Assisting in a Medical Emergency PDF

31 Assisting in a Medical Emergency L E A R N I N G A N D P E R F O R M A N C E O U TCO M E S Learning Outcomes On completion of this chapter, the student will be able to achieve the following objectives: 1. Pronounce, define, and spell the key terms. When cardi...

31 Assisting in a Medical Emergency L E A R N I N G A N D P E R F O R M A N C E O U TCO M E S Learning Outcomes On completion of this chapter, the student will be able to achieve the following objectives: 1. Pronounce, define, and spell the key terms. When cardiopulmonary resuscitation is initiated and the 2. Describe the preventive measures taken for a medical proper sequence of steps. emergency that might occur during dental treatment. Measures to prevent airway obstruction and choking during 3. Describe the elements of emergency preparedness required for dental treatment. successful management of medical emergencies. The use of a defibrillator in an emergency. 4. Give the common signs and symptoms of an emergency and 6. Describe the basic items included in an emergency kit. how to recognize them. 7. List the responsibilities of the dental assistant in an emergency. 5. Give the required emergency care standards, which include the 8. Describe medical emergencies experienced in the dental office following: and how to respond. Credentials and skills that a dental assistant must have for 9. Discuss the importance of proper documentation of medical emergency preparedness. emergencies. Fundamental aspects of basic life support. Performance Outcomes On completion of this chapter, the student will be able to meet competency standards in the following skills: 1. Accurately perform CPR on a simulated mannequin. Experiencing a stroke. 2. Accurately perform the Heimlich maneuver on a mannequin. Having a breathing problem. 3. Demonstrate use of the automated external defibrillator. Experiencing an allergic reaction. 4. Demonstrate preparation and placement of oxygen. Experiencing a seizure. 5. Demonstrate how to respond to a patient who is: Experiencing a diabetic emergency. Unconscious. Having chest pain. KEY TERMS acute referring to a difficult or severe condition with sudden cardiopulmonary resuscitation (CPR) onset (kahr-dee-oe-PUL-muh-nar-ee ree-suh-si-TAY-shun) a plan of allergen (AL-ur-jen) a substance that causes an allergic reaction action for restoring consciousness or life allergy (AL-ur-jee) response by the body to a foreign substance convulsion (kun-VUL-shun) medical condition in which or an allergen involuntary contraction of muscles take place; common with anaphylaxis (an-uh-fi-LAK-sis) extreme hypersensitive reaction to seizure disorders an antigen that can lead to life-threatening response epilepsy (EH-pi-lep-see) neurologic disorder with sudden angina (an-JYE-nuh) chest pain caused by inadequate oxygen to recurring seizures of motor, sensory, or psychic malfunction the heart erythema (er-i-THEE-muh) redness of the skin, often caused by antibodies protein produced by the immune system in response injury or irritation to the presence of a foreign substance gait a particular way of walking, or ambulating antigen (AN-ti-jen) a substance introduced into the body to hypersensitivity state of being excessively sensitive to a stimulate the production of an antibody substance, often with allergic reactions aspiration (as-pi-RAY-shun) the act of inhaling or ingesting, such hyperventilation abnormally fast or deep breathing as a foreign object hypotension (hye-poe-TEN-shun) an abnormal low blood asthma (AZ-muh) a respiratory disease often associated with pressure reading allergies and characterized by sudden recurring attacks of labored breathing, chest constriction, and coughing 432  CHAPTER 31 Assisting in a Medical Emergency 433 myocardial infarction (mye-oe-KAHR-dee-ul in-FAHRK-shun) ventricular fibrillation (VF) (ven-TRIK-yoo-lur fib-ri-LAY-shun) damage to the muscular tissue of the heart commonly caused by serious irregular cardiac rhythm that prevents the heart from obstructed circulation; also referred to as a heart attack pumping blood syncope (SING-kuh-pee) loss of consciousness caused by insufficient blood to the brain, also referred to as fainting A medical emergency is a condition or circumstance that requires treatment. Every member of the dental team must be prepared immediate attention toward a person who has been injured for an emergency when one occurs in the dental office. or has suddenly become ill. When a medical emergency Ongoing observation of the patient is an important part of occurs, it is not possible to refer to a medical textbook for answers; emergency preparedness. A calm, well-functioning staff can handle you must be prepared to respond immediately. Your knowledge an emergency in the dental office without complicating the serious- and skills could mean the difference between life and death. ness of the situation by frightening the patient. To prevent added At the time of a medical emergency, you may be the only person stress and complications, every staff member should know and in the room. If this happens, your first response is to the patient practice his or her role in emergency protocols before any emergency until the dentist, dental team, or medical assistance arrives for arises. A standardized procedure for the management of emergencies support. If this is the case, it will be your responsibility to use must be established and followed. well-chosen words of support, to show a willingness to help, and to demonstrate capable lifesaving skills. Assigned Roles Preventing a Medical Emergency In the management of an emergency, the combined efforts of trained persons are more efficient when each person takes on a One of the most important ways to prevent a medical emergency specific, assigned role. It is the responsibility of the dentist to is to know your patient. This means establishing open communication define these roles. Most often, dental team members will oversee with the patient about his or her health and maintaining a completed specific roles, as follows: and updated medical history before dental treatment begins. Front desk staff (business assistant) will call emergency services The front desk assistant (business assistant) is responsible for and remain on the telephone until appropriate medical assistance ensuring that patients update this information as they enter the arrives (Fig. 31.1). office. Once they have received the forms, patients should indicate any changes in their health, even if they were seen as recently as the previous week. A patient should also verify that the information is accurate by dating and signing the form (see Chapter 26 for a review of a medical history update). Most medical emergencies that occur in the dental office are initiated by either the stress that a person is undergoing in his or her personal life or the apprehension of going to the dentist. If a patient has memory of a negative experience in the dental setting, or is nervous about an upcoming procedure, the patient’s stress level could be heightened, which can lead to a medical emergency. RECALL 1. What is the best way to prevent an emergency? 