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					     Emergencies




(What to do when things go wrong)
             Dr. Hillam
           Team Meeting
          August 24, 2005
             Let’s just say…




• A fire erupts in the corner by the sandblasting
  unit…
               Or what if…
• While you are alone     • A patient calls shortly
  with a patient, she       after an appointment,
  starts wheezing           and says that he has
  heavily and panicking     hives and his throat
                            feels tight.
Or…
And finally, what if…
       Are these unrealistic?
• No
• Obviously some are more serious than
  others
• With regard to medical emergencies:
  – Pts are becoming older on average
  – Dental procedures are increasingly lengthy
    and complicated
  – There are more medical risk patients today
  – More and more drugs are on the market
               Presentation Outline:
•       Introduction
•       Prevention and Training
•       Three types of emergencies in the dental office
    –        Equipment/Facility Emergencies
         •         Smaller things
         •         Power outages
         •         Fires
    –        Medical Emergencies
         •         Prevention
               –        Thorough Health History
               –        Understanding common health problems
               –        Always treating people with care
         •         Training
               –        Specific emergency conditions
               –        Equipment
               –        In-office emergency protocol
    –        Occupational Emergencies.
         •         Universal Precautions
         •         Material Safety Data Sheets (MSDS)
         •         First aid kit
         •         Needlestick protocol.
Two ways to deal with
   emergencies:



      Prevention
          &
       Training
Prevention is a universal concept…
Especially among dental teams
            With this said…
• Not all emergencies are preventable.
• That’s where training comes in.
Training is knowing what to do…
In the midst of risk.
 And in the midst of risk,




You have to do the right thing at the right time.
                                Robert D. Hales:




“In the process of preparing to be a pilot , I was required to have training in a Link trainer, which simulated real flight. There, an
      instructor would acquaint us with the emergencies which could occur when flying a jet fighter, sometimes at the speed of
      sound.
For each emergency, we were taught the procedures for avoiding disaster. We would practice each procedure over and over, so if a
      real emergency came along we would have an automatic, preconditioned response. We would know exactly what we were to do
      if there happened to be a technical failure in the airplane. We would even choose the altitude at which we would bail out if the
      plane went out of control.
In our squadron I had a dear friend who… had not learned to listen to those with more knowledge and experience. When his turn
      would come to learn emergency procedures and to precondition his mental and physical responses so they would be
      automatic, even instantaneous, my friend would put his arm around the airman instructor and say, “Check me off for three
      hours of emergency procedure.” Then, instead of training, he would go to the pistol range or play golf or go to the officers’
      club. But he never learned the emergency procedures.
On one occasion he was asked what he would do in an emergency. His answer: “I am never going to bail out; I am never going to
      have an emergency.”
On an evening mission a few months later, fire erupted in his plane, and it dropped below 5,000 feet, spinning in flames. Noting the
      fire warning light, the younger pilot who was with him said, “Let’s get out of here.” And with the centrifugal force pulling
      against him, the younger man, who had taken his training seriously, bailed out. His parachute opened at once and he slammed
      to the ground, receiving serious injuries. But he survived.
On the other hand, my friend stayed with the airplane and died in the crash. He paid the price for not having learned the lessons that
      could have saved his life.”
     3 Kinds of emergencies
1. Equipment/Facility Emergencies.
2. Medical Emergencies.
3. Occupational Emergencies.
Equipment/Facility Emergencies
• Sometimes our equipment/facility goes wrong.
• In the past year, we have seen:
  –   Total power failure
  –   Tripped fuses
  –   Burned out light bulbs
  –   Empty O2 or N2O tanks
  –   Security breeches
  –   No suction
  –   Dead/sick fish
  –   Icy walkways
  Equipment/Facility Emergencies
• Thankfully, there are several emergencies
  that are much less common, such as:
  – Flood
  – Tornado
  – Bomb threat
  – Lightning strike
  – Burglary
  – Fire
The following emergencies vary in
           magnitude…
Light Bulbs
O2/N2O Tanks
Security Breeches
No Suction




Way to go, Mandy!
                Power Outages
• What problems does this pose?
  –   Pt. treatment
  –   Loss of light
  –   Phone failure
  –   Power surge
  –   Refrigeration failure


