Emergency medicine malamed by Louize Lobato

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4 CE credits This course was written for dentists, dental hygienists, and assistants.

Emergency Medicine A Peer-Reviewed Publication Written by Dr. Stanley Malamed

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Go Green, Go Online to take your course This course has been made possible through an unrestricted educational grant from HealthFirst. The cost of this CE course is $59.00 for 4 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

Educational Objectives Upon completion of this course, the clinician will be able to do the following: 1. Evaluate the completeness of the office’s current emergency medicine kit 2. Question patients in review of their health history to evaluate the potential for an emergency situation before it arises 3. Recognize the signs and symptoms of separate categories of medical emergencies 4. Describe the basic protocol for treating all medical emergencies and be able to apply the PABCD protocol to manage different emergency situations

Abstract Medical emergencies can and do occur, not only in your dental office but any place and at any time. The entire staff and designated in-office emergency team must be trained, and emergency equipment and drugs must be available and current. The best way to handle an emergency is to start by being prepared.

Introduction

A heart attack occurs every 20 seconds. About 25% of those who have heart attacks do not realize they are having them. Imagine you are treating a patient, stop treatment to ask her a question, and find that she is unresponsive. You quickly ask someone to tell the receptionist to call 911 and to bring you the oxygen tank. The oxygen tank finally arrives about 10 minutes later, but it is almost empty. You eventually get another oxygen tank from an assistant, but it has no tubing, so there is another delay in getting the patient oxygen. The paramedics finally arrive, but it is too late – the patient is dead. Were you prepared? You had the oxygen tank, the emergency kit, and CPR training. You may have thought you were prepared — until the patient died. Emergencies are rare in dental offices. Nonetheless, we must be prepared to manage medical emergencies when they do occur.

Preparation Your office must be prepared to deal with medical emergencies. You must find out from patients any medical conditions or medications they are or have been taking. The entire staff must be trained, a designated in-office emergency team must also be trained, and emergency equipment and drugs must be available and current. Without all these, you will not be prepared to handle medical emergencies. 2

Training the Entire Staff – Basic Life Support (CPR) Training Every single person who works in the dental office should receive CPR training. This is the most important step in preparing for or managing a medical emergency. Most states that require dentists and hygienists be trained in CPR for licensure mandate CPR recertification every two years — this is not adequate to be able to properly perform CPR. It is recommended that basic life support training be provided in the dental office annually. The In-Office Emergency Team The emergency team should ideally consist of at least three people, at a minimum two. The dentist is the team leader as soon as he or she arrives on the scene. Do not leave the patient alone during a medical emergency unless absolutely necessary. The duties of team members are found in Table 1. Table 1. The In-Office Emergency Team Team member 1: The person who first observes the emergency – could be any staff member. Responsible for staying with the patient, performing CPR as needed. Team member 2: The person who will get the emergency oxygen cylinder and emergency drug kit as soon as the person hears of the emergency and bring it to the location of the patient in distress. Team member 3: All other staff members. Handle other tasks as assigned by the dentist during the emergency. Call 911 if assigned to do so. A staff member should go to the lobby of the building and wait for the ambulance to arrive and also have the elevator waiting in the lobby to save time if in a multistory building. If another staff member is available, this person stands in the background and records the patient’s vital signs or what is happening. Calling for Help Knowing when to seek medical assistance and not hesitating to do so are crucial. Never hesitate – it is better to call than to attempt to handle the emergency yourself only to discover you cannot and it is too late. If you think that you need help, get it. If you do not know what is going on or are concerned about the situation, call for help. When in doubt, call for help. The most logical thing to do is to call 911, Emergency Medical Services (EMS). Their job is to save lives. The dentist is legally responsible during a medical emergency to keep the patient alive until he or she gets better or until someone who is better trained arrives on the scene to take over. If a team member calls 911 and EMS takes six minutes to arrive, then the dentist is responsible for keeping the person alive for those six minutes. If your office is in an isolated area, you may be responsible for the patient for a longer period of time. If so, basic training will be important for you; however, more advanced training may be necessary. Do not assume if you work in a medical–dental building that you can call one of the physicians down the hallway for www.ineedce.com

help – usually that is not the case, as they are not specialists in emergency medicine. Therefore, the recommendation is to always call 911.

