CHAPTER 8 Medical Emergencies

Margaret M. Walsh

Competencies

image Recognize persons at high risk for a medical emergency.
image Demonstrate protocols for performing Basic Life Support in adults, children, and infants.
image Demonstrate protocols for managing victims with partial airway obstruction and complete airway obstruction.
image Identify signs and symptoms of specific medical emergencies and appropriate treatment for each.
image List basic equipment and drugs for managing medical emergencies in the oral care environment.

Life-threatening emergencies can and do happen in the oral healthcare setting. Although the occurrence of such emergencies is infrequent, many factors increase the likelihood of such incidents during oral healthcare. These factors include the increasing number of older, medically compromised adults seeking care, medical advances in drug therapy, increased number of surgical procedures (e.g., dental implants), longer appointments, and the increasing use of drugs in the oral healthcare setting such as local anesthetics, sedatives, analgesics and antibiotics.1 Fortunately, other preventive factors minimize the occurrence of life-threatening incidents. These factors include a client pretreatment physical assessment consisting of a thorough health history questionnaire with special attention to medication usage and vital signs; an interview dialogue history; observation of general physical status using the American Society of Anesthesiologists (ASA) physical status classification (Box 8-1); anxiety recognition; and possible modification of care to minimize medical risks1 (see Chapter 10Chapter 11Chapter 12Chapter 37). Comprehensive documentation of all assessment findings is made in the client’s record and updated at each subsequent visit. The dental staff must be prepared to assist in the recognition and management of any potential emergency situation. Should a medical emergency arise, thorough knowledge of medical emergency protocols, well-trained office personnel, and availability of appropriate, well-maintained emergency equipment are vital in obtaining the best possible outcome.1

BOX 8-1 The American Society of Anesthesiologists (ASA) Physical Status Classification

Adapted from Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, Mosby, 2007.

ASA I: Healthy; no systemic disease
ASA II: Mild systemic disease
ASA III: Severe systemic disease that limits activity but is not incapacitating
ASA IV: Incapacitating systemic disease that is a constant threat to life
ASA V: A moribund patient not expected to survive 24 hours with or without an operation
ASA E: Emergency operation of any variety, with E preceding the number to indicate the patient’s physical status (e.g., ASA E-III or ASA E-IV)

Normally, oral healthcare is received in the hospital setting due to high-risk nature of health condition.

PREVENTING MEDICAL EMERGENCIES

Office Personnel and Environment Preparation

Preparation of all dental staff members and the office for medical emergencies should include:

image Staff training in Basic Life Support (BLS), practice in medical emergency surprise drills, and an annual refresher course in emergency medicine that includes all possible conditions, such as seizures, respiratory difficulty, and chest pain
image Posting of emergency assistance numbers
image Stocking of emergency drugs and equipment

Client Assessment

Client assessment data are used to create a care plan that will reduce the likelihood of a medical complication. If a client is found to be at high risk, the dentist and the client’s physician of record are consulted (Box 8-2). Medical consultation is obtained after the client’s dental and physical evaluation has been completed. The dental professional should be prepared to discuss fully with the physician the proposed oral healthcare plan and any anticipated problems. Based on this consultation the care plan is modified, or medications may be modified, to avoid emergencies. Reduction of the stressful environment by careful appointment planning, good communication and client rapport, and administration of antianxiety premedication also can improve clinical outcomes. The primary goal in the client assessment process is to determine the client’s physical and psychologic ability to handle the stress of the planned oral healthcare.1

BOX 8-2 Medical Consultation

Adapted with permission from Dr. W.H. Davis, Bellflower, California.

Obtain the client’s medical, dental, and pharmacologic histories.
Complete the physical assessments, including both oral examination and vital signs.
Provide a tentative care plan based on the client’s oral needs.
Make a general systemic assessment (choose a physical status category).
Consult the client’s physician, when appropriate, via telephone:
Physician’s receptionist:
Introduce yourself and give the client’s name.
Ask to speak with the physician.
Physician:
Introduce yourself.
Give the client’s name and the reason for the visit to you.
Relate briefly your summary of the client’s general condition.
Ask for additional information about the client.
Present your care plan briefly, including medications to be used and the degree of stress anticipated.
Discuss any problems.
After consultation, write a complete report of the conversation for records, and obtain a written report from the physician if possible.

Most health history forms include a medical alert box. This blank box usually appears on the top corner of the health history form. If a client has a condition (e.g., allergy, hypertension, adrenal insufficiency, requirement for antibiotic premedication) that if unrecognized places the client at risk for a medical emergency, this condition is written in red in the medical alert box clearly visible on the top of the health history form. The practitioner can then consider this condition as the care plan is developed and implemented.

Anxiety Recognition

Heightened anxiety and fear of dental care can lead to an acute exacerbation of medical problems such as angina, seizures, and asthma, as well as other stress-related problems such as hyperventilation and syncope (fainting). One of the goals of client assessment is to determine whether a client is psychologically capable of tolerating the stress associated with the planned care. Three methods of recognizing the presence of anxiety are the health history, the Dental Anxiety Questionnaire, and direct observation.1

Health History

Comprehensive health history questionnaires include one or more items relating to the client’s attitudes toward professional oral healthcare. An affirmative response to any question on the health history relating to prior negative dental experiences alerts the clinician to initiate a more in-depth discussion with the client to determine the cause of the fear and to discuss strategies available to help reduce fear and anxiety.

Dental Anxiety Questionnaire

An additional aid in the recognition of anxiety is the Dental Anxiety Questionnaire (see Chapter 37Figure 37-2Figure 37-3).2 This questionnaire has been reported to be a reliable aid in the recognition of anxiety. Answers to individual questions are scored 1 through 5 with response option “a” being assigned a score of 1 and response option “e” being assigned a score of 5. The maximum score possible is 20. Scores of 8 or above are associated with higher-than-normal anxiety levels and indicate that client anxiety needs to be addressed by the clinician before oral healthcare begins.

Direct Observation

Careful observation may permit recognition of unusually anxious individuals. Severely anxious individuals may be recognized by the following:

image Increased blood pressure and heart rate
image Trembling
image Excessive sweating
image Dilated pupils

Severely anxious persons most commonly appear in the dental office when they have a severe oral infection accompanied by a severe toothache. Although these individuals wish to have their dental problems alleviated, their underlying dental fear often makes it impossible for them to tolerate the procedure. As a result, severely anxious individuals usually are candidates for the use of either intravenous (IV) sedation or general anesthesia for dental treatment. A moderately anxious client (Box 8-3), however, is usually managed effectively by conscious sedation (Chapter 40) and/or behavioral techniques (Chapter 37).

BOX 8-3 Clinical Signs of Moderate Anxiety

Reception Area

Questions receptionist regarding injections or use of sedation
Nervous conversations with others in reception area
History of emergency dental care only
History of canceled appointments for nonemergency treatment
Cold, sweaty palms

In Dental Chair

Unnaturally stiff posture
Nervous play with tissue or handkerchief
White-knuckle syndrome
Perspiration on forehead and hands
Overwillingness to cooperate with clinician
Quick answers

Stress Reduction Protocols

Many medical emergencies are associated with stress. The stress-reduction protocols listed in Box 8-4 are based on the belief that the prevention or reduction of stress should start before the dental appointment, continue throughout treatment, and follow through into the postoperative period, if necessary.1

BOX 8-4 Stress-Reduction Protocols

Normal, Healthy, Anxious Client (ASA I)

Recognize the client’s level of anxiety.
Premedicate the evening before the dental appointment, as needed.
Premedicate immediately before the dental appointment, as needed.
Schedule the appointment in the morning.
Minimize the client’s waiting time.
Consider psychosedation during therapy.
Administer adequate pain control during therapy.
Length of appointment variable.
Follow up with postoperative pain and anxiety control.
Telephone the highly anxious or fearful client later the same day that treatment was delivered.

Medical Risk Client (ASA II, III, IV)

Recognize the client’s degree of medical risk.
Complete medical consultation before care, as needed.
Schedule the client’s appointment in the morning.
Monitor and record preoperative and postoperative vital signs.
Consider psychosedation during therapy.
Administer adequate pain control during therapy.
Length of appointment variable; do not exceed the client’s limits of tolerance.
Follow up with postoperative pain and anxiety control.
Telephone the higher medical risk client later on the same day that treatment was delivered.
Arrange the appointment for the highly anxious or fearful, moderate- to high-risk client during the first few days of the week (Monday through Wednesday in most countries; Saturday or Sunday through Monday in many Middle Eastern countries) when the office is open for emergency care and the treating doctor is available.

Recognition of Unconsciousness

Unconsciousness, whatever its cause, must be recognized quickly and managed effectively. In all cases in which loss of consciousness occurs, several basic life support steps must be implemented as soon as possible (Figure 8-1).

image

Figure 8-1 Dental hygiene actions taken in an emergency situation when client loss of consciousness occurs.

