Do you have an emergency medical response plan?

[Anonymous]

Medical emergencies occur in dental offices more often than we’d like to admit. Rather than waiting until it’s too late, be sure you and your staff are ready — today.

Do you have an emergency medical response plan in your office? Are you sure?

If not, how come? You probably have a retirement plan, a business plan, a financial plan, an insurance plan — but no emergency medical response plan? Is it an “I’ll get around to it sometime” thing?

What is your role in a medical emergency? Yes, you play a major part in the rescue of a patient! What is the role of your staff? Yes, they play a major role also!

How nice it is to have the entire team prepared, because your staff can offer advice and assist you during this chaotic event. A lot can happen during a life-threatening event, and if you’re not prepared, you will panic. When you panic, you will forget. But when you and your staff are prepared, even though it is stressful, hopefully all of you will be thinking and acting on the same page.

Team training is critical :
No one person can handle a medical emergency by themselves. One person has to stay with the patient and treat them. One person needs to call for medical service. One person needs to retrieve the AED and the Emergency Drug Kit. One person needs to be documenting fully everything that is happening. One person needs to assist the team leader who is treating the patient.

If you have an emergency medical response plan established before an emergency occurs, you will each know your role and duties when the time comes.

Accountability and liability:
If you place crowns, if you do root canals, if you do extractions, if you place implants, if you inject local anesthesia … basically, if you practice dentistry, you had better have — and be able to prove — an emergency medical response plan. Why? Because a medical emergency can happen at any time during any type of dental procedure, and you had better know how to respond when it does.

You have to worry about what might happen! There is not a single practitioner who can predict with 100% accuracy that a medical emergency will never occur in their office. Disregard any comments you have heard about medical emergencies being “rare” or “infrequent.” It is simply not true. Patients with multiple medical problems who are taking multiple medications seek dental treatment everyday.

More than a document:
So let’s face it: We will continue to experience medical emergencies in the dental office. And regardless of when they occur, your office must be ready and able to respond as well as react. The moment a patient experiences a medical problem, the dentist and staff will be held accountable for initiating a rescue. There can be no delay in the team’s response, and your documentation of your actions must be meticulous.

Your emergency medical response plan must be an ongoing, continual process, not an occasional event. It can’t be a one-page document that is placed on a wall that never gets seen or rehearsed.

So don’t wait until it is too late and you are saying to yourself, “Why didn’t I develop a medical emergency program for my office and stick with it?” You will not learn about an emergency medical response plan in dental school. You must do this for yourself, your staff, and most important, your patients.

        

[drmithila]

FACTS ON THE EMERGENCY DRUG KIT
An emergency drug kit is essential in the dental setting. The American Dental Asso­ciation states all dentists should have emergency drug kit and equipment along with the knowledge to properly use all items. The Council on Scientific Affairs has stated that “all dental offices” should maintain at least the basic recommended emergency equipment and drugs.1 Those drugs are albuterol, aspirin, diphenhydramine, epinephrine, glucose, nitroglycerin, and oxygen.

Emergency! What’s in the Emergency Kit?
Knowledge of the emergency drugs is a must for everyone on your dental team. Every person should be well versed in each com­ponent within the emergency drug kit. Each team member should know the action, the dose, and how to properly administer each drug in the kit. Rehearse this as a team each and every month. Never miss a month reviewing these drugs in the emergency drug kit.
The onset of a crisis is not the time to become familiar with the emergency drug kit. Sadly, so many dentists just believe that nothing will ever happen in their office. They do the first part right—that is—ordering and obtaining an emergency drug kit. Then they fail on the second part, knowing what is in the drug kit and how to use everything that it contains. Just because it is sitting on the shelf does not mean it is ready for use.
Emergency! Where is Our Emergency Kit?
Always know the location of your emergency drug kit. This also applies to the entire dental team. What good does an emergency drug kit do if it is locked-up somewhere in the dentist’s office? The emergency drug kit needs to be visibly seen in the office and in a central location. It must be readily available for any dental team member to obtain and its location should always be known by everyone on the team, including the doctor.

Emergency! Are You Reaching for an Expired Drug?
Always use an automatic renewal update program because doctors and their team al­ready have enough to do on a daily basis. Companies offer different types of renewal plans and you should investigate these plans fully with the company of your choice. In addition, you should know the cost of the renewal plan before you purchase a kit. Besides the renewal program, you should assign one team member in your office the duty of checking once a month for any drugs that might be expiring. This would also be a good time to rehearse the contents of the drug kit as well.
Never administer an expired drug! An expired drug is expired, period. It is good for nothing but pract­icing how to administer. However, you can use them for practice in mock emergency drills. If you are one of those who do not check their emergency drugs and then has a medical crisis, you are now a potential liability.
Read the Warnings on Your Local Anesthetic Inserts!
Read the package insert on the local anesthetic you are using everyday. Read the “WARNINGS” section be­cause it contains information that you will need to know before you administer that next local anesthetic. Are you injecting local anesthetic without having emergency drugs, equipment, and knowledge of their use in your office? This is a medicolegal binding document. You need to make abso­lutely 100% sure that you are fully compliant.