Emergency Equipment Oxygen Tank The oxygen tank is important – oxygen is the second-mostimportant drug in emergency medicine. Oxygen must be available in an “E” cylinder, which is about three feet high and contains enough oxygen to ventilate a nonbreathing adult for approximately 30 minutes. Ensure that all staff members know where the oxygen cylinder and emergency kit are kept and that they are readily accessible. The oxygen cylinder should be checked regularly to make sure there is sufficient oxygen in the tank and that all tubing and equipment is present and functioning. Pocket Mask This full-face mask is stored folded in on itself. When pressed, it becomes the same type of face mask used in general anesthesia to maintain the airway of an unconscious person. By holding the mask on properly and putting your mouth onto the mask, you can ventilate a person with 16% oxygen. Automated External Defibrillator (AED) The AED is a small lightweight device that monitors a person’s heart rhythm and talks a first responder through very simple steps to defibrillate the patient. Defibrillation is very important and is carried out by placing special pads on the torso that recognize a sudden cardiac arrest. For every minute that elapses until the time a heart attack patient is successfully defibrillated together with basic life support (BLS), the survival rate has been estimated to go down 10%. At one minute the survival rate is 90%, and by 10 minutes, 0%.

Drug Kit Except for drugs used for anaphylaxis, drug therapy will always be secondary to basic life support (BLS). Apart from oxygen used in BLS, there are six drugs in a bare-bones basic emergency kit, two injectable and four noninjectable. Injectable Drugs Epinephrine Epinephrine is the single most important drug in emergency medicine and is used when an anaphylactic reaction occurs. Anaphylaxis is life-threatening. Epinephrine is dosed in a 1:1000 (0.3 mg) concentration and must be available in a preloaded syringe. The faster the patient receives epinephrine, the greater the chance of survival. It is very common to need more than one dose. Therefore, in www.ineedce.com

addition to the preloaded syringe, the emergency kit should contain a minimum of two or three 1 ml glass ampoules of epinephrine 1:1000. There is no medical contraindication to the use of epinephrine in an anaphylactic reaction. Diphenhydramine (or Benadryl) Histamine blockers are used in the management of primarily non-life-threatening allergic reactions as well as in anaphylactic reactions after epinephrine has saved the person’s life. Diphenhydramine (or Benadryl) is the histamine blocker most commonly used in emergency drug kits. There are no contraindications to the administration of a histamine blocker during a medical emergency. As there is no urgency in giving the histamine blocker, it is not recommended to preload a syringe. Noninjectable Drugs Nitroglycerin Nitroglycerin, a vasodilator, must be included in the drug kit. Patients who have angina will bring their nitroglycerin with them, usually in tablet form. It is strongly recommended that the emergency drug kit contain Nitrolingual Spray. This is sprayed on the patient’s tongue for the translingual application of nitroglycerin, is as effective as tablets, and has a much longer shelf life. One spray equals one sublingual tablet. There are two contraindications to the administration of nitroglycerin: • A patient suffering from chest pain who is exhibiting signs of a drop in blood pressure (e.g., feels faint or dizzy). • A patient who has chest pain and has taken Viagra within the previous 24 hours. Viagra and nitroglycerin both lower blood pressure; if a patient takes both drugs within a 24-hour period, it can lead to unconsciousness Bronchodilator A bronchodilator is used to treat an acute asthmatic attack. Patients with asthma will bring their own medication to the office and should use their own inhalers if necessary. The office needs a bronchodilator in the emergency kit in case an asthmatic does not bring medication or a patient with no history of asthma goes into bronchospasm. The most commonly used drug in the U.S. is albuterol (Ventolin; Proventil), in an inhaler. The patient places the inhaler into the mouth and compresses the spray vial to express the bronchodilator while inhaling, then slowly exhales to disperse it in the bronchii. The bronchospasm will subside and go away within 30 seconds to one minute. Glucose (Sugar) Hypoglycemia, or low blood sugar, is a very common emergency in the dental office and is easily managed with sugar, which can be made available either in a tube (InstaGlucose) or as a bottle of orange juice or a nondiet soft drink. 3

Aspirin Aspirin is part of the prehospital treatment for suspected heart attack victims. One aspirin tablet (325 mg) chewed, not swallowed, is recommended in any patient who is suffering chest pain for the first time. There are three contraindications to the administration of aspirin: • A patient with an allergy to aspirin • A patient with a bleeding disorder of any type • A patient with a gastric or peptic ulcer There are no substitutes for aspirin in this situation. Secondary Drugs Aromatic Ammonia Aromatic ammonia is used to manage a patient who is fainting or has fainted. Ammonia vaporil is crushed between your fingers and held under the patient’s nose. The noxious odors stimulate movement, which increases blood flow to the patient’s brain if the person is in a supine position. In addition to ammonia being in the emergency kit, one or two vaporils should be taped to a wall or cabinet within arm’s reach in every treatment room.

