There is one basic portable emergency unit on each clinic floor that includes a portable oxygen tank, tubing, stethoscope, sphygmomanometer, and oral airway. In addition, there is a complete “crash cart” in the Oral Surgery Clinic, with facilities for managing cardiopulmonary resuscitation and defibrillation. The chairman of each department is to appoint a “custodian” of the emergency equipment. The “custodian” has the responsibility to see that all items are available in one location, are in working order, and that the O2 tank (E tank) has sufficient supply of gas in the cylinder. When full, the E tank gauge reads 1800-2300 psi. When the gauge reads 500 psi or less, the tank should be replaced with a full tank obtained from the Central Supply Department in the basement. Each department is responsible to replace missing and faulty components of the emergency unit. Stethoscopes and oral airways can be purchased by each department from Central Supply. It is critical that each student, staff, and faculty member familiarize him/herself with the operation of and the location of the nearest O2 unit on his/her regularly assigned floor, along with the AED.
ALL FACULTY, STAFF, AND STUDENTS SHOULD BECOME FAMILIAR WITH THE LOCATION AND OPERATION OF THE EMERGENCY RED PHONE.
- In an emergency, under no circumstances should the patient be left alone. After a quick initial assessment of the emergency condition, send an assistant, fellow student, or an instructor for the portable O2 unit on the floor.
- Send for the nearest instructor to help in assessing the problem.
- The Oral Surgery Clinic should be notified by use of the Red Phone, located on each floor on the wall between the restrooms: Use this phone first. (Oral Surgery can also be contacted at 8-4360 or 8-4359 during regularly scheduled clinic times.) If oral and maxillofacial personnel receive the call, the caller gives a description of the emergency and the exact location (floor, bay #), then Oral Surgery personnel go to the scene and assume responsibility for managing the emergency. If the phone is not answered after three rings, the call is automatically forwarded to the security desk at Boston Medical Center (BMC). The caller then informs security of the nature of the emergency and the exact location. The security officer calls 911 then calls the security officer stationed at the security desk at the School, who guides the response team to the emergency.
Most of the emergencies encountered will be minor (syncope, acute anxiety with hyperventilation) and require basic supportive therapy. Other emergencies (myocardial infarct, respiratory and/or circulatory collapse, seizures) require more active treatment. The Oral Surgery Clinic should be notified by the Red Phone. If the phones are not free, send a runner.
- There should be one person directing resuscitation measures. This is the key to avoiding confusion and tragedy. The student attending the patient should assume this role until an instructor arrives on the scene. The instructor should direct operations until Oral Surgery/EMT arrives.
- Only people immediately involved in the emergency should be in the area. Unnecessary crowds add to confusion and hinder resuscitation efforts. Someone should be assigned to disperse crowds and keep corridors free.
- Remember the patient’s family. At some point, advise friends or relatives in the reception area of the problem and provide reassurance that the situation is under control.
Responsibilities of the Oral Surgery Staff Once Advised of the Problem
- An oral surgeon is dispatched to the area identified by the caller with a portable oxygen delivery system and basic emergency drugs, etc.
- If necessary, after initial examination by the oral surgery resident and staff oral surgeon, the incident will be managed by the team present. The decision to activate the EMS will be determined by the emergency team, who will call security at 4-4444 and EMS will be called immediately. Security will take control of the elevator and direct EMS to the location of the emergency.
When Notifying Oral Surgery
- Go to the Red Emergency Phone.
- Pick up receiver and wait until someone answers.
- Give exact location (floor and bay #, location on floor [e.g., East Newton or Albany side], center) and brief description of the emergency.
- If for any reason the Red Phone is not operational, dial 8-4360, 8-4359 (the Oral Surgery Clinic number), or 4-4444 (security).
Steps in the Initial Management of Medical Emergencies
In most medical emergencies, success in treatment depends on quick assessment and efficient institution of supportive measures. By supportive measures we mean the maintenance of adequate airway, breathing, and circulation. Minor emergencies within the Dental School can be managed by the dental student in conjunction with a clinical instructor. In the event of a serious medical emergency, the Oral Surgery Emergency Team should be alerted and mobilized (see above).
Syncope results from anxiety and nervousness and is potentiated by lack of food, fever, infection, or lack of sleep. Impulses through the vagus nerve cause a dilation of the blood vessels in the splanchnic area and slow down the heart. This results in less blood flow to the brain, a temporary cerebral anoxia, and the patient faints.
- The patient may become anxious, sweaty, pale, nauseated and may ask for water.
- The patient may become unresponsive. This can range from drowsiness to actual seizure-like activity.
- The pulse will be weak and slow. Both systolic and diastolic blood pressure will be decreased.
