Medical Emergencies in the Dental Setting: Overview and General Approach

Core Review

Emergency Prevention

The most effective management of a medical emergency is PREVENTION:

1. Thorough medical history: Review and update at every appointment. Identify conditions that increase emergency risk (cardiovascular disease, asthma, diabetes, allergies, seizure disorders).

1. Vital signs assessment: Measure and record at every appointment. Abnormal findings may indicate elevated emergency risk.

1. Stress reduction protocol:
   • Schedule anxious patients for morning appointments (less anticipation anxiety)
   • Limit appointment length
   • Pre-medicate when appropriate (anxiolytics per physician consultation)
   • Effective pain control (adequate local anesthesia)
   • Good communication (tell-show-do, address patient concerns)
   • Consider nitrous oxide sedation for anxiety management

1. Recognition of pre-emergency signs:
   • Patient reports feeling "strange" or "not right"
   • Pallor, sweating, lightheadedness
   • Changes in vital signs
   • Take patient-reported symptoms SERIOUSLY

1. Emergency preparedness:
   • All staff trained in BLS (Basic Life Support) for healthcare providers
   • Emergency kit readily accessible, regularly checked, and current
   • Emergency protocols reviewed and practiced
   • Emergency contact numbers posted

Frequency of Medical Emergencies in Dentistry

The Systematic Emergency Response Protocol

The NBDHE expects you to know and apply a structured emergency protocol. The following is adapted from current AHA guidelines and dental emergency references:

R.E.S.P.O.N.D. Protocol:

R — RECOGNIZE the Emergency

• Is the patient showing signs of distress? (pallor, diaphoresis/sweating, altered consciousness, difficulty breathing, complaints of chest pain, etc.)
• Trust your observation and the patient's report of symptoms

E — EVALUATE the Patient

• Assess level of consciousness: "Are you okay? Squeeze my hand."
• If unresponsive: check pulse and breathing simultaneously for no more than 10 seconds
• Determine the most likely emergency based on presentation and medical history

S — STOP Treatment Immediately

• Remove all instruments and materials from the patient's mouth
• The emergency takes priority over any dental procedure

P — POSITION the Patient Appropriately

• Supine with feet elevated (Trendelenburg position): Syncope, shock, hypotension
• Upright or semi-upright: Respiratory distress (asthma, CHF, hyperventilation), conscious patient with difficulty breathing
• Supine: Cardiac arrest (for CPR)
• Left lateral recumbent (recovery position): Unconscious but breathing patient, seizure patient (post-ictal)

O — OXYGEN and Open Airway

• If the patient is conscious and breathing normally: monitor; oxygen may be administered if available and indicated
• If unconscious but breathing: head-tilt/chin-lift to open airway; administer oxygen if available
• If not breathing normally: initiate CPR (start chest compressions)

N — NOTIFY Emergency Services (Activate EMS)

• Call 911 or activate EMS if the situation is life-threatening or potentially life-threatening
• Designate a specific team member to make the call
• Provide: location, nature of the emergency, patient status, treatment initiated

D — DIRECT the Team

• Assign specific roles: one person with the patient, one calling 911, one retrieving emergency equipment, one waiting at the entrance to guide EMS

Additional key steps:

• Monitor vital signs throughout the emergency (BP, pulse, respirations, SpO₂)
• Document the event thoroughly after stabilization
• Transfer care to EMS when they arrive; provide a concise handoff

Patient Positioning by Emergency Type

Basic Emergency Kit

The dental office emergency kit should include:

Category 1: Airway and Breathing

• Pocket mask with one-way valve
• Portable oxygen with positive-pressure delivery capability (minimum E-size cylinder)
• Oropharyngeal and nasopharyngeal airways
• Bag-valve-mask (BVM) device
• Suction (high-volume)