2. What is a probable cause of most medical emergencies in the dental office? Emergency Preparedness While a patient is in the dental office, the dentist is responsible for the individual’s safety. If a medical emergency involving the patient arises, the dentist and staff members are responsible for providing emergency care until more qualified personnel arrive. Emergency first aid protocols must be established and routinely practiced in the dental office. Fig. 31.1 It is important to have open communication with emergency Successful management of medical emergencies in the dental personnel. (Copyright Wavebreakmedia Ltd/Wavebreak Media/Thinkstock. office requires preparedness, prompt recognition, and effective com.) 434 PART 6 Patient Information and Assessment Fig. 31.3 Poster shows the most common number to be dialed for emergency services—9-1-1. Fig. 31.2 Preparing oxygen for an emergency. (Copyright iStock.com/ Toa55.) The clinical assistant or dental hygienist will retrieve the oxygen unit and emergency drug kit and prepare for use (Fig. 31.2). The dentist, clinical assistant, or dental hygienist will remain with the patient to assist in assessment or with basic life support. Additional dental team members will respond to the needs of other patients in the office. Routine Drills Fig. 31.4 Emergency medical services personnel on the scene. (Copy- right Getty Images.) Training must be kept current. A “mock emergency” should be scheduled monthly in the dental office, so that dental team members can practice their roles, take on additional roles, and refine the RECALL office’s emergency plan. 3. Who is responsible for a patient’s safety in the dental office? 4. Who in the dental office would most likely oversee calling the Emergency Telephone Numbers emergency medical services? 5. Where should emergency phone numbers be kept in a dental office? A list of emergency numbers should be posted next to each telephone throughout the office. Maintaining a current list of these telephone numbers is an important part of emergency preparedness. Recognizing a Medical Emergency The list should include telephone numbers for emergency medical services (EMS) personnel, local police, and firefighters. In areas The dental staff must remain alert, knowing that a medical emergency of the United States and Canada, all three agencies can be reached can occur at any time. For this reason, ongoing observation of the by dialing 9-1-1 (Fig. 31.3). The availability of and response time patient in the reception area, in the dental chair, or leaving the office in which these services respond to emergencies vary widely according cannot be overemphasized. The “attentive” dental team observes the to the geographic area and the population served. Two important patient’s general appearance and gait as he or she enters the clinical factors in emergency preparedness to know are (1) the time it area. Note the patient’s response to routine questions. Slow responses takes for local EMS personnel to reach the dental office and (2) and changes in speech patterns from a previous appointment should the life support capabilities that are available on arrival of the EMS be noted for the dentist to evaluate. Recognition of a change in either staff (Fig. 31.4). Not all EMS personnel carry the same equipment physical or emotional presence is critical. or provide the same level of lifesaving care. A list of the telephone numbers of the nearest hospital, physi- Signs and Symptoms cians, and oral surgeons also should be available. These professionals would be able to offer the life support needed while waiting for When a medical emergency occurs, it is important to be attentive EMS personnel or another type of emergency response. and take note of the patient’s response to a symptom and your  CHAPTER 31 Assisting in a Medical Emergency 435 observation of the signs. A symptom is what the patient is telling arrests than are caused by any other rhythm (about 80%–90% of you about how he or she feels or what he or she is experiencing, cases). such as, “I feel dizzy,” “I’m having trouble breathing,” or “My arm Defibrillation must be started immediately to stop VF and hurts.” allow a normal heart rhythm to resume. The sooner defibrillation A sign is what you observe in a patient, such as a change in begins, the better are the victim’s chances of survival. If defibrillation skin color or an increase in respiratory rate. Because signs are is provided within the first 5 minutes of a cardiac arrest, the chance observed by you and/or another member of the dental team, they that the victim’s life can be saved is approximately 50%. For each are more consistent than the symptoms expressed by the patient. minute that passes during a cardiac arrest, however, the chance of resuscitation is reduced by 7% to 10%. After 10 minutes, very Emergency Care Standards little chance of successful rescue remains. Most dental offices are equipped with an AED. The AED is It is imperative that each member of the dental team has the attached to the patient, the power is turned on, and the device following credentials and skills as a practicing healthcare provider analyzes and defibrillates the patient without further input from in a dental office: the operator. A standard 110-volt current or battery powers this Ability to assess and record vital signs accurately (see portable defibrillator. The monitor is equipped with a display and Chapter 27) can print a copy of the victim’s heart rate. Basic life support for the healthcare provider (cardiopulmonary The AED is basically an advanced computer microprocessor resuscitation [CPR]) that assesses the patient’s cardiac rhythm and identifies any rhythm Heimlich maneuver (also known as