SYNCOPE, THE MOST COMMON MEDICAL EMERGENCY & PREPAREDNESS

SYNCOPE, THE MOST COMMON MEDICAL EMERGENCY & PREPAREDNESS

Medical emergencies can happen at any time, especially in the dental office.  We need to know which emergencies are most prevalent and how to prevent these emergencies and how to treat them and keep our patients safe. The most common medical emergencies are:

·      Loss of consciousness, syncope

·      respiratory distress

·      cardiac dysrhythmias

·      hyperventilation

·      allergic reaction

Patients tend to present anxious to their office appointment which means that these people have elevated circulating adrenaline levels to start out with. The dental office atmosphere, creates a reactive patient. Circulating catecholamines (epinephrine, norepinephrine) released by the adrenal glands affects the vital signs and responses to stimuli, also known as the “fight or flight” response. We all know that feeling of intense body warmth upon the endogenous epinephrine release to stimuli. Take vital signs on all patients presenting to the office, to know their baseline, to help recognize the patients who are at the most risk and to help guide therapy.

Loss of consciousness/syncope (LOC) is the most common medical emergency encountered in a dental office and over the lifetime of a practicing dentist it is likely they will encounter this issue several times. Knowing this, we need to be prepared to prevent, recognize and treat these problems. It is also well documented that the majority of syncopal episodes followed local anesthesia injection. Loss of consciousness is a symptom of the vasovagal reflex.

KNOW WHO IS AT RISK

I’ve witnessed syncope by individuals who were not the patient being treated. A dental assistant who was present while I treated a very foul smelling and painful dry socket (alveolar osteitis) had a moment of loss consciousness while standing next to the patient. This required I act quickly to help her from hitting her head on the equipment and chair on her way down. Another incident was during my first-year practicing after residency. A patient requiring multiple procedures asked if his partner could stay in the operatory during the procedure. Unbeknownst to me, the partner had a syncopal episode while I was focused on the patient which meant I couldn’t prevent his fall onto the floor. I quickly learned that allowing loved ones to stay may create a safety issue and liability on the part of the Doctor. It’s important to realize this may happen and prevent it by screening who may be present during a procedure. Providers should have a heightened sense of awareness at all times to detect and intervene at any moment in an emergency. A pregnant female is at most risk for syncope for several reasons that we won’t cover. This I know all too well when there were different times when ancillary staff have passed out at work during a morning huddle or otherwise, only to find out that they are pregnant.

One day while in my office which is part of a larger medical office building we heard a loud thud outside from the hall. Sure, enough it was someone who had passed out. Fortunately for them I had portable oxygen tanks and blood pressure cuff to monitor them until EMS arrived. The parent of a sedated patient also had an episode of syncope which we weren’t able to prevent that created a bigger problem because the woman was the escort for her sedated daughter.

CAUSES OF LOC

Modulation of the vasovagal (neurocardiogenic) reflex, occurs automatically with the end point of restoring blood flow and oxygen to the brain. Triggers that increase this have been identified as: Painful stimuli, prolonged standing, emotional stress i.e.: blood or a gruesome site. Vasovagal modulation causes vasodilatation of the peripheral blood vessels and a slowing of the heart rate, thus decreasing the hearts blood output, therefore lowering the availability of circulating oxygen to the brain. There are other causes for this response and they may be hypoglycemia, seizures, cardiogenic, or unusual situations like after micturition, coughing, stretching, & swallowing. The key is determining the triggers

PREVENTION

Know your patient and their medical history and know the triggers. Check vital signs and be prepared. Offer a calm friendly atmosphere to prevent anxiety. Know the patient and ask about prior dental care and elicit the patient’s feelings about past care and their current thoughts. Get a sense of the patients fears. Help them to choose the best alternatives, nitrous oxide, and parenteral sedation, to reduce their stress for extremely anxious patients and show them that you really care how they feel. This will do more for the patient than you realize. Show empathy and explain to them that they can endure the treatment, and cheer them on.

Perfect your local anesthetic technique:

·      If there is no contraindication for it, always use topical anesthesia.

·      Use warmed local anesthesia and inject slowly.

·      Shake and firmly pinch the lip tissues just before and during the injection process. The firm pressure and the movement are a distraction. The pressure acting as the initiator of the Gate control Theory of pain.

·      Seat the patient with their legs up and or supine during an injection to prevent having the head higher than the heart and the bulk of the blood supply, from the legs, closer to and easier to get to the heart so it can be readily pumped to the brain.

·      Maintain the patient in this position for a period of time after the injection and closely monitor their response.

RECOGNIZE THE SYMPTOMS:

·      Change in skin tone, pallor

·      Nausea, feel warm

·      Diaphoretic

·      Dry mouth

·      Tinnitus

·      Blurred vision, seeing spots

Be Prepared:

·      Take baseline vital signs and create that initial personal one-on-one encounter.

·      Place patients in a chair that reclines into Trendelenburg, pregnant women on left lateral decubitus position.

·      Have oxygen and spirits of ammonia capsules readily available.

·      Have oral and nasal airways in the event the patient remains unconscious to protect their oxygen supply.

·      Have sugar to administer if the patient is a diabetic or if there is a suspicion of hypoglycemia.

·      Cold wet compresses to the nape of the neck or forehead

·      If the patient doesn’t respond then it may be a more serious problem and start Basic life support BLS/Advanced cardiac life support ACLS protocol and activate the EMS and call 911.

I have administered local anesthesia when a patient has then lost consciousness and recovered quickly. The patient like many before them was unaware of their impending lights out and was unable to warn us so we could help them. It’s not uncommon for patients to ignore the signs of syncope or not have the ability to recognize them. Or, many believe they can control this. The point of control comes way before this point, because at this point it is too late. Control needs to occur with prevention. With

With my years of experience and my intuition I can easily spot when this process has started. In many cases I am aware before the patient knows themselves or before the patient can advise me that they are aware of it.

Lastly, it is important that your staff is aware of this problem because in many instances they encounter these patients that are anxious and can help in the calming process. Additionally, they can help prevent an episode of LOC in the office before it occurs. They should be trained on how to recognize it and what needs to be done. For many people the first step in getting that person supine.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998831/

The Girldoc😉