medical emergency preparedness in dental practice emergency preparedness in dental practice a...

Earn3 CE creditsThis course was

written for dentists, dental hygienists,

and assistants.

Supplement to PennWell Publications

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AbstractWhile life-threatening medical emergencies are uncommon in the dental practice environment, most professionals will be responsible for managing multiple emergency events throughout their careers. By planning for the unexpected, dental teams hone their skills and build the necessary confidence to cope with these high pressure situations. Although some emergencies are unavoidable, participants in this course will be provided with information and tools to prepare for, prevent and definitively manage the most common medical emergencies that occur in general dental practice.

Educational ObjectivesFollowing these units of instruction, the dental practitioner will be able to do the following:1. Describe ten practices that prepare

dental teams for the most common medical emergencies.

2. Define the potential roles of team members in a basic emergency action plan

3. Discuss how the American Society of Anesthesiologists physical status classification system can be used to identify “at risk” patients.

Author ProfileLinda Lawson, RDH, BS, is based in New York and has more than 17 years of experience in the dental profession. She received her associate's degree in 1999 from New York City College of Technology. In 2014, she attained her bachelor of science in dental hygiene from Farmingdale State College and was subsequently inducted into the Sigma Phi Alpha Dental Hygiene Society. In addition to clinical practice, Linda has worked as an adjunct dental assistant instructor and is currently a professional educator on behalf of Waterpik Inc. Linda is thrilled to be on the National Cancer Network (NCN) Visionary Team where she works to raise awareness to prevent late-stage diagnosis of all cancers.

Author DisclosureLinda Lawson, RDH, BS, has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

Publication date: May 2017 Expiration date: June 2020

This educational activity was developed by PennWell’s Dental Group with no commercial support. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content.Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%.CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products or services discussed in this educational activity. Heather can be reached at [email protected] Disclaimer: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.Image Authenticity Statement: The images in this educational activity have not been altered.Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents the most current information available from evidence based dentistry. Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient and improvements in oral health. Registration: The cost of this CE course is $59.00 for 3 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

PennWell designates this activity for 3 continuing educational credits.

Dental Board of California: Provider 4527, course registration number CA# 03-4527-15164“This course meets the Dental Board of California’s requirements for 3 units of continuing education.”

The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to (10/31/2019) Provider ID# 320452.

INSTANT EXAM CODE 15164

Medical Emergency Preparedness in Dental PracticeA Peer-Reviewed Publication Written by Linda Lawson, RDH, BS

2 www.DentalAcademyOfCE.com

Educational ObjectivesFollowing these units of instruction, the dental practitioner will be able to do the following:1. Describe ten practices that prepare dental teams for the

most common medical emergencies.2. Define the potential roles of team members in a basic

emergency action plan3. Discuss how the American Society of Anesthesiologists

physical status classification system can be used to identify “at risk” patients.

AbstractWhile life-threatening medical emergencies are uncommon in the dental practice environment, most professionals will be responsible for managing multiple emergency events through-out their careers. By planning for the unexpected, dental teams hone their skills and build the necessary confidence to cope with these high pressure situations. Although some emergencies are unavoidable, participants in this course will be provided with information and tools to prepare for, prevent and definitively manage the most common medical emergencies that occur in general dental practice.

The Effects of Optimism Bias“For myself I am an optimist - it does not seem to be

much use to be anything else.” — Winston S. Churchill

Human brains naturally generate pervasive optimism. For most, the day does not begin with opening one’s eyes and being consumed with a feeling of impending doom. Instead, our emotional well-being combined with our past experiences promotes a positive outlook in healthy individuals. In the work environment, “optimism bias” is generally viewed in a positive light. When it comes to the management of medical emergencies, however, solely relying on blind optimism over sober reality will typically result in emergency situations end-ing badly.

Developing a Comprehensive Preparedness ProgramMedical emergencies can be confusing and frightening; con-sequently, it is not uncommon for people to panic or become paralyzed with fear or indecision when faced with a crisis. Being ill-prepared often results in a delay in response time for the den-tal team, and an increase in the likelihood of mortality or serious morbidity for the victim. Thus, it is the obligation of the respon-sible dental practitioner to develop a clear medical emergency preparedness program to decrease the likelihood of unfavorable outcomes. Ten actions that will assist dental teams in becoming better prepared for emergency events are listed below.

Action #1: Accept That It Really Can Happen to You: Prevalence of Emergency EventsThe first step in preparing for a medical emergency is to accept that the possibility is real: An acute medical emergency can happen in any dental office at any given moment in time. While some emergencies take place by chance, others are directly linked to dental treatment. A survey of 4,039 private dentists in the United States and seven Canadian provinces revealed that more than 30,000 medical emergencies had occurred in their offices over a period of 10 years.1

While these statistics may seem high to some, advances in medicine and technology have resulted in a much older patient population in many practices. In the past, people were by and large edentulous by the time they reached old age. Today, se-niors are much more likely to seek dental care as many continue to have all or most of their dentition. Advances in health care have contributed to increased life spans and an increase in the number of medically compromised patients. This factor further escalates the likelihood of an emergency event occurring.2

Complications verses Life-Threatening EventsThe majority of emergency events are not life-threatening and are better classified as systemic “complications”. Signs and symptoms of complications can occur instantaneously or may be delayed.3 It is therefore essential that dental personnel are well-versed in recognizing the clinical presentations of the most common complications and/or emergencies that occur in the practice of dentistry. The emergency event that is reported most frequently is syncope, accounting for roughly 50% of all medical emergencies. Other frequently cited emergencies include suspected cardiovascular events, complications related to local anesthesia, allergic reactions, hypoglycemia4, seizures, bronchospasm, postural hypotension, diabetic emergencies, and swallowing of foreign bodies.5 Box I outlines some emer-gencies that might be encountered in the dental practice along with basic principles on how to safely and effectively manage them.