abdominal thrusts) for which a shock is indicated. The shock is an immense jolt of Operation of the automated external defibrillator (AED) electricity that is sent to the heart muscle to reestablish the proper rhythm of the heart. The AED (1) monitors the patient’s heart rhythm, (2) distinguishes VF from other abnormal heart rhythms Basic Life Support through computed analysis, and (3) automatically defibrillates if The fundamental aspects of basic life support include (1) imme- needed. diately recognizing an emergency, (2) activating the emergency See Emergency Procedure 31.2: Operating the Automated response system (ERS), (3) accurately performing CPR, and (4) External Defibrillator. applying defibrillation when appropriate. Choking Cardiopulmonary Resuscitation A sudden coughing spasm or movement by the patient during a In an emergency in which the patient is not breathing and the heart dental procedure may cause the accidental aspiration of a foreign is not beating, cardiopulmonary resuscitation (CPR) must be object. The patient’s discomfort is immediate; his or her hands initiated immediately. Time is critical in cardiac arrest, with each move to the throat as spasms of coughing or choking occur. minute that someone goes without CPR and the use of an AED The severity of the situation depends on (1) how forcefully the Based on the latest publication from the American Heart Associa- item is lodged in the person’s throat and (2) how much of the airway tion (AHA) and the American Red Cross, healthcare providers is blocked. The airway can become totally or partially blocked if are to follow the “Cardiac Chain of Survival.” The steps include: the patient inhales a small object, such as a crown, debris, or a (1) Recognizing the signs of cardiac arrest and then activating the tooth fragment. The three most important measures in preventing ERS, (2) providing CPR, with an emphasis on chest compression, airway obstruction during dental treatment include the following: (3) rapid defibrillation, (4) the inclusion of advanced emergency High-velocity suction medical services, and (5) advanced life support and post-cardiac care. Use of dental dam during routine procedures Follow the major sequence of steps—chest compressions, airway, Placement of a throat pack (gauze placed at base of throat) breathing (C-A-B)—for adults and pediatric patients (children See Emergency Procedure 31.3: Responding to the Patient With and infants). This sequence allows for the chest compressions to an Obstructed Airway, which reviews the steps that should be be initiated immediately and then followed by ventilation. taken in response to a choking patient. CPR combines external cardiac compressions to stimulate the heart with rescue breathing to ensure that adequate air is entering the lungs. This emergency support system is initiated immediately RECALL so that the flow of oxygen-carrying blood quickly reaches the brain. 6. When patients tell you how they feel, what is the term for such a The cells of the brain, the most sensitive tissue in the body, are “feeling”? irreversibly damaged after 4 to 6 minutes without oxygen. 7. What minimum credentials must you have to meet emergency care CPR for children and infants is like that for adults, but a few standards as a dental assistant? changes must be made to adapt to the anatomy and smaller bodies 8. What does the abbreviation CAB stand for in emergency care? of children. 9. What is the proper ratio of chest compressions to breaths for an adult victim when CPR is performed? See Emergency Procedure 31.1: Performing Cardiopulmonary 10. What does the abbreviation AED stand for? Resuscitation (One Person). 11. What is the danger of ventricular fibrillation? Automated External Defibrillator Emergency Equipment and Supplies Most sudden cardiac arrest victims are experiencing ventricular fibrillation (VF). VF is an abnormal, chaotic heart rhythm that In most dental offices, a standardized emergency kit is organized prevents the heart from pumping blood. VF causes more cardiac and equipped with emergency supplies (Fig. 31.5). A clinical 436 PART 6 Patient Information and Assessment assistant or hygienist is assigned with the responsibility of maintain- American Dental Association. Table 31.1 lists the most common ing and updating these supplies. lifesaving drugs that are included in a basic emergency kit, along Maintenance of a drug kit consists of the following: with their brand names, uses, routes of administration, and precau- Routine check of supplies for quality to determine whether they tions for use. are in working condition (rubber tubing, oxygen masks, tourniquets, intravenous lines, ventilation masks, blood pressure equipment) Oxygen Weekly examination for expiration of drugs within the emergency kit (drugs past the expiration date should be replaced immediately) Oxygen is the most frequently used “drug” in a medical emergency. Daily check of oxygen tank or tanks The ideal agent for the resuscitation of a patient who is unconscious The emergency medical kit contents should meet the basic but still breathing is 100% oxygen. If the patient is not breathing, standard of care, be compliant with state, province, or territory air must be forced into the lungs through rescue breathing or regulations, and be consistent with recommendations from the similar emergency measures. A portable unit with a tank of oxygen may be stored where it can be moved quickly into a treatment room if needed. A reserve tank of oxygen should be kept available for treatment in emergency situations. Remember, the oxygen cylinder is always color-coded green (Fig. 31.6). See Emergency Procedure 31.4: Preparing the Oxygen System. Fig. 31.5 Standardized color-coded basic emergency kit. (Courtesy HealthFirst, Mukilteo, WA.) Fig. 31.6 Mobile oxygen tank. (Courtesy HealthFirst, Mukilteo, WA.) TABLE 31.1 Recommended Drugs to Be Included in a Basic Emergency Kit Drug Brand or Common Name Use Route Oxygen N/A Respiratory distress Inhaled Ammonia inhalant Spirits of ammonia Fainting Inhaled Epinephrine Autoinjector Allergic reaction IM, IV, subcutaneous Adult 0.3 mg EpiPen Pediatric 0.15 mg Diphenhydramine Benadryl Allergic reaction IV, deep IM Nitroglycerin (tablet/spray) Nitrostat Angina Sublingually Albuterol Ventolin Bronchospasm with/asthma Inhaled Aspirin Bayer Myocardial infarction Orally Oral glucose gel/orange juice concentrate Glucose Hypoglycemia Orally IM, Intramuscular; IV, intravenous.  