Management of Medical Emergencies All medical emergencies are managed in basically the same way, using the PABCD protocol. Conscious Patients Whichever position is most comfortable for the patient is the position of choice (P). If the person is breathing or talking to you, then the airway is open. Since the patient is conscious, his or her heart is beating. When the conscious patient speaks, you have assessed the person’s airway (A), breathing (B), and circulation (C) just by listening to them. You do not have to do anything for A, B, or C. P. Positioning patient A. Airway B. Breathing C. Circulation D. Definitive care Unconscious Patients Unconsciousness patients should be in the supine position – lying face up with the feet elevated slightly. The most common reason for loss of consciousness is low blood pressure. In the supine position, the patient’s head and heart are parallel to the floor, increasing blood flow to the brain, and the patient can still breathe adequately. Do not put an unconscious patient in a head-lower-than-heart position – this has the opposite effect. 4

Airway management, the next step, is critically important. In unconscious patients the muscles relax, including the tongue, which falls backward into the airway due to gravity and either totally or partially obstructs the airway. The Head Tilt/ Chin Lift is used to maintain the airway and is very simple to accomplish – place one hand on the patient’s forehead, place two fingers under the jaw, and rotate the head back; since the tongue is attached to the mandible, it is lifted from the airway when you lift the mandible. Next, check whether the patient is breathing (B) (air going in and out). While maintaining Head Tilt/Chin Lift, place your ear one inch away from the patient’s mouth and nose, while looking at the patient’s chest to see if the patient is trying to breathe. This is a very important concept: the airway could be obstructed, but the patient would still automatically attempt to breathe and move their chest. You need to physically feel and hear the patient’s breath. If you feel or hear air coming out of the patient’s mouth and nose, the airway is open and the person is breathing. If the patient is not breathing, the rescuer must deliver two complete full ventilations to get oxygen to the patient’s lungs and blood. Checking circulation (C) is the next step. You need to know if the blood that now contains oxygen is circulating through the body and going to the patient’s brain. Maintain the Head Tilt/ Chin Lift and check the carotid artery for a pulse. It is vitally important to know how to locate the carotid artery. Missing and misdiagnosing the carotid artery is a life-and-death mistake. To locate the carotid artery, maintain the Head Tilt with one hand, place the index and middle fingers of the opposite hand on the patient’s Adam’s apple (thyroid cartridge), and slide them down along the neck (towards the rescuer) until the fingers fall into the groove formed by the sternocleidomastoid muscle. The carotid artery is located in that groove. Palpate the carotid pulse for no more than 10 seconds. If the pulse is not present, start doing chest compressions to circulate blood, which contains oxygen, to the patient ’s brain to keep the patient alive. The last step is definitive care (D). P, A, B, and C are basic life support. Definitive care is the stage where you will diagnose the problem. If a diagnosis can be made and the office has the appropriate drugs and equipment, you can treat it. If you cannot diagnose the problem, or do not feel comfortable treating it, call 911.

Specific Medical Emergencies We will now look at some of the emergencies you may encounter in the office and their management using PABCD. Hypoglycemia Hypoglycemia, or low blood sugar, is most likely in a diabetic, particularly the type 1 insulin-dependent diabetic. The classic signs and symptoms are that the patient is cold, www.ineedce.com

sweaty, shaking, and mentally disoriented. Many patients, however, do not exhibit these. Therefore, when reviewing the patient’s medical history, it is important to ask diabetic patients to list their signs and symptoms. Before you start dental treatment, ask your patients these questions: “When did you last take your insulin?” and “When did you last eat?” If the patient took insulin and hasn’t eaten recently, give the patient some orange juice before you start your treatment. Mental confusion or mental disorientation is often the first sign of hypoglycemia. If a diabetic patient shows either of these signs, stop treatment and apply the PABCD protocol as follows: Conscious diabetic – position comfortably. A, B, and C are not required, because the person is talking to you. Definitive care is simply the administration of sugar. If you have orange juice or a soft drink, give the patient four ounces, wait about five minutes, give the person four ounces more, wait five minutes more, and then give the patient the last four ounces. Within that 15-minute period, the person’s mental clarity will return and the signs of hypoglycemia will subside. The problem will be resolved. Under a different scenario, a patient could collapse. Team member 1 should determine loss of consciousness by “shake and shout,” and call for help. Begin the PABCD protocol as follows: Unconscious diabetic — Place in the supine position. A, B, C – check the airway by performing a Head Tilt/Chin Lift, check for breathing (look, listen, feel), and check for a carotid pulse. The emergency team should come to the scene with the emergency kit and oxygen. No drugs should be administered, because at that moment you do not know what the problem is. You have a known diabetic, probably hypoglycemic, who is unconscious, is breathing, and has a pulse. The most prudent treatment is to maintain BLS, notify EMS, and allow them to make a definitive diagnosis and treat the patient. Epilepsy Epilepsy occurs when the signals in the brain are disrupted, leading to a seizure. It is important to ask epileptic patients the following questions when reviewing their medical history: What type of seizure do you have? The most common type of seizure is the grand mal seizure. This lasts in total from two to three minutes, during which the body will alternate between phases of full body rigidity and relaxation. After this the patient remains unconscious for a while and will awaken experiencing confusion and extreme fatigue. What medication(s) are you taking to control your seizures and how effective are they? What is your aura? Some patients have an aura – this could be visual such as seeing rainbows, or www.ineedce.com