Action #2: Detail Your Basic Action Plan in WritingCreating a basic action plan with a team approach should be one of the first steps in planning for an emergency event. Each team member should be trained to perform specific tasks and their assigned roles should be outlined in a written plan. The Occupational Health and Safety Administration (OSHA) requires all employers with eleven or more staff members to have a written emergency action plan detailing the steps to be taken in the event of an emergency.6 Ultimately, the goal of the basic action plan is to preserve life3 by managing the patient’s condition until he/ she fully recovers or until emergency medical services (EMS) arrive. More specifically, the most principal role for the dental professional during an emergency situation is to prevent, or correct, inadequate oxygenation of the brain and heart.5

www.DentalAcademyOfCE.com 3

Condition Risk Factors Clinical Presentation Drug, Dosage, and Route

Management

Vasovagal Syncope Anxiety (Common risk factor in dental practice)24

Dizziness, pallor, cold sweat, slowing of pulse, nausea, vomiting, loss of conscioussness24

Place aromatic ammonia under the patient’s nose25

Dosage: one to 2 vaporules25

Deliver 100% oxygen24

Place patient in a supine position;20,24 if consciousness is not regained in 30-60 seconds, consider a more complete differential diagnosis20

Angina Pectoris Reported history of coronary artery disease29

Stable angina can be triggered by stress, exposure to very cold or very hot temperatures, heavy meals, smoking29

Chest Pain that is significant but not severe20, 26 (can last up to 20 minutes) 26

Chest fullness, burning, tightness, dyspnea diaphoresis 26

Typically not the patient’s first time experiencing this type of pain20

One sublingual (0.4 mg) tablet or one spray (0.4 mg) from nitroglycerin spray atomizer administered every 5 minutes (3 doses) 26

***Do not administer nitroglycerin to patients who have taken an erectile dysfunction drug in the previous 24 hours20,25

Stop the procedure26

Allow the patient to rest26

Continuously monitor vital signs26

Place patient in a semi reclined position26

Provide supplemental oxygen if necessary26

Mild Allergic Reaction

Itching, hives, rash20

Patient is conscious with a verified airway that is patent20

Administer a histamine blocker such asdiphenhydramine (Benadryl)20

Assist the patient into a comfortable position20

Seizure Previous diagnosis of epilepsy20

Stress can be a trigger34

Light can be a trigger- (offer patients dark colored safety glasses and do not direct the operator light into the patient’s eyes)34

Signs and Symptoms vary depending on the type of seizure34

Simple seizures- consciousness is not impaired34

Complex seizures- consciousness is impaired34

Motor Seizure: the body stiffens and muscles will jerk34

Sensory Seizure: affects the senses (i.e, tingling, smell a bad odor, taste things not present in the mouth, ringing in the eyes, spinning feeling) 34

Autonomic Seizure: affects the nervous system (i.e., sweating, change in heart rate) 34

Psychic Seizure: manifests as strong, sudden emotions (i.e, anxiety, happiness) 34

Tonic-Clonic (Grand mal)- Monotonous epileptic cry at onset;Convulsions that start as fast small amplitude movements and progress to slower larger movements34

Atonic Seizure: manifests as a sudden loss in muscle strength34

Patients typically have a strong pulse when having a seizure20

Oxygen at a rate of 6-8L/minute28

Remove foreign materials from the patient’s mouth20

Place the patient on his side to minimize aspiration28

Use passive restraint to minimize the chance of injury34

Call 911 if1. the patient is unconscious for more than 5 minutes34

2. the patient becomes cyanotic28

3. it is the patient’s first seizure34

Box 1: Overview and Management of Common Medical Emergencies in Dental Practice


Asthmatic Attack(Bronchospasm)

Respiratory distress Bronchodilator via metered dose inhaler (i.e. Albuterol)12,20,25

Administer epinephrine parenterally if the patient loses consciousness20

Assist patient into an upright position20

Ensure that the patient has a patent airway20

Hyperventilation(Anxiety Associated)

Anxiety33 Tingling in fingers or lips, involuntary spasm of peripheral musculature, dizziness24

Unnaturally deep, fast breathing, weakness, feeling of a ‘tight’ chest, sweating, increased heart rate (tachycardia), palpitations33

Loss of consciousness is uncommon, but can occur33

*DO NOT administer oxygen5

Methods to increase CO2:1. Have patient hold breathe for as long as possible33

2. Have patient breathe in and out while cupping his hands around his mouth33 3. Use a non-re-breathing face mask. Cover holes with fingers and do not turn on O2

33

Hypoglycemia -Insulin Shock

Patient took too much insulin or glucose lowering medication by mistake25

Patient missed a meal after taking insulin or glucose lowering medication20,24

Feels faint, hungry, slurs speech24

Experiences diaphoresis and tachycardia followed by confusion and eventual loss of consciousness20

BP is typically normal20

Conscious Patients: Administer glucose tablets, one tube of glucose gel or juice12,25

Call 911 if patient becomes unconsciousness

* DO NOT place any substance in an unconscious person’s mouth that is liquid or can turn to liquid at body temperature20

Sudden Cardiac Arrest (SCA)

Coronary heart disease21

History of arrhythmias21

Personal or family history of SCA21

Previous heart attack21

Inherited disorders that make you prone to arrhythmias21

Drug or alcohol abuse21

Unconscious and without a pulse20 Call 911 immediately

Initiate rapid defibrillation of the heart using an Automated External Defibrillator (AED)13,16

Early application of effective CPR

Myocardial Infarction

Some risk factors include: Age, smoking, high blood pressure, high cholesterol, high triglycerides, diabetes, family history, inactivity, obesity, stress31

Radiating chest pain down the left side of the body (mandible, neck, arm, shoulder)20

Decrease in BP20

Atypical pain often seen in women:1. Shortness of breath20

2. Unexplained elevated blood sugar20

3. Cold sweat, nausea, jaw pain, lightheadedness32

One 325 mg nonenteric, coated aspirin tablet, chewed and swallowed12,25

Oxygen3

Morphine3

Nitroglycerine3

Nitrous oxide in a 50:50 concentration, 3,31 if morphine is unavailable3

Call 91132


Management

Box 1: (continued)