CHAPTER 31 Assisting in a Medical Emergency 437 RECALL in positioning. Patients most often a%ected are those who receive nitrous oxide–oxygen or intravenous sedation and those who are 12. What is the most frequently used “drug” in a medical emergency? pregnant. The duration of unconsciousness is very brief, usually lasting Emergency Responses only seconds to minutes. If unconsciousness persists for a longer time, other causes are probably present, and appropriate action The diagnosis of a specific condition is not your responsibility. As must be taken immediately. a dental assistant, your responsibilities in relation to an emergency See Emergency Procedure 31.5: Responding to the Unconscious are to (1) recognize the signs and symptoms of a significant medical Patient. complaint and (2) provide appropriate support to the dentist in the implementation of emergency procedures. The Pregnant Patient During assessment of a medical emergency, the primary factor in determining the manner of treatment is the physical change in While in a supine position, the pregnant patient may feel dizzy the patient. The physical changes most often observed during a or light-headed and may faint after being repositioned upright. dental office emergency include the following: This reaction results from pressure of the enlarged uterus on the Unconsciousness, the state of unresponsiveness to sensory abdominal veins. stimulation In contrast to the procedure for postural hypotension, the patient Altered consciousness, with the patient conscious but acting should be turned onto her left side or moved into an upright strangely sitting position. Change of position relieves pressure on involved Respiratory distress, in which the conscious patient has difficulty blood vessels. breathing Convulsions, which are uncontrolled skeletal muscle contractions RECALL Chest pain in the conscious patient Most emergencies in the dental office occur during or imme- 13. A patient who is unresponsive to sensory stimulation is in what state? diately after the administration of local anesthesia or at the beginning 14. What is the medical term for fainting? of a procedure. The types of procedures during which medical emergencies most frequently arise in the dental office are tooth extractions and endodontic treatment. In these two procedures, Cardiac Emergencies adequate pain control may be difficult to achieve, and patient anxiety can be high. Angina The patient with angina will experience severe chest pain because Common Medical Emergencies Experienced the heart muscle is deprived of adequate oxygen. Although it is painful, angina does not usually lead to death or permanent heart in the Dental Office damage. However, such chest pain indicates that the person has some degree of coronary artery disease. Syncope Because the signs and symptoms of angina and those of myo- Syncope, commonly referred to as fainting, is one of the most cardial infarction are very similar, it is important for the clinician frequent medical emergencies in the dental office. Syncope is caused to distinguish angina by using the following criteria: by an imbalance in the distribution of blood to the brain and to Pain from angina usually lasts 3 to 8 minutes. the larger vessels within the body. This reduced blood flow to the Angina pain is relieved or eased promptly by the administration brain causes the patient to lose consciousness. of the drug nitroglycerin. Psychological factors that can contribute to syncope include A patient with angina should specify this condition on the stress, apprehension, fear, and the sight of blood or the sight of a medical history. certain instrument. Physiologic factors can include remaining in one A patient with a history of angina usually carries some form position for a long time, being in a confined environment, skipping of nitroglycerin to relieve the symptoms of an attack. a meal or being hungry, and experiencing fatigue or exhaustion. Even if a patient has a history of angina, when an attack strikes, The patient may complain of symptoms, and the signs may be it is important to remember that the patient could be having noticed for several minutes before the patient loses consciousness. a heart attack and to respond appropriately. Fainting is not harmful to the patient if someone is there to protect the person during unconsciousness. Even though it is quite Acute Myocardial Infarction common, syncope is one emergency that may be prevented by During an acute myocardial infarction, commonly known as a close observation of the patient. heart attack, the muscles of the heart are damaged because of an insufficient oxygen supply. If this damage is severe enough, the patient will die; however, prompt medical treatment can help limit Postural Hypotension damage to the heart. Postural hypotension, also referred to as orthostatic hypotension, Although other conditions have similar symptoms, any unex- is a level of altered consciousness that may lead to loss of conscious- plained chest pain should be treated as a potential acute myocardial ness. This emergency commonly occurs when the patient assumes infarction. Time is important, and the response of the dental team an upright position too quickly. must be swift and prudent. Postural hypotension results from insufficient blood flow to the See Emergency Procedure 31.6: Responding to the Patient With brain and may occur in a patient immediately after a sudden change Chest Pain. 438 PART 6 Patient Information and Assessment Cerebrovascular Accident The symptoms of anaphylaxis can be life threatening and may develop very quickly. Without appropriate care, the patient could A cerebrovascular accident (CVA), commonly referred to as a stroke, die within a few minutes is the interruption of blood flow to the brain. If blood flow is See Emergency Procedure 31.9: Responding to the Patient Who interrupted for enough duration, damage to the brain may occur, Is Experiencing an Allergic Reaction. resulting in loss of brain function. Most CVAs occur in older individuals who have other predisposing diseases, such as arterio- Epileptic Seizure sclerosis, heart disease, or uncontrolled high blood pressure. See Emergency Procedure 31.7: Responding to the Patient Who Epilepsy is a neurologic disorder characterized by recurrent episodes Is Experiencing a Cerebrovascular Accident (Stroke). of seizures. In most patients, seizures or convulsions are controlled with