4.1 Dental Office Medical Emergencies, Anaphylaxis & Resuscitation Protocols

4.1 Dental Office Medical Emergencies, Anaphylaxis & Resuscitation Protocols

Medical emergencies in dental practice present unpredictable, high-acuity challenges requiring immediate diagnostic recognition and systematic, evidence-based management. Dental practitioners in Australia must maintain active certification in basic life support (BLS), maintain an appropriately equipped emergency kit, and execute resuscitation protocols aligned with the Australian Resuscitation Council (ARC) guidelines and Therapeutic Guidelines: Dental (eTG).

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Dental Practice Emergency Preparedness & Drug Kit

Under Australian Dental Board guidelines, all dental facilities must possess emergency equipment and medications maintained within valid expiration dates and checked weekly. The essential dental emergency kit comprises specific first-line medications and airway management hardware.

Essential Emergency Drug Cabinet

Essential Resuscitation Equipment

• Automated External Defibrillator (AED) with adult and paediatric pads.
• Bag-Valve-Mask (BVM) Resuscitator with reservoir bag and transparent adult/paediatric masks.
• Oropharyngeal (Guedel) Airways (sizes 1 to 4) and Nasopharyngeal Airways.
• High-capacity Portable Suction Unit with rigid Yankauer suction tips.
• Blood Glucose Monitor (Glucometer) with test strips and lancets.
• Automated Sphygmomanometer & Pulse Oximeter.

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Resuscitation Algorithm: Australian Resuscitation Council (ARC) Guidelines

The ARC DRSABCD basic life support flow chart provides the standardized sequence for managing any collapsed or unresponsive patient in the dental clinic.

+---------------------------------------------------------------------------------------------------+
|                                   ARC DRSABCD ACTION PLAN                                         |
|                                                                                                   |
|  D - DANGER         ===> Check for environmental hazards (electricity, gas, sharp instruments)    |
|  R - RESPONSE       ===> Check responsiveness (Talk and Touch: "Can you hear me? Open your eyes") |
|  S - SEND for help  ===> Call Emergency Services (000 in Australia) & request MICA / AED          |
|  A - AIRWAY         ===> Open airway (Head tilt-chin lift or Jaw thrust); clear obstructions      |
|  B - BREATHING      ===> Look, listen, and feel for normal breathing (max 10 seconds)            |
|  C - CPR            ===> Start 30 chest compressions : 2 rescue breaths (100-120 bpm, 5-6 cm)    |
|  D - DEFIBRILLATION ===> Attach AED as soon as available; follow voice prompts                     |
+---------------------------------------------------------------------------------------------------+

High-Quality Cardiopulmonary Resuscitation (CPR) Metrics

• Compression Rate: 100 to 120 compressions per minute.
• Compression Depth: One-third of the anterior-posterior chest depth (~5 to 6 cm in adults).
• Chest Recoil: Allow complete chest recoil after each compression; minimize interruptions.
• Ventilation Ratio: 30 compressions to 2 rescue breaths using BVM connected to 100% oxygen.
• AED Operation: Apply self-adhesive pads (right upper sternum below clavicle, left anterior axillary line). If a shockable rhythm (Ventricular Fibrillation or Pulseless Ventricular Tachycardia) is detected, clear all personnel and deliver shock, immediately resuming CPR for 2 minutes.

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Anaphylaxis: Pathophysiology & Emergency Protocol

Anaphylaxis is a severe, rapidly progressive, systemic IgE-mediated Type I hypersensitivity reaction characterised by life-threatening airway compromise, respiratory distress, and cardiovascular collapse. Common triggers in dental practice include local anaesthetic preservatives (sodium metabisulfite), antibiotics (penicillins), latex, chlorhexidine, and NSAIDs.