Anaphylactic Reaction

Previous anaphylaxis22

Allergies or asthma22

Certain other conditions: heart disease and mastocytosis22

Signs and symptoms typically occur in the following order:1. Urticaria, itching, flushing, hives2. Rash3. Rhinitis4. Bronchospasm5. Laryngeal Edema6. Weak Pulse-Syncope7. Loss of Consciousness8. Cardiac Arrest27

Epinephrine IM Auto-Injector0.3 mg to 0.5mg intramuscular25;Repeat every 5 minutes if no response20

Adjunct treatment: Bronchodilator,25 Antihistamine25,27 (50 mg intramuscular or intravenous), Corticosteroids (to prevent relapse),Supplemental oxygen27

Call 91120,27

Place patient in supine position20

Administer positive pressure oxygen via a bag-valve-mask device20

Stroke (CVA) Longstanding hypertension,30 poor diet, smoking, diabetes, physical inactivity, obesity, high cholesterol, atrial fibrillation, carotid artery disease, peripheral artery disease, sickle cell disease23

Transient ischemic attacks (TIAs), or minor strokes: dizziness, diplopia, hemiplegia, and altered speech30

Severe stroke: sudden or temporary weakness or numbness of the face and other body parts, loss of speech or difficulty speaking or understanding speech, visual changes, and unexplained loss of balance or dizziness30

100% oxygen if patient is experiencing apnea20

Call 91130

Maintain the patient’s airway30


Management

Box 1: (continued)

Action #3: Assign Roles to Your Emergency TeamThe in-office emergency team should consist of at least three staff members where any properly trained staff member can lead the management of the crisis. In the event of a medical emergency, the leader would announce the emergency situa-tion to the staff, assess the patient, direct another team member to call for emergency medical services (EMS), and manage the patient’s circulation, airway, and breathing, (CAB) until emer-gency assistance arrives. Team member 2 is typically required to assist the leader in basic life support (BLS) and/or monitor vital signs. Team member 3 (and 4 if available) is delegated to tasks that include bringing any and all necessary equipment to the team leader as instructed, calling 9-1-1, meeting EMS at the front entrance, and detailing a written chronological record of all events.7 Box 2 outlines potential roles for a dental team during an emergency situation. It is important to note that emergency preparedness is not licensed based; therefore, roles are interchangeable so long as clear communication is present.7

Action #4 Practice Using Effective Communication MethodsIn the event of an emergency, the dental team should consider using a “closed-loop” method of communication.7 This means that when the leader sends a message, the team member ac-knowledges receiving the instruction, thereby confirming that the message was heard and understood. The team leader should

only assign the next task after he has received a clear response from the team member that the first task was understood.7

Figure 1: Closed Loop Communication Model

Team membercon�rms thatthe message

was heard andprovidesfeedback

Team Leaderidenti�es the

team memberby name andgives a clear,

verbal message

Team Leaderacknowledges or

corrects

Team membercompletes the

task andconsults withthe leader as

needed

“O.K. Dr. Jones,It’s in the

emergency kit, right?.”

“Yes, hurry up.”“Here it is, Dr. Jones.

Do you need anything else?”

“Lauren, go get the Epi-Pen.”

Action #5: Take an Annual Basic Life Support Refresher Course Basic Life Support (BLS), or Cardiopulmonary Resuscita-tion (CPR) at the healthcare provider level, is unequivocally the most important aspect in successfully managing medical emergencies in the dental setting. When performing CPR, it is recommended that chest compressions should match the


tempo of the song, "Staying Alive" and the CPR cycle should be initiated at a rate of 30 compressions to 2 rescue breaths in adults and 15 compressions to 2 rescue breaths in children when two rescuers are present.8 Due to space constraints in dental treatment rooms, it is generally not recommended to move a patient from a dental chair to perform CPR. Instead, a short inflexible cardiac board should be placed under the prone patient when chairs have softer padding in order to maximize the effectiveness of chest compressions. In addition, a dental stool can be adjusted and positioned under the head of the chair to minimize rocking when performing CPR.9

In 2010, the American Heart Association (AHA) reoriented the guidelines for CPR and Emergency Cardiovascular Care (EEC) from A-B-C (Airway, Breathing, Compressions) to C-A-B (Compressions, Airway, Breathing) to reduce time to initi-ation of chest compressions. The 2010 Guidelines also changed the recommended compression rate from “approximately” 100/minute to a compression rate of “at least” 100/minute. The need for high quality chest compressions was stressed as rescuers were prompted to push hard and fast, minimize interruptions, allow full chest recoil, and avoid excessive ventilation.10

In 2015, the AHA further refined its guidelines based on preliminary data implying that excessive compression rates and depths negatively affect outcomes. Healthcare providers (HCPs) were still advised to perform a minimum of 100 chest

compressions/minute; however, the new recommendation placed limits on compressions to a maximum of 120 per min-ute. In addition, the suggested compression depth of 2 inches (5 cm) for the average adult was restated; however, the new 2015 Guidelines limit compression depth to no greater than greater than 2.4 inches [6 cm]).11

Although there are some state dental boards that do not mandate refresher BLS for license renewal, BLS Healthcare Provider (BLS-HCP) is considered the level of training re-quired for dentists and dental hygienists who administer local anesthesia.12 The supplementary drug package insert that ac-companies all local anesthetic drugs clearly states:

“Dental practitioners and/or clinicians who employ lo-cal anesthetic agents should be well versed in diagnosis and management of emergencies that may arise from their use. Resuscitative equipment, oxygen, and other resuscitative drugs should be available for immediate use.” Resuscitative equipment has been interpreted in court as integral to the ability to perform BLS. Training in the use of all resuscita-tive equipment is essential for proper utilization.12,13

Moreover, although many states require dentists and hy-gienists to complete CPR recertification every two years, the AHA recommends that healthcare professionals complete BLS on an annual basis.11,12 This is necessary as the AHA consistent-

Box 2: Sample Team Approach to Managing Medical Emergencies

Team Member #1 : Leader • Assesses the patient7

• Announces the emergency7 and remains with the patient25 • Implements Basic Life Support if required7, 12, 25