medication. Under stressful conditions, however, a seizure Hyperventilation can still occur. As discussed in Chapter 29, there are two main Hyperventilation, which is precipitated (initiated) by stress and categories of seizures: generalized and partial. It is important to anxiety, is an increase in the frequency or depth (or both) of respira- understand the clinical considerations from the di%erent types. tion. As a result, the patient takes in too much oxygen. The patient (See Emergency Procedure 31.10: Responding to the Patient Who will usually remain conscious. Is Experiencing a Convulsive Seizure). This medical emergency can occur when a patient is extremely anxious or apprehensive before undergoing dental treatment. To Diabetes Mellitus prevent or reduce hyperventilation, the dental team should always be alert and be prepared to help the patient deal with severe Diabetes mellitus is a metabolic disorder that results from distur- apprehension in a positive manner. bances in the body’s normal insulin mechanism. The disease is See Emergency Procedure 31.8: Responding to the Patient With classified in two categories: Breathing Difficulty. Type 1 diabetes mellitus, in which the patient becomes insulin dependent Type 2 diabetes mellitus, in which the patient manages a proper Asthma Attack diet and takes medication Asthma is a pulmonary disorder characterized by attacks of sudden When the balance shifts, with too much or too little food onset, during which the patient’s airway narrows, causing difficulty in ingested, insulin levels can change, resulting in hyperglycemia (too breathing, coughing, and a wheezing sound. An allergic reaction, severe much blood sugar) or hypoglycemia (too little blood sugar) (see emotional stress, or respiratory infection could cause an asthma attack. Chapter 29). Patients with asthma generally carry an inhaler that contains medication (bronchodilator) to relieve the first symptoms of an Hyperglycemia attack. It is essential that asthma be identified on the patient’s Hyperglycemia results from an abnormal increase in the glucose medical history, and that the patient brings his or her inhaler to (sugar) level in the blood. If untreated, hyperglycemia may progress each dental appointment (see Emergency Procedure 31.8). to diabetic ketoacidosis and a life-threatening diabetic coma. Hypoglycemia Hypoglycemia results from an abnormal decrease in the glucose RECALL level in the blood. This condition can manifest rapidly. The most 15. What is the medical term for chest pain caused by the heart muscle common causes of hypoglycemia are skipping a meal, taking too being deprived of oxygen? much insulin without adequate food intake, or exercising excessively 16. What is the medical term for stroke? without appropriate adjustment of insulin and food intake. (See 17. Patients with asthma will usually carry what form of medication? Emergency Procedure 31.11: Responding to the Patient Who Is Experiencing a Diabetic Emergency. RECALL Allergic Reaction 18. What type of allergic reaction can be life threatening? An allergy, also referred to as hypersensitivity, is an altered state 19. What condition results from an abnormal increase in blood glucose? of reactivity that occurs in body tissues in response to specific antigens. An antigen is a substance that causes an immune response through the production of antibodies. An antigen that can trigger Documentation of an Emergency the allergic state is known as an allergen. Although the patient’s health history is the primary factor in When a medical emergency arises in the dental office, full docu- determining risk for allergy, every new drug or dental material mentation of the delivery of care and the outcome is essential. introduced to a patient could possibly produce a reaction. Of After such an emergency, the dentist will make extensive notes in concern is the increasing incidence of allergic reactions to the latex the patient’s record to explain exactly what happened, indicate the used in examination gloves and dental dams. treatment provided, and describe the patient’s condition at the The two most important factors to consider when managing time he or she left the office. an allergic reaction are (1) the speed with which symptoms appear If an emergency is not fully resolved while the patient is in the and (2) the severity of the reaction. A localized allergic response office, the dentist may telephone the patient, the family, or the is usually slow to develop. Mild symptoms typically include itching, patient’s physician the next day to inquire about the patient’s erythema, and hives. health.  CHAPTER 31 Assisting in a Medical Emergency 439 Patient Education the Internet has dramatically changed the way America commu- nicates with individuals, emergency systems, and hospitals. Patients are more aware of their own health status today than ever Advances in digital and compression technology mean that vast before. Most patients can follow through with their personal care amounts of information can be stored on ever-smaller chips. plan and know when to seek professional help. Important applications of this technology include the creation of Throughout the media, such as television and social media, digital medical libraries and medical databases. The potential also you may see a report of a child who saved a person’s life because exists to develop electronic medical record systems and credit card–sized the child saw a TV show that discussed CPR or the Heimlich “smart cards” that store personal medical information. maneuver. The more the healthcare sector discusses the importance of individual awareness through workshops and patient education, Critical Thinking the better able patients are to help themselves or others at a time of need. 1. You are escorting a patient to the treatment area and notice that she appears flushed and is perspiring. You take her vital Legal and Ethical Implications signs and note a rapid heart rate and a decrease in her blood pressure. What warning sign does this represent regarding a As a dental healthcare professional, you often will be asked for medical emergency? dental and medical advice from your patients, family, and friends. 