jada-2010-reed-20s-4s

10.14219/jada.archive.2010.03492010;141(suppl 1):20S-24SJADA

Kenneth L. ReedRecognizing a Patient's DistressBasic Management of Medical Emergencies:

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20S JADA, Vol. 141 http://jada.ada.org May 2010

Early recognition of medical emer-gencies begins at the first sign orsymptom.1 Familiarity with thepatient’s medical profile aidsimmensely in recognition;

knowing what to expect and what to look forpromotes a faster response. The dentistneeds to focus on what is happening with apatient minute by minute because distrac-tions slow response time.

By performing a simple visual inspectionof the patient, the dentist can determine ifhe or she has various diseases such as obe-sity, a history of cerebrovascular accident(CVA) (stroke), Parkinson disease, jaundice,exophthalmos, breathing difficulties andheart failure (orthopnea).

When treatment is indicated, the dentistshould proceed without hesitation. Often,management of medical emergencies in thedental office is limited to supportingpatients’ vital functions until emergencymedical services (EMS) arrives. This isespecially true in the case of major mor-bidity such as myocardial infarction or CVA.Treatment should consist minimally of basiclife support and monitoring of vital signs.2

The dentist never should administer poorlyunderstood medications.

An emergency management plan, asdescribed by Haas3 in this supplement andby Peskin and Siegelman,4 is of paramountimportance. The dental team’s ultimate goal

Dr. Reed is an associate professor in residence, School of Dental Medicine, University ofNevada, Las Vegas; assistant director, Advanced Education in General Dentistry, ArizonaRegion, Lutheran Medical Center, Brooklyn, N.Y.; and a clinical associate professor,Endodontics, Oral and Maxillofacial Surgery and Orthodontics, the Herman Ostrow Schoolof Dentistry of USC, Los Angeles. Address reprint requests to Dr. Reed, 4700 W. FlyingDiamond, Tucson, Ariz. 85742, e-mail “[email protected]”.

Basic management of medical emergenciesRecognizing a patient’s distress

Kenneth L. Reed, DMD

Background and Overview. Medical emergencies canhappen in the dental office, possibly threatening a patient’slife and hindering the delivery of dental care. Early recogni-tion of medical emergencies begins at the first sign of symp-toms. The basic algorithm for management of all medicalemergencies is this: position (P), airway (A), breathing (B),circulation (C) and definitive treatment, differential diag-nosis, drugs, defibrillation (D). The dentist places an uncon-scious patient in a supine position and comfortably positions a conscious patient. The dentist then assesses airway,breathing and circulation and, when necessary, supports thepatient’s vital functions. Drug therapy always is secondary tobasic life support (that is, PABCD). Conclusions and Clinical Implications. Promptrecognition and efficient management of medical emergenciesby a well-prepared dental team can increase the likelihood ofa satisfactory outcome. The basic algorithm for managingmedical emergencies is designed to ensure that the patient’sbrain receives a constant supply of blood containing oxygen.Key Words. Medical emergencies; basic life support;seizures; hypoglycemia; chest pain; angina pectoris; acutemyocardial infarction; bronchospasm; syncope; allergy.JADA 2010;141(5 suppl):20S-24S.

A B S T R A C T

Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.

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is the prevention of life-threatening emergencies.While the focus of this article is the recognition

of patients in distress, I should point out that den-tists initially should manage all medical emergen-cies in the same way by using what is known as thebasic algorithm5(p60):dposition (P) the patient; dairway (A);dbreathing (B);dcirculation (C);ddefinitive treatment, consisting of differentialdiagnosis, drugs and defibrillation (D).

Although many different medical emergenciesmay occur in the dental office, some are seenmore often than others. I will not attempt to beexhaustive in this article; for a comprehensivereview, readers should refer to one of the text-books on the topic.5,6 This article serves as a briefreview of some of the commonly encountered med-ical emergencies in the dental office. I examinesome of these medical emergencies and their mostcommon manifestations and lightly touch on somepotential treatments.

