Medical Emergencies in the Dental Setting
Surveys have shown that in a 10-year period, 90 percent of dentists have encountered at least one medical emergency. Medical emergencies will continue to be a reality in the dental practice. Preparedness is critical to ensure the safety of patients and prevent catastrophic outcomes.
A young adult male presented to a dentist for removal of wisdom teeth. The patient had an intense fear of dentistry and was reluctant to undergo the procedure. His complete medical history was unknown because he was adopted, although medical history prior to the procedure was insignificant. An oral benzodiazepine was prescribed, and the patient was instructed to take the medication one hour before arrival. The patient was assessed after he arrived, and vital signs were stable. He was very quiet and soft-spoken when he was taken to the dental operatory, and the dental team assumed that the pre-medication had achieved the desired result. An IV was inserted without difficulty, and before the parenteral sedation was administered, the patient verbally stated, “I feel really strange.”
The patient suddenly became unresponsive and he developed respiratory depression and subsequent cardiac arrest. The dentist instructed his staff to call emergency medical services (EMS) and also ordered the practice’s automatic emergency defibrillator (AED) and crash cart.
The crash cart was located in operating suite # 3, and the patient was in suite #1. The hallway between the two suites was blocked by a copy machine, and the cart had to be routed through another area of the office to reach the patient. In addition, the wheels of the cart were in a locked position, and efforts to push the cart forward caused it to fall over, and its contents were dropped on the floor. The dental assistant retrieved the items from the floor, placed them back into the cart, and finally delivered it to the operatory suite.
The dentist requested additional medications after the crash cart arrived. The hygienist retrieved the medications from the crash cart and noticed that they were expired. The dentist requested an alternate medication, but it was not available in the dental practice. An oxygen tank was used to resuscitate the patient, but gas in the tank was minimal and was completely depleted prior to the arrival of the EMS team. In addition, although the AED battery was not inspected for a year, it was effective.
The patient was resuscitated with a combination of the AED and medications in the operatory suite. EMS transported the patient to the hospital, and cardiac tests concluded a familial polymorphic ventricular tachycardia (FPVT) diagnosis.
Risk Management Discussion
A pre-assessment of the patient was completed, but the medical crisis ensued rapidly and without warning. The dental practice failed to conduct regularly-scheduled inventory of medications and routine comprehensive practice drills prior to the event. The absence of those protocols did not prepare the dentist and his staff for medical emergencies.
Although FPVT is rare, it is an example of a possible scenario that can surprise dental staff that treats patients who appear to be healthy. Inadequate or unavailable medical histories and communication failures may lead to adverse outcomes. In this case, the patient’s verbal concern prior to parenteral sedation was an indicator of a likely respiratory depression. Emergencies which can develop without warning include altered consciousness, cardiovascular events, allergies, respiratory issues, seizures, and diabetes-related symptoms. Patient safety unpreparedness, combined with unexpected medical conditions, demonstrates a need for improved systems for handling emergency situations which arise in the dental office.
Risk Management Strategies
- Review state laws regarding emergency preparedness as it applies to your practice.
- Prepare your team to recognize signs of urgent/emergent situations. Ensure that each employee has the appropriate level of training in life support and pharmacology of anxiolytics and sedatives.
- Assign all emergency-related tasks to individual staff members and have a back-up plan for staff absences.
- Develop written protocols for handling emergencies of all types.
- Practice pre-procedure briefings with all involved, including the patient.
- Perform and document routine checks on medical emergency supplies and medication inventory, including expiration dates and battery life as applicable.
- Perform emergency drills and mock-ups for all types of medical, behavioral and physical situations.
- Follow your state laws and dental board’s recommendations regarding disclosure after negative incidences occur.