2. How would the dental team respond to the patient described You must be very careful about what you say to people. You are in question 1? not in the position to diagnose an illness, and you must not do 3. The dentist has just finished administering local anesthesia when so under any circumstance. a patient complains of shortness of breath and “not feeling In the case of an emergency, however, the situation is different. well.” What medical emergency would you suspect, and how You are protected under the “Good Samaritan Law,” which states should the dental team respond? that if you try your best to do what can reasonably be done by 4. What should be kept available in the dental office for a patient others with the same training, the victim cannot legally hold you with hypoglycemia? responsible if something goes wrong. 5. Why would you not place anything in a patient’s mouth during a grand mal seizure? Eye to the Future ELECTRONIC RESOURCES New technology is allowing individuals with serious medical Additional information related to content in Chapter 31 can be conditions to live a normal life with confidence that the emergency found on the companion Evolve Web site. medical system will be alerted when the need arises. Furthermore, Practice Quiz EMERGENCY PROCEDURE 31.1 Performing Cardiopulmonary Resuscitation (One Person) Consider the following with this procedure: The procedure is to be documented in the patient record. Equipment and Supplies Mannequin approved by the American Heart Association (AHA) and equipped with a printout for demonstration of proper technique (for instruction purposes and mock emergency drills). Procedural Steps for Adult, Child, and Infant CPR Determine Unresponsiveness Approach the victim and check for signs of circulation, such as normal breathing, coughing, or movement in response to stimulation. Touch or tap the victim and ask, “Are you OK?” Assessment 1. Firmly place your hand on the person’s shoulder and ask, “Are you OK?” 2. Confirm if the person is breathing by holding your ear close to the person’s mouth/nose and watch for chest to rise and fall. If the person is not breathing, activate the emergency response system. Initiate Assistance and Get AED 3. If there is no response, call for assistance and ask someone to call 9-1-1 and to obtain an AED/defibrillator if available. 4. If you are alone, and your patient is an adult, phone 9-1-1 first, and then begin compressions. 5. If the patient is a child, give 2 minutes of compression first, then call (Copyright American Heart Association.) 9-1-1. Continued 440 PART 6 Patient Information and Assessment EMERGENCY PROCEDURE 31.1 Performing Cardiopulmonary Resuscitation (One Person)—cont’d Pulse Check and Initiate Compressions Airway and Ventilation 6. To perform a pulse check, palpate a carotid pulse. If you do not feel a 13. Opening the airway (followed by rescue breaths to improve oxygenation pulse within 10 seconds, start chest compressions. and ventilation) should be completed only if there are two rescuers and 7. Kneel at the victim’s side opposite the chest. Move your fingers up the one of the rescuers is trained in CPR. ribs to the point where the sternum and the ribs join. Your middle finger 14. Once chest compressions have been started, a trained rescuer should should fit into the area, and your index finger should be next to it across deliver rescue breaths by mouth-to-mouth or bag-mask to provide the sternum. oxygenation and ventilation, as follows: 8. Place the heel of your hand on the chest midline over the sternum, just Deliver each rescue breath over 1 second. above your index finger. Place your other hand on top of your first hand Give enough tidal volume to produce visible chest rise. and lift your fingers upward off the chest. Use a compression-to-ventilation ratio of 30 chest compressions to 2 ventilations. (From Sorrentino SA, Remmert LN: Mosby’s essentials for nursing assis- tants, ed 5, St Louis, 2014, Mosby.) 9. Bring your shoulders directly over the victim’s sternum as you compress downward and keep your arms straight. 10. Provide 30 chest compressions at a rate of 100 per minute with adequate depth. Specific techniques to remember during compressions are as follows: (From Sorrentino SA, Remmert LN: Mosby’s essentials for nursing assis- Push hard and fast. tants, ed 5, St Louis, 2014, Mosby.) Allow complete chest recoil after each compression. Minimize interruptions in compressions. Repeat ongoing cycles of CPR until EMS arrives, the person starts Avoid excessive ventilation. breathing, someone comes with an AED, or another trained rescuer If multiple rescuers are available, they should rotate the task of takes over. compressions every 2 minutes. 15. Document emergency response in the patient record. 11. For adults and children over 8 years of age, compress the chest a depth of at least 2 inches (5 cm). 12. For infants, compress the chest a depth of about 1.5 inches (4 cm). EMERGENCY PROCEDURE 31.2 Operating the Automated External Defibrillator Consider the following with this procedure: The procedure is to be documented in the patient record. Equipment and Supplies Automated external defibrillator (AED) Electrode lines Paddles  CHAPTER 31 Assisting in a Medical Emergency 441 EMERGENCY PROCEDURE 31.2 Operating the Automated External Defibrillator—cont’d Procedural Steps 7. Clear the patient (i.e., make sure no one is in direct contact with the 1. Activate the emergency response system. patient), and press the analyze button (or let the machine analyze 2. Begin providing compressions while the second responder readies the automatically after the pads have been attached). AED close to the victim’s chest. 3. Turn on the power by lifting the top of the case and turning on the power switch. 4. Position the defibrillator machine on the left side of the patient’s head, close to the ear. Turn on the power by lifting the top of the case or turning on the power switch. 8. If the machine advises shock, confirm that everyone present is clear of the patient, and then deliver a shock. 5. Attach the electrode lines to the paddles. 9. After shock delivery, the rescuer should immediately begin chest compressions, followed by checking the pulse. 10. After 5 cycles of CPR, the AED should then analyze the cardiac rhythm and deliver another shock if indicated. 11. Document emergency response in the patient record. 6. Attach the paddles to the patient, one at the left sternal border and the second on the right side above the nipple area. Illustrations (except for the photo of the defibrillator) from Kostelnick C: Mosby’s textbook for long-term care nursing assistants, ed 7, St Louis, 2015, Mosby. 