RESPIRATORY DISTRESS

Respiratory distress in a dental patient may takeone of many forms. For example, the precipitatingproblem may be asthma, an allergic reaction,tachypnea (hyperventilation, a pulmonaryembolus, acute congestive heart failure, diabeticketoacidosis, hyperosmolar hyperglycemic nonke-totic syndrome) or unconsciousness.

Clinicians can recognize respiratory distress ina patient through a variety of manifestations.Probably the most common cause of respiratorydistress seen in dental patients is asthma, alsoknown as acute bronchospasm.7 Patients with thistype of respiratory distress typically will want tosit upright (position). The dentist follows this withan evaluation of the patient’s airway. Is it patent?By definition, conscious patients who can talkhave a patent airway, are breathing and have suf-ficient cerebral blood flow and blood pressure toremain conscious. Definitive treatment includesadministration of a bronchodilator. For consciouspatients, this bronchodilator commonly isalbuterol, administered via a metered-doseinhaler. If the patient loses consciousness or isuncooperative with administration of albuterol viainhalation or if bronchospasm is refractory toadministration of albuterol, telephoning EMS (9-1-1) and administering epinephrine parenter-ally (intramuscularly) are indicated. Subcuta-

neous administration no longer is thought to bemost efficacious.8,9

CHEST PAIN

Another potential medical emergency seen indental offices is chest pain.10 Many factors mayprecipitate chest pain, such as acute myocardialinfarction (AMI), angina, paroxysmal supraven-tricular tachycardia, gastroesophageal reflux dis-ease, anxiety and costochondritis.

When describing their chest pain, manypatients do not describe the feeling as pain per se.They commonly use terms such as “squeezing,”“tightness,” “fullness,” “constriction,” “pressure”or “a heavy weight” on the chest. There are manypotential causes of chest pain. I will examine twothat the dentist can manage, or begin to treat, inthe dental office. I will not address chest pain ofnoncardiac origin, although it certainly is validand somewhat common in the population at large.

If a patient is experiencing chest pain, he orshe will let the dentist know, so recognition of theproblem will not be difficult. A conscious patientexperiencing chest pain is free to be in any posi-tion that is comfortable. As stated earlier, thesepatients often will want to sit upright. Consciouspatients who can talk have a patent airway, arebreathing and have sufficient cerebral blood flowand blood pressure to retain consciousness. Thedifficulty for the dentist is the differential diag-nosis of chest pain.11

Angina pectoris and AMI are the two mostlikely cardiac problems in a conscious patient whois exhibiting chest pain in the dental office. Otherpossibilities exist, but this article focuses on therecognition and early treatment of these twocommon entities. If the patient had experiencedcardiac arrest, he or she would not be conscious.

Differential diagnosis. A differential diag-nosis of chest pain involves looking at a numberof signs and symptoms. One consideration is thepatient’s history. Has he or she ever experiencedanginal chest pain? If so, it is likely that the cur-rent chest pain is angina pectoris. However, ifthis is the patient’s first episode of chest pain, thedentist should treat him or her as if it were anAMI and have EMS transfer the patient as

ABBREVIATION KEY: AMI: Acute myocardial infarc-tion. CVA: Cerebrovascular accident. EMS: Emergencymedical services. MONA: Morphine, oxygen, nitroglyc-erin and aspirin. PABCD: Position, airway, breathing,circulation, definitive treatment.


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quickly as possible to a hospital. The differential diagnosis of chest pain in a

conscious patient in the dental office also includesan evaluation of the quality of the pain. If thepain is significant but not severe, the chances arebetter that it is caused by angina pectoris, notAMI. Pain that radiates, commonly to the leftside of the body—the left mandible, left arm, leftshoulder—more likely is caused by AMI than byangina pectoris.12(p460) However, not all pain asso-ciated with AMI radiates, and some patients haveatypical pain when experiencing an AMI. Forexample, patients with diabetes and women oftenexperience an unusual shortness of breath, anunexplained elevation of blood sugar levels orboth as a symptom of an AMI but often experi-ence no chest pain at all (that is, silent myocar-dial infarction).13

