In my experience, colleagues have expressed anxiety in the management of medical emergencies in the dental surgery. Proper training and simulated emergencies can lessen the dental team’s anxiety toward medical emergencies and allow them to be prepared.
What is the role of a dental nurse in the management of a medical emergency?
The dental team’s goal in the event of a medical emergency is the management of the situation in order to sustain life until the emergency medical service (EMS) arrives.
The Dental Council of Ireland states that a ‘dental nurse must be competent in basic emergency resuscitation procedures’.
This is an area of public concern, as many dental nurses are currently practising without a qualification and may not be receiving the information they need to understand the importance of this type of training.
The chain of survival is comprised of four links: early access, early cardiopulmonary resuscitation (CPR), early defibrillation and early advanced care. Each link is dependant upon the others and all must be completed to achieve the best outcome possible in a medical emergency.
Changes regulating basic life support and CPR
Recent changes in the guidelines for basic life support (BLS) and CPR have been published by the European Resuscitation Council and can be found at www.erc.edu. These guidelines include changes regarding the rate of compressions and ventilations, automated external defibrillator use and the length of rescue breaths.
Guidelines stress: ‘Push hard, push fast: compress at a rate of 100 compressions per minute, allow full chest recoil after each compression, minimise interruptions in chest compressions and avoid hyperventilation’ (American Heart Foundation, 2006).
It is our responsibility as healthcare providers to update our skills in accordance with these new guidelines and practise our skills as a dental team. The Dental Council guidelines state: ‘Every member of the dental team should be trained in resuscitation. Training should be a team activity and should be regularly practised in the surgery under simulated conditions, with refresher training courses at appropriate intervals’.
Early access refers to the activation of the EMS. This should be done immediately, as soon as it is recognised that the emergency is beyond the dental team’s scope of treatment. If ever in doubt, the EMS should be activated.
In Ireland the emergency numbers are 999 and 112. 112 is recognised throughout the European Union and will override a mobile phone PIN number. During a call to the EMS the caller should give the following information:
• The caller’s name
• Exact location
• Telephone number
• Describe the patient (age and gender)
• The nature of the emergency (if it is a cardiac arrest request a cardiac ambulance)
• The emergency equipment that is on the scene
• What treatment, if any, has been provided
• Ask if the operator requires any more information.
Early basic life support and cardiopulmonary resuscitation
Upon recognising the signs and symptoms of a medical emergency, it is the responsibility of the dental team to deliver basic life support.
In each emergency the first step is to check for dangers to the patient and the dental team. Any dangers or possible dangers must be removed prior to delivering basic life support (such dangers may include water spills, local anaesthetic syringes, etc).
The next step is to check the patient’s position. If the patient is conscious and can speak, the position should be wherever the patient is most comfortable. For example, if a patient is experiencing an asthma attack but can still speak, leave the patient in the position that is best for them. If the patient has become non-responsive, the patient’s position should be supine, which is lying back with the feet slightly elevated.
Basic life support is often described as the ‘ABC&D’s’ of a medical emergency. This is the management of the airway, breathing and circulation of the patient, and the use of an automated external defibrillator (AED).
Early BLS and CPR will only buy a patient time until the emergency services arrive. The aim of BLS is to maintain the normal functioning of the brain, heart and lungs. It is the combination of rescue breaths and chest compressions that allows the oxygen and blood to be pumped to the vital organs, to retain their functionality until the EMS arrives.
An automated external defibrillator is a portable device that is used to shock the heart into a normal rhythm when it is experiencing ventricular fibrillation. If a patient is experiencing ventricular fibrillation (VF), their heart is quivering uncontrollably and is not able to maintain normal function. In the event that a patient shows no signs of circulation, a defibrillator should be used as soon as possible. If a patient has no circulation and the medical emergency was not witnessed, one minute of CPR should be delivered prior to placing on the AED.
The AED has self-adhesive pads that are attached to a patient’s chest and that analyse the patient’s heart rhythm. The AED will only advise the rescuer to shock if a patient is experiencing ventricular fibrillation. Once VF is detected, the audio on the machine will advise the rescuer to deliver a shock. The shock will ‘stun’ the heart, stopping all function, allowing it to restart into a normal rhythm. If VF is experienced, the only treatment is defibrillation and it is most effective if the first shock is delivered less than three minutes from the time the patient collapses.
If the dental surgery has an AED you will be able to deliver the first three links in the chain of survival and increase your patient’s chance of living in the event of a medical emergency. Without an AED, they will be dependent upon the arrival of the EMS.
Early advanced care
Early advanced care refers to the arrival of the emergency medical service, which will deliver advanced life support and, if necessary, transfer the patient to the hospital.
Organisation and efficiency prior, during and post-medical emergency
Organisation and efficiency are imperative in dealing with a medical emergency. It is often the role of the dental nurse to prepare the emergency equipment and to maintain it prior to its use during a medical emergency. Discussion in relation to the preparation and maintenance of the emergency kit will be covered in subsequent articles.
The dental nurse is responsible for the recognition of the signs and symptoms of a medical emergency. It is not our role to diagnose, but with the recognition of signs and symptoms we can ensure that we are prepared to assist with the management of the emergency. The dental nurse should also be able to record and take the patient’s vital signs.
Another responsibility of the entire dental team is the simulation of medical emergencies. Regular practice of simulated emergencies will help to prepare the dental team in the event of a real emergency. After each simulation, time must be taken as a team to review how the emergency was responded to in order to clarify the roles of each member, determine how efficient the response was and if there were any uncertainties of any members as to their role. All of the simulations should be documented in a training manual, which may also be maintained by the dental nurse.
With proper training and revision of skills the dental team can ensure it is prepared to respond appropriately and efficiently in the case of a medical emergency. It is essential that all members of the dental team are trained in basic life support and that these skills are routinely revised. The dental nurse must take responsibility for training in the area of basic life support and the updating of these skills.