a sound or smell, but it is always the same. If you know what the patient’s aura is, you may recognize a seizure as it begins. Have you ever had a seizure that did not stop? Have you ever been hospitalized for your seizures? A seizure that lasts for five minutes or longer is called status epilepticus and is life-threatening. You may be in the middle of treatment when a patient’s seizure starts. If the patient is a minor, call the parent into the room. The PABCD protocol for epileptic patients is as follows: If possible, remove the doughnut or pillow from the dental chair. Position the patient so that he or she cannot hit any sharp objects. One rescuer can stand by the patient’s arms and one by the patient’s legs, gently holding and protecting the patient from injury. Maintain the patient’s airway by performing a Head Lift/Chin Tilt. Check for breathing (look, listen, feel), and check for the carotid pulse. When the patient awakes tell the person where he or she is, what happened, and that everything is under control. If the parent of a minor patient notices that something about the seizure is different and tells you to call 911, immediately do so. Once the seizure has stopped, the paramedics who arrive on the scene will stabilize the patient and transport the patient to the hospital for definitive care. In any situation in which you are uncomfortable, call 911 immediately. Asthma Asthma, or bronchospasm, occurs when the smooth muscles surrounding the bronchii go into spasm. The airway is narrowed, and breathing becomes extremely difficult. An acute asthma attack that is not treated promptly can be fatal. When an asthmatic patient comes to the dental office for the first time, you must ask the following questions: What type of asthma do you have? How often do you have asthmatic attacks? What triggers your asthmatic attacks? Asthmatics can have either allergic asthma or nonallergic asthma. Nonallergic asthma is very often induced by fear and anxiety – be aware: if such a patient fears going to the dentist, he or she will likely have an asthmatic attack in the dental chair. What are you allergic to? What medications do you take for your asthma? Asthmatics usually take two medications: an inhaler such as albuterol used to manage acute episodes as well as preventive medication taken once daily. When you call to confirm patients’ appointments, remind them to bring their inhalers with them. Have you ever had an asthmatic attack that didn’t stop and that required hospitalization? That question will help you determine whether to notify 911. The PABCD protocol is started when the patient is positioned comfortably. The first thing that a patient having an acute asthma attack will do is sit up. A, B, and C need 5

not be done, because the patient is breathing (albeit with difficulty) and is conscious. Definitive care is simply to give the patient his or her own bronchodilator. The usual dose is two puffs of the medication, and within 15 to 30 seconds the bronchospasm is broken, with a second dose five minutes after the first if the bronchospasm did not stop. Once the asthmatic attack is over, it is OK to continue with the planned dental treatment if both the clinician and the patient are comfortable doing so. Find out first why the asthma attack happened – if it was fear, treat the fear first. Allergic Response: Anaphylaxis Common allergens include penicillin, latex, aspirin, strawberries, shellfish, and peanuts. Histamine, released by mast cells, produces virtually all the clinical signs and symptoms associated with allergic reactions, including rash, bronchospasm, and vasodilation. The severity of the allergic reaction depends upon how rapidly and where these chemicals are released. Delayed-onset allergies most commonly involve only the skin and are not life-threatening. Immediate-Onset Allergies (Anaphylaxis) develop in seconds or minutes following allergen exposure. Immediate-onset allergies are life-threatening, usually involving the respiratory and cardiovascular systems and producing bronchospasm and a drop in blood pressure. This requires immediate emergency management to keep the person alive. The PABCD protocol to manage anaphylaxis is as follows: All patients will initially be conscious, allowing you to position them comfortably and move to definitive care. If patients are unconscious, place them in the supine position. Assess airway and breathing, and take any necessary action. Have one of your staff call 911. Immediately get the preloaded epinephrine syringe and give the injection in the deltoid, tongue, or lateral thigh. Be prepared to monitor A, B, and C until help is on the scene and to readminister epinephrine in approximately five minutes, if necessary. Epinephrine is the drug of choice – it acts as a bronchodilator and elevates blood pressure.

