EMERGENCY PROTOCOL SCENARIOS - AAO · EMERGENCY PROTOCOL SCENARIOS American Association of...

EMERGENCY

PROTOCOL

SCENARIOS

American Association of Orthodontists

Robert D. Elliott, DMD, MS

www.pedospringboard.com

©Copyright Pedo Springboard 2014

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TABLE OF CONTENTS

I. List of Medications Page 3

II. Basic Emergency Equipment Page 5

III. Emergency Team Page 6

IV. Emergencies and Their Management Page 8

Syncope Page 9

Allergic Reactions Page 10

Hypoglycemia/ Insulin Shock Page 12

Convulsions – Seizures Page 13

Bronchospasm (Asthma) Page 14

Vomiting, Aspiration & Choking Page 15

Hypotension Page 16

Angina Pectoris (chest pain) Page 17

Myocardial Infarction & Cardiac Arrest Page 18

Hyperventilation Page 19

V. Sample Check List Forms Page 21

VI. Employee Compliance Signature Log Page 25

VII. Vital Signs Recording Sheet Page 27

VIII. Emergency Fire Exit Plan Page 28


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I. LIST OF MEDICATIONS

ALBUTEROL (VENTOLIN/PROVENTIL) – bronchodilator

Inhaler, for asthma attacks

ANTIHYPOGLYCEMICS (cake icing, Coca-cola, sugar)

For unexplained unconsciousness and seizures of unknown origins

Glucagon, orange juice, cake icing

AMMONIA INHALANT

Syncope

Crushed between fingers and placed under nose

ATROPINE (anticholinergic agent, anti-asthmatic, bronchodilator)

Bradycardia

Bronchospasms

Dosage: .02 mg/kg every 5 minutes

BENADRYL (DIPHENHYDRAMINE) – histamine blocker

For delayed allergic reactions

Dosage: Adult: 50mg injected IM (deep)

Child: 25mg injected IM (deep)

Oral Dosage: <6 yrs: 1 teaspoon (12.5 mg)

6-12 yrs: 2 teaspoons (25 mg)

>12 yrs: 4 teaspoons (50 mg)


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DEXAMETHASONE (steroid)

Treat airway edema (Severe Allergic Reactions, Anaphylaxis)

Dosage: .03-.15 mg/kg/day

EPINEPHRINE 1:1000 - bronchodilator

For acute allergic reactions, asthma attacks, bradycardia and cardiac

arrest

Delivered by injector stick (pre-loaded syringes 2-3 x 1ml)

Dosage: Adult: 0.3 - 0.5 mg/kg

Child: .01 mg/kg

NITROGLYCERINE - vasodilator

For chest pain of angina pectoris

Dosage: .4mg tablets (sublingual) or .4mg/spray

Note: tablets will only have a 12 day shelf life once exposed to light

and air

OXYGEN

“E” cylinder delivery tanks

to aid in breathing difficulties or as blow by


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II. BASIC EMERGENCY EQUIPMENT

OXYGEN DELIVERY SYSTEM

Delivers positive pressure oxygen

Must maintain a patent airway

Must have an airtight seal of mask on face

Various sizes of masks

SUCTION SYSTEM AND TIPS

Tips need to be large diameter and rounded to suction vomitus and

blood (high vacuum suction)

Manual suction if power goes out

AED (portable pulse oximeter recommended)

BLOOD PRESSURE CUFF AND STETHOSCOPE

Crash Cart Supplies: www.healthfirst.com

http://www.healthfirst.com/


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III. EMERGENCY TEAM

DR. _________________________

Performs basic life support

Administers medications

FIRST CLINICAL ASSISTANT

Notifies TWO other assistants for help

Gets emergency kit

Passes drugs and equipment

Helps administer basic life support

Ventilates patient

SECOND CLINICAL ASSISTANT

Calls 911 – STAY ON THE PHONE

States the MEDICAL EMERGENCY (ie: “Respiratory

Depression”)

States “This is a DENTAL office, not a medical

office” – “there is NO physician present!”

THIRD CLINICAL ASSISTANT

Monitors vital signs

Record keeping – use “Vital Signs Recording” sheet

FOURTH CLINICAL ASSISTANT

Calls Admin via intercom and informs of

emergency/situation - CODE BLUE!