Blood pressure. Blood pressure also mightindicate whether the patient is experiencingangina pectoris or an AMI. If the patient’s bloodpressure is elevated during this episode of chestpain, angina more likely is the cause.10 This eleva-tion may be a response to the pain being experi-enced. If the blood pressure falls below thepatient’s baseline value or the immediate preop-erative value, the dentist should consider an AMI;if the pump (the heart) has been injured, it is lessefficient, resulting in a decreased cardiac outputand subsequent drop in blood pressure.12(p475)

Definitive treatment. Definitive treatmentfor angina pectoris requires the administration ofa nitrate, commonly nitroglycerin, via sublingualtablet or translingual or transmucosal spray. Prehospital treatment of a patient suspected ofhaving AMI typically involves the administrationof morphine, oxygen, nitroglycerin and aspirin(MONA), in addition to notifying EMS. Giventhat most dental offices do not have morphine,the dentist may substitute nitrous oxide/oxygenin a 50:50 concentration.14

ALTERED CONSCIOUSNESS

As with respiratory distress, altered conscious-ness or unconsciousness may occur owing to avar iety of precipitating factors. Some of theseinclude significant hypotension from any cause,hypoglycemia, CVA, illicit drug use, AMI andseizure.

Dizziness developing in the dental office mayhave many origins, but low blood pressure in thebrain often is the ultimate cause. The easiest andleast invasive way to increase blood flow to the

brain is to place the patient in a supine position.Patients in whom dizziness is the only symptomare conscious and able to talk (airway, breathingand circulation have been assessed and ensured).Definitive treatment consists simply of placing thepatient properly in a supine position. Once thepatient is positioned, the dentist should determinethe cause of the dizziness. Was it initiated byvasovagal syncope? Hypoglycemia? Hypovolemia?

Vasovagal syncope. Vasovagal syncope in thedental office often is caused by anxiety, whichneeds to be addressed properly. For somepatients, this may mean that the dentist simplyneeds to take more time explaining the dentalprocedure to them, thus allaying their fears.Other patients may require pharmacologicalintervention (that is, sedation). Inhalation seda-tion (nitrous oxide/oxygen) may be ideal for somepatients, while enteral sedation may be moreappropriate for others. Some patients benefitmost from parenteral (that is, intramuscular,intranasal) moderate sedation and others mayrequire general anesthesia to properly addresstheir anxiety.

Hypoglycemia. Dentists also should considerhypoglycemia in a differential diagnosis of dizzi-ness. Frequently, the patient has a history of dia-betes. Patients with type 1 diabetes (and somewith type 2) self-administer insulin to lower ahigh glucose level (hyperglycemia) toward theupper limit of normal (120 milligrams/deciliter).Patients with diabetes must ingest food immedi-ately after administering insulin to prevent thedevelopment of hypoglycemia as a result of theinsulin injection. The most common cause ofhypoglycemia in patients with type 1 diabetes isnot eating after administering insulin.

Patients with clinically significant hypo-glycemia may be recognizable because they com-monly experience diaphoresis and tachycardiaand feel faint. Subsequently, they may experiencemental confusion and, ultimately, the loss of con-sciousness. As long as the patient retains con-sciousness, the clinician should allow him or herto remain in a comfortable position. Consciouspatients with hypoglycemia have a patent airway,are breathing and have an adequate pulse. Thetreatment of choice for patients with hypo-glycemia is administration of sugar. Unconsciouspatients with hypoglycemia require parenteraladministration of sugar. Absent a proficiency invenipuncture, the dentist should activate EMS.Malamed5(p283) recommends that a dentist never


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place any drug or other substance in the mouth ofan unconscious patient that is a liquid or mightbecome a liquid at body temperature.

Fainting, or vasovagal syncope, is the mostcommon medical emergency seen in the dentaloffice.15 The basic algorithm for dealing with it isthe same as that for dizziness described earlier.The dentist or a team member should place thepatient in a supine position. Most patients withsyncope have a patent airway, are breathing anddemonstrate an adequate pulse. Patients whofaint typically respond to positional changeswithin 30 to 60 seconds. If the patient does notrespond in this time frame, he or she did notsimply faint, and the dentist must consider amore complete differential diagnosis of loss of con-sciousness. Although many possible explanationsexist, the more common reasons a patient losesconsciousness in the dental office (assuming nomedications have been administered) are syncope,low glucose level, CVA and cardiac arrest.