Team Member #2 • Retrieves the “Crash Cart” which includes: • Oxygen cylinder12,25

• automated external defibrillator (AED)7,25

• emergency medications12,25 • electronic BP device (monitors blood pressure and heart rate) • pulse oximeter• Connects the oxygen to the appropriate delivery system

• Assists with Basic Life Support (BLS)7,12

• Monitors vital signs12

• Regularly checks the oxygen gauge to ensure sufficient oxygen levels • Prior to an emergency event: Performs a daily check of the emergency oxygen system to ensure that there is adequate oxygen in the event of an emergency7

Team Member #3 • Prepares emergency drugs for administration7,12

• Assists with BLS as directed7

• Prior to an emergency event: Runs an AED self-test (daily) to check the battery and electrical components

Team Member #4 • Calls 9-1-1 using a landline (if possible) to expedite EMS response time7,12,25

• Meets paramedics at the building’s entrance way7,25 • Keeps a written chronological record of events7,12,25 which includes: • Patient’s vital signs7

• Timing and amount of medications administered7

• Patient’s response to the treatments7

• Relieves other team members as required• Prior to an emergency event: Periodically checks the emergency kit to ensure contents have not expired (monthly)

Note: Many roles are interchangeable and will depend on the number of team members in the dental practice.5


ly assesses its CPR methods and procedures making modifica-tions when needed. As a result, previously taught ideas could undergo minor to moderate variations that healthcare providers may be unaware of if refresher courses were taken biannually.

Action #6: Know the Location and Proper Utilization of Emergency Drugs and EquipmentAcquiring and maintaining emergency drugs and equipment for the dental practice is an essential component of emergency preparedness. Too often, dental teams make the mistake of storing emergency kits in locations that are difficult to access. Drugs and equipment should always be stored in a central location for quick and easy retrieval during urgent situations to minimize response time. In addition, it is plausible for an emergency event to occur outside of the dental operatory; as a result, storage cases or carts containing essential drugs and equipment must be portable so that teams can respond to any person in any room of the office.13

OxygenOxygen (O2) is used in almost all emergency situations with the exception of hyperventilation.5 If possible, O2 saturation levels should be monitored with a pulse oximeter before, during and following oxygen therapy. In addition, high flow oxygen (15 liters per minute) should be administered and titrated accord-ingly based on O2 saturation levels when managing a critically ill patient.14

Oxygen should always be available in a transportable unit, preferably an “E”-size cylinder which holds over 600 liters, so that it can be administered in any area of an office.5,15 Portable oxygen tanks enable the dental team to deliver oxygen under positive pressure to anyone who is unconscious or not venti-lating properly. Bag-valve-mask devices (i.e., Ambu-Bag) with an oxygen reservoir connected to an oxygen supply is the most efficient technique of ventilating high concentrations of inspired oxygen in patients when respiration has ceased.

Automated External DefibrillatorThe automated external defibrillator (AED) is an indispens-able piece of equipment that has become the standard of care in oral health care settings. According to the American Heart Association, more than 350,000 cardiac arrests occur outside of the hospital setting in the United States each year.16 This life-threatening medical condition is typically caused by ven-tricular fibrillation (VF), an abnormal heart rhythm in which the electrical impulses in the heart’s lower chambers become rapid and erratic, often without warning.16 As the heart quivers uselessly, it loses its ability to pump blood to the body’s vital organs. Failure to immediately respond to cardiac arrest will result in loss of consciousness and respiratory activity followed by death.17

The dental team’s basic action plan for a Sudden Cardiac Event (SCA) must be designed so that an AED is deployed in

a quick and efficient manner as the survival probability is near zero after eight to ten minutes. Successfully managing a SCA entails immediately recognizing the emergency, rapidly initiat-ing a 911 call, and deploying an AED within 4-5 minutes.18

AED’s are voice-prompted, computer-driven, devices that work by analyzing the heart’s rhythm releasing an elec-trical shock to the heart via pads placed on the victim’s chest if needed. This shock, called defibrillation, is the only effec-tive treatment to reestablish a normal sinus rhythm when a person is experiencing cardiac arrest.15 It is worth noting that excessive chest hair can interfere with the AED’s pad to skin contact. While some AED devices include razors, chest hair can be more quickly removed with a piece of duct tape to al-low for better adherence of the pad to the victim’s chest. Other important AED considerations include placing pads at least one inch from pacemakers and not deploying the device when metal objects (i.e., jewelry, piercings, the metal underwire of a bra) are in close contact with the adhesive pads.

AED’S are extremely effective in restoring a normal heart rhythm when it is deployed immediately and operated properly. Statistics indicate that each minute without defibril-lation results in a decrease in survival rate by approximately 10%.17 The AHA now includes defibrillation in its “chain of survival,” and since 1998, hands-on AED training is included in all AHA Healthcare Provider and Heartsaver® courses. Furthermore, some states, including Florida, Washington, and Illinois, mandate that dentists keep an AED on premises.15

Emergency preparedness is particularly central in saving the life of a SCA victim because it impossible to predict when an event will occur. Most victims of SCA have never been la-beled as “high risk”, roughly 20 percent have no prior history of heart disease, and 10 percent of SCA events occur in persons under the age of 40. What’s more, the overwhelming majority of SCA events do not occur in a hospital type setting.18

Emergency Drug KitThe contents of the emergency kit should be packed in an appropriately labeled designated storage unit. Furthermore, contents should be checked periodically to ensure that no drugs in the kit have expired. According to Rosenberg (2010),15 the following drugs should be included in the basic drug kit for dental practice: epinephrine (for treating cardiovascular and respiratory manifestations of acute allergic reactions), diphenhydramine (for management of mild allergic reactions), nitroglycerin (for treatment of acute chest pain caused by angina pectoris), bronchodilators (to treat bronchospasm caused by an asthmatic attack or anaphylaxis), glucose (to treat hypoglycemia), and aspirin (to prevent further clot formation during an evolving myocardial infarction). Box 3 lists the basic emergency drugs and equipment for the general dental practice. Note that the kit would be more extensive for the dental provider who administers oral sedation or intravenous anesthesia.


