Dent Clin N Am 52 (2008) 605608

Preparing the Dental Oce for Medical

Emergencies
Harry Dym, DDSa,b,c,*
a

Department of Dentistry and Oral Maxillofacial Surgery, The Brooklyn Hospital Center,
121 Dekalb Avenue, Brooklyn, NY 11201, USA
b
Woodhull Hospital, Brooklyn, NY, USA
c
Department of Oral and Maxillofacial Surgery, Columbia University College
of Dental Medicine, New York, NY, USA

When planning to open a private oce that is patient oriented, employee

friendly, and doctor centered, knowledge in many nonclinical areas such as
patient billing, infection control, accounting, and so forth is, of course, mandatory. However, an area that is most critical but sometimes overlooked by
dentists when establishing new oces is preparation for the management of
oce medical emergencies. Although such oce medical emergencies are
infrequent, the dentist will often be held legally responsible for any untoward outcome allegedly resulting from causation or mismanagement of
those medical emergencies. With the elderly population growing, the number of patients who are on multiple medications for underlying medical conditions will certainly be increasing.
This article does not focus on the diagnosis and management of specic
medical and dental emergencies, or on a detailed pharmacologic discussion
of the drugs used, but rather, on the policies, equipment, and personnel
needed to prepare for dealing with emergencies, should they occur. No discussion of techniques or the underlying physiology is discussed because this
information is readily available elsewhere [1,2].
Oce equipment
Dental oces should be prepared to provide basic airway management,
which includes the ability to administer 100% oxygen through a portable
O2 source. One E oxygen tank, when full, will last approximately 60
* Department of Dentistry and Oral Maxillofacial Surgery, The Brooklyn Hospital
Center, 121 Dekalb Avenue, Brooklyn, NY 11201.
E-mail address: hdymdds@yahoo.com
0011-8532/08/$ - see front matter 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2008.02.010
dental.theclinics.com

606

DYM

minutes when given at a 10 L per minute ow rate. The dentist must frequently check to ascertain the O2 tank status, even if two tanks are available
for backup. Oxygen can be delivered by way of a nasal cannula, face mask,
or face mask with reservoir. It is the authors opinion that all oces should
have an Ambu bag and a full face mask, merely to allow the dentist to provide positive pressure ventilation should the need rise. A nasal and oral
airway should also be part of most dentists airway management kit.
Stethoscope and sphygmomanometer (with child- and adult-size cus)
and an assortment of syringes and needles should also be considered as
part of the dental oces basic emergency equipment. The one device that
has now become ubiquitous in its presence in almost all public places is
the automatic external debrillator (AED). The survival rate in cardiac
arrests approaches 30% if early debrillation is administered, accompanied
by advance cardiac life support. The AED also eliminates the need for training in rhythm recognition but it does require the dentist and key sta to be
trained in its use by participating in the American Heart Associations basic
cardiopulmonary resuscitation course. See Box 1.
Emergency drugs
General dentists and dental specialists should develop an emergency box
that is dedicated to emergencies and stocked with the following key basic
resuscitation drugs. Those oces providing intravenous sedation will certainly have more comprehensive emergency drugs available.
Aromatic ammonia: Syncope is the most common medical emergency in
the dental oce. Vaporable aromatic ammonia is available and, when

Box 1. Basic emergency equipment

Tourniquets
Syringes
Ambu bag
Oropharyngeal and nasopharyngeal airways
Normal saline 0.9%, 1000-mL bags
18-and 20-gauge angiocatheters
Yankauer suction tip
Portable oxygen system (E cylinder size)
Stethoscope
Sphygmomanometer (child and adult sizes)
EKG/defibrillator (AED)
Sterile water for injection

PREPARING THE DENTAL OFFICE FOR MEDICAL EMERGENCIES

607

cracked or crushed, it releases a noxious odor that stimulates the respiratory and vasomotor centers of the medulla. When combined with
placing the patient in a Trendelenburgs position and providing supplemental oxygen, most patients will return to consciousness.
Aspirin: The American Heart Association recommends that patients
experiencing an acute myocardial infarction chew an aspirin. Chewing
a buered aspirin (325 mg) for 30 seconds and then swallowing it with
water is thought to have a rapid and sustained eect.
Nitroglycerine: Nitroglycerine is recommended for relief of angina in
patients who have a past history, and for those with a new onset of angina with a suspected myocardial infarction. Nitroglycerin is available
as a 0.4-mg metered aerosol. The spray does not require special storage
and has a 3-year shelf life; the tablet form requires special storage in
light-resistant containers and loses its potency in 12 weeks. Administration of this drug is safe, with headaches, dizziness, and ushing as possible side eects.
Inhaled beta2-agonists: Bronchodilators are the main drug groups used
for the treatment of wheezing and bronchospasm. Selective beta2agonists are the preferred drugs because they minimize the side eects,
including tachycardia, hypertension, angina, restlessness, and ushing.
Albuterol is the preferred choice because it is the most selective of the
beta2-agonists and it comes in a metered dose inhaler.
Epinephrine: Epinephrine is a sympathomimetic drug that acts on alpha
adrenergic and beta adrenergic receptors with primary eects being
bronchodilation, vasoconstriction, and increased rate and force of
cardiac contraction, along with stabilization of mast cells (involved
in severe allergic reactions.) See Box 2.
Hypoglycemic agent (D50W): The purpose of oral hypoglycemic agents is
to increase blood glucose levels in patients who are conscious and
hypoglycemic. All oces should store a simple sugar source such as
fruit juices. If the patient cannot swallow, dextrose 50% in water
(D50W) should be used by way of any intravenous route.

Box 2. Basic drug emergency kit

Epinephrine 1mg/mL (1:1000 dilution)
D50W 50 mL ampule 0.5g/mL
Oxygen
Nitroglycerin tablets or spray 0.4 mg per tablet
Albuterol; metered inhaler
Hydrocortisone 300 mg ampule
Spirits of ammonia (vaporable)

608

DYM

Sta and oce preparation

The dentist should develop a protocol and policy for his/her sta to
follow when a medical emergency arises. The dentist and key sta should
be certied in basic life support and trained as rst responders. The front
oce should have the phone numbers of the areas local ambulance or emergency medical service, local emergency department, and an adjacent internist or oral and maxillofacial surgeon in the same building. A code word
should be established in the oce to inform the sta of an ongoing emergency so that sta can coordinate the proper emergency response.
The emergency kit should be updated regularly and, along with oxygen,
should be placed in an area that is readily accessible.
Mock emergencies should be performed regularly so that the sta will
respond appropriately should the need arise.
Finally, dental oces should develop cheat sheets (these are also available for purchase), cards that list the type of emergency occurring, with the
appropriate actions to be taken by the doctor and sta.

References
[1] Dym H. Stocking the oral surgery oce emergency cart. In: Ogle OE, editor. Pharmacology,
oral and maxillofacial surgery clinics of North America, vol. 13. Philadelphia: Saunders; 2001.
[2] Saef SN, Bennett JD. Basic principles and resuscitation. In: Bennett JD, Rosenberg MB,
editors. Medical emergencies in dentistry. Saunders; 2002.