BASIC LIFE SUPPORT SEQUENCE

Basic Life Support (BLS), also known as P-A-B-C (positioning, airway, breathing, circulation), consists of applying, as needed, the procedures of positioning (P), airway maintenance (A), breathing (B), and circulation (C) to any medical emergency victim. These procedures are applied until recovery, until the victim can be stabilized and transported to an emergency care facility, or until advanced life support is available. Cardiopulmonary resuscitation (CPR) and emergency cardiac care include defibrillation (D) as part of BLS for healthcare providers.3 All dental personnel need to be certified at least at the level of BLS for the healthcare provider. In addition, all dental personnel need to be trained together at least annually so that they may interact effectively as a team when medical emergencies arise. BLS courses are sponsored by many organizations, including the American Heart Association, the American Red Cross, and fire departments.

The BLS sequence follows.

Recognition of Unconsciousness

The unconscious person is one who does not respond to sensory stimulation such as shaking and shouting “Are you alright?” (Figure 8-2). Pain is another stimulus that may be used to determine the client’s level of consciousness. Pinching of the suprascapular region usually evokes a motor response from a conscious person.1 Lack of response to this stimulation indicates the person is unconscious.

image

Figure 8-2 Unconsciousness is determined by performing the “shake-and-shout” maneuver, gently shaking the shoulders and calling the client’s name.

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

Terminate Dental Hygiene Care, Summon Assistance, and Position the Client

As soon as the loss of consciousness is recognized, the hygienist terminates the dental hygiene procedure, activates the office emergency team, and places the unconscious person into the supine (horizontal) position. In the supine position, the brain is at the same level as the heart and the feet are slightly elevated to a 10- to 15-degree angle. A major objective in the management of unconsciousness is the delivery of oxygenated blood to the brain. The horizontal position helps the heart to accomplish this, and elevating the feet further increases the return of blood to the heart (Figure 8-3). Any extra head supports such as pillows need to be removed from the headrest of the dental chair when the client loses consciousness (Figure 8-4).

image

Figure 8-3 Placement of unconscious client in the supine position with feet slightly elevated.

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

image

Figure 8-4 Any extra head support should be removed from the headrest of the dental chair when the client loses consciousness.

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

Assessment of Airway, Breathing, and Circulation

After the unconscious person is positioned (P), the next step is to assess and maintain an open airway (A), check for breathing (B), and check for circulation (C) (Procedure 8-1). If breathing and pulse rate are below normal limits, summon help to call for emergency medical services (EMS) (e.g., 911 in the United States and Canada; 000 in Australia; 119 in Japan; 112 or 999 in the United Kingdom; and 112 in most of Europe; standard on Global System for Mobile Communications [GSM] mobile phones). See Box 8-5 for information to be given to the EMS dispatcher.

Procedure 8-1 INITIAL ASSESSMENT

EQUIPMENT

Resuscitation mask and other protective barriers

STEP 1

Tap the person on the shoulder and shout, “Are you okay? Are you okay?” (For an infant, gently tap the shoulder or flick the foot.) (See Figure 8-2.)

STEP 2

If no response, summon help to call emergency medical services (EMS) (e.g., 911) and to bring an automated external defibrillator (AED) in case it is needed.

STEP 3

Place the unconscious client in the supine position with feet slightly elevated (See Figure 8-3).

STEP 4

Open victim’s airway:

Tilt the head back and lift the chin. Place one hand on the victim’s forehead and apply firm, backward pressure with the palm to tilt the head back. Place fingers of other hand under the bony part of the jaw near the chin, and lift to bring the chin forward and the teeth almost to occlusion (Figure 8-10).
If you suspect neck injury, use the jaw-thrust maneuver: Grasp angles of the victim’s lower jaw and lift with both hands, thus displacing the mandible forward while tilting the head backward (see Figure 8-8).
Look, listen, and feel for normal breathing and chest movement for no more than 10 seconds. Place your ear over victim’s mouth and nose while maintaining an open airway. Look at victim’s chest to check for rise and fall (Figure 8-11).
Irregular, gasping, or shallow breathing is not normal breathing.

STEP 5

Check the pulse:

For an adult or child, assess for presence of the carotid pulse for no more than 10 seconds (see Figure 8-9).
For an infant, check the brachial pulse on the inside of the upper arm between the infant’s elbow and shoulder.

STEP 6

If there is a pulse but no movement or breathing:

Position the resuscitation mask over the victim’s nose and mouth, tilt the head back, and lift the chin to open the airway.
Form an airtight seal with the mask against the face, and give two rescue breaths by breathing into the mask (one breath every 5 seconds for adults) (Figure 8-12).
If there is no mask, perform two rescue breaths via mouth-to-mouth resuscitation (see Procedure 8-2).
Each rescue breath (one breath every 5 seconds for adults) should last about 1 second and make the chest clearly rise.
Note: For a child, the head is only slightly tilted past the neutral position. One breath is delivered every 3 seconds (Figure 8-13).
Note: For an infant (1 to 12 months), the chin is lifted to open the airway but the head is kept in a neutral position. Also, the mask is inverted if there is no infant mask available. One slow gentle breath (a puff) is delivered every 3 seconds.
If the chest rises and falls with delivery of two rescue breaths, remove the resuscitation mask, recheck breathing, and check for the presence of a pulse for no more than 10 seconds.
If the chest does not rise and fall with delivery of two rescue breaths, remove the resuscitation mask and reposition the airway by tilting the head farther back or initiating the jaw-thrush maneuver. Then replace the mask and deliver two rescue breaths again.

STEP 7: WHAT TO DO

If there is breathing and a pulse:

Continue to monitor the ABCs until help arrives.
Administer emergency oxygen, if available.

If there is a pulse but no movement or breathing:

Reposition the airway by tilting the head farther back or initiating the jaw thrust maneuver.
Replace the mask and deliver two rescue breaths again.
If the chest rises and falls with each respiration, begin rescue breathing (see Procedure 8-2).
If the rescue breaths still do not make the chest clearly rise, then initiate the procedure for unconscious choking (see Procedures 8-3 and 8-4).

If there is no pulse:

CPR is initiated immediately (see Procedure 8-5).

STEP 8

After emergency care, document the situation on an incident report form (see Figure 8-48) and in the client’s chart. Provide a copy of incident report to EMS technician if victim is being transferred to a hospital.

BOX 8-5 Information Given to the Emergency Medical Services Dispatcher

Location of the emergency (with names of cross-streets, if possible)
Number of telephone from which the call is made
What happened (e.g., heart attack, seizure)
Condition of the victim
Aid being given to the victim
Any other information requested
Caller should hang up only when told to do so.

In an unconscious person the tongue falls backward against the wall of the pharynx, producing airway obstruction. The head tilt–chin lift technique is the most important step in maintaining an open airway. The procedure is performed by placing one hand on the unconscious person’s forehead and applying a firm, backward pressure with the palm; then the tips of the index and middle fingers of the other hand are placed on the symphysis of the mandible, lifting the mandible as the forehead is tilted backward. For an adult, the victim’s head is extended so that the chin points up into the air in line with the earlobes, lifting the mandible and tongue off the pharyngeal wall (Figure 8-5). For a child, the head is only slightly tilted past the neutral position (Figure 8-6). Maintaining the person’s head in the head tilt–chin lift, the clinician then places his or her ear 1 inch from the unconscious person’s nose and mouth while looking toward the chest for visual signs of chest respiratory movements (Figure 8-7). Breathing is assessed for at least 5 seconds, but no more than 10 seconds. Feeling or hearing air at the person’s nose and mouth indicates effective spontaneous breathing is present. Although head tilt–chin lift establishes an open airway in most situations, occasionally an airway may remain obstructed. In such cases, additional forward movement of the mandible using the jaw-thrust technique usually will remove the obstruction. To perform the jaw-thrust maneuver, the clinician must be located behind the top of the supine unconscious person’s head, and the clinician’s elbows are stabilized on the surface of the dental chair. The clinician places his or her fingers behind the posterior of the ramus of the mandible and then displaces the mandible forward while tilting the head backward (Figure 8-8).

image

Figure 8-5 For an adult, when the unconscious person’s head is extended properly, the tip of the chin points up into the air in line with the earlobes (black line), lifting the mandible and tongue off the pharyngeal wall.

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

image

Figure 8-6 Head tilt–chin lift position in a child.

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

image

Figure 8-7 The look-listen-feel technique. While maintaining head tilt, the clinician assesses airway patency by placing the ear 1 inch from the client’s nose and mouth and watching the chest for spontaneous respiratory movements.