In each of these examples of unconsciousness,the initial management of the emergency is thesame. The dentist should place the patient in asupine position. If he or she has not respondedwithin one minute, the clinician probably can ruleout syncope. The dentist then should open theairway and assess breathing (“look, listen andfeel”16). If the patient is breathing, the next step isto check his or her circulation. Does the patienthave a palpable pulse at the carotid artery(brachial artery in infants)?

Patients who are breathing spontaneously andnormally may be experiencing hypoglycemia or aCVA, but not cardiac arrest. In cardiac arrest, thepatient does not breathe spontaneously (agonalbreathing notwithstanding). A patient with apnearequires positive pressure ventilation with 100percent oxygen.

Patients placed in a supine position who do notrespond within 30 to 60 seconds but are breathingspontaneously likely are experiencing hypo-glycemia or a CVA. If the patient’s blood pressureis normal (that is, close to baseline values—partof assessing circulation), the problem probably isa low glucose level. If the patient’s blood pressureis alarmingly high, the dentist must strongly con-sider the possibility that the event is a CVA.

SEIZURES

Seizures are rare in dental offices, especially inpatients who never have had them. Patients whoconvulse in the dental office typically have a

seizure history and often are characterized ashaving epilepsy.17 The initial treatment forseizures is the same as that for any other medicalemergency. The patient experiencing a general-ized tonic-clonic seizure is unconscious andshould be placed in a supine position. The dentistshould perform a “head tilt and chin lift” to theextent possible. Patients who are seizing arebreathing and have adequate cardiovascular func-tion, which the dentist can verify by checking forand finding a strong pulse.

The dentist or a team member must remove all dental instruments and supplies from thepatient’s mouth and protect the patient fromharm. No one should place anything in the mouthof a patient who is seizing. If someone familiarwith the patient is present (such as a parent,spouse or professional caregiver), a team membershould bring the person into the operatory andask him or her to evaluate the patient. He or shemay determine that this is a typical seizure forthe patient, in which case simple monitoring issufficient, or he or she may feel that this seizureis unusually severe and suggest that someonecontact EMS.

ALLERGY-RELATED EMERGENCIES

Allergy-related emergencies are rare but possiblein the dental office. The most common allergen inthe dental environment today is latex.18 Anallergy can be mild or severe. If the patient hasitching, hives, rash or a combination of these, theallergy may be considered mild (non–life threat-ening). However, if the patient experiences respi-ratory or cardiovascular compromise—that is, theloss of consciousness due to difficulty in breathingor inadequate blood pressure and blood flow tothe brain—the dentist should treat the allergy asa life-threatening situation.

Mild allergy. If the allergy is mild (that is,itching, hives, rash or a combination of these) andthe patient remains conscious, he or she shouldbe made comfortable. The conscious patient whois talking has verified that the airway is patent,he or she is breathing and he or she has cardio-vascular function adequate to maintain conscious-ness. In this case, the dentist should administer ahistamine blocker, such as diphenhydramine, viaintramuscular or intravenous injection.

Severe allergy. If the allergy is severe, thepatient has lost, or soon will lose, consciousness.The dentist should place the patient in a supineposition, open the airway and evaluate breathing.


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Often, breathing is spontaneous. If the patient isnot breathing, the clinician must administer posi-tive pressure oxygen via a bag-valve-mask device.If the patient has lost consciousness, his or hercerebral blood pressure is too low. To support circulation, as well as to dilate the bronchiolesand minimize any potential swelling of laryngealtissues, the dentist must administer epinephrineas soon as possible. Someone also must contactEMS, as the patient requires additional treatmentin a hospital’s emergency department.

