate 30-year increase in life expectancy from the early 1900s until 2000.

b. Many more medically compromised patients are seen in dental offices than ever before.

c. The decreased use of prescription drugs.

d. a & b

e. All the above.

2. Which of the following is the most important aspect in the prevention of life-threatening emergencies.

a. Routinely asking the patient to complete a health history.

b. Having the patient provide a complete listing of drugs he or she has been prescribed.

c. Purchasing a current drug reference.

d. Being completely familiar with the patient's medical history and current condition.

e. b and c


[1.] McCarthy F: Essentials of Safe Dentistry for the Medically Compromised Patient.

[2.] Requa-Clark B: Applied Pharmacology for the Dental Hygienist

[3.] Malamed SF: Medical Emergencies in the Dental Office, 5th ed. St. Louis, Mosby, 2000.

[4.] Chernega: Emergency Guide for Dental Auxiliaries, 2nd ed. Albany, NY, Delmar Publishers Inc., 1994.

[5.] American Red Cross: Responding to Emergencies, 2nd ed. St. Louis; Mosby Lifeline, 1996.

[6.] Little, W, Falace D: Dental Management of the Medically Compromised Patient, 5th ed. St. Louis, The C.V. Mosby Company, 1997.

Patricia Nunn, RDH, MS, is chair of the Department of Dental Hygiene at the University of Oaklahoma College of Dentistry in Oklahoma City. She has been in dental hygiene education for more than 27 years. She has taught at the University of Louisiana and Costal Bend Community College in Texas. Nunn has been a clinical columnist for Access magazine and has written widely about oral health care topics.
COPYRIGHT 2000 American Dental Hygienists' Association
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2000 Gale, Cengage Learning. All rights reserved.

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Author:Nunn, Patricia
Publication:Journal of Dental Hygiene
Geographic Code:1USA
Date:Mar 22, 2000
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