Clinical Presentation Matrix

Immediate Anaphylaxis Treatment Protocol

1. Stop Exposure: Immediately cease administration of suspected allergen (e.g., stop antibiotic infusion, remove latex/chlorhexidine).
2. Call Emergency Assistance: Call 000 immediately for an ambulance.
3. First-Line Pharmacotherapy — Adrenaline (1:1,000):
   • Adult Dose: 0.5 mg (0.5 mL of 1:1,000) via intramuscular (IM) injection into the mid-anterolateral thigh.
   • Paediatric Dose (6–12 years): 0.3 mg (0.3 mL) IM.
   • Paediatric Dose (<6 years): 0.15 mg (0.15 mL) IM.
   • Repeat Interval: If clinical improvement is inadequate, repeat IM adrenaline every 5 minutes.
4. Patient Positioning (CRITICAL):
   • Lay Patient Flat with Legs Elevated: Preserves central blood volume and venous return.
   • WARNING: Do NOT allow the patient to sit up or stand. Abrupt postural changes in anaphylaxis cause sudden venous pooling, leading to profound hypotension and fatal empty ventricle syndrome.
   • Exception: If breathing difficulty is the predominant symptom, the patient may sit semi-recumbent, but monitor blood pressure continuously.
5. High-Flow Oxygen: Administer 100% oxygen via a non-rebreather mask at 10–15 L/min.
6. Second-Line Adjuncts: Antihistamines (Promethazine/Cetirizine) and Hydrocortisone (100–200 mg IV/IM) are strictly secondary and must never delay adrenaline administration.

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Acute Severe Asthma & Bronchospasm

Acute severe asthma in the dental chair is precipitated by stress, cold air, airborne allergens, or drugs (NSAIDs, sulfites). Characterized by severe bronchospasm, mucosal oedema, and hypersecretion.

Management Flowchart (The 4 x 4 x 4 Protocol)

1. Positioning: Seat patient upright and comfortable.
2. Inhaled Salbutamol via Spacer:
   • Administer 4 separate puffs of Salbutamol (100 µg/puff) into a spacer device.
   • Direct patient to take 4 normal tidal breaths from the spacer after each puff.
3. Observation: Wait 4 minutes.
4. Re-evaluation: If no improvement, administer another 4 puffs of Salbutamol.
5. Emergency Escalation: If severe distress persists, call 000. Administer IM Adrenaline 0.5 mg (1:1,000) for life-threatening, refractory status asthmaticus.

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Vasovagal Syncope (Fainting)

Vasovagal syncope accounts for over 60% of all medical emergencies in dental practice. Induced by emotional stress, pain, or needle phobia, triggering excessive vagal tone.

• Pathophysiology: Severe parasympathetic activation causes profound bradycardia, combined with sympathetic withdrawal causing peripheral vasodilation $\rightarrow$ cerebral hypoperfusion.
• Prodromal Symptoms: Lightheadedness, nausea, diaphoresis (cold sweats), pallor, pupillary dilation, loss of consciousness.
• Management:
  1. Position patient supine with legs elevated (Trendelenburg position).
  2. Maintain airway (head tilt-chin lift), loosen tight clothing around neck.
  3. Administer high-flow oxygen.
  4. Apply cold compress to forehead; monitor pulse and blood pressure until full recovery.

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Hypoglycaemic Crisis

Hypoglycaemia in diabetic patients (blood glucose $<4.0\text{ mmol/L}$) is commonly precipitated by dental stress, skipped meals prior to appointments, or accidental overdose of insulin/sulfonylureas.

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Acute Coronary Syndromes (ACS) & Angina

Acute myocardial ischaemia presenting as chest pain, tightness, radiation to left arm or jaw, dyspnoea, and diaphoresis.

Differential Management Protocol

1. Stop Procedure: Seat patient comfortably upright. Call 000 if pain is severe or accompanied by dyspnoea.
2. Glyceryl Trinitrate (GTN): Administer GTN sublingual spray 400 µg (1 puff under tongue).
   • Re-evaluation: If pain persists after 5 minutes, administer a 2nd dose of GTN.
   • Maximum Limit: Up to 3 doses within 15 minutes.
   • Contraindication: GTN is strictly contraindicated if the patient has taken sildenafil or tadalafil (PDE-5 inhibitors) within the preceding 24–48 hours (risk of profound refractory hypotension).
3. Suspected Myocardial Infarction: If pain is unresolved after GTN or accompanied by hemodynamic instability:
   • Call 000 immediately.
   • Administer Aspirin 300 mg chewed (inhibits platelet aggregation).
   • Administer supplemental oxygen if SpO2 $<94%$.

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Epilepsy & Prolonged Seizures (Status Epilepticus)

Generalized tonic-clonic seizures in the dental chair require protection from mechanical trauma.

• Immediate Safety: Move dental equipment, light, and sharp instruments away. Do NOT restrain limbs or force objects into the mouth.
• Status Epilepticus Definition: Continuous seizure activity lasting $>5\text{ minutes}$ or recurrent seizures without intermediate recovery of consciousness.
• Pharmacological Intervention: Administer Midazolam 10 mg buccally (instilled into the buccal mucosa between cheek and lower gums) or 10 mg intranasally (5 mg in elderly/children). Call 000 immediately.