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

image

Figure 8-8 To perform the jaw-thrust technique, the clinician must grasp the angles of the mandible with both hands and displace the mandible forward. A, Side view. B, Front view.

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

Circulation is checked by palpating the carotid artery in the neck for a pulse (Figure 8-9).

image

Figure 8-9 Carotid artery is located in groove between the trachea and the sternocleidomastoid muscle. Head tilt must be maintained.

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

image

Figure 8-10

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

image

Figure 8-11

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, Mosby, 2007.)

image

Figure 8-12 Position the resuscitation mask, and breathe into the mask while tilting the head and lifting the chin to open the airway.

(From Henry M, Stapleton E: EMT: prehospital care, ed 3, St Louis, 2007, Mosby/JEMS.)

image

Figure 8-13 Holding pocket mask on face.

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

What to Do

Further assessment and decision making are based on the following:

image If the unconscious person is breathing and there is a carotid pulse, the airway is managed via head tilt–chin lift and the dental team proceeds with additional management including the administration of oxygen and monitoring of vital signs (blood pressure, heart rate, and respiration). The pulse needs to be rechecked every 2 minutes for at least 5 seconds but not more than 10 seconds.
image If there is a pulse but breathing is absent or inadequate, two rescue breaths are delivered. If each of the rescue breaths causes the chest clearly to rise, then the airway is determined to be open. Because there is a palpable pulse, it is necessary to continue with rescue breathing only (Procedure 8-2).
image If there continues to be no breathing with each of the two rescue breaths, then the airway is repositioned using the jaw-thrust technique and two rescue breaths are delivered again. If the rescue breaths still do not make the chest clearly rise, then the procedure for unconscious choking is initiated. (See Procedure 8-7 for the unconscious choking adult or child.) The pulse, however, continues to be checked every 2 minutes for at least 5 seconds but no more than 10 seconds.
image If there is no carotid pulse, cardiopulmonary resuscitation (CPR) is initiated immediately. (See Procedures 8-3 and 8-4 for CPR for adult, child, and infant.)

Procedure 8-2 RESCUE BREATHING—ADULT, CHILD, INFANT

EQUIPMENT

Resuscitation mask (see Figures 8-14 and 8-15)
Other protective barriers

STEPS 1-6

Initial assessment (see Procedure 8-1)

STEP 7

Perform rescue breathing if there is a pulse but no movement or breathing.

Position yourself at the client’s side.
Open the airway.
For an adult, the tip of the chin points up in the air in line with the ear lobes (see Figure 8-5).
For a child, the child’s head is only slightly tilted past the neutral position to open the airway (see Figure 8-13).
For an infant (1 to 12 months old), the chin is lifted to open the airway but the head is kept in a neutral position (Figure 8-17).
Mouth-to-mask resuscitation:
Place the resuscitation mask on the victim’s face with the narrow portion over the bridge of the nose and the wider part in the cleft at the chin (see Figure 8-16). (For an infant, invert the mask if no pediatric mask is available [see Figure 8-17]).
Using the hand that is closer to the top of the victim’s head, place the index finger and thumb along the border of the mask while using the other hand to place the thumb along the lower margin of the mask and grasping the mandible with the index, middle, and ring fingers (see Figure 8-12).
Place your mouth on the breathing port of the mask, and breathe air into the victim’s mouth and nose (Figure 8-18).
For an adult, blow one rescue breath every 5 seconds (see Figure 8-18). (Count 1001, 1002, 1003, 1004, 1005.)
For a child, blow one rescue breath every 3 seconds. (Count 1001, 1002, 1003.)
For an infant, administer a slow, shallow, gentle breath every 3 seconds (just enough to make the chest rise). (Count 1001, 1002, 1003.)
If there is no mask available, perform mouth-to-mouth resuscitation.
For an adult or a child, maintain head tilt while pinching the victim’s nostrils closed with the thumb and index finger, take a deep breath, form a tight seal around the victim’s mouth, and blow air into the mouth. Adequate ventilation is achieved when the victim’s chest visibly rises with each ventilatory effort (Figure 8-19).
For an infant, place your mouth over the infant’s nose and mouth to form an airtight seal to prevent air from escaping through the nose (Figure 8-20).
Each rescue breath should last about 1 second and make the chest clearly rise.

STEP 8

Continue to give one rescue breath about every 5 seconds.

Each rescue breath should last about 1 second.
Watch the chest clearly rise when giving each rescue breath.
Do this for about 2 minutes, then recheck the pulse.

STEP 9

Remove the resuscitation mask, look for movement, and recheck for breathing (Figure 8-21).
Check for a pulse for at least 5 seconds but no more than 10 seconds (Figure 8-22).

STEP 10: WHAT TO DO

If there is a pulse but still no movement or breathing:

Replace the mask and continue rescue breathing.
Look for movement and recheck for breathing and a pulse about every 2 minutes.

If movement, breathing, and a pulse are present:

Continue to monitor the ABCs.
Administer emergency oxygen, if available.

If there is no movement, breathing, or pulse:

Perform cardiopulmonary resuscitation (CPR) (Procedure 8-3).

STEP 11

After emergency care, document the situation on an incident report form (see Figure 8-48) and in the client’s chart. Provide a copy of incident report to EMS technician if victim is being transferred to a hospital.

Procedure 8-3 ONE-RESCUER CARDIOPULMONARY RESUSCITATION (CPR) FOR ADULT, CHILD, AND INFANT

EQUIPMENT

Resuscitation mask
Other protective barriers
Automated external defibrillator (AED)

STEP 1-6

Complete Steps 1-6, Initial Assessment (see Procedure 8-1).
If the victim has no pulse, begin CPR.

STEP 7

Find the correct hand position to give compressions.

Remove clothing covering the victim’s chest.
Place the heel of one hand on the center of the chest between the nipples.
Place the other hand on top and intertwine the fingers. Keep fingers off the chest when giving compressions.
Position your shoulders over your hands with your elbows locked (Figure 8-28).
Use your body weight, not your arms, to compress the chest.

STEP 8

Give 30 chest compressions.

For an adult, compress the chest about 1½ to 2 inches.
For a child, compress the chest about 1 to 1½ inches.
Let the chest fully recoil to its normal position after each compression.
Compress at a rate of about 100 compressions per minute.
Count out loud to keep an even pace (“1 and 2 and 3 and…”).

STEP 9

Replace the resuscitation mask and give two rescue breaths.

Each rescue breath should last about 1 second.
Give rescue breaths that make the chest clearly rise (Figure 8-29).

STEP 10

Do cycles of 30 compressions and two rescue breaths. Reassess victim after four cycles (i.e., two ventilations, 30 compressions each cycle).

STEP 11: WHAT TO DO

If there is a pulse, continue rescue breathing at one breath every 5 seconds.
If there is no pulse, continue CPR until:
Another trained rescuer arrives and takes over
An AED is available and ready to use
You are too exhausted to continue
You notice an obvious sign of life

STEP 12

After emergency care, document the situation on an incident report form (see Figure 8-48) and in the client’s chart. Provide a copy of incident report to EMS technician if victim is being transferred to a hospital.

Procedure 8-4 TWO-RESCUER CARDIOPULMONARY RESUSCITATION (CPR)—ADULT AND CHILD

EQUIPMENT

Resuscitation mask
Other protective barriers
Automated external defibrillator (AED)

STEPS 1-10

Completed by Rescuer 1 (see Procedure 8-3).

STEP 11

Rescuer 2 finds the correct hand position to give compressions.

Places the heel of one hand on the center of the chest
Places the other hand on top

STEP 12

Rescuer 2 gives chest compressions when Rescuer 1 says, “Victim has no pulse. Begin CPR.”

Adult: 30 compressions; compress the chest about 1½ to 2 inches
Child: 15 compressions; compress the chest about 1 to 1½ inches
Lets the chest fully recoil to its normal position after each compression
Compresses at a rate of about 100 compressions per minute

STEP 13

Rescuer 1 replaces the mask on the victim’s face and gives two rescue breaths.

Each rescue breath should last about 1 second.
Gives rescue breaths that make the chest clearly rise.

STEP 14

Do about 2 minutes of compressions and breaths.

STEP 15

Change positions:

Rescuer 2 calls for a position change by using the word “change” at the end of the last compression cycle.
Rescuer 1 gives two rescue breaths.
Rescuer 2 moves to the victim’s head with his or her own mask.
Rescuer 1 moves into position at the victim’s chest and locates correct hand position on the victim’s chest.
Changing positions should take less than 5 seconds.

STEP 16

Continue CPR until:

Help arrives
An AED is available and ready to use
You are too exhausted to continue
You notice signs of life

STEP 17

After emergency care, document the situation on an incident report form (see Figure 8-48) and in the client’s chart. Provide a copy of incident report to EMS technician if victim is being transferred to a hospital.

