Preparing for a Medical Emergency Involving Anesthesia

By R. John Brewer, EMT-P

Medical emergencies in the dental office related to anesthesia are something that all dentists need to be ready to manage. This article is intended to help you prevent these situations or be better prepared when they occur.

There are various levels of anesthesia that need to be reviewed to help understand the various medical emergencies that can arise:

  1. Topical/Local Anesthesia
  2. Anxiolysis/minimal sedation: Defined as minimally depressed level of consciousness. Patients are able to maintain an airway and respond appropriately to verbal command physical stimulation. Pennsylvania law defines this as one drug at the manufacturer’s recommended dose (MRD) or nitrous oxide administration, for which Restricted II Anesthesia Permit is required.
  3. Moderate sedation: A drug induced depression of consciousness during which patients respond purposefully to verbal or light tactile stimulation. No interventions are required to maintain a patent airway, spontaneous ventilations are adequate, and cardiovascular function is maintained. If a provider administers oral sedatives above the MRD or combines with nitrous oxide, this meets the criteria of moderate sedation, for which a Restricted I Anesthesia Permit is required.
  4. Deep Sedation/General Anesthesia: A drug-induced depressed level of consciousness during which patients may or may not be aroused to painful stimuli. The ability to maintain ventilatory function may be impaired. In Pennsylvania, this can only be provided by an oral surgeon or Dental Anesthesiologist who maintains an unrestricted anesthesia permit.

This article is intended for the general practitioner who at times provide minimal sedation. The three key components in managing medical emergencies are:

  1. Prevention
  2. Recognition
  3. Treatment 

Preventing medical emergencies in the office should be everyone’s goal. Dentists need to be aware of how at risk your patients are to medical emergencies. Every patient should have height, weight, and ASA status documented. Medical history forms need to be completed, reviewed, and updated with the patient at every visit. Vital signs need to be taken and recorded on every patient. This includes blood pressure, pulse oximetry, and pulse rate.

While reviewing forms and taking vital signs, a cardiac, respiratory, and neurological exam needs to be completed. Simply asking, “Over the past several days have you experienced any dizziness, blurred vision, headaches, chest pain, shortness of breath?”covers the three main systems that would be a concern to the dentist. Good communication with the patient’s physicians is important to make sure the patient can tolerate the proposed treatment. The dentist should request the patients most recent history and physical, including medications, allergies, recent lab work, EKGs, and hospital admissions.

Unfortunately, not all emergencies are going to be prevented. There are situations beyond the doctor’s control: Call it bad luck or Murphy’s Law, but emergencies will occur. The goal is to then recognize and treat before it becomes life-threatening.

The most common medical emergencies that the dental team needs to recognize and be prepared to manage can be broken down into four categories:

I. Respiratory
a. Foreign body airway obstruction
b. Emesis/aspiration
c. Laryngospasm (moderate-deep-general anesthesia)
d. Bronchospasm (i.e. asthma)
e. Hyperventilation

II. Cardiac
a. Chest pain
b. Hypertension
c. Hypotension
d. Syncope
e. Cardiac arrest

III. Allergic Reactions
a. Mild
b. Moderate
c. Severe

IV. Other
a. Seizures
b. Stroke
c. Diabetic emergencies
d. Overdose

Once the emergency is recognized, the dental team must then begin the treatment phase. The dentist must be prepared to manage these emergencies for at least 20 minutes until EMS arrival. The dental team does not need to diagnose, but should be able to manage patient symptoms. Treatment does not always mean giving a drug or calling 911. However, there should never be a delay in calling 911 or administering a drug if it is indicated. Documentation during these emergencies is essential. The following times need to be documented so that after the emergency has subsided, you can go back and list the treatment completed.

• Time of Emergency
• Time 911 Contacted
• Time EMS Arrived
• Time EMS Departed

The following equipment is necessary to manage a medical emergency in the office:
☑ “E” Cylinder oxygen tank w/adjustable regulator, 0–15 liters
☑ Adult and pediatric bag valve mask
☑ Nasal cannulas
☑ Basic/rebreather oxygen masks
☑ Nebulizer masks
☑ Various size blood pressure cuffs (manual)
☑ Stethoscope
☑ Automated blood pressure cuff
☑ Glucometer

The following drugs are what is recommended for the “basic drug kit”:
☑ One bottle of 81 chewable aspirin
☑ One bottle of nitroglycerine tablets
☑ One oral or liquid diphenhydramine
☑ One Injectable diphenhydramine
☑ Apple juice boxes
☑ Oral glucose
☑ Proventil inhaler
☑ 2.5mg albuterol/3cc saline
☑ Epi Pen adult
☑ Epi Pen junior
☑ Naloxone
☑ Flumazenil
☑ 3cc syringes
☑ 1cc syringes
☑ Mucosal atomization devices

A large storage or tackle box is recommended to keep everything in one central location, along with the oxygen tank and AED. It is imperative that someone is responsible for checking the equipment and drugs in the office regularly. The AED should be looked at daily and the drugs checked monthly. One way to be prepared for these emergencies is to continually educate the entire staff on medical emergencies. Ideally, this training can be held in your office with both lecture and hands-on simulated training.

Keys to good emergency management include:

  • Remain calm
  • Call 911 early
  • Remember Circulation Airway Breathing (CAB)
  • Keep track of time
  • Be managing the patient when EMS walks in
  • Good documentation
  • Pre-plan: The dentist and team should knowtheir responsibilities
  • Maintain the proper drugs and equipment
  • Look for danger in every patient
  • Prepare for emergencies, they are going to happen
  • Do the right things and do the things right