EMERGENCY EQUIPMENT
Besides the emergency drug kit, be sure you have an automated external defibrillator (AED) as well as equipment to maintain an airway. The AED should be in every dental office. What will you do when a patient has a sudden cardiac arrest (SCA) in your office? What drug will you administer for a SCA? NONE! The only treatment for a SCA is an AED! Will EMS be at your office within 4 minutes to deliver the first shock? No! This is a piece of equipment you cannot afford to be without in your of­fice. Do you have the proper equipment to maintain an airway? Do you have equipment to retrieve an object that might occlude an airway? Do you have equipment to maintain an airway once it is opened? Do you have equipment to deliver positive pressure? Don’t attempt the “Ziploc” approach to airway equipment. Purchase an airway kit and reduce your stress

        

[drmithila]

EMERGENCY DRUGS

The drugs listed below, may or may not be included in your emergency drug kit. The list represents what may be found in an “optimum emergency drug kit.” Substitution of drugs within the same class is acceptable and may even be preferred if a provider is more familiar with using them. Furthermore, the information below is to be used as instructional and does not guarantee to prevent an unfavorable outcome, result, or death. Practitioners may choose to deviate from the list of medications based upon their clinical experience, training, and factors unique to that individual.
To better assist you in understanding the drugs in the emergency drug kit, we went to Southern Anesthesia & Surgical and used their Medical Alert Rescue Kit (MARK) Series of emergency drug kits. They have developed a drug kit for every type of practitioner. We will first define the drugs contained within the MARK Classic Emergency Drug Kit. We have listed the generic name followed by trade name in ( ) and the action along with brief description of that drug: (a) indicates in kit.

aAlbuterol (Proventil)—Bron­chodilator: Stimulates beta-2 adrenergic receptors causing bronchodilation.
aAspirin—Antplatelet: Inhibits prostaglandin synthesis and inhibits platelet aggregation irreversibly.
aAtropine (Atropine)—Anti­cholin­ergic: Antagonizes acetylcholine at the muscarinic receptors, increasing the heart rate as well as having an antisialagogue effect.
aDiphenhydramine (Benadryl)—Antihistamine: Antagonizes histamine at the H-1 receptor, causes sedation, and has an anticholinergic effect.
aEpinephrine (Adrenaline)—Car­diac stimulant/anaphylaxis: Activates alpha- and beta-adrenergic receptors increasing heart rate, myocardial contractility, bronchial dilation, and de­creases peripheral vascular resistance.
aGlucose Tabs or Insta-Glucose —Antihypoglycemic: Increases glucose level for treatment of hypoglycemia.
aNitroglycerin (Nitrostat)—Anti­anginal: Stimulates cGMP production which relaxes vascular smooth muscle specifically in the coronary arteries.

        

[drmithila]

Airway Kit:
bAdenosine (Adenocard)—Anti­arrhythmic: Used for treatment of par­oxysmal supraventricular tachycardia by slowing conduction time through the atrioventricular (AV) node as well as interrupting the re-entry pathways through the AV node.
bAmiodarone (Cordarone)—Anti­arrhythmic: A Class III agent that in­hibits adrenergic stimulation which pro­­longs the action potential, de­creases AV conduction and sinus node function which is used for life-threatening recurrent ventricular fibrillation or hemodynamically-unstable ventricular tachycardia.
bDexamethasone—Anti-inflammatory: A corticosteroid se­creted by the adrenal cortex which has anti-inflammatory, antiallergic, glucocorticord activity, and stimulates gluconeogenesis.
bDextrose (50% Dextrose)—Anti­hypoglycemic: A source of calories and fluid for patients that are not able to take oral fluids in the event of a hypoglycemic reaction.
bDiazepam (Valium)—Anti­con­vulsant: A benzodiazepine that acts on the inhibitory neurotransmitter gamma amino butric acid (GABA), limbic system, hypothalamus, and thalamus to produce sedation, antianxiety effect, and skeletal muscle relaxation.
bDigoxin (Lanoxin)—Antiar­rhy­thmic: Used for the treatment of slowing the ventricular rate in atrial fibrillation, atrial flutter, and paroxysmal atrial tachycardia as well as treatment of congestive heart failure.
bFlumazenil (Romazicon)—Benzo­diazepine antagonist: Reverses effect of benzodiazepines by competitively inhibiting the GABA receptors.
bFurosemide (Lasix)—Diuretic: Used for the management of congestive heart failure by inhibiting reabsorption of sodium and chloride in the ascending loop of Henle and distal renal tubule leading to an increased excretion of water, sodium, magnesium, chloride, and calcium.
Glucagon (GlucoGen)—Antihypo­glycemic: Causes a rise in blood glucose levels by promoting hepatic glyco­genolysis and gluconeogenesis.
Hydrocortisone (Solu-Cortef)—Anti-inflammatory: A corticosteroid secreted by the adrenal cortex which has anti-inflammatory, antiallergic, mineralocorticord activity, and stimulates gluconeogenesis.
Midazolam (Versed)—Anticon­vulsant: A benzodiazepine that acts on the inhibitory neurotransmitter GABA, limbic system, hypothalamus, and thalamus to produce sedation, anti­anxiety effect, and skeletal muscle relaxation.
bNalbuphine (Nubain)—Narcotic: Binds to opiate receptors producing analgesia.
bNaloxone (Narcan)—Narcotic antagonist: Reverses the effect of narcotics by competitively inhibiting narcotic receptor sites.
bProcainamide (Pronestyl-SR)—Antiarrhythmic: Used for the treatment of ventricular tachycardia, premature ventricular contractions, paroxysmal atrial tachycardia, and atrial fibrillation.
bPromethazine (Phenergan)—Antiemetic/antihistamine: Used for the treatment of allergic reactions, anti­emetic, and sedation.
bSodium Bicarbonate—Alka­linizing agent: Used for the management of metabolic acidosis.
bVasopressin (Pitressin)—Anti­diuretic hormone: Adjunctive treatment used in pulseless ventricular tachycardia/ventricular fibrillation.
bVerapamil (Isoptin/Calan)—Anti­arrhythmic: Used for the treatment of paroxysmal supraventricular tachycardia, atrial flutter, and atrial fibrillation.

        

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