Rescue Breathing

Rescue breathing is a technique for breathing air into a victim to give him or her oxygen needed to survive. The air the healthcare provider exhales contains enough oxygen to keep a person alive. Although there are several techniques for rescue breathing, in this chapter the mouth-to-mask ventilation primarily is emphasized. When giving rescue breaths, a normal breath is taken and then breathed into the victim’s mouth and nose using a resuscitation mask (Figures 8-14 and 8-15). If no mask is available, mouth-to-mouth ventilation is initiated (see Procedure 8-2). Each breath should last about 1 second and make the chest clearly rise. For an adult, one breath is given every 5 to 6 seconds (10 to 12 breaths per minute) (Box 8-6). For a child or infant, one breath is given every 3 seconds. The carotid pulse is checked again after 2 minutes.3 Rescue breathing is continued until one of the following occurs:

image The victim begins to breathe independently.
image Another trained rescuer takes over.
image The rescuer is too exhausted to continue.
image The victim has no pulse, in which case the healthcare provider begins CPR (Box 8-7).
image

Figure 8-14 Pocket mask.

(Courtesy Sedation Resource, Lone Oak, Texas, www.sedationresource.com.)

image

Figure 8-15 A resuscitation mask with required characteristics.

BOX 8-6 Rescue Breathing for the Adult Victim

Adapted from American Heart Association: BLS for healthcare providers student manual, Dallas, 2006, American Heart Association.

Give one breath every 5 to 6 seconds (10 to 12 breaths per minute).
Give each breath in 1 second.
Each breath must result in visible chest rise.
Check the pulse again in about 2 minutes.

BOX 8-7 Pulse Check

Adapted from American Heart Association: BLS for healthcare providers student manual, Dallas, 2006, American Heart Association.

If the rescuer is unsure whether or not the victim has a pulse, chest compression should be started.
Unnecessary cardiopulmonary resuscitation is less harmful than not performing chest compression when the victim truly needs it.

Resuscitation Masks

Resuscitation masks are flexible, dome-shaped devices that cover a victim’s mouth and nose and allow the healthcare provider to breath air into a victim without making mouth-to-mouth contact. It is recommended that dental hygienists have their own resuscitation mask in their operatory. Resuscitation masks have several benefits:

image They supply air to the victim more quickly through both the mouth and nose.
image They create a seal over the victim’s mouth and nose.
image They can be connected to emergency oxygen if they have an oxygen inlet.
image They protect against disease transmission when rescue breaths are given.

A resuscitation mask should have the following characteristics:

image Be easy to assemble and use.
image Be made of transparent, pliable material that allows the clinician to make a tight seal over the victim’s mouth and nose.
image Have a one-way valve for releasing exhaled air away from the rescuer.

Mouth-to-Mask Ventilation

For mouth-to-mask ventilation to be performed, head tilt–chin lift must be maintained. The mask is placed on the victim’s face with the narrow portion over the bridge of the nose and the wider part in the cleft of the chin (see Figure 8-13). Using the hand that is closer to the top of the victim’s head, the index finger and thumb are placed along the border of the mask while the thumb of the other hand is placed along the lower margin of the mask (Figure 8-16). The remaining fingers of the hand closer to the victim’s neck are placed along the bony inferior border of the mandible, which is then lifted. Head tilt–chin lift is then performed to establish a patent airway. While head tilt–chin lift is maintained, the rescuer presses firmly and completely around the outside margin of the mask to obtain an airtight seal, with the remaining fingers along the lower margin of the mask to seal the mask against the victim’s face. The mask is held in position with one or two hands as needed, maintaining both an airtight seal and a patent airway. The rescuer’s mouth is placed on the breathing port of the mask, and air is forced into the victim until the chest is seen to rise (see Figure 8-12). The rescuer positions himself or herself at the victim’s side, enabling a lone rescuer to perform chest compressions if needed. Air is delivered over 1 second to make the victim’s chest rise (see Box 8-6).

image

Figure 8-16 Mouth-to-mask ventilation demonstrating finger positioning.

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

image

Figure 8-17

(Courtesy Sedation Resource, Lone Oak, Texas, www.sedationresource.com.)

image

Figure 8-18

(From Henry M, Stapleton E: EMT: prehospital care, ed 3, St Louis, 2007, Mosby/JEMS.)

image

Figure 8-19

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

image

Figure 8-20

(From Potter PA, Perry AG: Fundamentals of nursing, ed 7, St Louis, 2009, Mosby.)

image

Figure 8-21

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

image

Figure 8-22

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

Oxygen-Enriched Ventilation

Whenever possible, the rescuer should ventilate with supplemental oxygen (O2); however, rescue breathing must never be delayed until supplemental O2 becomes available. It is recommended that every oral healthcare setting have at least one portable E cylinder of O2 with adjustable O2 flow and a positive-pressure demand-valve mask unit (Figure 8-23). The E cylinder of O2 provides approximately 30 minutes of O2. Although O2 is beneficial to the unconscious patient, the clinician should receive adequate training in airway management through mouth-to-mask or mouth-to-mouth ventilation because administration of enriched O2 is effective only as long as O2 remains in the compressed gas cylinder.

image

Figure 8-23 Positive-pressure demand valve.

(Courtesy Sedation Resource, Lone Oak, Texas, www.sedationresource.com.)

CARDIAC ARREST

Each year, approximately 500,000 people die of cardiac arrest, which stops respiration and blood circulation. Cardiac arrest may result from an acute reaction to medication, myocardial infarction, respiratory arrest, electric shock, drowning, trauma, asphyxiation, shock, or cardiac arrhythmia. The heart’s electrical system controls its pumping action.

The Heart’s Electrical System

Under normal conditions, (1) specialized cells of the heart initiate and transmit electrical impulses that travel through the upper chambers of the heart (the atria) to the lower chambers of the heart (the ventricles) and (2) electrical impulses reach the muscular walls of the ventricles and cause the ventricles to contract. This contraction forces blood out of the heart to circulate through the body. The contraction of the left ventricle results in a pulse. The pauses between the pulse beats are the periods between contractions. When the heart muscles contract, blood is forced out of the heart. When they relax, blood refills the chambers.

Any damage to the heart from disease or injury can disrupt the heart’s electrical system, which can stop circulation. The two most common treatable abnormal rhythms initially present in sudden cardiac arrest victims are ventricular fibrillation (V-fib) and ventricular tachycardia (V-tach). V-fib is a state of totally disorganized electrical activity in the heart resulting in quivering of the ventricles. In this state, the ventricles cannot pump blood and there is no movement or breathing and no pulse. V-tach is very rapid ventricular contraction. Although there is electrical activity resulting in a regular rhythm, the rate is often so fast that the heart is unable to pump blood properly. As with V-fib, there is no movement or breathing and no pulse.

Clinical death is cessation of the heart and respiratory effort; it may be reversible with CPR if initiated within 4 to 6 minutes. A person who is unconscious, is not moving or breathing, and has no pulse is in cardiac arrest and needs CPR. When started promptly, CPR can help by supplying oxygen to the brain and other vital organs. In many cases, however, CPR by itself cannot correct the underlying heart problem, but V-fib and V-tach can be corrected by early defibrillation. Delivering an electrical shock with an automated external defibrillator (AED) (Figure 8-24) disrupts the electrical activity of the V-fib or V-tach long enough to allow the heart to spontaneously develop an effective rhythm on its own. If V-fib or V-tach is not interrupted, all electrical activity will eventually cease (asystole), a condition that cannot be corrected by defibrillation. AEDs provide an electrical shock to the heart, called defibrillation. The sooner the shock is administered, the greater the likelihood of the victim’s survival.4

image

Figure 8-24 Automated external defibrillator.

(From Henry M, Stapleton E: EMT: prehospital care, ed 3, St Louis, 2007, Mosby/JEMS.)

Effective Emergency Response

To effectively respond to cardiac emergencies, it helps to understand the importance of the cardiac chain of survival. The four links in the cardiac chain are as follows:

image Early recognition of the emergency and early access to EMS. The sooner more advanced personnel or the local emergency number is called, the sooner EMS personnel arrive and take over.
image Early CPR. CPR helps supply oxygen to the brain and other vital organs to keep the victim alive until an AED is used or advanced medical care is given.
image Early defibrillation. An electrical shock called defibrillation may restore a normal heart rhythm. Each minute defibrillation is delayed reduces the victim’s chance of survival by about 10%.
image Early advanced medical care. EMS personnel provide more advanced medical care and transport the victim to the hospital.