442 PART 6 Patient Information and Assessment EMERGENCY PROCEDURE 31.3 Responding to the Patient With an Obstructed Airway Consider the following with this procedure: The procedure is to be documented in the patient record. Signs and Symptoms Patient grasping at throat—the universal sign of choking Ineffective cough High-pitched breathing sound Respiratory difficulty Change in skin color (Copyright iStock.com/Pixel_away.) 3. Grasp the fist with the other hand and forcefully thrust both hands into the abdomen, using an inward and upward motion. 4. Repeat these thrusts until the object is expelled. Responding to the Conscious Seated Patient 5. Do not try to move the patient out of the dental chair before you administer the Heimlich man euver. PURPOSE Patient movement may cause the lodged item to be swallowed. 6. Place the heel of one hand at the patient’s abdomen above the navel and well below the xiphoid process. (Copyright iStock.com/Pixel_away.) 7. Place the other hand directly over the first hand. Administer a firm, quick, upward thrust into the patient’s diaphragm. Procedural Steps 8. Repeat this maneuver 6 to 10 times as needed until the object is Care of the Patient dislodged or until advanced emergency assistance arrives. 1. If the patient cannot speak, cough, or breathe, the airway is completely 9. Document emergency response in the patient record. blocked. Immediately call for assistance and begin administering abdominal thrusts (Heimlich maneuver). 2. Make a fist with one hand and place the thumb side of hand against the patient’s abdomen, just above the navel and below the xiphoid process of the sternum.  CHAPTER 31 Assisting in a Medical Emergency 443 EMERGENCY PROCEDURE 31.4 Preparing the Oxygen System Consider the following with this procedure: The procedure is to be documented in the patient record. NOTE: If the dental office is equipped with a nitrous oxide–oxygen unit, the oxygen from these units can be used in emergency situations. Equipment and Supplies Portable oxygen system Gauge regulator Tubing Face mask Procedural Steps 1. Confirm that the cylinder contains oxygen by checking the color and the pin index grouping. 4. Tighten the clamp to ensure an adequate seal. 5. Open the valve two full turns. Check the pressure gauge to make sure that it is showing approximately 2000 pounds per square inch. PURPOSE This much pressure is necessary for the oxygen to flow at a proper rate. 6. Attach the tubing, if it is not already attached. 2. Slowly open the main valve at the top of the cylinder until gas starts to come out; then immediately close the valve. 7. Position the mask comfortably over the patient’s face. NOTE Make sure that the mask is positioned so that it covers the nose 3. Attach the regulator by aligning the pin index into the cylinder holes. and mouth and forms a good seal. 8. Document emergency response in the patient record. 444 PART 6 Patient Information and Assessment EMERGENCY PROCEDURE 31.5 Responding to the Unconscious Patient Consider the following with this procedure: The procedure is to be 2. Loosen any binding clothes on the patient. documented in the patient record. 3. Have an ammonia inhalant ready to administer by waving it under the patient’s nose several times. Syncope (Fainting) 4. Have oxygen ready to administer. Signs and Symptoms 5. Monitor and record the patient’s vital signs. Feeling of warmth or flushing (flushed) 6. If unresponsive, call for emergency assistance (9-1-1). Nausea Rapid heart rate Postural Hypotension Perspiration Signs and Symptoms Pallor (pale skin color) Low blood pressure Lower blood pressure Altered state of consciousness to possible loss of consciousness Response Steps Response Steps 1. Place the patient in a subsupine position with the head lower than the 1. Place the patient in a subsupine position with the head lower than the feet. feet. PURPOSE This position causes blood to flow away from the stomach and PURPOSE This position causes blood to flow away from the stomach and back toward the brain; this is frequently sufficient to revive the patient. back toward the brain; this is normally enough to revive the patient. 2. Establish an airway. 3. Slowly move the patient into an upright position. 4. Monitor and record vital signs. 5. If unresponsive, call for emergency assistance (9-1-1). EMERGENCY PROCEDURE 31.6 Responding to the Patient With Chest Pain Consider the following with this procedure: The procedure is to be Acute Myocardial Infarction (Heart Attack) documented in the patient record. Signs and Symptoms Chest pain ranging from mild to severe Angina Attack Pain in the left arm, the jaw, and the teeth Signs and Symptoms Shortness of breath and sweating Tightness or squeezing sensation in the chest Nausea and vomiting Pain radiating to the left shoulder Pressure, aching, or burning feeling of indigestion Pain radiating to the left side of the face, the jaw, and the teeth Generalized feeling of weakness Response Steps Response Steps 1. Call for emergency assistance (9-1-1). 1. Call for emergency assistance (9-1-1). 2. Position the patient upright. 2. Initiate basic life support (CPR) if the patient becomes unconscious. 3. Medicate with nitroglycerin (tablets, spray, or topical cream). 3. Ready the nitroglycerin from the office’s emergency kit. 4. Administer oxygen. 4. Administer oxygen. 5. Monitor and record vital signs. 5. Monitor and record vital signs.  CHAPTER 31 Assisting in a Medical Emergency 445 EMERGENCY PROCEDURE 31.7 EMERGENCY PROCEDURE 31.8 Responding to the Patient Who Is Experiencing a Responding to the Patient With Breathing Difficulty Cerebrovascular Accident (Stroke) Consider the following with this procedure: The procedure is to be Consider the following with this procedure: The procedure is to be documented in the patient record. documented in the patient record. Hyperventilation Signs and Symptoms Signs and Symptoms Paralysis Rapid, shallow breathing Speech problems Light-headedness Vision problems Tightness in the chest Possible seizure Rapid heartbeat Difficulty swallowing Lump in the throat Headache Panic-stricken appearance Unconsciousness Response Steps Response Steps 1. Place the patient in a comfortable position. 1. Call for emergency assistance (9-1-1). 2. Use a quiet tone of voice to calm and reassure the patient. 2. Initiate basic life support (CPR) if the patient becomes unconscious. 3. Have the patient breathe into his or her cupped hands. 