Chest Pain A patient may complain of a vague pain in the area of the chest. This could be cardiac or noncardiac in origin. Two common cardiac syndromes are angina pectoris and acute myocardial infarction (heart attack). Angina Pectoris The patient will usually describe an angina attack as tightness, heaviness, or a constricting feeling in the chest and will often make a fist and hold it against the chest to describe this. The patient will know that it is an angina attack. Use the PABCD protocol to manage this patient. Position the patient comfortably. A, B, and C need not be done, because the patient is conscious and talking. 6

Definitive treatment is to simply give patients their nitroglycerin and let them medicate themselves. The average dose is two tablets placed under the tongue. The tablets dissolve, and within one to two minutes the attack is over. The nitroglycerin spray from the emergency drug kit should be used if the patient forgot his or her medicine or it doesn’t work (e.g., it has expired). The usual dose is two sprays within two minutes to resolve the attack. Oxygen can be given any time during the attack. Planned dental treatment can continue if both the clinician and patient are comfortable. In the following four situations, the first thing to do is to call EMS because the patient is probably having a myocardial infarction and not an angina attack: • A patient tells you that the pain is getting worse. • The patient takes three doses of nitroglycerin at fiveminute intervals and the pain doesn’t go away. • The patient takes nitroglycerin and the pain goes away but comes back. • A patient with no prior history of cardiovascular disease has chest pains for the first time. Myocardial Infarction (MI) A myocardial infarction occurs when muscle distal to a blood clot in the coronary artery no longer receives any blood and the heart muscle in that area begins to die. Heart muscle takes approximately six hours to die; until then it is considered injured. Injured heart muscle can trigger irregular heartbeats, which may stop the heart from beating or from beating enough to keep the body alive. This is a cardiac arrest. It is possible to survive a heart attack with little to no permanent damage if the patient gets hospital treatment within the first six hours of onset. The patient experiencing acute myocardial infarction is conscious and feels crushing, intense, radiating pain. Classic myocardial pain radiates from the chest into the stomach, giving a bloated feeling. The pain radiates down the left arm, usually as a tingling sensation in the arm and pinkie finger, and may radiate to the left side of the patient’s neck and mandible. The patient’s skin is normally an ashen gray color. The mucus membranes may be cyanotic, and the patient may be sweating profusely. If you suspect a patient is having a myocardial infarction, start to position the patient comfortably. A, B, and C need not be done, because the patient is breathing and can speak to you. You need to call EMS immediately and move on to definitive care. There are four things that can be done to manage this victim: morphine, oxygen, nitroglycerin, and aspirin (MONA). Morphine is not available in a dental office. However, the combination of 50% nitrous oxide and 50% oxygen is as effective as IV morphine in treating the pain of acute myocardial infarction. www.ineedce.com

Oxygen must be administered. A five-liter flow of oxygen will help deliver more oxygen to the muscles and brain. This will also help the patient feel and look a little bit better. Nitroglycerin should be administered if it hasn’t already been. A dose of two sprays or two tablets is recommended. One adult-dose aspirin tablet (325 mg) is administered; it should be chewed and dissolved in the mouth, not swallowed whole. Aspirin has thrombolytic properties, so it prevents the blood clot from getting any larger. Aspirin should not be administered to patients with contraindications. Once the paramedics arrive, they will start an IV, monitor the victim’s heart with an electrocardiogram, deliver appropriate medications, and transport the patient to the hospital for further care. Cardiac Arrest If the patient becomes unconscious before the arrival of EMS, the PABCD protocol is followed, according to the BLS protocol. Successful management of this event might look as follows: Position the patient supine and perform “shake and shout.” The patient is unconscious. The airway is checked by using a Head Lift/ Chin Tilt. Breathing is assessed. In this particular patient, when the carotid pulse is checked, but there is none. The dentist tells the assistant to notify EMS, “We have a cardiac arrest.” The dentist begins performing one-rescuer CPR at a ratio of 15:2 (compressions: ventilations) while the other assistant gets the emergency drugs and equipment. Once EMS has been notified, the assistant and the doctor work as a two-person rescue team, continuing to perform CPR at a ratio of 15:2. The other assistant returns with the emergency drug kit, the oxygen cylinder, and the AED. The oxygen cylinder is turned on, and the patient is ventilated with positive pressure oxygen. The AED is placed by the patient’s left shoulder and turned on. At this point CPR is discontinued and instructions from the AED are followed. Paramedics should transport the patient to the hospital for further treatment.

Conclusion Medical emergencies can and do occur, not only in your dental office, but also at any place and at any time. The best way to handle an emergency is to start by being prepared. This course covers the most common medical emergencies that the dental practitioner, or anyone else, for that matter, may have to face. The main purpose of this course is to provide you with the necessary information to save the life of someone experiencing a medical emergency. Be prepared, and make sure the entire staff is ready to work together to manage these situations should the need ever arise. www.ineedce.com