Admin team member will go outside and wait for

EMS to arrive

Make sure EMS is escorted to office and room

where emergency is being managed


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EMERGENCY ROAD MAP

R ecognition

Unconsciousness

Altered consciousness

Respiratory difficulty

Seizure

Drug related emergency

Chest pain

1. Discontinue treatment

2. Assess level of consciousness

3. Position patient accordingly

4. Suction if needed

A ssess Consciousness

1. ALERT – is patient aware of surroundings?

2. VERBAL – can patient respond to questions?

3. PAIN – does patient react to peripheral pain?

4. UNRESPONSIVE to verbal command or pain – CALL 911!

P osition - If Unconscious:

1. Place patient in supine position

2. Elevate feet slightly above head

3. P-CAB’s if needed

R eassess patient


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IV. EMERGENCIES AND THEIR

MANAGEMENT

TABLE OF CONTENTS

Syncope Page 9

Allergic Reactions Page 10

Hypoglycemia/ Insulin Shock Page 12

Convulsions – Seizures Page 13

Bronchospasm (Asthma) Page 14

Vomiting, Aspiration & Choking Page 15

Hypotension Page 16

Angina Pectoris (chest pain) Page 17

Myocardial Infarction & Cardiac Arrest Page 18

Hyperventilation Page 19


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SYNCOPE

50% of all dental emergencies produced by a sudden drop

in blood pressure which decreases oxygen supply to brain.

Dizziness associate with fainting

Patient feels warm, is pale, sweaty, nauseous and tachycardic

Patient may feel nauseous for next 24 hours

MANAGEMENT

1. Position patient in supine position

2. Elevate legs

3. Administer oxygen

1. Administer ammonia inhalant

If no recovery in SECONDS, call 911!

5. Observe for one hour – should not leave office alone


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ALLERGIC REACTIONS

A hypersensitive state acquired through exposure to an allergen or re-

exposure that produces a heightened capacity to react.

Reactions can be mild, delayed (up to 48 hrs.), immediate and/or life

threatening

15% of all adverse drug reactions are immunologic or true allergies

N20/02 has never been known to elicit an allergic response

A good thorough history is crucial!

TYPES OF RESPONSES:

SKIN REACTIONS – symptoms include urticaria (smooth, elevated

patches of skin with itchiness), erythema and angioedema

RESPIRATORY REACTIONS – symptoms include bronchospasm, local

edema of larynx leading to airway obstruction

ANAPHYLAXIS – the most acute and life threatening! Death can

occur in minutes! Patient symptoms include nausea, itchiness, flushing,

hives on face and chest, vomiting, cramps.

Respiratory symptoms then follow – tightness in chest,

coughing, wheezing.

Cardiovascular symptoms follow – pallor, light headiness,

palpitations, tachycardia, hypotension, arrhythmias, loss of

consciousness, and finally cardiac arrest. This is known as

anaphylactic shock.


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SKIN REACTIONS

1. Administer an antihistamine or benadryl

a. Child under 6yo: 1.2tsp to 1 tsp (12.5mg per tsp)

b. Child (6-12 yrs): 1-2tsp (12.5mg per tsp)

c. Child over 12 - Adult (>60kg): 2-4 tsp (12.5mg per tsp)

2. Continue with oral benadryl for 3-5 days prescribed before leaving

3. Refer to an allergist/consult with a physician

If severe reaction:

1. Epinephrine IM or SC Note: onset of action for IM is 10 minutes (peaks at

30 min); oral takes 60 minutes and is not effective

2. Call 911 or have medical consultation before discharge

RESPIRATORY REACTIONS

1. Refer to Bronchospasm section

2. Laryngeal Edema –

a. place patient in supine position and elevate

legs

b. administer epinephrine IM from preloaded syringe

0.3-0.5 mg/kg ADULT

0.01 mg/kg CHILD (up to .3mg)

c. maintain patent airway

GENERALIZED ANAPHYLAXIS

1. Call 911

2. Supine position

3. Institute BLS

a. monitor and record vital signs

b. administer O2

c. CPR

4. Administer epinephrine 1:1000 concentration sub Q

0.3-0.5 mg/kg ADULT

.01 mg/kg CHILD

5. Administer benadryl (diphenhydramine) IM in front of upper leg

50mg ADULT

25mg CHILD (approx. 1cc)

6. Should see resolution in minutes

7. Administer second dose, if necessary

8. When stable, give benadryl IM in front of upper leg to decrease chance of

recurrence

9. Contact MD for consultation of admission to hospital for monitoring


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HYPOGLYCEMIA / INSULIN SHOCK

Low blood sugar

Associated with Type I Diabetes (Insulin Dependent Diabetes

Mellitus)