• Several months ago:
  – Nearby construction crew hit underground powerline,
    and a fuse was tripped.
                  Power Outages, cont.
From Provo City Web Site,
   http://www.provo.org/index.php?module=ibcms&fxn=ppd.Power_Outages_main:

During the Power Outage
     –   Check your fuses or circuit breakers.
     –   Check and see if your neighbors’ power is out.
     –   Call the Provo City Power “Help Line” at 852-6000 to report outage. If phone lines are busy, please try again.
         Report things you have seen or heard that may be helpful such as a broken pole, a tree on a line, downed
         lines, a loud boom, or a flash of light.
     –   Unplug all your appliances. The surge of power that comes when power is restored could ruin appliances.
     –   Turn off all but one or two light switches so you will know when your service is back on.
     –   Open refrigerator door only to take food out, close as quickly as possible. A refrigerator or freezer will
         maintain foods for up to 12 to 48 hours or longer, depending on the room temperature and frequency of
         opening.
     –   Use camping equipment outside, six feet away from everything. Use only a fireplace, properly installed wood
         stove or a new style kerosene heater in a safe area with outside air coming into area.
     –   Do not allow children to carry lanterns, candles or fuel.
After the Power Outage
     –   When power is restored, plug in appliances.
     –   Be patient. Provo City Power will repair major electric lines which serve hundreds of customers before they
         can repair scattered outages. Emergency services, major communication facilities, and customers on life
         support equipment must also take priority.
     –   Examine your frozen food. If it still contains ice crystals, it may be refrozen. If meat is off color or has an odd
         odor, throw it away.
                         FIRE!
What fire hazards are in
 our office?
  –   Computers
  –   Autoclaves
  –   Ultrasonic
  –   X-Ray processors
Wasatch Jr. High Fire
           • July 12, 2005
           • “A school once filled with
             the chatter of students
             and lessons from
             teachers, is now a
             hollowed-out, charred
             shell.”
           • “Principal Doug Bingham
             said…the fire was found
             coming from a computer
             server in the media
             center.”
Two ways to deal with
   emergencies:



      Prevention
          &
       Training
               FIRE! cont.
• Prevention
  – Turn off flames
  – Keep things clean
  – Turn autoclaves, towell warmers off
  – Turn computers off at the end of the day
                 Fire! cont.
• Emergency protocol:
  – Fire extinguishers
    • Where are they?
    • How do we use them?
  – Call 911
  – Evacuation protocol
                 Fire! cont.
• Fire extinguishers
  – Where are they?
  – How do we use them?
Where are they?
Where are they?
Where are they?
       Medical Emergencies
• Most medical emergencies are caused by:
  – Physical or emotional stress
  – Drug reactions
  – Preeixisting systemic disease
• On the rise:
  – Pts are becoming older on average
  – Dental procedures are increasingly lengthy and
    complicated
  – There are more medical risk patients today
  – More and more drugs are on the market
  – Conscious sedation tecniques
Two ways to deal with
   emergencies:



      Prevention
          &
       Training
Prevention of Medical Emergencies
• Thorough Health History
• Understanding common health problems
• Always treating people with care
       Thorough health history:
•   Written med hx, regularly updated
•   Dialogue hx
•   Blood pressure
•   Physical exam (watch gait)
•   ASA categories
      Common health problems:
•   Diabetes
•   Pregnancy
•   Post radiation treatment
•   Post M.I.
•   Asthma
•   Allergies
•   Kidney disease
•   Liver disease
      Treating people with care:
• Some of the most common emergencies are
  related to anxiety:
  –   Syncope
  –   Hyperventillation
  –   Angina
  –   Asthma
  –   Seizures
• Other emergencies are related to carelessness:
  – Sitting patients up too fast
  – Not aspirating during anesthesia
  – Finishing N2O too quickly
  Training for medical emergencies
• Understanding common medical
  emergencies
• Knowing location of all equipment, and
  basic info regarding their use
• Agreeing upon an in-office emergency
  response protocol*