3. Monitor and record vital signs. NOTE Some sources will indicate to breathe into a paper bag, but a patient’s cupped hands have been found to be better. THINK YOU ARE HAVING A STROKE? PURPOSE This response increases the carbon dioxide supply and CALL 9-1-1 IMMEDIATELY! restores appropriate oxygen and carbon dioxide levels in the blood. F.A.S.T. is an easy way to remember the sudden signs of stroke. When you can spot the signs, you’ll know that you need to call 9-1-1 for help right away. F.A.S.T. is: F Face Drooping Does one side of the face droop or is numb? Ask the person to smile. Is the person’s smile uneven? A Arm Weakness Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward? S Speech Difficulty Is speech slurred? Is the person unable to speak or hard to understand? Ask the person to repeat a simple sentence, like “The sky is blue.” Is the sentence repeated correctly? Time to call 9-1-1 T If someone shows any of these symptoms, even if the symptoms go away, call 9-1-1 and get the person to the hospital immediately. Check the time so you’ll know when the first symptoms appeared. Asthma Attack Signs and Symptoms Coughing Wheezing Increased anxiety Pallor Cyanosis (bluish skin around the nails) Increased pulse rate Response Steps 1. Call for assistance. 2. Position the patient as comfortably as possible (upright is usually best). 3. Have patient self-medicate with an inhaler. 4. Administer oxygen as needed. 5. Assess and record vital signs. 446 PART 6 Patient Information and Assessment EMERGENCY PROCEDURE 31.9 EMERGENCY PROCEDURE 31.10 Responding to the Patient Who Is Experiencing an Responding to the Patient Who Is Experiencing a Allergic Reaction Convulsive Seizure Consider the following with this procedure: The procedure is to be Consider the following with this procedure: The procedure is to be documented in the patient record. documented in the patient record. Localized Rash Generalized Seizure (Grand Mal) Signs and Symptoms Signs and Symptoms Itching Unconsciousness Erythema (skin redness) Increased body temperature Hives Rapid heart rate Increased blood pressure Response Steps 1. Identify area of rash. Response Steps 2. Monitor and record vital signs. 1. Call for emergency assistance (9-1-1). 3. Prepare an antihistamine for administration if necessary. 2. If a seizure occurs while the patient is in the dental chair, quickly 4. Be prepared to administer basic life support (CPR) if necessary. remove all materials and dental instruments from the mouth and place 5. Refer the patient for medical consultation. the patient in a supine position. PURPOSE If the patient has an allergic reaction once, he or she may PURPOSE The patient could inflict self-harm if something is in the become increasingly hypersensitive and may have a life-threatening mouth. Do not place anything in the patient’s mouth during a seizure. response the next time. 3. Protect the patient from self-injury during movements caused by the convulsion. Anaphylaxis 4. Prepare anticonvulsant (diazepam) from the drug kit if necessary. Signs and Symptoms 5. Initiate basic life support (CPR) if necessary. Feeling physically ill 6. Monitor and record vital signs. Nausea and vomiting Shortness of breath Partial Seizure (Petit Mal) Heart arrhythmia (irregular heartbeats) Signs and Symptoms Sudden drop in blood pressure Intermittent blinking Loss of consciousness Mouth movements Blank stare Response Steps Not responsive to surroundings; seems to be in his or her “own world” 1. Call for emergency assistance (9-1-1). 2. Place the patient in a supine position. Response Steps 3. Start basic life support (CPR) if the patient becomes unconscious. 1. Protect patient from self-injury. 4. Prepare EpiPen for administration. 2. Monitor and record vital signs. 5. Administer oxygen. 3. Refer patient for medical consultation. 6. Monitor and record vital signs. EMERGENCY PROCEDURE 31.11 Responding to the Patient Who Is Experiencing a Diabetic Emergency Consider the following with this procedure: The procedure is to be PURPOSE If the patient has already eaten but has not taken insulin, he documented in the patient record. or she needs insulin immediately. 2. Retrieve the patient’s insulin if it is available. If able, the patient should Hyperglycemia self-administer the insulin. Signs and Symptoms 3. Call for emergency assistance (9-1-1) if necessary. Excessive urination 4. Provide basic life support (CPR) if the patient becomes unconscious. Excessive thirst, dry mouth, and dry skin 5. Monitor and record vital signs. Acetone breath (fruity smell) Blurred vision and headache Hypoglycemia Rapid pulse Signs and Symptoms Lower blood pressure Mood changes Loss of consciousness Hunger Perspiration Response Steps Increased anxiety 1. If the patient is conscious, ask when he or she last ate, whether the Possible unconsciousness patient has taken insulin, and whether he or she brought insulin along to the dental appointment.  CHAPTER 31 Assisting in a Medical Emergency 447 EMERGENCY PROCEDURE 31.11 Responding to the Patient Who Is Experiencing a Diabetic Emergency—cont’d Response Steps 3. Call for emergency assistance (9-1-1) if necessary. 1. If the patient is conscious, ask when he or she last ate, whether he or 4. Provide basic life support (CPR) if the patient becomes unconscious. she has taken insulin, and whether he or she brought insulin along to the 5. Monitor and record vital signs. dental appointment. 2. Give oral glucose from emergency kit or a concentrated form of carbohydrate, such as a concentrated orange juice. PURPOSE These substances will be absorbed rapidly into the bloodstream. PART 7 Foundation of Clinical Dentistry 32 The Dental Office, 449 35 Dental Handpieces and Accessories, 485 33 Delivering Dental Care, 460 36 Moisture Control, 498 34 Dental Hand Instruments, 473 37 Anesthesia and Pain Control, 515 Before a clinical dental assistant can practice and perfect a skill, he or she must first understand how the skill is performed. Your role will be ever-changing as the advances of technology progress in the field of dentistry. The chapters in this section concentrate on the preclinical skills and how dental care is delivered. Specific areas include the layout and design of the dental office, the importance of team dentistry, expanded functions, instruments and supplies used in general dental procedures, and the importance of patient comfort during dental treatment, with the use of moisture control and anesthesia and pain control methods. 448