Will see mental confusion, mild muscle tremor, diaphoresis, cold

feeling and tachycardia

Usually seen when patient doesn’t eat prior to appointment

If patient must be fasting then insulin should be adjusted per

physician

If blood sugar falls too low, seizures and loss of consciousness follow

MANAGEMENT

1. End procedure

2. Make patient comfortable

3. Check blood glucose (<60 is a problem for a child)

Infant normal 50-80 mg/dL

Child 1-16yo 60-100 mg/dL

>16yo normal 74-106 mg/dL

4. Give patient sugar (cake icing, orange juice, candy)

4. Maintain patent airway

5. Check and record vitals:

Blood pressure

Respiration rate

Pulse

INSULIN SHOCK

If unconscious:

2. call 911

3. Administer 100% oxygen

4. Administer cake icing mucosally by placing under maxillary lip

and continue oxygen delivery

5. Alternatively administer 50% Dextrose intravenously


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CONVULSIONS - SEIZURES

Seen commonly in epileptics but can be elicited by stress, overdose of

local anesthetic or intravascular injection of local anesthetic.

Usually associated with hyperventilation, hypoxia, anoxia, and

hypercarbia

Patient requires adequate ventilation

Most seizures last 2-5 minutes

MANAGEMENT

1. End procedure

2. Call 911

3. Position patient in supine position

4. Gently hold patient’s arms and legs to prevent injury (allow

controlled movement)

5. Do not place anything in patient’s mouth

6. Keep airway patent

1. Administer 100% oxygen

2. Maintain A, B, C’s!

3. Consider benzodiazepine – Valium dose (max 10mg) or

Versed dose (max 20mg)

Note: Morbidity and mortality can occur post seizure!


14

BRONCHOSPASM

(asthmatic attack)

A constriction of smooth bronchial muscle causing respiratory distress,

dyspnea, wheezing, flushing, cyanosis, perspiration, tachycardia, and

anxiety

There is a higher percentage of bronchospasm noted in

children!

MANAGEMENT

1. End Treatment immediately

2. Position patient in semi-erect position

3. Monitor with pulse oximeter

4. Initiate bronchodilation:

a. albuterol via inhaler first!

b. epinephrine .3mg, if no resolution

5. Begin oxygen delivery through nasal cannula*

6. May need positive pressure oxygen if patient starts

to desaturate.

7. MAINTAIN the AIRWAY !

*Note: Oxygen alone will NOT end bronchospasm!!


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VOMITING and ASPIRATION

Aspirating solid material can lead to airway obstruction and death

Aspirating liquid matter can trigger laryngospasm or bronchospasm

FOREIGN-BODY AIRWAY

OBSTRUCTION

AIRWAY- AIRWAY- AIRWAY

1. Call 911

2. Position head

3. Remove foreign bodies and suction

4. Secure and evaluate adequacy of airway

5. Deliver positive pressure oxygen

ASPIRATION MANAGEMENT for CHILD or ADULT

1. Administer abdominal thrusts (child/adult)

2. Cup hands around waist standing behind patient (thumbs inward)

3. Deliver forceful and upward thrusts above bellybutton

ASPIRATION MANAGEMENT for INFANT

1. Administer back slaps and chest thrusts

If unconscious:

1. Lay flat on floor or dental chair

2. Turn face to side and perform finger sweep to remove any

debris that may have become dislodged

3. Attempt to ventilate

4. If unsuccessful, deliver 6-10 abdominal thrusts

5. Perform finger sweep again

6. Attempt to ventilate again

7. BLS and A,B,C’s as needed

8. Tracheal intubation if necessary


16

HYPOTENSION

Low blood pressure

Child’s minimal systolic blood pressure is:

70mm Hg + 2(age)

ie: 4 yr. old child = 78 mm Hg = (70 + 2(4))

Usually caused by too much premed, overdose of local anesthetic,

intravascular injection, hemorrhage, postural changes, abnormal

circulatory system, unmanaged diabetes

Patient will be restless, anxious, disoriented, cold, pale with clammy

hands and dilated pupils

MANAGEMENT

1. Know patient’s pulse and BP prior to sedation

2. End procedure

3. Call 911

4. Position patient in supine position, legs elevated

5. Nitrous oxide off, Oxygen on

6. Antidotal drugs/reversal drugs if needed

7. BLS, CAB’s if needed


17

ANGINA PECTORIS

A substernal thoracic pain due to inadequate coronary circulation

Associated with exercise, emotion or heavy meal

Patient describes tightness in chest, palpitations, faintness, dizziness

or indigestion

MANAGEMENT

4. End procedure


6. Place nitroglycerin* under tongue if needed

7. Administer oxygen (100%) or oxygen (70%) and nitrous oxide(30%)

8. Place pulse oximeter on patient

9. Monitor blood pressure

10. Transfer to hospital as needed

If no resolution:

1. Consider as an acute myocardial infarction and begin ABC’s!

*Note: Nitroglycerin tablets lose their effectiveness and shelf-life once

exposed to air (12 days). Should use the sublingual nitroglycerin spray

(.4mg/spray) in emergency kit.