*This is the most important thing we will discuss.
  What medical emergencies are
        most common?
• 10 year study by Stanley Malamed
• 4200 questionnaires, 3800 participants
• Question: how many of the following
  emergencies have you seen in the last 10
  years?
      Among 3800 dental offices:
•   15, 407 episodes of Syncope
•   2,583 episodes of mild allergy
•   2,552 episodes of Angina
•   2,475 episodes of Postural (orthostatic) Hypotension
•   1,595 Seizures
•   1,326 episodes of Asthma
•   1,326 episodes of hyperventilation
•   913 epinephrine reactions
•   890 episodes of insulin shock
•   336 episodes of cardiac arrest
•   304 anaphylactoid reactions
Emergency Medical Equipment:
•   Oxygen tank
•   Drug kit
•   AED (Automatic External Defibrillator)
•   Telephone
Oxygen tank
      • In the lab
      • Positive pressure
Drug Kit
    • “Sav-A-Life Systems”
    • Under the sink in Tx
      room #2 (Debbie)
    • Emergency drugs
    • Updated regularly
Drug Kit, cont.
AED
 • AED = Automatic
   External Defibrillator
 • More and more prevalent
 • “Cardiopulmonary
   resuscitation, usually known as
   CPR, provides temporary
   artificial breathing and
   circulation.
   It can deliver a limited amount
   of blood and oxygen to the
   brain until a defibrillator
   becomes available.
   However, defibrillation is the
   only effective way to
   resuscitate a victim of
   ventricular fibrillation.”
                                  More on AED’s
•   What is AED?
    Automated External Defibrillators or Automatic External Defibrillators or AEDs or AED Defibrillators, are small,
    lightweight devices that look at a person's heart rhythm (through special pads placed on the torso) and can
    recognize ventricular fibrillation (VF), also known as "sudden cardiac arrest" or SCA. If SCA is present, an AED
    will advise, and will talk the responder through some very simple steps to defibrillate. AEDs are designed to be
    used by lay rescuers or "first responders".
•   Who Can Use an AED?
    Anyone, even children 11 years of age and up can be trained to use an AED.
•   Are All AEDs the Same?
    While all AEDs are designed to defibrillate, they vary in the capabilities of their waveform technology (i.e. the
    “therapy” itself), rhythm recognition, ease of use, safety, weight, and manufacturer's support. It is important to
    consider these issues as well as the quality of research that has gone into any particular AED when evaluating
    them.
•   Are There Limits Regarding Who the AED Can Be Used On?
    Typically, children over 55 lbs (25 kg) or 8 years of age are defibrillated as adults. AED defibrillation therapy is
    appropriate for infants and children, as well as adults, as long as the appropriate pads are used.
•   Are There Any Warning Signs of SCA?
    No, and sadly enough the first sign of heart problems in most men is sudden cardiac arrest. SCA claims more than
    350,000 lives each year, primarily because lifesaving treatment, that is, early defibrillation, does not reach the
    victims within the first critical minutes.
•   Does the AED Take the Place of CPR?
    No. The AED is part of CPR. For maximum benefits (that is, best chance of survival) you must use the two tools
    together!
•   Can I Hurt Someone with an AED?
    No! There are two things to remember here:
    - AEDs will not shock someone who does not need to be shocked. It’s that simple. - A victim of SCA is essentially
    dead. Early defibrillation represents that person’s only chance for survival.
•   What About Using an AED on Metal or Wet Surfaces?
    Always check with the manufacturer, but most AEDs because they are self grounded, can be safely used in wet
    environments and on metal surfaces with no risk to the victim or rescuer.
•   Reference: http://www.aedsafety.com/
                     Still more on AED’s
•   Heart disease is the number 1 killer in the United States. Every day, more than 2600 Americans
    die from cardiovascular disease, which amounts to 1 death every 33 seconds.
•   Most of these deaths occur with little or no warning, from a syndrome called sudden cardiac
    arrest. The most common cause of sudden cardiac arrest is a disturbance in the heart rhythm
    called ventricular fibrillation.
•   Ventricular fibrillation is dangerous because it cuts off blood supply to the brain and other vital
    organs.
•   The ventricles are the chambers that pump blood out of the heart and into the blood vessels. This
    blood supplies oxygen and other nutrients to organs, cells, and other structures.
•   If these structures do not receive enough blood, they start to shut down, or fail.
•   If blood flow is not restored immediately, permanent brain damage or death is the result.