Action #7: Identify Patient Specific Risk Factors by Acquiring a Comprehensive Health HistoryAs stated earlier, prevention is key to successfully managing emergency events. This includes updating and verbally re-viewing each patient’s health history at every dental visit; it is both mandatory and necessary. The health history form should consist of relevant and detailed questions in order to accurately document the patient’s condition while the health history in-terview acts to clarify the significance of any stated medical condition to the proposed dental treatment plan.19

While it is true that any person can experience medical com-plications while undergoing dental treatment, an updated and accurate health history provides the necessary information to help identify “at risk” patients. “Identification of at-risk patients will allow modifications to be made to treatment planning and may highlight those patients whose treatment may be more appro-priately conducted at specific times or in specialist centres.”13 At minimum, health history forms should include questions related to the family medical history, known allergies, medication history, past and present illness, recent diagnoses of medical or mental health conditions, and previous surgeries/ hospitalizations.

Step #8 Take Vital Signs Prior to Administering TreatmentMeasuring and recording blood pressure prior to administer-ing dental treatment is fundamental in preventing emergency events in the dental practice. Blood pressure readings aid in identifying patients with hypertension, a condition that con-tributes to a myriad of health conditions including heart attack and stroke.2 The American Society of Anesthesiologists physi-cal status (ASA PS) classification system is currently in use as the standard for treating dental patients. After reviewing the pertinent medical history information, the dentist should as-

sign the patient a classification based upon his or her present medical conditions.

ASA PS I patients would be considered normal and healthy. ASA PS II patients suffer from mild systemic disease while ASA PS III patients suffer from severe systemic disease. Pa-tients that fall within the category of ASA PS IV have a severe systemic disease that constantly threatens their life. Patient’s that are placed in the category of ASA PS V are typically hospi-talized and terminally ill.19 Dental treatment recommendations regarding ASA PS classifications and blood pressure readings are outlined in Box 4.

Step #9 Perform a Visual Inspection Prior to Initiating Dental Treatment A simple visual inspection can provide useful information as to whether or not a dental patient is considered “at risk”. Diseases that can be identified by conducting a visual inspec-tion include jaundice, Parkinson disease, obesity, a history of cerebrovascular accident (CVA), exophthalmos, orthopnea and heart failure.20 Furthermore, a visual inspection combined with open communication throughout the appointment can assist dental personnel in identifying a patient who is experiencing anxiety. Since stress is a major contributing factor to medical emergencies,2 the dental team should employ stress reduction tactics during treatment, thereby potentially reducing the risk to the patient. These protocols are grounded in the belief that stress reduction should start before initiating dental therapies, continue throughout the dental appointment, and if deemed necessary, continue into the postoperative phase of treatment.19

Dental personnel should be familiar with the signs and symp-toms of anxiety which include stiff posture, cold or sweaty palms, “white knuckle” syndrome, excessive sweating, dilated pupils, and increased blood pressure and/or heart rate.2

Box 3: Emergency Drugs and Equipment Checklist for the General Dental Practice

Equipment:

• Automated External defibrillator (AED)12,13,15,25

• Supplemental Oxygen delivery devices- (Bag mouth mask device, positive pressure mask, nasal cannula, nasal hood)12,15

• Auxiliary supplies to effectively administer emergency drugs • Syringes, needles,12 alcohol wipes ect…• Oropharyngeal airways to maintain a patient’s airway in the event of an obstruction12

• Magill forceps to retrieve objects that have been lodged in the hypopharynx12,15 • Automated blood glucose monitoring device13

• Sphygmomanometer with adult small, medium and large cuff sizes15

Emergency Drugs (adults):

• Oxygen12 (Portable E-Cylinder tank)13,15, 25

• Epinephrine -Injectable- 1:1000(.03mg) - (2 Twinject® syringes)12,15,25

• Diphenhydramine (i.e., Benadryl)- 50mg/mL12,15,,25

• Nitroglycerin (Nitrolingual Spray .04 mg recommended)12,15,25 • Bronchodilator in a metered-dose inhaler (i.e., Albuterol)12,15,25

• Nonenteric, coated aspirin 325mg (to be chewed and swallowed)12,15,25

• Glucose source12,15,25 (Solution, tablets, gel, powder)13

• Aromatic Ammonia15,25


Box 4: Risk Factor/ Blood Pressure Protocol for Dental Treatment

ASA PS Rating Definition With Examples Blood Pressure Reading

Action Regarding Blood Pressure

Treatment Recommendation

ASA PS I Healthy

Non-smoker,Major organ systems appear in good health. Patients are able to walk up one flight of stairs or two level city blocks without distress. Little or no anxiety35

Under 60 years of age19

Systolic is less than 140 and diastolic isless than 90 mm Hg§19

Recheck BP‡ in 6 months2

“Green Light” for all dental treatment19,35

ASA PS II Mild to Moderate Disease

Non-insulin dependent diabetes, prehypertension, epilepsy, asthma, thyroid conditions35

Also includes current smokers, social alcohol drinker including obesity, pregnant patients35, healthy ASA I patients with extreme anxiety19

Systolic is 140-159 and/or diastolic is 90-94 mm Hg19

Recheck BP for three consecutive appointments;2

If measurement exceeds these values- rated and treated as ASA PS II.2

“ Yellow Light” for dental treatment- Minimal risk yet still proceed with caution19,35

May need medical consultation for certain dental procedures35

ASA PS III Moderate to Severe Systemic Disease that Limits Activity but is not Incapacitating

History of more than three months of angina pectoris, transient ischemic attack, myocardial infarction, cerebrovascular accident, congestive heart failure, coronary artery disease with stents, slight chronic obstructive pulmonary disease, and poorly controlled insulin dependent diabetes or hypertension as well as morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker35

Systolic is 160 - 199 and/or diastolic is95-114 mm Hg19

Recheck BP in 5 minutes. If still at these values, rate as ASA PS III2

"Yellow Light" for treatment, with a slight to strong warning signifying to proceed with extreme caution during dental treatment35