- Maneuvers to make the patient more comfortable during syncope or impending syncope are: tilt chair backwards so that the feet are above the level of the head (Trendelenburg position); apply cool, wet towel to the forehead; loosen restrictive clothing; remove bulky sweaters. As mentioned above, lack of food, specifically sugar, may predispose to syncope. If this is the case, treat the patient to orange juice or cola.
- Normally, when a person faints, he/she falls down. This is actually a protective mechanism since the heart pumps blood to the brain more efficiently when the brain is at the same level as the heart. Therefore, lay the patient down (tilt the dental chair backwards) to increase blood flow to the head.
- Establish the airway. If the patient is unconscious, his/her tongue may fall back and obstruct the airway. To re-establish the airway, bring the mandible forward by pushing the mandible forward at the angles. If necessary, insert an oral airway, but only if the patient is unconscious.
- Breathing: the brain wants oxygen. Once you have established the airway, you can now administer oxygen via a face mask. If unconscious, give oxygen.
- Circulation: check the vital signs. Take blood pressure. As stated above, there may be brachycardia (pulse below 60) and hypotension (BP 70/50). You have already aided cerebral circulation by laying the patient back. Check the patient’s pupils. In syncope they will be constricted. Dilated pupils may indicate that the brain is not getting enough oxygen. Crushing an ammonia inhalant under the patient’s nose will stimulate respiration and may quickly increase the cerebral oxygen supply.
Simple syncope will most often respond to these measures. If the patient does not come around in a minute or so, either more aggressive treatment is needed or the problem may be more severe. Continue oxygen, recheck vital signs, and notify the Oral Surgery Emergency Team via the Red Phone or a runner.
If the patient is conscious and he/she has an obstructed airway, the patient will become excited, reach for his throat, and will show evidence of stridor, wheezing or snoring. Ask the patient if he/she can speak. Look, listen, and feel for breathing. If the patient becomes unconscious, establish unresponsiveness (shake shoulder—shout, “Are you okay?” and “Are you choking?” and check mouth for obstructive material. Have a student, dental assistant, or instructor notify the Oral Surgery Emergency Team immediately via the Red Phone.
Management (Conscious Patient):
- Occasionally, foreign bodies (e.g., teeth, inlays, small dental instruments) will be dislodged or dropped in the mouth and fall back into the oropharynx. Hopefully, the patient will cough up the object. He may, however, swallow it or aspirate it. If he aspirates the foreign body it may become lodged in between the vocal cords and lead to laryngospasm (use of the rubber dam prevents this from happening). If the foreign body can be seen, retrieve it with a hemostat or suction apparatus. If during treatment the patient becomes agitated or struggles to sit up, allow him or her to do so. The patient may be trying to cough up a foreign body.
- If the patient cannot cough up the foreign body and it cannot be immediately seen and retrieved, employ the Heimlich maneuver.
- This is done by standing behind the victim’s waist. Grasp one fist with your other hand and place the thumb side of your fist between breastbone and navel. Pull fist into abdomen with quick upward thrusts.
- As an alternative to the abdominal thrust (e.g., for a pregnant patient) use four chest thrusts. This consists of standing behind the victim and placing your arms under the victim’s armpits to encircle the chest. Grasp one fist with the other hand and place thumb side of fist on breastbone. Pull with a quick, backward thrust.
- Alternate the above maneuvers in rapid sequence until the patient coughs up a foreign body or becomes unconscious. If the patient becomes unconscious, follow the protocol for unconscious patient with obstruction.
- Following retrieval of the foreign body, oxygenate the patient.
Management (Unconscious Patient)
If the patient becomes unconscious, observe the following protocol:
- Establish unresponsiveness—shake shoulder, shout, “Are you okay?”
- Lay the patient flat. Do not keep him or her in sitting position, as this prevents maintenance of cerebral circulation.
- Open the airway and establish breathlessness (look, listen, and feel). Tilt head with one hand on forehead. Place ear over mouth and observe chest.
- Attempt to ventilate. If airway becomes obstructed, reposition head and reattempt to ventilate.
- If airway still remains obstructed, perform abdominal thrusts: Position yourself with your knee close to victim’s hips. Place heel of one hand between lower breastbone and navel and second hand on top. Press into abdomen with quick upward thrusts. Use the same hand position and performance as in applying close chest cardiac compression.
- Reposition head. If the airway remains obstructed repeat above sequence.
This implies that the patient is making no effort to breathe, although the airway may be clear.
- Thoroughly check the mouth for obstruction material and sweep out of the mouth with finger.
- Ventilate the patient using the portable oxygen unit. An oropharyngeal airway may be needed.