Author Profile Dr. Stanley Malamed Dr. Malamed was born and raised in the Bronx, New York, graduating from the New York University College of Dentistry in 1969. He then completed a dental internship and residency in anesthesiology at Montefiore Hospital and Medical Center in the Bronx, New York, before serving for two years in the U.S. Army Dental Corps at Fort Knox, Kentucky. In 1973, Dr. Malamed joined the faculty at the University of Southern California School of Dentistry in Los Angeles, where today he is professor and chair of the Section of Anesthesia and Medicine. Dr. Malamed is also a diplomate of the American Dental Board of Anesthesiology, as well as a recipient of the Heidebrink Award (1996) from the American Dental Society of Anesthesiology and the Horace Wells Award from the International Federation of Dental Anesthesia Societies, 1997 (IFDAS). Dr. Malamed has authored more than 85 scientific papers and 16 chapters in various medical and dental journals and textbooks in the areas of physical evaluation, emergency medicine, local anesthesia, sedation, and general anesthesia. In addition, Dr. Malamed is the author of three widely used textbooks, published by CV Mosby Inc: Handbook of Local Anesthesia (4th edition, 1997) and Sedation: A Guide to Patient Management (3rd edition, 1995). In his spare time, Dr. Malamed is an avid runner and exercise enthusiast, and admits an addiction to the New York Times crossword puzzle, which he has done daily since his freshman year in dental school.

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health dictionary, ed 5, St. Louis, 1998, Mosby. Angst DM, Bensinger DA: Angina. In Cardiopulmonary emergencies, Springhouse, Pa, 1991,Springhouse. Apstein C’s, Lorell BH: The physiological basis of left ventricular diastolic dysfunction, J Card Surg 3(4):475485, 1988. Benett JD, Rosenberg MB: Medical Emergencies in Dentistry. W.A. Saunders, Philadelphia 2002. Block Drug company: Vital response crisis management system, Jersey City, NJ, 1988, the company (videotape). Buisseret PD: Allergy, Sci Am 247:86, 1982. Caranasos GJ: Drug reactions. In Schwartz GR, editor: Principles and practice of emergency medicine, Philadelphia, 1992, Lea & Febiger. Chen MD, Greenspoon JS, Long TL: Latex anaphylaxis in an obstetrics and gynecology physician, Amer J Obstet Gynecol 166(2):968, 1992. Cohn PF, Braunwald E: Chronic coronary artery disease. In Braunwald E, editor: Heart disease: a textbook of cardiovascular medicine. Ed 5, Philadelphia, 1997, WB Saunders. Diamond GA, Forrester JS: Analysis of probability as an aid in the clinical diagnosis of coronary heart disease, N Engl J. Med 300:1350, 1979. Djukanovic R and others: Mucosal inflammation in asthma, Am Rev Respi Dis 142(2);434-457, 1090. Ebert RV: Response of normal subjects to acute blood loss, Arch Int Med 68:578, 1941. Eisenber MS, Bergner L. Hallsrom A: cardiac resuscitation in the community: importance of rapid provision and implications for program planning, JAMA 241:1905, 1979. Epstein C’s, Lorell BH: The physiological basis of left ventricular diastolic dysfunction, J Card Surg 3(4):475485, 1988. Erie JK: Effect of position on ventilation. In Faust RJ, editor: Anesthesiology review, New York,1991 Churchill livingstone. Fast TB, Martin MD, Ellis TM: Emergency preparedness: a Survey of dental practitioners, J Am Dent Assoc 112(4):499-501, 1986. Fundamentals of BLS for Healthcare providers, American heart Association. Stapleton ER editor 2001. Gazes PC, Mobley EM Jr., Faris HM Jr., Duncan RC, Humphries GB: Preinfarction (unstable) angina: a prospective study~ten year follow-up, Circulation 48:331, 1973. Gell PGH, Coombs RRA: Clinical aspects of immunology, ed 4, Oxford & London, 1982, National safety Council: Accident facts, Chicago, 1984, The Council.Blackwell Scientific. Goldberg AH: Cardiopulmonary arrest, N Engl J Med 290:381, 1974. Gordon AS and others: Mouth-to-mouth versus manual artificial respiration for children and adults, JAMA 167:320, 1958. Guildner CW: Resuscitation: opening the airway – a comparative study of techniques for opening an airway obstructed by the tongue, JACEP 5:588, 1976.