Early Recognition and Cardiopulmonary Resuscitation

If a person is seated in the dental chair at the time of collapse, the dental hygienist assesses the ABCs. If there is no breathing or pulse, EMS is summoned (see Box 8-5), and effective CPR may be performed with the unconscious victim supine in the dental chair.1 CPR is a combination of rescue breaths and chest compressions (Table 8-1). Effective chest compressions are essential for high-quality CPR. Effective chest compressions circulate blood to the victim’s brain and other vital organs. CPR prolongs the period of time that the myocardium remains in ventricular fibrillation, increasing the likelihood that defibrillation will terminate ventricular fibrillation and allow the heart to resume an effective rhythm and effective systemic perfusion.

TABLE 8-1 Summary of Techniques for Adult, Child, and Infant Cardiopulmonary Resuscitation

image

To ensure high-quality CPR, the following requirements must be met:

image Chest compressions should be performed at a rate of about 100 compressions per minute.
image Chest compressions should be deep: 1½ to 2 inches for an adult, 1 to 1½ inches for a child, and ½ to 1 inch for an infant.
image The chest should fully recoil to its normal position after each compression before the next compression is started.

The rescuer compresses the lower half of the sternum in the middle of the chest. The heel of one hand is placed on the middle of the sternum between the nipples with the heel of the other hand placed on top so that the two hands are overlapped and parallel. The fingers of the two hands are then interlaced, with the fingers of the top hand pulling the fingers of the lower hand upward. Only the heel of the lower hand remains in contact with the victim’s chest (Figure 8-25).

image

Figure 8-25 Proper location and hand position for adult chest compression.

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

To maximize chest compressions, the rescuer’s shoulders must be directly over the victim’s sternum, and the rescuer’s elbows are locked straight. The dental chair is lowered to allow the rescuer to bring shoulders directly over the victim’s sternum (Figure 8-26).

image

Figure 8-26 Proper rescuer position for adult chest compression.

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

Bending of the elbows greatly decreases effectiveness and leads to rapid rescuer fatigue (Figure 8-27).

image

Figure 8-27 Improper positioning (elbows bent, shoulders at angle to chest).

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

image

Figure 8-28

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

image

Figure 8-29

(From Henry M, Stapleton E: EMT: prehospital care, ed 3, St Louis, 2007, Mosby/JEMS.)

image

Figure 8-30

(From Henry M, Stapleton E: EMT: prehospital care, ed 3, St Louis, 2007, Mosby/JEMS.)

image

Figure 8-31

(From Henry M, Stapleton E: EMT: prehospital care, ed 3, St Louis, 2007, Mosby/JEMS.)

image

Figure 8-32

(From Henry M, Stapleton E: EMT: prehospital care, ed 3, St Louis, 2007, Mosby/JEMS.)

image

Figure 8-33

(From Henry M, Stapleton E: EMT: prehospital care, ed 3, St Louis, 2007, Mosby/JEMS.)

image

Figure 8-34

(From Chapleau W: Emergency first responder: making the difference, St Louis, 2004, Mosby.)

image

Figure 8-35

(From Chapleau W: Emergency first responder: making the difference, St Louis, 2004, Mosby.)

image

Figure 8-36

(From Chapleau W: Emergency first responder: making the difference, St Louis, 2004, Mosby.)

image

Figure 8-37

(From Chapleau W: Emergency first responder: making the difference, St Louis, 2004, Mosby.)

image

Figure 8-38

(From Chapleau W: Emergency first responder: making the difference, St Louis, 2004, Mosby.)

image

Figure 8-39

(From Chapleau W: Emergency first responder: making the difference, St Louis, 2004, Mosby.)

image

Figure 8-40

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

image

Figure 8-41

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

image

Figure 8-42

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

image

Figure 8-43

(From Chapleau W: Emergency first responder: making the difference, St Louis, 2004, Mosby.)

image

Figure 8-44

(From Chapleau W: Emergency first responder: making the difference, St Louis, 2004, Mosby.)

image

Figure 8-45

(From Potter PA, Perry AG: Fundamentals of nursing, ed 7, St Louis, 2009, Mosby.)

image

Figure 8-46

(From Chapleau W: Emergency first responder: making the difference, St Louis, 2004, Mosby.)

See Procedure 8-3 for one-rescuer CPR for an adult and child and Table 8-1 for a summary of CPR techniques for adult, child, and infant care. A compression-ventilation ratio of 30 compressions to two breaths is currently recommended for one-rescuer resuscitations. A 30 : 2 compression-ventilation ratio is tiring. Therefore, when an additional rescuer is available, two-rescuer CPR is provided (see Procedure 8-4). In two-rescuer CPR, one rescuer gives rescue breaths and the other rescuer gives chest compressions. It is recommended to switch the compressor every 2 minutes (or after five cycles of compressions). Every effort is made to accomplish the switch in less than 5 seconds. When providing two-rescuer CPR to an adult, rescuers perform 30 compressions and two rescue breaths during each cycle. When performing two-rescuer CPR on a child or infant, rescuers change the compression to ventilation ratio to 15 : 2. This ventilation ratio provides more frequent respiration for children and infants.

Use of an Automated External Defibrillator

An automated external defibrillator (AED) is an automated device that recognizes in an unconscious pulseless person an abnormal heart rhythm that needs a shock to develop a normal heart rhythm by defibrillation (see Figure 8-24). When a cardiac arrest occurs and the victim does not respond to the initial four or five cycles of chest compressions, an AED should be used as soon as it is available and ready to use.

The AED charges itself and prompts the operator if it is necessary to deliver a life-saving shock to the victim by pressing a button. If the AED advises that a shock is needed, the rescuer follows protocols to provide one shock followed by five cycles (about 2 minutes) of CPR.

When a single rescuer encounters a nonresponsive person with no pulse, he or she immediately asks for help to summon EMS (e.g., 911), which is critical for the person’s survival, and to bring an AED if available. The single rescuer starts with 2 minutes (four or five cycles) of CPR. The AED is used after four or five cycles of CPR, only if the victim is not breathing and has no pulse (see Procedure 8-5 for one rescuer using AED). Chest compressions increase the likelihood that a successful shock can be delivered to a victim who has experienced a sudden cardiac arrest, especially if more than 4 minutes have elapsed since the victim’s collapse.

Procedure 8-5 SINGLE RESCUER USING AN AUTOMATED EXTERNAL DEFIBRILLATOR (AED)—ADULT AND CHILD

Adapted from American Red Cross: Skill sheet using an AED-adult and child, Washington, DC, American Red Cross.

EQUIPMENT

Automated external defibrillator (AED) (see Figure 8-24)

STEPS 1-6

Complete Initial Assessment (see Procedure 8-1); verify the absence of breathing and pulse (Figure 8-30).

STEP 7

Begin CPR (see Procedure 8-3).
After five cycles, stop CPR.
Position the defibrillator machine on the left side of the victim’s head.
Turn on the AED.

STEP 8

Wipe the chest dry.

STEP 9

Attach the electrode lines to the pads (Figure 8-31).

STEP 10

Attach the pads to the victim.

Remove the cover from the adhesive side of the pads.
Place one pad on the upper right side of the victim’s chest above the nipple area.
Place the other pad on the victim’s lower left side at the left sterna border (Figure 8-32). Make sure the pads are not touching.
For a child, use pediatric AED pads if available. Make sure the pads are not touching.

Note: If the pads risk touching each other on a child, place one pad on the child’s chest and the other pad on the child’s back (between the shoulder blades).

STEP 11

Plug the connector into the AED, if necessary.

STEP 12

Clear the victim.

Make sure that nobody, including you, is touching the victim.
Tell everyone to “stand clear.”

STEP 13

Push the “analyze” button. Let the AED analyze the heart rhythm (Figure 8-33).

STEP 14

If a shock is advised, push the “shock” button.

Look to see that nobody is touching the victim.
Tell everyone to “stand clear.”

STEP 15

After the shock or if no shock is indicated:

Give five cycles (about 2 minutes) of CPR before analyzing the heart rhythm again.
If no shock advised, give 5 cycles or about 2 minutes of CPR.
If at any time you notice an obvious sign of life, stop CPR and monitor the ABCs. Administer emergency oxygen, if it is available and you are trained to do so.

STEP 16

After emergency care, document the situation on an incident report form (see Figure 8-48) and in the client’s chart. Provide a copy of incident report to EMS technician if victim is being transferred to a hospital.

Note: If two trained responders are present, one should perform CPR while the second responder operates the AED.

In two-rescuer CPR, while chest compressions are being performed by the first rescuer, the second rescuer prepares to use the AED. Box 8-8 describes the two-rescuer AED technique for an adult.