Category 2: Primary Emergency Drugs

• Epinephrine 1:1,000 (for intramuscular injection) — anaphylaxis
• Nitroglycerin (sublingual tablets or spray) — angina
• Aspirin (chewable, 325 mg) — suspected MI
• Albuterol (metered-dose inhaler with spacer) — asthmatic attack/bronchospasm
• Diphenhydramine (oral or injectable) — allergic reactions
• Oral glucose (gel, tablets, or liquid) — hypoglycemia

Category 3: Secondary Drugs and Supplies

• Ammonia inhalants (for syncope — use with caution)
• Aromatic ammonia spirit
• Syringes and needles
• Alcohol wipes
• Tourniquet
• Stethoscope and sphygmomanometer
• Pulse oximeter
• Glucometer
• AED (Automated External Defibrillator)

Important: The exact contents of the emergency kit vary by state requirements and practice setting. All drugs must be current (not expired). The kit must be checked regularly.

Stress-Related Psychogenic Emergencies

Hyperventilation:

• Cause: Anxiety-induced rapid, deep breathing leading to excessive CO₂ elimination (hypocapnia). This causes cerebral vasoconstriction, reducing brain blood flow.
• Signs/Symptoms: Rapid breathing, lightheadedness, tingling/peripheral paresthesia (lips, fingers), carpopedal spasms (hands/fingers curl due to hypocalcemia from alkalosis), feeling of suffocation, chest tightness
• Management:
  1. Stop treatment, remove instruments
  2. Position the patient upright
  3. Calm, reassuring communication
  4. Instruct the patient to slow breathing; breathe with them at a normal rate
  5. If severe: have the patient breathe into cupped hands or a paper bag (rebreathe CO₂) — note: this is controversial and should only be used when you are certain the diagnosis is hyperventilation (not asthma, PE, or other respiratory emergency)

Legal and Documentation Considerations

• All emergencies must be documented in the patient record:
  • Time of onset
  • Description of signs and symptoms
  • Vital signs (BP, pulse, RR, SpO₂) — serial readings if available
  • Treatment provided (drug name, dose, route, time)
  • Patient response
  • EMS activation time and arrival
  • Transfer of care documentation
  • Outcome and follow-up

• Incident report: An internal report separate from the patient record may be completed for risk management purposes

• Standard of care: Dental professionals are held to the standard of care for their profession. The dental hygienist must be able to recognize and initiate emergency management within their scope of practice.

Clinical Application

Scenario: During scaling and root debridement, a 68-year-old male patient becomes pale and diaphoretic. He says, "I don't feel good... I feel like I'm going to pass out." You note that his breathing is shallow. Medical history: hypertension, takes lisinopril. Vital signs at the start: BP 145/88, pulse 82.

Response:

1. Recognize: Signs of possible syncope or cardiovascular event. Take seriously.
2. Stop: Remove instruments and suction immediately.
3. Position: Place the patient supine with feet elevated (do NOT sit the patient up — if it is syncope from hypotension, sitting up worsens cerebral perfusion).
4. ABCs: Open airway, check breathing and pulse. Administer oxygen if available.
5. Monitor: Recheck BP and pulse. If the patient recovers rapidly (improvement within 1-2 minutes), it was likely vasovagal syncope.
6. If chest pain is present or symptoms persist: Activate EMS. This could be angina or MI.

Common Traps

• TRAP: Sitting a syncopal patient upright. When the patient says they feel faint, the correct response is to place them supine with feet elevated IMMEDIATELY. Sitting them up reduces cerebral blood flow further and may cause loss of consciousness.
• TRAP: Assuming all chest pain is anxiety. Chest pain in a dental setting must be treated as cardiac until proven otherwise. Medical history review helps, but new-onset chest pain = emergency.
• TRAP: Using a paper bag for any patient with difficulty breathing. This is ONLY appropriate for confirmed hyperventilation. If the patient has asthma, CHF, PE, or another respiratory emergency, the paper bag is dangerous.
• TRAP: Continuing treatment despite the patient reporting feeling unwell. STOP immediately. No dental procedure is worth the risk of a preventable medical emergency.