Medical emergencies can and do happen in a dental office. Successful management of an emergency requires preparation and practice. While having proper tools is essential, knowing how to use them is imperative for the best outcome in a crisis situation.
Part of that preparation includes having an adequate emergency kit containing eight essential drugs, according to Dr. Mort Rosenberg in the special 2010 JADA publication about dental office emergencies.
Most of those drugs will fit neatly into a well organized box, such as the one pictured. However, the most critical drug in saving lives cannot be boxed and requires an adequate delivery system along with the knowledge of how to administer it.
Oxygen is the most important component of the medical emergency kit, and it must be present in a dentist’s office. The chances of oxygen being used in an emergency are greater than 90%, according to Dr. Stanley Malamed, Dr. Jeffery Bennet; and Dr. Morton Rosenberg, DMD, in their books Medical Emergencies in the Dental Office and Medical Emergencies in Dentistry.
“Oxygen is of primary importance in any medical emergency.” Dr. Morton Rosenberg, DMD
Sourcing oxygen can be done with portable e-cylinder tanks or large stationary tanks plumbed into the facility. These sources can then be accessed in three ways.
OXYGEN CART WITH AN E-CYLINDER
Accessing the oxygen in an e-cylinder requires a regulator. This can be a simple click style regulator with a barbed outlet. The flow rate should go as high as 15 liters per minute (LPM). Once the regulator is on the tank, the tank must be opened by turning the built-in toggle handle or an oxygen key. The flow of oxygen is then controlled by the dial on the regulator.
O2 WALL OUTLET
An O2 wall outlet is generally plumbed into the larger stationary tanks. Accessing the oxygen through the wall outlet can be accomplished by using a quick connector specific to the style of outlet. Customized quick connect sets are available that include a click style regulator. Just like the one on the portable tank, it’s important that the regulator be able to deliver oxygen at a flow rate of up to 15 LPM in order to provide 100% positive pressure oxygen.
NITROUS OXIDE FLOWMETERS
An often overlooked method of accessing oxygen is through a nitrous flowmeter. Most current model nitrous units have an auxillary oxygen outlet similar to the wall outlet. These outlets are situated in variable places on or near the flowmeter. In addition to the style of outlet, the location will determine the type of quick connect set that will work best.
Older flowmeters may not have an oxygen outlet; in which case, you can employ an appropriate nitrous cannula adapter.
Oxygen delivery to a spontaeneously breathing person can be accomplished with a nasal cannula, a standard mask, or a non-rebreather mask. However, a person experiencing impaired breathing or who is unconscious will require a more advanced device such as a bag valve mask resuscitator (BVM) or a demand valve.
The flow rate should be adjusted according to the specific adjunct being used to deliver oxygen. Using an inadequate flow for the specified device can result in insufficient delivery of oxygen and adversely affect the outcome of the emergency.
Long tubing with two nasal prongs on the patient side and a standard oxygen connector on the opposite end is a nasal cannula. The oxygen connector is pushed onto the barbed outlet on a regulator, then placed on the patient.
The cannula should be oriented in such a way that the nasal prongs go inside the nostrils in a downward fashion. The tubing should not drape around the head. It is held behind the ears and tucked under the chin.
The flow rate of oxygen via a nasal cannula should be 1-6 LPM. The oxygen concentration at these rates would be 23-45%.
The standard oxygen mask covers the mouth and nose and has long tubing with a standard oxygen connector at the end. Once connected to the barbed outlet on the regulator, the oxygen flow rate should be set for 5-10 LPM. This gives an oxygen concentration of 40-60%.
The non-rebreather mask is a variant of a standard mask that includes a reservoir bag below the mask. This is the more commonly used mask in emergencies. The flow rate should be at least 10–15 LPM. With this flow rate, 90-100% oxygen is delivered.
DEMAND VALVE RESUSCITATOR
A demand valve is a manually triggered oxygen-powered device that is seemingly simple to use; however adequate skills are required to avoid unintended consequences to the patient, such as over inflation of the lungs. Therefore, it is not the preferred device to utilize in an emergency without proper training and practice.
The demand valve is operated by placing the face mask over the nose and mouth and pressing a button to inflate the lungs of a non-breathing patient. The preset flow rate of 40 LPM delivers 100% positive pressure oxygen.
Connecting this device to an oxygen source will require a regulator with a threaded DISS port or a quick connect appropriate to the oxygen source.
BAG-VALVE MASK (BVM) RESUSCITATOR
The bag valve mask resuscitator is the most reliable and commonly used method of delivering oxygen to a non-breathing patient. Ventilating with a BVM is a life-saving skill that should be practiced on an ongoing basis.
A standard bag valve mask consists of a cushioned face mask that covers the nose and mouth, a self inflating bag, an oxygen reservoir, and oxygen connection tubing.
The appropriate sized mask is held firmly in place while the bag is squeezed to inflate the lungs. In order to deliver 100% positive pressure oxygen, the oxygen flow rate should be set to at least 15 LPM.
One valuable benefit of a bag valve mask resuscitator is that it can be utilized to save a life—even when used without an oxygen source, in which case 21% room air oxygen will be delivered.
Attach the oxygen tubing to the regulator by pushing it onto the barbed outlet. In the case of a threaded port on the end of the oxygen tubing, push it firmly onto the barbed outlet ignoring the threads.
Oxygen administration is essential in managing most emergencies. Usages of a mask and a cannula are common, but understanding how oxygen is delivered from the source to the patient is often not addressed. Knowledge of the sources of oxygen in a dental office and what is required for them to be functional and effective is crucial to successfully managing an emergency.