- Alert Oral Surgery Emergency Team but do not stop breathing for the patient, once every three or four seconds.
Cardiac Arrest or Circulatory Collapse
The heart stops beating and blood (and therefore oxygen) doesn’t circulate to vital areas. There are many causes for this but initial treatment is uniformly based on the “ABC’s.” Recognition of the problem is based on observation and the vital signs. Therefore, take vital signs early when a patient collapses. Usually when the heart stops, breathing stops, and there is a need for cardiopulmonary resuscitation (CPR).
- Once the cardiac arrest is recognized, call Security (4-4444) to activate EMS.
- Lay the patient down flat in a chair. If the equipment around the dental chair is encumbering you, get the patient out of the chair and onto the floor. Send for the portable emergency unit on the floor.
- Start and continue CPR until EMT arrives.
Seizures of various types are dangerous because the patient can be injured during the seizure and prolonged seizures can stress the heart.
- Stay with the patient and protect him/her. Lay the patient down and remove objects with which he/she can injure him/herself.
- Increased activity equals increased oxygen use, therefore, give oxygen with prolonged seizures. DO NOT ATTEMPT TO FORCE OBJECTS BETWEEN THE TEETH.
- With prolonged seizures or bodily injury call the Oral Surgery Emergency Team via the Red Phone.
Occasionally, an extremely anxious patient will become excited and breathe very rapidly. In doing this, he/she breathes out excess carbon dioxide. This upsets the normal acid base balance of the blood and produces respiratory alkalosis. Alkalotic blood is incompatible with normal muscle function and causes tetany (abnormal prolonged muscle contraction). Carbon dioxide in the blood triggers normal respiratory drive and lack of carbon dioxide may produce apnea.
- This is one of the only situations where oxygen is contraindicated in the management.
- Verbally try to calm the patient down and slow down his/her breathing.
- You must give the patient back the carbon dioxide lost. Have the patient breath continuously into a paper bag or into their cupped hands and the patient rebreathes his/her own carbon dioxide.
Assume that anyone who becomes anxious, sweaty, and pale and complains of chest pain is having an heart attack until proven otherwise. Patients die from heart attack due to:
- Heart failure: enough of the heart fails that it becomes an inefficient pump.
- Arrythmias: during or after the heart attack the remaining heart muscle is irritable and prone to arrythmias.
- Mobilize resuscitation unit on floor, alert a clinic instructor and the Oral Surgery Emergency Team (via the Red Phone).
- Oxygen should be given if heart attack is suspected. Because the pump is inefficient, any blood that does circulate should be maximally oxygenated.
- A patient with a history of angina should have his/her nitroglycerin with him/her and place it where it is accessible to the student (e.g., on the bracket tray). Simple angina should respond to nitroglycerin and rest within five minutes. Repeat administration of nitroglycerin in 5 minutes. If it does not, be suspicious of heart attack.
- If the patient does become more alert, continue to monitor vital signs and continue to administer oxygen. The Oral Surgery Emergency Team will activate EMS by calling Security at 4-4444.
Although most intravascular injections should be preventable with an aspiration syringe, they do occur. The symptoms are occasionally confused with syncope but the signs are different enough to make the diagnosis relatively simple. The symptoms are usually due to the vasoconstrictor and not the anesthetic itself. As opposed to syncope the results of intravascular epinephrine will be tachardia and a bounding pulse. The patient will feel flushed, anxious, and may be aware of a rapid pulse.
- A young patient with a healthy cardiovascular system can usually tolerate the intravascular injection and generally needs reassurance only.
- An elderly patient or one with a known heart disease may get into difficulty. The increased rate and force of heart contracture will increase its demand for oxygen and possibly result in angina, infarction, or arrythmia. As soon as the intravascular injection is recognized, administer oxygen, calm patient, and administer nitroglycerin if available.
Precautionary and Preventive Measures
Measures can be taken to prevent medical emergencies or at least increase your readiness for them.
- Know your patient well. Take a good medical history, record BP, P, and respiratory rate and current medication taken. Consult the patient’s physician if the history is unclear and complicated.
- Make the patient comfortable. Have the patient remove heavy clothing and loosen neckties. Be sure the operatory is well ventilated.
- Sick patients should be given short, morning appointments so they will be well rested. Make sure they have eaten breakfast. On the other hand, a person with angina will be more prone to an attack after a heavy meal.
- If a patient with significant cardiopulmonary history or a frail elder says he/she does not feel well that day, evaluate the patient by taking their BP, P, and respiratory rate then cancel treatment for that day. Unless the patient is not medically stable, you can discharge the patient or have someone accompany him/her home.
