Responding to Cardiac Arrest

According to the American Heart Association, 735,000 Americans experience a myocardial infarction each year; of these, 635,000 are first-time cardiac events.¹ Heart disease remains the leading cause of death for both men and women, and claims more lives than all forms of cancer combined. Each day, approximately 2150 Americans die from heart disease, stroke and other cardiovascular diseases — this equates to a death every 40 seconds.¹ With the prevalence of heart disease continuing to increase, it is possible that a patient, dental team member or visitor may experience a cardiac event while in the dental office.

All dental team members need to be prepared to handle a medical emergency. Every office should have a rehearsed emergency management plan, as well as a fully stocked emergency kit (Table 1 and Table 2). It is also recommended that each patient receive a complete medical history review — including recording of vital signs — at each dental visit. While any number of medical emergencies may occur in a dental office, this article will focus exclusively on chest pain and cardiac arrest.

CHEST PAIN

The primary difference between chest pain and cardiac arrest is that a patient experiencing chest pain will almost always remain conscious. Of course, chest pain can quickly progress into arrhythmias, which can cause unconsciousness and cardiac arrest.

There are many potential causes of chest pain, such as acute myocardial infarction (AMI), angina pectoris, paroxysmal supraventricular tachycardia, gastroesophageal reflux disease, anxiety and costochondritis. When patients describe chest pain, they commonly use terms such as squeezing, tightness, constriction, pressure, or the feeling of a heavy weight on the chest.

If a patient begins to experience chest pain, call for help and assist the patient into a comfortable position (most will want to sit upright). While circumstances can change in an instant, if the patient is awake and talking, we can be assured that they have a patent airway, are breathing, and have sufficient cerebral blood flow and blood pressure to retain consciousness for the time being. Angina pectoris and AMI are the two most common causes of cardiac-related acute chest pain among conscious patients. The challenge for dental teams is to provide a quick differential diagnosis.²

All dental team members need to be prepared to handle a medical emergency. Every office should have a rehearsed emergency management plan, as well as a fully stocked emergency kit

Establishing a differential diagnosis of chest pain involves evaluating a number of signs and symptoms. One consideration is the patient’s medical history. Has he or she ever experienced anginal chest pain? If so, it is likely the current chest pain is angina pectoris. If this is the patient’s first episode of chest pain, however, dental team members should treat it as if it were AMI and have emergency medical services (EMS) transfer the patient to a hospital as quickly as possible.

The quality of pain must also be evaluated to determine a cause. If the pain is significant but not severe, angina pectoris is most likely the culprit, not AMI. Angina pectoris is chest pain or discomfort when the heart is not receiving an adequate supply of blood and oxygen. Pain that radiates, commonly to the left side of the body — for example, the left mandible, arm or shoulder — is more often caused by AMI than by angina pectoris. Not all pain associated with AMI radiates, however, and some patients have atypical pain. For example, women and patients with diabetes often experience an unusual shortness of breath and/or an unexplained elevation of blood sugar levels as symptoms of AMI, but no chest pain. This is described as silent myocardial infarction.³

Blood pressure also might indicate whether the patient is experiencing angina pectoris or AMI. Although exceptions have been reported, if the patient’s blood pressure is elevated during the episode of chest pain, angina pectoris is most likely the cause.⁴ This elevation may be a response to the pain felt by the patient. If the blood pressure falls below the patient’s baseline value or immediate preoperative value, dental team members should consider AMI. If the pump (i.e., heart) has been injured, it is less efficient, and this results in a decreased cardiac output and subsequent drop in blood pressure.⁵

Angina pectoris and acute myocardial infarction are the two most common causes of cardiac-related acute chest pain among conscious patients. The challenge for dental teams is to provide a quick differential diagnosis

Definitive care for chest pain requires the administration of supplemental oxygen and nitroglycerin (via sublingual tablet or spray). If this resolves the pain, the episode was likely angina pectoris. If the pain is persistent or worse, AMI should be suspected. Immediate activation of EMS, as well as the administration of aspirin, is indicated. Nitrous oxide/oxygen in a 50:50 concentration may also be administered.⁶ If the patient loses consciousness, begin chest compressions and basic life support immediately. Table 3 describes the steps to follow once a cause of the chest pain has been determined.