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MYOCARDIAL INFARCTION

(heart attack)

Mimics angina yet pain is more severe and prolonged.

Produced by partial or complete occlusion of blood flow through one

or more coronary arteries

Leads to necrosis of heart muscle

MANAGEMENT

1. End procedure

2. Make patient comfortable and proper positioning

3. Administer oxygen (100%) or oxygen (70%) and nitrous oxide (30%)

4. Administer pain relief – one aspirin and nitroglycerine spray under

tongue

5. Call 911

6. Monitor patient vitals

7. Prepare for CPR

CARDIAC ARREST

1) Recognize no pulse

2) Call 911

3) Initiate CPR ~ CAB’s

4) Give oxygen

5) Attach monitor/ defibrillator - determine if rhythm is shockable with defibrillator

6) If not a shockable rhythm, resume CPR


19

HYPERVENTILATION

Usually anxiety induced when patient breathes more rapidly and deeply

than usual

Toes and fingers feel cold and tingly

Patient feels lightheaded and has pain in chest

Most common in late teens to late 30’s

MANAGEMENT

1. End procedure


3. Communicate with patient/continue to talk to

4. Have patient re-breath exhaled air by cupping hands – which

also helps warm them


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WHEN TO CALL

911

1. Patient is unresponsive to verbal command or pain stimuli

2. Convulsion or seizure episode

3. Hypertension is unrelieved

4. Unconscious hypoglycemia

5. Hypotension (low blood pressure)

6. Laryngospasm

7. Myocardial Infarction

8. Syncope without recovery immediately after ammonia inhalant and

positioning

V. OFFICE CHECK LIST

SAMPLE FORMS

1. Eye Wash Inspection Station Check List

2. Oxygen Tank System Weekly Check List

3. Emergency Drug Kit Monthly Check List


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EYE WASH STATION

INSPECTION

Date Checked Initials


23

OXYGEN TANK SYSTEM Weekly Check

Week Ending Initials Week Ending Initials


24

EMERGENCY DRUG KIT Monthly Check

Month Ending Initials Month Ending Initials


25

EMPLOYEE COMPLIANCE

SIGNATURE LOG

MONTH COMPLETED:

Employee

Signature

Date

Completed

Reviewed

Manual ()

MONTH COMPLETED:

Employee

Signature

Date

Completed

Reviewed

Manual ()


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MONTH COMPLETED:

Employee

Signature

Date

Completed

Reviewed

Manual ()

MONTH COMPLETED:

Employee

Signature

Date

Completed

Reviewed

Manual ()

MONTH COMPLETED:

Employee

Signature

Date

Completed

Reviewed

Manual ()

VITAL SIGNS RECORDING SHEET

Patient Name: Date:

Likely Event Occurring:

Beginning time of recording: Person Recording:

START

3

min

5

min

7

min

10

min

13

min

15

min

18

min

20

Min

23

min

25

min

SaO2 (%)

Pulse (bpm)

BP (mm/Hg)

RR (bpm)

100% Oxygen Administration? No Yes – Time:______

Nitrous Oxide/Oxygen Administration? No Yes -- _____% Nitrous Oxide & _____% Oxygen

Supplemental Drug Delivery? No Yes –Name of Drug:

Amount of Drug: Time Administered:

Delivery Route: Delivered By:

Normal Vital Signs

ADULT: SaO2: 98%-99% Pulse: 60-80 bpm BP: <140/<90 RR: 14-20 bpm

ADULT RESCUE BREATHING: 1 breath / 6-8 sec. ADULT CPR: (dual) 30 comp/2 breaths

CHILD (2-6): SaO2: 98%-99% Pulse: 80-100 bpm BP: 100/66 RR: 20-30 bpm

CHILD RESUCE BREATHING: 1 breath/6-8 sec. CHILD CPR (dual): 15 compressions/2 breath (one palm only!)


28

INSERT

EMERGENCY

FIRE EXIT PLAN

HERE

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