Medical Emergencies in the Dental Office
Diana, a 25-year old patient, undergoes a tooth extraction under local anesthesia in the dental clinic. Shortly after receiving the local anesthetic, Diana begins to show signs of respiratory distress. Dr. Williams, the dentist, suspects a systemic adverse reaction and immediately calls for help, as Diana becomes unconscious. Cardiopulmonary resuscitation (CPR) is indicated and initiated with chest compressions. Ann, the dental hygienist, activates emergency medical services (EMS) by calling 911 and clearly states the emergency. David, a dental assistant, obtains the automated external defibrillator (AED) and emergency kit, which are readily available.
Dr. Williams continues CPR, cycles of 30 compressions and two ventilations, and Ann attaches the AED and follows the prompts until EMS arrives. David documents vital signs on a recording sheet while the receptionist, Mary, waits at the building entrance for EMS. EMS arrives, and the patient is stabilized, returned to normal breathing and circulation, and is taken to the hospital for further monitoring and evaluation. As a result of the team’s effort, Diana received the appropriate level of emergency care.
Together, the team provided an immediate response to this emergency. Each staff member took on an assigned role they had practiced during mock drills and applied skills learned in basic life support (BLS) training. After the event, a debriefing was held, and the team discovered that the patient had been sensitive to local anesthetics in the past. The dental practice is fully committed to performance improvement opportunities and acquires additional information on preventing and responding to medical emergencies.
The Bottom Line
Potentially life-threatening medical emergencies can occur in the dental office setting. Medical emergencies may be directly related to a dental therapy or manifest from underlying medical conditions. Early effective treatment is essential. Dental providers and staff should be trained on the prevention, recognition, and collaborative management of medical emergencies before a medical emergency occurs. Listed below are specific actions health centers and free clinics can take to prepare for, prevent, recognize, and manage medical emergencies.
Target 1. Know your patients
- Instruct patients or caregivers to complete a medical/dental history questionnaire before any dental treatment and ensure information is updated at every visit. The questionnaire should include medical and dental history changes since the last visit, new medications, allergies, and a pain assessment.
- Complete an assessment and physical examination tailored to meet the needs of the proposed procedure and anesthesia, including the following:
- Review of current medications and allergies
- Visual inspection of the patient’s airway
- Monitoring and recording of the patient’s vital signs (blood pressure, heart rate and rhythm, and respiratory rate) before treatment; for medically compromised patients, the American Dental Association (ADA) recommends taking a patient’s blood pressure at every visit, based on findings of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure
- Complete a risk assessment by assigning a physical status category to the dental patient receiving conscious sedation, based on the American Society of Anesthesiologists physical status classification system.
- Consult with the patient’s primary care physician or specialists when appropriate to mitigate risk.
Target 2. Prepare for medical emergencies by implementing prevention strategies
- Ensure all staff is trained in BLS and that each person knows what to do and can act promptly.
- Conduct a Survey on Preparedness for Medical Emergencies in the Dental Practice.
- Provide response guide and resources for staff training and reference.
- Develop a written action plan, including an in-office emergency response team, with specific roles and assigned duties.
- Conduct mock emergencies, with reflective debriefing and the use of a crisis checklist, to help office staff become more confident when a real emergency occurs.
- Check with state dental associations or the facility’s state’s board of dental practice to establish required emergency drugs and equipment.
- Perform routine checks on medical emergency supplies and medication inventory, including expiration dates and battery life as applicable.
- Implement stress reduction strategies such as providing premedication for anxious patients; scheduling patients who are medically compromised or who have heightened anxiety early in the day, and keeping the visit as short as possible; minimizing wait times in the reception area or dental chair; and using non-pharmaceutical techniques such as music and video.
Target 3. Recognize early warning signs and clinical manifestations of patient distress
- Before any dental treatment, assess the patient’s level of pain, fear, stress, and anxiety. Heightened anxiety and fear can lead to an acute exacerbation of medical problems such as hypertension, angina pectoris, seizures, asthma, and other stress-related problems such as hyperventilation and vasodepressor syncope.
- Educate staff on the signs and symptoms of common medical emergencies such as syncope, anaphylaxis, asthma attack (bronchospasm), hypoglycemia, seizures, angina, myocardial infarction, or partial or complete airway obstruction (e.g., foreign body aspiration).
Target 4. Implement a clear and concise protocol for managing and responding to medical emergencies
- Implement basic protocol in managing medical emergencies by following BLS and P (position) → C (circulation) → A (airway) → B (breathing) → D (definitive care) (PCABD) algorithms.
- Delegate assigned team members quickly who will, for example, stay with the patient and administer BLS with AED as needed, activate EMS, obtain the emergency drug kit or equipment, monitor vital signs and assist with BLS, keep a written timeline of events, and hold doors in the lobby or building while awaiting the arrival of EMS.
- Consider a checklist or scripting of information to provide when calling EMS.
- Use effective communication techniques such as SBAR (situation, background, assessment, and recommendation), call-out, and check-back to clearly and accurately exchange information during emergencies.
Want to learn more? See the guidance articles Office Medical Emergencies and Managing Risks in Ambulatory Care and the Risk and Safety E-News item Sedating Children for Dental Work: Safety Considerations.
All resources are provided for FREE by ECRI on behalf of HRSA. Don’t have access or want to attend a free, live demonstration of the website? Email [email protected] or call (610) 825-6000 ext. 5200. Additional resources include the ADA Medical Emergencies in the Dental Office, resources from the National Network for Oral Health Access, and the American Academy of Family Physicians Mock Emergency Evaluation Tool.