Will need medical consultation before all dental care35

ASA PS IV Severe Systemic Disease

History of less than three months of unstable angina pectoris, myocardial infarction, cerebrovascular accident, severe congestive heart failure, coronary artery disease with stents, ongoing ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, disseminated intravascular coagulation, moderate to severe chronic obstructive pulmonary disease, including uncontrolled diabetes, hypertension, epilepsy, or thyroid condition35

Systolic is greater than 200 and/ordiastolic is greater than 11519

Recheck the patient in 5 minutes. If pressure is still elevated, immediate medical consultation is indicated2

"Red Light", with a strong warning indicating that the risk involved in treating the patient is too great to proceed with planned dental treatment35

Note: Elective care is contraindicated; Emergency care: noninvasive or in a controlled environment35

ASA PS V Terminally ill and not expected to survive more than 24 hours with or without an operation35

*NA for general dental practice

*NA for general dental practice

“Red Light" for dental care and all care is done in a hospital setting35

Palliative care only35

Based on the American Society of Anesthesiologists physical status (ASA PS) classification system‡BP: Blood pressure.§mm Hg: Millimeters of mercury.


Step #10 Practice Makes Perfect: Perform Mock Emergency DrillsIn the event of a crisis, knowing what to do versus actually prac-ticing what to do are two very different things. This point was substantiated during the 2008 University of Michigan School of Dentistry study on the ability of dental students to manage a simulated angina attack.1

Of the subjects tested, 68 percent independently iden-tified the need for oxygen and the correct location of the equipment in the dental school. Only 15 percent of the students completed the experiment within a predetermined optimal time frame, and 50 percent of all students did not successfully operate the tank regulator to administer oxy-gen correctly. Although most participants in the study were able to verbalize the proper protocol for managing medical emergencies, the chairside execution in this situation dem-onstrates room for improvement.1

The results of the study highlight the potential disconnect between instruction in the classroom and actual clinical prac-tice. Performing routine simulated emergency drills bridges the gap between this disconnect and improves confidence in dental practitioners when it comes to emergency management.

ConclusionIn conclusion, dental teams should be prepared to prevent what is preventable and effectively manage what is not. Although some medical emergencies can never be prevented, best prac-tice dictates that teams receive the proper training and make the necessary preparations in order to increase the likelihood of a successful outcome during an urgent and emergent medical situation. In addition, regular audits should be carried out in the dental practice in order to ensure that the response to an emergency event is maximized. Emergency equipment and drug kits should be checked weekly, and response time of team members should be timed during mock drills. Preparing for emergency events in advance gives the dental team the ability to identify deficiencies and take the necessary steps to imple-ment improvement.13

References1. Le, T. L., Scheller, E. L., Pinsky, H. M., Stefanac, S.J., & Taichman,

R. S. Ability of Dental Students to Deliver Oxygen in a Medical Emergency. J Dent Edu. 2009; 73, (4): 499-508

2. Nunn P. Medical Emergencies in the Oral Health Care Setting. J Dent Hyg. 2000; 74(2): 136-151.

3. Prasad, K. D., Hegde, C., Alva, H., and Shetty, M. Medical and Dental emergencies and complications in dental practice and its management. J of Edu and Ethics in Dentistry. 2012; 2, (1): 13-19.

4. Anders, P.L., Comeau, R.L., Hatton, M., and Neiders, M.E. The Nature and Frequency of Medical Emergencies among Patients in a Dental School Setting. J of Dent Edu. 2010. April; 74(4):392-6.

5. Hass, D. A. Management of Medical Emergencies in the Dental Office- Conditions in Each County, the Extent of Treatment by the Dentist. Anesth Prog. 2006. Spring; 53(1):20-24. Reprint

6. Collins D. Emergency Planning and Disaster Recovery in the Dental Office. American Dental Association Council on Dental Practice, 2003; 1-47

7. Haas, Daniel A. Preparing Dental Office Staff Members for Emergencies- Developing a Basic Action Plan. JADA. 2010; 141: 9s-13s.

8. CPR Cardiopulmonary Resuscitation (2017). Retrieved from the National CPR Foundation website on April 4,2017. Web: https://www.nationalcprfoundation.com/courses/healthcare-provider-basic-life-support-2/cpr/

9. Chapman, P.J. and Penkeyman, H.W. Successful Defibrillation of a dental patient in cardiac arrest. Australian Dental Journal. 2002;47:(2):176-177.

10. Highlights of the 2010 American Heart Association Guidelines for CPR and ECC. (2010). American Heart Association. Retrieved on April 4, 2017. Web: Highlights of the 2010 American Heart Association Guidelines for CPR and ECC. (2010). American Heart Association.

11. Neumar,R.W., Shuster, M., Callaway, C.W., Gent, L.M., Atkins, D.L., Bhanji, F., Brooks, S.C., de Caen, A.R., Donnino, M.W., Ferrer, J.M.E., Kleinman, M.E., Kronick, S.L., Lavonas, E.J., Link, M.S., Mancini, M.E., Morrison, L.J., O’Connor, R.E., Samson, R.A., Schexnayder, S.M., Singletary, E.M., Sinz,E.H., Travers, A.H., and Wyckoff, Hazinski, M.F. Part 1: Executive Summary 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care pdf. Circulation. 2015; 132: S315-S367.

12. Malamed, S. Medical Emergencies: Preparation & Management. Quality Resource- Metlife Dental Quality Initiatives Program. 2004-2008;2. Retrieved on April 4, 2107.http://www.drmalamed.com/downloads/files/MetLife_Medical_Emergencies_2007.pdf

13. Wilson, M. H., McArdle, N. S., Fitzpatrick, J. J., Stassen, L. F. A. Medical Emergencies in Dental Practice. J Irish Dent Ass, 2009; 55(3): 131-143.

14. Jevon, P. Emergency Oxygen Therapy in the Dental Practice: Administration and Management. British Dental Journal. 2014; 216, 113 – 115.

15. Rosenberg, M. Preparing for Medical Emergencies- the Essential Drugs and Equipment for the Dental Office. JADA. 2010; 141: 14s-19s.