BOX 8-8 Automated External Defibrillator Two-Rescuer Technique (Adult)

First rescuer provides CPR.
Second rescuer prepares to use the automated external defibrillator (AED).
Second rescuer does the following while minimizing interruptions in chest compressions of no more than 10 seconds.
1. Removes clothing covering the victim’s chest to allow rescuers to provide chest compressions and to apply the AED electrode pads.
2. Places the AED at the victim’s side near the rescuer who will be operating it (i.e., the side of the victim opposite the rescuer performing chest compressions).
3. Turns on the AED (POWER ON) and follows voice prompts.
4. Attaches adult AED electrode pads.
5. Removes the backing from the adhesive electrode pads.
6. Attaches the adhesive electrode pads to the bare skin of the victim as per diagrams on electrodes.
7. Attaches the electrode cable to the AED.
8. Ensures that no one is touching the victim or resuscitation equipment while the AED is analyzing the heart rhythm (ANALYZE).
9. Pushes ANALYZE button if needed.
10. Ensures that no one is touching the victim or resuscitation equipment while following prompts to deliver a shock.
11. Starts CPR immediately (beginning with chest compressions) after delivery of shock.
12. If no shock is indicated, as per AED voice prompts, resumes CPR, beginning with chest compressions.

The entire dental team should conduct a cardiac arrest drill at least semiannually. Practicing a variety of scenarios will prepare the staff to respond rapidly and effectively in a real emergency.

OBSTRUCTED AIRWAY

An obstructed airway occurs when an object prevents the exchange of air in an individual. A foreign-body obstruction may occur in the following situations:

image During eating (food particle blocks airway)
image During a dental procedure (aspiration of a dental instrument or piece of equipment)
image During resuscitation (aspiration of vomitus or blood)
image When unconscious (tongue falls backward, blocking pharynx)

If the victim has a partial airway obstruction with good air exchange and can cough forcefully, the hygienist should not interfere with attempts to dislodge the object but should remain with the victim until it is dislodged or help arrives. See Procedure 8-6 for management of partial airway obstruction with poor air exchange and complete airway obstruction in the conscious victim. (See Box 8-9 for signs of complete airway obstruction.) See Procedure 8-7 for management of the unconscious victim with complete airway obstruction. See Procedures 8-8 and 8-9 for management of the conscious and unconscious infant with complete airway obstruction.

Procedure 8-6 CONSCIOUS CHOKING—ADULT AND CHILD

EQUIPMENT

Resuscitation mask
Other protective barriers

STEP 1

Ask the person, “Are you choking?”

If the person is coughing forcefully, encourage continued coughing.
A conscious victim who is clutching his or her throat with one or both hands is usually choking. (Figure 8-34).

STEP 2

If the person cannot cough, speak, or breathe, have someone else summon advanced medical personnel.

STEP 3

Get consent before helping a conscious choking victim (e.g., “Is it OK if I try to help you?”).

STEP 4

Lean the victim forward and give five back blows with the heel of your hand.

Position yourself slightly behind the victim.
Provide support by placing one arm diagonally across the chest, and lean the victim forward.
Firmly strike the victim between the shoulder blades with the heel of your hand.

STEP 5

Give five abdominal thrusts.

Adult: Stand behind the victim.
Child: Stand or kneel behind the child depending on the child’s height. Use less force on a child than you would on an adult.
Use one hand to find the navel.
Make a fist with your other hand and place the thumb side of your fist against the middle of the victim’s abdomen, just above the navel and well below the tip of the xiphoid process (Figure 8-35).
Grab the fist with your other hand (Figure 8-36).
Press the fist into the victim’s abdomen with a brisk inward and upward motion. Give quick upward thrusts. Each thrust should be a distinct attempt to dislodge the object (Figure 8-37).
Note: Use chest thrusts if:
You cannot reach far enough around the victim to give abdominal thrusts
The victim is pregnant (Figure 8-38)

STEP 6

Continue giving five back thrusts and five abdominal thrusts until:

The foreign body is forced out.
The victim begins to breathe or cough forcefully.
The victim becomes unconscious.

STEP 7

After emergency care, document the situation on an incident report form (see Figure 8-48) and in the client’s chart. Provide a copy of incident report to EMS technician if victim is being transferred to a hospital.

BOX 8-9 Signs of Complete Airway Obstruction

Inability to speak
Inability to breathe
Inability to cough
Universal sign for choking
Panic

Procedure 8-7 UNCONSCIOUS CHOKING—ADULT AND CHILD

SITUATION

The victim is unconscious, and rescue breaths do not make the chest clearly rise.

STEP 1

Place the victim in the supine position with his or her head in neutral position.

For adult: Reposition the airway by tilting the head farther back, and try two rescue breaths again.
For child: Reposition the airway by retilting the child’s head slightly past the neutral position, and try two rescue breaths again.

STEP 2

If rescue breaths still do not make the chest clearly rise, give five chest thrusts.

If victim is not in the dental chair, straddle the victim’s legs or thighs (Figure 8-39).
If victim is in the dental chair, place your knees close to the victim’s hip either on the left or the right side of the chair (Figure 8-40).
Place the heel of one hand against the victim’s abdomen, on the center of the chest above the navel and well below the tip of the xiphoid process.
Place the other hand directly on top of the first hand.
Press into the victim’s abdomen with a quick inward and upward motion. (Do not direct the force laterally.)
Keep your fingers off the chest when giving chest thrusts.
Use your body weight, not your arms, to compress the abdomen.
Position your shoulders over your hands with your elbows locked (Figure 8-41).
For a child, use one hand to compress the abdomen and place the other hand on the child’s forehead.
Perform up to five abdominal thrusts.

STEP 3

Look inside the victim’s mouth. Grasp the tongue and lower jaw between your thumb and fingers and the jaw. Look to see if the object has been dislodged and is visible. If the object is visible it should be removed. (New guidelines do not recommend a blind finger sweep.) SeeFigure 8-42.

For an adult, remove the object with your index finger by sliding the finger along the inside of the cheek, using a hooking motion to sweep the object out.
For a child, remove the object with your little finger by sliding it along the inside of the cheek, using a hooking motion to sweep the object out.

STEP 4

Replace the resuscitation mask and give two rescue breaths.

STEP 5: WHAT TO DO

If the rescue breaths still do not make the chest clearly rise, repeat steps 1 to 4.
If the rescue breaths make the chest clearly rise, remove the mask, look for movement, and check for breathing and a pulse for no more than 10 seconds.
If there is movement, breathing, and a pulse:
Continue to monitor ABCs.
Administer emergency oxygen if available.
If there is a pulse but no movement or breathing, give rescue breathing (see Procedure 8-2).
If there is no movement, breathing, or pulse, perform CPR (see Procedure 8-3 for one-rescuer CPR; see Procedure 8-4 for two-rescuer CPR).

STEP 6

After emergency care, document the situation on an incident report form (see Figure 8-48) and in the client’s chart. Provide a copy of incident report to EMS technician if victim is being transferred to a hospital.

Procedure 8-8 CONSCIOUS CHOKING—INFANT

SITUATION

The infant cannot cough, cry, or breathe.

STEP 1

Carefully position the infant face down along your forearm.
Support the infant’s head and neck with your hand.
Lower the infant onto your thigh, keeping the infant’s head lower than his or her chest.

STEP 2

Give five back blows.

Use the heel of your hand.
Give five back blows between the infant’s shoulder blades (Figure 8-43).
Note: Use less force when giving back blows to an infant than would be given to a child.

STEP 3

Position the infant face-up along your forearm.

Before turning the infant, position the infant between both of your forearms, supporting the infant’s head and neck.
Turn the infant face-up.
Lower the infant onto your thigh with the infant’s head lower than his or her chest.

STEP 4

Give five chest thrusts.

Put two or three fingers on the center of the chest just below the nipple line (Figure 8-44).
Compress the chest five times about ½ to 1 inch.
Each chest thrust should be a distinct attempt to dislodge the object.

STEP 5

Look for object in the mouth. Grasp the tongue and lower jaw between your thumb and fingers and lift the jaw.

STEP 6

If you see an object, remove it with your little finger by sliding it along the inside of the cheek, using a hooking motion to sweep the object out.

step 7: WHAT TO DO

Continue giving five back blows and five chest thrusts until:

The object is forced out.
The infant begins to cough or breathe on his or her own.
The infant becomes unconscious (see Procedure 8-9).

STEP 8

After emergency care, document the situation on an incident report form (see Figure 8-48) and in the client’s chart. Provide a copy of incident report to EMS technician if victim is being transferred to a hospital.

Procedure 8-9 UNCONSCIOUS CHOKING—INFANT

SITUATION

The infant does not move or breathe and does not respond to sensory stimulation.

STEP 1

If rescue breaths do not make the chest clearly rise, reposition the airway by retilting the infant’s head and try two rescue breaths again.

Keep one hand on the infant’s forehead to maintain an open airway, and seal the nose and mouth with your mouth or a resuscitation mask (Figure 8-45).

STEP 2

If rescue breaths still do not make the chest clearly rise, remove the resuscitation mask (if available) and give five chest thrusts.