BLEEDING

Dentists deal with bleeding every day, so it rarelyconstitutes a significant medical emergency. How-ever, there are times when significant bleedingmay turn into a medical emergency. If the greaterpalatine artery is inadvertently cut, for example,the dentist must control the bleeding quickly orthe outcome may be poor. Patients who are hem-orrhaging typically are conscious, so keepingthem comfortable is a key component in man-aging the emergency. Placing the patient in asupine position will increase blood pressure in thehead and generally is not indicated. Although it isimportant to verify that the airway is patent atall times, only the most severe and unrelentingcases of intraoral hemorrhage require placementof an advanced airway (that is, nasopharyngealairway, laryngeal mask airway, supraglotticairway [King LT airway, King Systems,Noblesville, Ind.] or endotracheal tube).19 Theseconscious, spontaneously ventilating patients whoare bleeding profusely are treated most commonlywith local measures only. Pressure to the affectedsite, with or without suturing, addresses theproblem adequately in most cases.20

CONCLUSION

Medical emergencies can occur in the dentaloffice, and it is important for the entire dental

team to be prepared for them. Regardless of theirspecific type, they are best managed in basicallythe same way: position the patient; assess theairway, breathing and circulation; and providedefinitive treatment. ■

Disclosure. Dr. Reed did not report any disclosures.

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2. Fukayama H, Yagiela JA. Monitoring of vital signs during dentalcare. Int Dent J 2006;56(2):102-108.

3. Haas DA. Preparing dental office staff members for emergencies:developing a basic action plan. JADA 2010;141(5 suppl):8S-13S.

4. Peskin RM, Siegelman LI. Emergency cardiac care: moral, legal,and ethical considerations. Dent Clin North Am 1995;39(3):677-688.

5. Malamed SF. Medical Emergencies in the Dental Office. 6th ed. St.Louis: Mosby; 2007.

6. Bennett JD, Rosenberg MB. Medical Emergencies in Dentistry.Philadelphia: Saunders; 2002.

7. Malamed SF. Emergency medicine: beyond the basics (publishedcorrection appears in JADA 1997;128[8]:1070). JADA 1997;128(7):843-854.

8. Korenblat P, Lundie MJ, Dankner RE, Day JH. A retrospectivestudy of epinephrine administration for anaphylaxis: how many dosesare needed? Allergy Asthma Proceed 1999;20(6):383-386.

9. Webb L, Greene E, Lieberman PL. Anaphylaxis: a review of 593cases. J Allergy Clin Immunol 2004;113(2 suppl):S240.

10. Garfunkel A, Galili D, Findler M, et al. Chest pains in the dentalenvironment [in Hebrew]. Refuat Hapeh Vehashinayim 2002;19(1):51-59, 101.

11. Kreiner M, Okeson JP, Michelis V, Lujambio M, Isberg A. Cranio-facial pain as the sole symptom of cardiac ischemia: a prospective mul-ticenter study. JADA 2007;138(1):74-79.

12. Malamed SF. Sedation: A Guide to Patient Management. 5th ed.St. Louis: Mosby; 2010:460, 475.

13. Grundy SM, Howard B, Smith S Jr, Eckel R, Redberg R, BonowRO. Prevention Conference VI: Diabetes and Cardiovascular Disease—executive summary: conference proceeding for healthcare professionalsfrom a special writing group of the American Heart Association. Circu-lation 2002;105(18):2231-2239.

14. Homayounfar SH, Broomandi SH. Evaluation of Entonox as ananalgesic for relief of pain in patients with acute myocardial infarction.Iran Heart J 2006;7(3):16-19.

15. Findler M, Elad S, Garfunkel A, et al. Syncope in the dental envi-ronment [in Hebrew]. Refuat Hapeh Vehashinayim 2002;19(1):27-33, 99.

16. 2005 American Heart Association guidelines for cardiopulmonaryresuscitation and emergency cardiovascular care. Part 4: adult basiclife support. Circulation 2005;112:IV-19–IV-34.

17. Bryan RB, Sullivan SM. Management of dental patients withseizure disorders. Dent Clin North Am 2006;50(4):607-623, vii.

18. Desai SV. Natural rubber latex allergy and dental practice. N ZDent J 2007;103(4):101-107.

19. Moghadam HG, Caminiti MF. Life-threatening hemorrhage afterextraction of third molars: case report and management protocol. J CanDent Assoc 2002;68(11):670-674.

20. Cheng CK, Gaia BF, de Oliveira Neto HG, Martini MZ, Aburad A,Shinohara EH. Severe hemorrhage during an incisional biopsy: areport of a case. J Contemp Dent Pract 2007;8(3):97-103.


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