MEDICAL EMERGENCIES IN THE DENTAL PRACTICE

1. INTRODUCTION

Fortunately, medical emergencies in the dental office are a rare occurrence.  Unfortunately, this rarity prevents us from becoming comfortable with management of problems, and worse still, may lead to complacency.  In light of their uncommon occurrence, it is useful to revisit the subject, sometimes from a different perspective.  The perspective taken for today's discussion is a relatively broad one, allowing for a  "from first principles " approach to the prevention of preparation for, recognition of and action involved in the management of medical emergencies.

2. DEFINITION

A medical emergency is a stress induced, relatively sudden, acute, uncontrolled failure of physiologic adaptation capability (or decompensation in the face of stress ).

A. Stress induced:  This implies that there is usually a more or less recognizable cause or identifiable stress that is driving the system toward failure.  This could be the presence of an allergen, anxiety, drugs or foreign object in the airway that stresses the system maximally and beyond in such a manner that the system is no longer able to cope.

B.Relatively  sudden:  While some emergencies occur rapidly, many take time to evolve.  An identifiable, gradual chain of events often conspire to lead a patient to the point where they are maximally stressed and failure occurs as the last link in the chain.  Prevention centres on breaking the chain of events prior to reaching failure.

C. Acute: The central theme of all emergencies is that they are acute occurrences happening right now.  From this perspective they require immediate recognition and attention.

D.Uncontrolled failure: Emergencies rarely display intrinsic control by the patient.  Clearly, the patient’s system has lost the ability to respond to the stress and extrinsic help must be brought in.  The key to management of emergencies is the resumption of control by the clinician.

E.Decompensation: Loss of compensation implies that compensation was happening in the first place.  In the normal healthy subject, this ability to compensate for stress or strategic reserve is maximal and much has to happen before the system is no longer able to adapt to rising levels of stress.  In the medically compromised patient, some of this reserve has been lost as a function of the underlying illness and decompensation or failure occurs earlier and in the face of lower levels of stress.

F. Examples:

                 An excellent model for medical emergency is the coronary stress test.  In this example, the stress is the treadmill, specifically related to its slope and its rate.  As the slope and rate of the treadmill increases, the stress to the heart and the demand for coronary perfusion of the myocardium increases.

                While the angina attack or the MI that the patient experiences while having the test is a relatively sudden event, the steps leading to the acute event took place over a well defined interval and occurred in a clearly laid out pattern.

Although the progression to the angina attack or the MI may have been drawn out, the event itself is acute and must be recognized and dealt with immediately by the stress lab technician.  If  the patient has gone on to having an MI during the stress test, the extent of the damage is essentially uncontrolled unless the technician intervenes, stops the test and begins supportive management immediately.

                The stress test is designed to assess the patient's coronary reserve. "Failing" a stress test means the patient's reserve was minimal in the first place and that decompensation or failure is likely to occur very early in the process of applying stress to the system.

What is a medical emergency?

A medical emergency can be described as any situation in which a patient becomes ill, may become unconscious and ultimately their life may be at risk due to a failure of an effective oxygenated circulation to the brain and vital organs. There are certain specific emergencies that are the most commonly encountered in General Dental Practice and all DCPs should be familiar with their presentation and management, these are shown in table 1.

Table 1 :Specific Medical Emergencies

·         Choking

·         Asthma

·         Anaphylaxis

·         Hyperventilation

·         Respiratory arrest

·         Angina

·         Myocardial infarction

·         Seizures

·         Faints/syncope

·         Cerebro-vascular accident (stroke)

·         Cardiac arrest