Put two or three fingers on the center of the chest just below the nipple line (Figure 8-46).
Compress the chest approximately ½ to 1 inch.
Each chest compression should be a distinct attempt to dislodge the object.
Compress at a rate of approximately 100 compressions per minute.

STEP 3

Look for object in the mouth. Grasp the tongue and lower jaw between your thumb and fingers and lift the jaw.

STEP 4

If you see an object, remove it with your little finger by sliding it along the inside of the cheek, using a hooking motion to sweep the object out.

STEP 5

Replace the resuscitation mask (if available) and give tworescue breaths.

STEP 6: WHAT TO DO

If the rescue breaths still do not make the chest clearly rise and there is still a pulse, repeat steps 1 to 5.
If the rescue breaths make the chest clearly rise, remove the mask, look for movement, and check for breathing and a pulse for no more than 10 seconds.
If there is movement, breathing, and a pulse:
Continue to monitor ABCs.
Administer emergency oxygen if available.
If there is a pulse but no movement or breathing, give rescue breathing (see Procedure 8-2).
If there is no movement, breathing, or pulse, perform CPR (see Procedures 8-3 and 8-4).

STEP 7

After emergency care, document the situation on an incident report form (see Figure 8-48) and in the client’s chart. Provide a copy of incident report to EMS technician if victim is being transferred to a hospital.

OXYGEN ADMINISTRATION

During a medical emergency the body tissues may have an increased demand for oxygen or a diminished ability to receive or use oxygen, thus necessitating the administration of higher oxygen concentrations than exist in room air. Indications for oxygen administration include syncope, cardiac problems, and some respiratory difficulties. Oxygen should not be administered to a person experiencing an episode of hyperventilation. High levels of oxygen are contraindicated for individuals with chronic obstructive pulmonary disease (COPD) such as emphysema (see Chapter 49).

As discussed earlier, the E cylinder is the recommended portable oxygen tank for in-office use. A clear facemask with a positive-pressure apparatus (Ambu bag) used to deliver the surrounding air to the victim is particularly valuable to prevent disease transmission between rescuer and victim. Competence in the use of the office oxygen system before an emergency occurs is essential.

For a conscious client, a nasal cannula (Figure 8-47) at a flow rate of 2 to 6 L/min or facemask at 8 to 12 L/min adequately delivers supplemental oxygen. The client should be allowed to breathe at his or her own rate while respiration rate and vital signs are monitored and medical assistance is summoned (see Chapter 11).

image

Figure 8-47 The conscious client may receive supplemental oxygen via nasal cannula or the nasal hood (not shown) of an inhalation sedation unit.

(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)

The unconscious client with adequate respiratory effort should receive the same type of oxygen administration, with careful observation should the respiratory effort diminish. An unconscious client without adequate respiratory effort should be placed in a supine position and the airway opened with the head tilt–chin lift maneuver (see the discussion of BLS). The clinician then secures the mask over the client’s face to cover the nose and mouth, starts the oxygen flow from the cylinder so that the flow inflates the positive-pressure bag, compresses the positive-pressure bag once every 3 to 5 seconds to inflate the victim’s lungs, observes for chest movement and exhalation, repositions the victim’s head if lungs are not adequately inflating, proceeds with the ABC assessment of BLS, and activates the EMS.

BASIC EMERGENCY DRUG KIT

The emergency drug kit should contain only drugs that the dental hygienist or dentist is trained to administer. Maintaining IV medications used for advanced life support in an emergency drug kit suggests that the need for these drugs is realized and that they can be administered competently. Maintaining an advanced emergency drug kit without the training to obtain IV access may subject the dental hygienist or dentist to liability claims. The emergency kit should contain the basic drugs and items listed in Table 8-2. In the event of an emergency, the hygienist stops all dental procedures and uses the steps found in Figure 8-1 to take action.

TABLE 8-2 Basic Emergency Drug Kit

Drug/Route Administered Action Indication
Aromatic ammonia/inhaled Chemical irritant Syncope (fainting)
Epinephrine pen/subcutaneous Cardiac stimulant and bronchodilator Acute allergic reaction: acute bronchospasm (asthma)
Nitroglycerin/sublingual Relaxes smooth muscle and dilates coronary arteries Angina pectoris
Glucose/oral as sugar cubes, orange juice, or nondiet soft drink Elevates blood sugar Hypoglycemia
Bronchodilator/inhaled (albuterol, proventil, terbutaline) Dilates bronchi Bronchospasm; asthma
Antihistamine/oral (Benadryl) Decreases the allergic response Allergic reaction
Oxygen/inhaled Increases oxygen to the brain Respiratory distress

Other medications may be included for use in advanced cardiac life support, but advanced training is needed to administer them.

MANAGEMENT OF SPECIFIC MEDICAL EMERGENCIES

Recognition of certain medical emergencies is essential for early intervention and appropriate treatment. When a medical emergency arises, the client’s symptoms and vital signs need to be assessed rapidly. Guided by symptoms and vital signs, an assessment of the client’s state of consciousness and neurologic, respiratory, or cardiac status is performed. From this information, the type of emergency is identified and treatment rendered. Signs and symptoms of various conditions and the treatments for these disease processes are listed in Table 8-3. In all cases the ABCs of BLS should be followed:

image Airway assessed and maintained
image Breathing assessed and maintained with ventilatory support provided as needed
image Circulation maintained using CPR