16. About Cardiac Arrest. (30 August 2016). American Heart Association. Retrieved on April 4, 2017. Web: http://www.heart.org/HEARTORG/Conditions/More/CardiacArrest/About-Cardiac-Arrest_UCM_307905_Article.jsp#.V-hiL8ftqFI

17. Kandray D, Piersen J, Benner R. Attitudes of Ohio Dentists and Dental Hygienists on the Use of Automated External Defibrillators. J Dent Edu. 2007; 71(4): 480-486.

18. Lazar, R.A. AEDs in Dental Offices- Practical Considerations and Risk-Management Strategies for the Dental Practitioner. Dental Economics. N.d.; 97(10). Web: http://www.dentaleconomics.com/articles/print/volume-97/issue-10/features/aeds-in-dental-offices.html

19. Malamed S. Knowing your patients. JADA. 2010, May; 141(Supp 1): S3-S7

20. Reed, K L. Basic Management of Medical Emergencies- Recognizing a Patient’s Distress. JADA. 2010, May; 141: 20s-24s.

21. Who is at Risk for Sudden Cardiac Arrest? (Updated June 2016). National Institutes of Health Website. https://www.nhlbi.nih.gov/health/health-topics/topics/scda/atrisk

22. Anaphylaxis Symptoms and Causes. (updated February 2014). Mayo Foundation for Medical Education and Research (MFMER) http://www.mayoclinic.org/diseases-conditions/anaphylaxis/symptoms-causes/dxc-20307213

23. Stroke Risks The Changes You Make Now Might Change What Happens Later. (updated February 2017). American Stroke Association. Retrieved on February 27, 2017. Web: http://www.strokeassociation.org/STROKEORG/AboutStroke/UnderstandingRisk/Understanding-Stroke-Risk_UCM_308539_SubHomePage.jsp

24. Medical Emergencies in Dental Practice- Practice Standard Te Kaunihera Tiaki Niho. (December 2016). Dental Council New Zealand. http://www.dcnz.org.nz/assets/Uploads/Practice-standards/Medical-Emergencies.pdf

25. Malamed, S. Emergency medicine. Dental Economics. 2010: 100(2). Retrieved on February 27, 2017. Web: http://www.dentaleconomics.com/articles/print/volume-100/issue-2/features/emergency-medicine.html

26. Dental Emergencies - Angina Pectoris. (August 2016). Oral Care India. Medindia Ltd. Web.: http://oralcareindia.com/dental_emergencies/ang_pectoris.asp

27. Anaphylaxis and Allergy. (March 2016). Oral Care India. Web: http://www.oralcareindia.com/dental_emergencies/allergy.asp

http://www.ncbi.nlm.nih.gov/pubmed/?term=Anders%20PL%5BAuthor%5D&cauthor=true&cauthor_uid=20388811

http://www.ncbi.nlm.nih.gov/pubmed/?term=Hatton%20M%5BAuthor%5D&cauthor=true&cauthor_uid=20388811


1. Once an emergency is recognized, the emergency basic action plan is activated and team members should:a. React immediatelyb. Remain calmc. Perform their roles as outlined in the written

emergency pland. All of the above

2. Managing a medical emergency always begins with:a. Calling 911b. Prevention of the emergency in the first placec. Bringing the dentist the emergency drug kitd. Putting the patient/victim into supine position

3. The Occupational Safety and Health Administration (OSHA) requires offices to have a written emergency plan if the number of staff members meets or exceeds _______ employees.a. 9b. 10c. 11d. 12

4. The goal of the basic action plan is:a. Manage the situation until the patient recoversb. Manage the patient until emergency services

arrivec. Prevent the patient from losing oxygen to the

braind. All of the above

5 The recommended minimum number of staff that is required to make up an in-office emergency team is:a. 2b. 3c. 4d. 5

6. In most cases, the dental team member who leads the emergency is the:a. Dentistb. Dental hygienistc. Dental Assistantd. Office manager

7. During an emergency, the team leader typically takes on the following roles:a. Announces the emergency to the other team

membersb. Directs another team member to call 911c. Manages the victim’s airway, breathing, and

circulationd. All of the above

8. The best method of communication during a medical emergency is:a. Open loop communicationb. Closed loop communicationc. Non-verbal communicationd. Written communication

9. The recommended time frame for dental professionals to complete BLS recertification is every ______.a. 6 monthsb. Yearc. Two yearsd. Three Years

Questions

Online CompletionUse this page to review the questions and answers. Return to www.DentalAcademyOfCE.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

28. Aragon, C and Burneo, J. (March 2007). Understanding the patient with epilepsy and seizures in the dental practice. Journal Canadian Dental Association. 73(1):71-6.

29. Angina Pectoris -Stable Angina. Reviewed July 2015. American Heart Association website. http://www.heart.org/HEARTORG/Conditions/HeartAttack/SymptomsDiagnosisofHeartAttack/Angina-Pectoris_UCM_437515_Article.jsp#.WOGyCsceDME

30. Burgess, J and Meyers, AD. (updated Nov 9, 2015). Management of the Dental Patient with Neurological Disease. Retrieved on February 27, 2017. Web: http://emedicine.medscape.com/article/2091727-overview#a3

31. Understand Your Risks to Prevent a Heart Attack. (updated September 2016). American Heart Association. Retrieved on February 27, 2017. Web: http://www.heart.org/HEARTORG/Conditions/HeartAttack/UnderstandYourRiskstoPreventaHeartAttack/Understand-Your-Risks-to-Prevent-a-Heart-Attack_UCM_002040_Article.jsp#.WOpIQcceDME

32. Heart Attack Symptoms in Women. (Updated January 2017). American Heart Association Website. Retrieved on April 4, 2017. Web: http://www.heart.org/HEARTORG/Conditions/HeartAttack/WarningSignsofaHeartAttack/Heart-Attack-Symptoms-in-Women_UCM_436448_Article.jsp#.WOpKKsceDME

33. Berridge, Wendy. (18 July 2014). Dealing with hyperventilation in practice. Dentistry.co.uk. Retrieved on April 3, 2017. Web: http://www.dentistry.co.uk/about-us/contact-us/

34. Jacobsen, P and Eden, O. Epilepsy and the Dental Management of the Epileptic Patient. J Contemp Dent Pract 2008, January. 9(1): 054-06.