Healthfirst corporation: Emergency medicine, Seattle, 1991, The Corporation (videotape). Leonard M: An approach to some dilemmas and complications of office oral surgery, Aust Dent J 40(3):159-163, 1995. Locker D, Shapiro D, Liddell A: Overlap between dental anxiety and blood-injury fears:psychological characteristics and response to dental treatment, Behav Res Ther 35(7):583590, 1997. Malamed SF: Beyond the basics: emergency medicine in dentistry, J Am Dent Assoc 128(7):843-854, 1997. Malamed SF: managing medical emergencies, J Am Dent Assoc 124:40-53, 1993. Malamed SF. Medical Emergencies in the Dental Office. 5th ed, Mosby, St. Louis 2000. Markis JE, Gorlin R, Mills RM, and others: Sustained effect of orally administered isosorbide dinitrate on exercise performance of patients with angina pectoris, Am J Cardiol 43:265, 1979. Maseri A: Aspects of the medical therapy of angina pectoris, Drugs 42 (suppl 1):28-30, 1991. Morrow GT: Designing a drug kit, Dent Clin North Am 26(1):21-33, 1982. Mosby’s medical, nursing, and allied health dictionary, ed 5, Anderson KN, editor, St. Louis,1998, Mosby. Portier P, Richet C: De l’action anaphylactique des certain venins CR Soc Biol (Paris) 54:170, 1902 National safety Council: Accident facts, Chicago, 1984, The Council. Netter FH: Atlas of human anatomy, ed 2, East Hanover, NJ, 1997, Novartis. Pascoe DJ: Amaphylaxis. In Pascoe DJ, Grossman J, editors: Quick reference to pediatric emergencies, ed 3, Philadelphia, 1984, JB Lippincott. Portier P, Richet C: De l’action anaphylactique des certain venins CR Soc Biol (Paris) 54:170,1902 Ricci DR, Moscovich MD, Kinahan PJ: preliminary experience at a Canadian centre with directional coronary atherectomy for complex lesions, Can J Cardiol 7(9):399-406, 1991. Warren SD, Bremer DL, Orgain ES: Long-term propranolol therapy for angina pectoris, Am J. Cardiol 37:420, 1976. Waters D, Lam J, Therous P: Newer concepts in the treatment of unstable angina pectoris, Am J Cardiol 68(12):34C41C. Wright KE jr, McIntosh HD: Syncope: a review of pathophysiological mechanisms, Progr Cardiovasc Dis 13:580, 1971.

Disclaimer The author of this course has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

Reader Feedback We encourage your comments on this or any PennWell course. For your convenience, an online feedback form is available at www.ineedce.com.

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Questions 1. People always realize when they are having a heart attack. a. True b. False

2. Basic life support should be learned by _________. a. the dentist every three years b. only the receptionist c. the entire staff annually d. only those treating patients

3. The first person of an in-office emergency team_________. a. is the first person to arrive on the scene b. may or may not be the doctor c. may need to administer basic life support d. all of the above

4. In a medical emergency, only call Emergency Medical Services (911) when you are absolutely sure that you need them. a. True b. False

5. Anaphylaxis is_________. a. an immediateonset allergic reaction of b. life threatening c. treated in a medical emergency with a preloaded syringe of epinephrine d. all of the above

6. One epinephrine syringe may not be enough to treat anaphylaxis, so your emergency drug kit should contain two or three additional ampoules of epinephrine. a. True b. False

7. Diphenhydramine, commonly known as Benadryl®, _________. a. is used to treat allergic reactions b. is a histamine blocker c. does not need to be available in a preloaded syringe d. all of the above

8. Which of the following applies to nitroglycerin spray? a. It has a longer shelf life than nitroglycerin tablets. b. One spray is equivalent to one sublingual tablet. c. It is a vasodilator. d. all of the above

9. Patients who are contraindicated to receive nitroglycerin are _________. a. those with chest pain who are exhibiting signs of a drop in blood pressure b. those with chest pain who have taken Viagra® within the previous 24 hours c. those with chest pain d. a and b

10. Bronchodilators for the acute treatment of asthma are available in_________. a. a liquid syrup b. a tablet c. an inhaler d. none of the above www.ineedce.com

11. Glucose can be administered in a medical emergency _________. a. as a treatment for chest pain b. in the form of a nondiet soft drink or orange juice c. as a treatment for hypoglycemia d. b and c

12. Oxygen must be available in _________. a. a “B” cylinder b. a “D” cylinder c. an “E” cylinder d. an “F” cylinder

13. It is recommended that aromatic ammonia be within arm’s reach in every treatment room. a. True b. False

14. An AED is unnecessary in managing a cardiac emergency. a. True b. False

15. The acronym for managing medical emergencies is_________. a. ABCD b. PACD c. DCBA d. PABCD

16. If you place your patient in the supine position, they are positioned _________. a. vertically b. lying down with their feet slightly elevated c. horizontally with their head slightly higher than their feet d. none of the above

17. By listening to a conscious patient speak, you assess their _________. a. airway b. breathing c. circulation d. all of the above

18. To open a patient’s airway you must perform _________. a. Chin Lift/ Head Tilt b. Chin Tilt/Head Lift c. Head Tilt/Chin Lift d. Any of the above

19. A person’s chest movement is an automatic sign that they are breathing. a. True b. False

20. The carotid pulse is palpated for no more than _________. a. 10 minutes b. 10 seconds c. 5 minutes d. 5 seconds

21. Chest compressions are started if the patient has no pulse. This circulates blood, which contains oxygen, to the patient’s brain. a. True b. False