TABLE 8-3 Management of Specific Medical Emergencies

Condition Signs and Symptoms Management
Syncope (fainting) Feeling of warmth, flushed skin, nausea, rapid heart rate, perspiration, pallor. Sudden, transient loss of consciousness. Place in Trendelenburg’s position (client’s head lower than legs); loosen any binding clothes; maintain airway; administer oxygen; pass crushed ammonia capsule under victim’s nose; place cool, damp cloth on forehead; reassure; monitor and record vital signs.
Shock Skin pale and clammy, change in mental status and eventual unconsciousness if untreated, drop in blood pressure, increase in pulse and respiratory rate. Position in Trendelenburg, maintain airway, monitor vital signs, administer oxygen, activate emergency medical services (EMS) and initiate Basic Life Support (BLS) and transport to nearest emergency room; start large-bore intravenous (if trained). (May be lactated Ringer’s solution or blood, depending on the diagnosis.)
Hyperventilation Rapid or excessively deep respirations, light-headedness, dizziness, tingling in extremities, tightness in the chest, rapid heartbeat, lump in throat, panic-stricken appearance. Terminate procedure, use a quiet tone of voice to calm and reassure the client; encourage slow, deep breaths; have client breathe into a paper bag or cupped hands; do not administer oxygen.
Asthma Coughing, shortness of breath, wheezing, pallor, anxiety, use of accessory muscles for breathing, cyanosis, increased pulse rate. Assist client to a position that facilitates breathing (upright is usually best), have client self-medicate with inhaler, administer oxygen, monitor vital signs, if necessary activate EMS and initiate BLS.
Angina pectoris Transient ischemia (lack of oxygenated blood) of the myocardium (heart muscle) manifested by crushing, burning, or squeezing chest pain, radiating to left shoulder, arms, neck, or mandible and lasting 2 to 15 minutes; shortness of breath; diaphoresis (sweating). Terminate procedure, position client upright, monitor and record vital signs, administer oxygen, have client self-medicate with personal nitroglycerin supply (tablets, spray, or topical cream). If client does not have the medication, obtain nitroglycerin from the drug kit; if pain is not relived by rest and/or nitroglycerin (0.4 mg every five minutes for three doses), activate EMS and treat as a myocardial infarction.
Myocardial infarction (heart attack) Mild to severe chest pain; pain in the left arm, jaw, and possibly teeth, not relieved by rest and nitroglycerin; cold, clammy skin; nausea; anxiety; shortness of breath; weakness; perspiration; burning feeling of indigestion. Terminate procedure, activate EMS, place client supine, initiate BLS as needed, prepare nitroglycerin from the emergency kit, administer oxygen, monitor and record vital signs.
Cardiac arrest Ashen, gray, cold clammy skin; no pulse; no heart sounds; no respirations; unconscious. Activate EMS and initiate BLS.
Congestive heart failure Shortness of breath, weakness, cough, swelling of lower extremities, pink frothy sputum, distention of jugular veins. Terminate procedure, place chair back in upright position, administer oxygen, monitor vital signs, consult physician of record, activate EMS if necessary.
Stroke or cerebrovascular accident (CVA) The supply of oxygen to the brain cells is disrupted by ischemia, infarction, or hemorrhage of the cerebral blood vessels; sudden weakness of one side, difficulty of speech, temporary loss of vision, dizziness, change in mental status, nausea, severe headache, and/or convulsions. Terminate procedure, monitor vital signs, monitor airway, administer oxygen and initiate BLS as needed, activate EMS.
Hemorrhage
Arterial blood is red in color and “spurts.”
Venous blood is darker in color and “oozes.”
Compression over hemorrhage: for bleeding from a dental extraction or surgical site, pack the area with gauze and have the client bite down until bleeding stops; for nosebleeds, apply pressure to bleeding side, or pack the bleeding nostril with gauze; for severe bleeding, watch for signs of shock and activate EMS.
Seizure    
Generalized tonic-clonic (grand mal) seizure Aura (change in taste, smell, or sight preceding seizure), loss of consciousness, sudden cry, involuntary tonic-clonic muscle contractions, altered breathing, and/or involuntary defecation or urination. Terminate procedure, lower dental chair and clear area of all sharp and dangerous objects, make no attempts to restrain the person; protect the head, assess and establish an airway, monitor vital signs, initiate BLS and activate EMS if needed—if stable, allow client to rest, arrange for medical follow-up, and arrange for assistance in leaving the dental facility.
Nonconvulsive (petit mal) seizure Sudden momentary loss of awareness without loss of postural tone, a blank stare, and a duration of several to 90 seconds, muscle twitches. Terminate procedure, observe closely, clear area of sharp objects, provide supportive care, may need physician evaluation.
Adrenal crisis (cortisol deficiency) Confusion, weakness, lethargy, respiratory depression, hypercalcemia, shocklike symptoms—weak, rapid pulse and low blood pressure—abdominal pain, loss of consciousness. Terminate procedure, activate EMS, place in Trendelenburg’s position, monitor vital signs, administer oxygen, establish and maintain airway, initiate BLS as needed, transport to nearest emergency room.
Diabetic Emergency    
Hypoglycemia (hyperinsulinism) Mood changes, hunger, headache, perspiration, nausea, confusion, irritation, dizziness and weakness, increased anxiety, possible unconsciousness. Terminate procedure, administer oral sugar. If client conscious, ask when ate last and whether has taken insulin. Give concentrated form of oral sugar (e.g., sugar packet, cake icing, concentrated orange juice, apple juice, sugar-containing soda). If client is unconscious, activate EMS and place the sugar on the oral mucosa of the lower lip. Initiate BLS.
Hyperglycemia (ketoacidosis) Polydipsia (excessive thirst); polyuria (excessive urination); polyphagia (excessive hunger); labored respirations; nausea; dry, flushed skin; low blood pressure; weak, rapid pulse; acetone breath (“fruity” smell), blurred vision, headache, unconsciousness. Terminate procedure, activate EMS and provide BLS if necessary. If client is conscious, ask when ate last, whether has taken insulin, and whether client brought insulin to the appointment. Retrieve client’s insulin. If able, client should self-administer the insulin; monitor and record vital signs.
Allergic Reaction    
Localized rash Itching, skin redness, hives. Call for assistance; prepare an antihistamine for administration; be prepared to administer BLS if needed.
Anaphylaxis Urticaria (itchy wheals, also known as hives), angioedema (swelling of mucous membranes such as lips, tongue, larynx, pharynx), respiratory distress, wheezing, laryngeal edema, weak pulse, low blood pressure; may progress to unconsciousness and cardiovascular collapse. Terminate procedure; immediately activate EMS; establish and maintain airway; place in supine position; monitor vital signs; administer oxygen; initiate BLS as needed; if qualified, administer epinephrine.
Reactions to local anesthesia
Toxicity from local anesthesia: light-headedness, blurred vision and slurred speech, confusion, drowsiness, anxiety, tinnitus, bradycardia, tachypnea.
Toxicity from vasopressor or vasoconstrictor: anxiety, tachycardia, tachypnea, chest pain, dysrhythmias, cardiac arrest.
Assess airway, breathing, circulation; initiate BLS as needed, administer oxygen, activate EMS as needed.

Proper documentation of the emergency is required. The medical emergency incident report form in Figure 8-48 can be used for this purpose. A member of the oral care team should be assigned the responsibility to record information on the medical incident report form during the emergency situation. In the event that the victim is transferred to a hospital, a copy of the incident report and health history forms should accompany the victim.

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Figure 8-48 Medical emergency incident report form.

CLIENT EDUCATION TIPS

image Explain the importance of having an accurate health, dental, and pharmacologic history in medical emergency prevention.
image Explain the importance of taking prescribed medications for medical emergency prevention.
image Teach stress reduction strategies (see Chapter 37).
image Explain that complying with medication schedules, seeking regular preventive care, and reporting unusual symptoms immediately to a healthcare professional can prevent emergencies.

LEGAL, ETHICAL, AND SAFETY ISSUES

image Taking a complete health, dental, and pharmacologic history is one step to reduce the risk of emergencies.
image Ensure that clients seek prompt medical care when signs and symptoms of potential disease are evident.
image Good Samaritan statutes generally provide immunity from civil prosecution to those rendering care in emergency situations. These statutes were enacted so that health professionals can render care to victims and be protected from lawsuits for negligent harm. These statutes vary from state to state, but gross negligence or willful misconduct is not covered in most jurisdictions. Gross negligence is the intentional failure to perform a task with reckless disregard of the consequences that affects the life of another, or a conscious act or omission that may result in grave injury.
image Under Good Samaritan statutes, services must be provided free of charge at the scene of an emergency (not within a healthcare environment). The definition of scene of an emergency remains open for debate; however, most courts exclude hospitals, dental offices, and other healthcare facilities. These statutes do not cover an emergency resulting from the actions of a provider during the course of treatment.
image The dental team should be trained in BLS annually and to use all of the basic drugs contained in the emergency kit maintained within the dental practice setting.
image A medical emergency incident report form needs to be completed to document the situation, the victim’s response and vital signs, treatment and medications administered, and emergency response time. A copy of this form, along with a copy of the client’s health history form, should accompany the victim to the emergency room.
image Each member of the oral care team should have a specific role to play in the event of an emergency. These roles should be reviewed and practiced periodically.

KEY CONCEPTS

image Complete assessment of the client, including health, dental, and pharmacologic history and vital signs, is essential in the prevention of medical emergencies. Conditions that place a client at risk for a medical emergency should be written in red in the medical alert box of the health history form.
image Use stress reduction protocols to prevent anxiety-related emergencies (see Chapter 37).
image If a client is found to be at high risk, the client’s physician should be consulted and the care plan and appointment schedule adjusted to avoid possible emergency situations.
image The office staff needs to be competent in using the emergency equipment and emergency drug kit and should practice medical emergency drills using a variety of scenarios.
image When a medical emergency arises, rapid assessment of signs and symptoms along with vital signs will lead to the appropriate diagnosis and treatment. Document any client response that may lead to an emergency situation; document any client emergency.
image Complete a medical emergency report form to accompany the client to the hospital emergency room.

CRITICAL THINKING EXERCISES

1. Syncope is one of the most common medical emergencies occurring in the dental setting. Discuss steps to prevent an episode of syncope in a client. Review the signs and symptoms of syncope and the management of this condition.
2. A client complains of squeezing chest pain and shortness of breath and exhibits significant diaphoresis. What condition(s) are you most concerned about? Discuss appropriate management for this client’s condition. What could have been done to reduce the risk of this occurring?
3. Locate the emergency drug kit in the healthcare facility. Identify each drug and item in the kit and its intended use. Check the expiration dates on all items. How is the emergency kit systematically updated to ensure currency of all items? How is the staff trained to e nsure that all contents of the emergency kit can be used when necessary?
4. What is the emergency protocol in the healthcare facility? Does each member of the healthcare team have a clear role to play in the event of an emergency? Define these roles.
5. Role-play the following emergency situations: cardiac arrest, insulin shock, diabetic coma, epileptic seizure, reaction to the local anesthetic agent, anaphylactic shock, obstructed airway, syncope.
6. Use the Internet to determine how symptoms may differ between a man and a woman experiencing cardiac arrest.
7. Use the Internet to find information on the automated external defibrillator (AED). Explain its purpose and the procedure for use.

ACKNOWLEDGMENT

The authors acknowledge Lynn Utecht for her past contributions to this chapter.

Refer to the Procedures Manual where rationales are provided for the steps outlined in the procedures presented in this chapter.

REFERENCES

1. Malamed S.F. Medical emergencies in the dental office, ed 6. St Louis: Mosby; 2006.

2. Corah N.L. Development of a dental anxiety scale. J Dent Res. 1969;48:596.

3. American Heart Association in collaboration with International Liaison Committee on Resuscitation. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2000;102:11.

4. American Red Cross. CPR/AED for the professional rescuer. 2006.

Visit the image website at http://evolve.elsevier.com/Darby/Hygiene for competency forms, suggested readings, glossary, and related websites..