- Make sure a patient with a history of angina brings his/her nitroglycerin with him/her, and place it accessible to student (on the tray is a good place).
- Diabetics most often get into difficulty from hypoglycemia (not enough sugar in the blood). This happens when they take their insulin or pill and do not have breakfast. Make sure you instruct these patients to eat a normal breakfast. Schedule these patients for morning appointments.
- Verify that the patient with a history of asthma has an inhaler on hand if the need arises.
Procedure in the Event of Questionable Swallowing or Aspiration of a Foreign Body or Acute Respiratory Obstruction
It goes without saying that utmost care must be exercised during all clinical procedures to prevent breakage of instruments or appliances, and to prevent any situations in which a patient might swallow or inhale these or other foreign objects.
There may be occasions, however, when a patient being treated by the most skilled and careful operator may do so. Sometimes patients are immediately aware that something has been swallowed but many times they do not realize that anything has happened. Occasionally, the operator may think the foreign body has fallen somewhere outside the oral cavity when actually it has been swallowed or aspirated without the patient’s awareness.
WHENEVER A FOREIGN BODY CANNOT BE LOCATED, THE OPERATOR SHOULD ASSUME IT HAS BEEN SWALLOWED UNTIL PROVEN OTHERWISE.
Procedures for Questionable Swallowing or Aspiration of Foreign Body
- Do not panic and do not leave the patient unattended.
- Inform the instructor and mobilize the portable emergency unit. Alert the Oral Surgery Emergency Team (via the Red Phone).
- The patient may not be aware of swallowing or aspirating a foreign body. If the patient becomes agitated or tries to sit up, allow him/her to do so. The patient may be trying to cough up a foreign body, an indication of aspiration.
- If the patient shows no evidence of respiratory obstruction and/or appears to have swallowed the foreign body, alert the Oral Surgery Emergency Team, who will call Security at 4-4444. The patient should be referred to the Emergency Room for appropriate radiographic evaluation.
- Instruct the patient to watch for passage of the object and try to recover it. If it is not recovered, periodic films should be taken until there is evidence that the object has passed.
- The student should obtain an Accident Reporting and Treatment Form (ART) (<<need link>>) and fill it out. This should be filed in the patient’s chart.
Procedure for Acute Respiratory Obstruction
- Do not panic and do not leave the patient unattended.
- Inform the instructor and institute emergency treatment for acute airway obstruction. (See “Respiratory Obstruction or Arrest: Conscious Patient.”)
- Have someone in the immediate area telephone the Oral Surgery Emergency Team via the Red Phone.
- If the patient loses consciousness and the Oral Surgery Emergency Team has not arrived, institute emergency treatment for respiratory obstruction, unconscious patient.
- If the foreign body is retrieved, oxygenate the patient. If the patient remains unconscious, continue oxygenating. If the patient becomes apneic or pulseless, institute CPR.
- If the foreign body is not retrieved and the patient is conscious and well oxygenated, make arrangements with the hospital Emergency Room (8-6200) to obtain a chest film.
- The student, staff person, and oral surgeon faculty and/or resident should accompany the patient to the Emergency Room located at H-1, 70 East Newton Street, Boston.
- The student will stay with the patient until final disposition. The student is to call the Assistant Dean for Clinical Education’s office at 8-4845 immediately upon receiving complete knowledge of the disposition and inform the Assistant Dean for Clinical Education of the findings.
- When the patient has been cleared for dismissal, the student should fill out an “Incident Form” (need link).
- The School will receive a written report of the radiology examination, one copy of which should be placed in the patient’s file. If the student receives a written report, he is to place it in the hands of the Assistant Dean for Clinical Education.
- There is no charge to the patient. All bills incurred will be billed to and paid for by the School (through the Dean’s Office or the Department of Oral Surgery, which have a special billing number for this sole purpose).
Red Emergency Telephones
To establish a system to respond to a medical emergency within Boston University Henry M. Goldman School of Dental Medicine during normal and off hours.
Oral Surgery Department will handle all medical emergencies for first response during normal business hours. After-hours medical emergencies are handled by BMC Security 4-4444. BMC Security will call 911 to activate EMS (Emergency Medical Services).
Red Emergency Telephones have been installed on all floors of the building. These are for the sole purpose of reporting medical emergencies and communications with the emergency personnel.
On each floor of the building there is a Red Emergency Phone in the corridor opposite the back stairwell between the restroom doors.
- Go to the Red Emergency Phone.
- Pick up receiver (phone will dial direct to Oral Surgery Department).
- Off-hours phone will go to BMC Security 4-4444.
- When the person answers, give the location and description of the emergency.
- Stand by the patient. Under no circumstances should the patient be left alone.
Oral Surgery/BMC Security