•   Ventricular fibrillation often can be treated successfully by applying an electric shock to the chest
    with a procedure called defibrillation.
•   In coronary care units, most people who experience ventricular fibrillation survive, because
    defibrillation is performed almost immediately.
•   The situation is just the opposite when cardiac arrest occurs outside a hospital setting. Unless
    defibrillation can be performed within the first few minutes after the onset of ventricular fibrillation,
    the chances for reviving the person (resuscitation) are very poor.
•   For every minute that goes by that a person remains in ventricular fibrillation and defibrillation is
    not provided, the chances of resuscitation drop by almost 10 percent. After 10 minutes, the
    chances of resuscitating a victim of cardiac arrest are near zero.
•   Cardiopulmonary resuscitation, usually known as CPR, provides temporary artificial breathing and
    circulation.
•   It can deliver a limited amount of blood and oxygen to the brain until a defibrillator becomes
    available.
•   However, defibrillation is the only effective way to resuscitate a victim of ventricular fibrillation.
•   Reference: http://www.emedicinehealth.com/articles/10873-1.asp
      Why do we need to have
    emergency systems in place? :
• General Rule: You will be
  nervous, you will not think
  clearly in an emergency.
  Therefore:
   – Habits take over
   – Be calm (don’t yell down
     the hall)
   – Systems must be in place.
   – Systems must be reviewed
     and rehearsed
 What systems need to be in place
  during a medical emergency?
• Chairside assistant will:
   – Position patient.
   – Administer O2, turn off N20
   – Activate in-office emergency protocol, using an agreed-upon
     term (“code orange”?)
   – Monitor vital signs
• Agree upon a term, such as “code orange.”
• Front desk will:
   – Be ready to call EMS
   – Gather doctor(s)
   – Take drug kit/equipment to emergency site
• Assistants and hygenists will:
   – Stay with patients. Temporize with cavit if necessary.
   – Be ready to help in other ways if necessary.
           N20 Overdose?
• Nitrous Oxide affects some more
  profoundly than others.
• Keep the following in mind with everyone:
  – Diffusion hypoxia is prevented by using
    straight O2 for ~5 min.
  – Don’t underestimate the need recovery time.
              CPR Review:
•   What are the age categories?
•   How many compressions and breaths?
•   When to activate EMS?
•   What is the sequence to follow upon
    finding an unconscious patient?
   Occupational Emergencies
• Like any work environment, we are around several
  hazards, including high heat, sharp objects, blood, etc.
• Eyewear: it is available, and we recommend you wear it.
• Material Safety Data Sheets (MSDS) for potentially toxic
  materials are available.
• First aid kit
• Needlestick protocol.
   – The risk of occupationally related blood borne viral infection from
     patient to dentist or vice versa is exceptionally low. The
     introduction of universal precautions and hepatitis B
     immunisation by the dental profession has done much to reduce
     the risks of such occupational infections.
   – Use good re-capping technique
• More OSHA related training is available.
     Needle-Stick Procedures,
          From July/August 2005 UDA Journal

1. The employee reports to the dentist-employer.
2. The dentist immediately (within two to three
   hours if possible) makes available at no cost to
   the employee:
  1. A confidential medical evaluation from a health care
     professional which includes:
     1. Evaluation of the exposure incident
     2. Counseling to your employee about what has happened
     3. Instruction to your employee about how to prevent further
        spread of any potential infection
     4. Testing of the employee and the source patient (unless the
        status is already known) for symptoms related to HIV
     5. All test results being given to your employee
     Needle-Stick Procedures,
          From July/August 2005 UDA Journal

1. The employee reports to the dentist-employer.
2. The dentist immediately (within two to three
   hours if possible) makes available at no cost to
   the employee (cont’):
  1. A confidential medical evaluation from a health care
     professional
  2. Follow-up medical care including post-exposure
     prophylaxis, if medically indicated
  3. The dentist:
     1. Receives a written report from the health care professional
     2. Provides a copy of the written report to the employee within
        fifteen days of receipt.
Questions?

				
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