35. ASA Physical Status Classification System For Dental Patient Care 2017. (updated March 2017) Retrieved on March 18, 2016. Web: http://www.dhed.net/ASA_Physical_Status_Classification_SYSTEM.html

Author ProfileLinda Lawson, RDH, BS, is based in New York and has more than 17 years of experience in the dental profession. She received her associate's degree in 1999 from New York City College of Technology. In 2014, she attained her bachelor of science in dental hygiene from Farmingdale State College and was subsequently inducted into the Sigma Phi Alpha Dental Hygiene Society. In addition to clinical practice, Linda has worked as an adjunct dental assistant instructor and is currently a professional educator on behalf of Waterpik Inc. Linda is thrilled to be on the National Cancer Network (NCN) Visionary Team where she works to raise awareness to prevent late-stage diagnosis of all cancers.

Author DisclosureLinda Lawson, RDH, BS, has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.



Questions (continued)

10. The most effective method of delivering oxygen to a person who is unconscious and not ventilating properly is through the use of:a. Positive pressure provided by a centrally plumbed

oxygen system and a single-use nasal hoodb. Negative pressure provided by a centrally

plumbed oxygen system and a single-use nasal hood

c. Positive pressure provided by a portable oxygen system prefilled E-cylinder, demand valve, hose, and adult resuscitation mask

d. Negative pressure provided by a portable oxygen system prefilled E-cylinder, demand valve, hose, and adult resuscitation mask

11. All of the following useful equipment are recommended to be included in a basic dental emergency kit except:a. Magill forcepsb. Vital signs monitoring equipmentc. Portable suction unitd. Intravenous fluids

12. Statistics suggest that each minute without defibrillation results in a decline in survival rate by approximately:a. 5%b. 10%c. 15%d. 20%

13. The only effective method of restoring a normal sinus rhythm in a person who is experiencing cardiac arrest is to:a. Administer rescue breaths followed by chest

compressionsb. Defibrillate the patient with an electrical charge

delivered through self-adhesive padsc. Perform an endotracheal intubationd. Administer oxygen under pressure

14. All of the following are drugs that should be included in a dental office’s basic drug kit except:a. Epinephrineb. Bronchodilatorc. Nitroglycerind. Insulin

15. Dental office emergency equipment must be:a. Portableb. Stored in a common locationc. Stored in a locked box or closetd. Both A and B

16. Unanticipated problems with the medical emergency protocol or medical equipment can be best identified and corrected by:

a. Performing mock emergency drillsb. Being flexible and open-minded as an

emergency is in progressc. Keeping a log of the emergency eventsd. Researching the best emergency protocols

17. The health history interview and questionnaire should be taken:a. At the patient’s first visit and updated at every

6-month recare appointmentb. At the patient’s first visit and updated at every

appointment thereafterc. Only if major restorative or dental surgery is

requiredd. On an annual basis

18. Maintaining an updated and accurate medical history:a. Helps identify at-risk patientsb. Allows the dentist to make proper modifications

to treatment planning c. Highlights which patients should have dental

treatment performed in a specialist settingd. All of the above

19. The American Society of Anesthesiologists physical status classification system states that patients who suffer from mild systemic disease are classified as:a. ASA PS Ib. ASA PS IIc. ASA PS IIId. ASA PS IV

20. The purpose of the health history interview is to:a. Accurately record the patient’s medical

conditionsb. Accurately detail the patient’s visual conditions

such as weight and pallor c. Accurately document the patient’s vital signsd. None of the above

21. If a blood pressure reading of 163/102 is detected before initiating dental therapy, the dental professional should:a. Advise the patient and check it again in six

monthsb. Advise the patient and recheck the reading over

the next three appointmentsc. Reschedule the appointment and refer the

patient to his/her physiciand. Call 911 as immediate medical consultation is

indicated

22. Which of the following is a condition that cannot be recognized by a simple visual inspection?a. Jaundiceb. Orthopneac. Rheumatoid arthritisd. Parkinson’s disease

23. Most victims of sudden cardiac arrest:a. Have a prior history of heart diseaseb. Are typically under the age of 40c. Are under general anesthesia in the hospital

settingd. None of the above

24. Patients who fall within this category have a severe systematic disease that constantly threatens their life.a. ASA Ib. ASA IIIc. ASA IVd. ASA V

25. Signs and symptoms of stress include all of the following except:a. Excessive sweatingb. Dilated pupilsc. Decreased heart rated. Stiff posture

26. Methods of identifying deficiencies in the emergency action plan include:a. Time team members during mock drillsb. Periodically check emergency drug kits to ensure

its contents have not expiredc. Getting CPR recertification on a biannual basisd. Both A & B

27. The most common medical emergency that arises in dental practice is:a. syncopeb. hypoglycemiac. chokingd. mild allergic reaction

28. Which of the following is the best method of managing a patient who is experiencing an acute angina attack?a. Administer epinephrine IMb. Administer a nitrate via transmucosal sprayc. Administer 100% oxygend. Administer nitrous oxide in a ratio of 50/50

29. All of the following are methods of managing hyperventilation except:a. Having the person breathe into a paper bagb. Having the person hold his-her breath for 10

secondsc. Initiating stress reduction techniquesd. Administering oxygen via a face mask

30. The only effective means of managing sudden cardiac arrest is to:a. Utilize an automated external defibrillator

within 4-5 minutes of the onsetb. Perform rescue breaths and chest compressionsc. Administer epinephrine 1:000 IMd. None of the above

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

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Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 3 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 800-633-1681

Educational Objectives1. Describe ten practices that prepare dental teams for the most common medical emergencies.

2. Define the potential roles of team members in a basic emergency action plan

3. Discuss how the American Society of Anesthesiologists physical status classification system can be used to identify “at risk” patients.

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