CARDIAC ARREST

Cardiac arrest can occur at any time, and may or may not be preceded by chest pain. Witnessing a patient experiencing cardiac arrest in the dental office is rare, but possible. In fact, this medical emergency can occur in the parking lot, waiting room or dental chair. Prompt recognition and management that includes early chest compressions, ventilation, immediate access to EMS, and defibrillation are critical.⁷

During cardiac arrest, the heart is unable to adequately pump blood and oxygen to the body. Without proper oxygenation, the patient quickly loses consciousness. Once cardiac arrest is recognized, the dental team must immediately call EMS, begin chest compressions, and retrieve the emergency kit with the portable oxygen tank, bag-valve mask and automated external defibrillator. High quality CPR improves the victim’s chances of survival, so it is essential that every member of the dental team is trained and competent in basic life support. Minimally, this training should take place annually so that team members can maintain their skills.

According to guidelines released by the American Heart Association in 2015,⁸ health care providers trained in basic life support should be able to assess pulse and breathing simultaneously in less than 10 seconds. It should be noted that agonal breathing or gasping is not considered normal breathing.

Chest compressions should begin immediately at a rate of 100 to 120/minute, with a compression depth of at least two inches (and no more than 2.4 inches) in an adult, while allowing complete chest recoil. The dental team should use the automated external defibrillator as soon as it is available, minimizing chest compression interruptions.

Meanwhile, open the airway with a head tilt/chin lift (Figure 1), and begin rescue breathing at a compression-to-ventilation ratio of 30:2. Rescue breathing by the health care professional is most often performed with a bag-valve mask device plugged into the portable oxygen tank at 10 to 15 L/minute. It is important to give effective breaths that make the chest rise and avoid excessive ventilation. The American Heart Association recommendation for a cardiopulmonary resuscitation cycle of chest compressions is two minutes. This is the cycle programmed into the automated external defibrillator. Table 4 is a flow chart of the steps to follow when a patient experiences cardiac arrest.

SUMMARY

Dental team members should receive annual comprehensive training on basic lifesaving techniques to ensure that all personnel are prepared to perform these duties at a moment’s notice. Scheduled, formal reviews of the office’s emergency plan and medical emergency kit will also help ensure that team members are prepared. Dental professionals are integral to the promotion and maintenance of oral health, and, with proper training and equipment, they can also save lives in the face of a life-or-death emergency.

References

1. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics: 2015 Update. Available at: https://www.heart.org/idc/groups/ahamah-public/@wcm/ @sop/ @smd/ documents/ downloadable/ucm_470707.pdf. Accessed June 1, 2016.
2. Kreiner M, Okeson JP, Michelis V, Lujambio M, Isberg A. Craniofacial pain as the sole symptom of cardiac ischemia: a prospective multicenter study. J Am Dent Assoc. 2007;138:74–79.
3. Grundy SM, Howard B, Smith S Jr, Eckel R, Redberg R, Bonow RO. Prevention Conference VI: Diabetes and Cardiovascular Disease — executive summary: conference proceeding for healthcare professionals from a special writing group of the American Heart Association. Circulation. 2002;105:2231–2239.
4. Garfunkel A, Galili D, Findler M, et al. [Chest pains in the dental environment]. Refuat Hapeh Vehashinayim. 2002;19:51–59,101.
5. Malamed SF. Sedation: A Guide to Patient Management. 5th ed. St. Louis: Mosby; 2010:475.
6. Homayounfar SH, Broomandi SH. Evaluation of Entonox as an analgesic for relief of pain in patients with acute myocardial infarction. Iran Heart J. 2006;7:16–19.
7. Phero JC. Basic life support is critical to successful cardiopulmonary resuscitation. Inside Dentistry. 2011;3:122–123.
8. American Heart Association. Highlights of the 2015 American Heart Association Guidelines Update for CPR and ECC. Available at: https://eccguidelines.heart.org/ wp-content/uploads/2015/10/2015-AHA-Guidelines-Highlights-English.pdf. Accessed June 1, 2016.

From Decisions in Dentistry. July 2016;1(09):48–51.