22. To locate the carotid artery, _________. a. maintain Head Tilt with one hand b. place the index and middle fingers of the opposite hand on the patient’s Adam’s apple c. slide fingers down into the groove formed by the sternocleidomastoid muscle d. all of the above

23. If you are uncomfortable treating the medical emergency you should _________. a. call the doctor down the hall b. call the patient’s family c. call 911 d. none of the above

24. The most common treatment for someone with low blood sugar (hypoglycemia) is _________. a. oxygen b. epinephrine c. sugar d. aspirin

25. It is important to ask your patients about their seizures so you will know _________. a. how they start b. how long they last c. whether you need to call 911 d. all of the above

26. An asthma sufferer should have relief from a bronchospasm within ________ seconds of taking _____ puffs of an inhaler. a. 15–30, 2 b. 30–45, 2 c. 45–32, 3 d. 15–30, 3

27. The average dose of sublingual nitroglycerin is _______. a. 1 tablet b. 2 tablets c. 3 tablets d. 4 tablets

28. If an angina attack does not go away, or if the pain gets worse or comes back, you should suspect that the patient is having a myocardial infarction. a. True b. False

29. A combination of 50% nitrous oxide and 50% oxygen is as effective in treating pain as _________. a. morphine b. nitroglycerin c. aspirin d. epinephrine

30. Epinephrine is the drug of choice in the treatment of anaphylaxis because it _________. a. acts like a bronchodilator b. elevates blood pressure c. lowers blood pressure d. a and b 9

ANSWER SHEET

Emergency Medicine Name:

Title:

Address:

E-mail:

City:

State:

Telephone: Home (

)

Office (

Specialty:

ZIP: )

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. Mail completed answer sheet to

Educational Objectives

Academy of Dental Therapeutics and Stomatology, A Division of PennWell Corp.

1. Evaluate the completeness of the office’s current emergency medicine kit 2. Question patients in review of their health history to evaluate the potential for an emergency situation before it arises

P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447

3. Recognize the signs and symptoms of separate categories of medical emergencies 4. Describe the basic protocol for treating all medical emergencies and be able to apply the PABCD protocol to manage different emergency situations

For immediate results, go to www.ineedce.com and click on the button “Take Tests Online.” Answer sheets can be faxed with credit card payment to (440) 845-3447, (216) 398-7922, or (216) 255-6619. P ayment of $59.00 is enclosed. (Checks and credit cards are accepted.)

Course Evaluation Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. 1. Were the individual course objectives met? Objective #1: Yes No

Objective #3: Yes No

Objective #2: Yes No

Objective #4: Yes No

If paying by credit card, please complete the following: MC Visa AmEx Discover Acct. Number: _______________________________

2. To what extent were the course objectives accomplished overall?

3. Please rate your personal mastery of the course objectives.

4. How would you rate the objectives and educational methods?

5. How do you rate the author’s grasp of the topic?

6. Please rate the instructor’s effectiveness.

7. Was the overall administration of the course effective?

8. Do you feel that the references were adequate?

Yes

9. Would you participate in a similar program on a different topic?

Yes

Exp. Date: _____________________ Charges on your statement will show up as PennWell

10. If any of the continuing education questions were unclear or ambiguous, please list them. ___________________________________________________________________ 11. Was there any subject matter you found confusing? Please describe. ___________________________________________________________________ ___________________________________________________________________ 12. What additional continuing dental education topics would you like to see? ___________________________________________________________________ ___________________________________________________________________

AGD Code 142

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. AUTHOR DISCLAIMER The author of this course has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. SPONSOR/PROVIDER This course was made possible through an unrestricted educational grant from HealthFirst. No manufacturer or third party has had any input into the development of course content. All content has been derived from references listed, and or the opinions of clinicians. Please direct all questions pertaining to PennWell or the administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@ pennwell.com. COURSE EVALUATION and PARTICIPANT FEEDBACK We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: macheleg@pennwell.com.

INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification forms will be mailed within two weeks after taking an examination. EDUCATIONAL DISCLAIMER The opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily reflect those of PennWell. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.

COURSE CREDITS/COST All participants scoring at least 70% (answering 21 or more questions correctly) on the examination will receive a verification form verifying 4 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 4527. The cost for courses ranges from $49.00 to $110.00. Many PennWell self-study courses have been approved by the Dental Assisting National Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet DANB’s annual continuing education requirements. To find out if this course or any other PennWell course has been approved by DANB, please contact DANB’s Recertification Department at 1-800-FOR-DANB, ext. 445.

RECORD KEEPING PennWell maintains records of your successful completion of any exam. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt. CANCELLATION/REFUND POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. © 2008 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell