Emergency cardiac care. Moral, legal, and ethical considerations.

According to the American Heart Association, "Successful completion of an ACLS course means in accordance with the cognitive and performance standards of the American Heart Association. It does not warrant performance, nor does it, per se, qualify or authorize a person to perform any procedure. It in no way related to licensure, which is a function of the appropriate legislative, health or educational authority." The same can be said for BLS; however, with the recent revisions in ECC programs, even this disclaimer has been eliminated from the most recent textbooks in BLS and ACLS. This is in keeping with "...the American Heart Association's reaffirmation of its role as an educational resource rather than as a certifying agency." Lay public course participants in BLS (which technically includes dentists) will now receive course participation cards. Health care provider course participants will continue to receive "course completion cards" if all criteria have been satisfied by the student. The trend is to categorize what was previously termed testing as evaluation. Certification has become a thing of the past. It is unclear at this time what the impact this policy change will have on agencies who rely upon documentation from the American Heart Association to satisfy requirements that have been imposed upon dentists and other health professionals for initial licensure and relicensure. Semantics aside, one thing that remains clear is the expectation of the dentist with regards to emergency management. Expertise (for lack of a better term) in specific aspects of ECC remains a standard. For all dentists, expertise in BLS is that standard. For dentists administering deep sedation and general anesthesia, expertise in ACLS is the community standard. Although there is some ambiguity for those dentists administering conscious sedation, at the very least, they should have expertise in BLS. In addition, they are strongly encouraged to have expertise in ACLS, particularly because the limited hours of training in conscious sedation provide less medical background than is acquired during training in deep sedation and general anesthesia. In addition, the dentist is ultimately responsible for the demeanor of his or her office and staff. In the prehospital dental office setting, the matter of converting a dental office team geared to efficient delivery of dental procedures, into a team primed to perform emergency cardiac care seems daunting. This is especially so if the dentist has little undergraduate or clinical preparation for managing life-threatening emergencies. Therefore, an emergency management plan (with oversight for its implementation by the dentist) is of paramount importance.

Major morbidity or mortality from office anesthetic procedures: a closed-claim analysis of 13 cases.

A closed-claim analysis of anesthetic-related deaths and permanent injuries in the dental office setting was conducted in cooperation with a leading insurer of oral and maxillofacial surgeons and dental anesthesiologists. A total of 13 cases occurring between 1974 and 1989 was included. In each case, all available records, reports, depositions, and proceedings were reviewed. The following were determined for each case: preoperative physical status of the patient, anesthetic technique used (classified as either general anesthesia or conscious sedation), probable cause of the morbid event, avoidability of the occurrence, and contributing factors important to the outcome. The majority of patients were classified as American Society of Anesthesiologists (ASA) status II or III. Most patients had preexisting conditions, such as gross obesity, cardiac disease, epilepsy, and chronic obstructive pulmonary disease, that can significantly affect anesthesia care. Hypoxia arising from airway obstruction and/or respiratory depression was the most common cause of untoward events, and most of the adverse events were determined to be avoidable. The disproportionate number of patients in this sample who were at the extremes of age and with ASA classifications below I suggests that anesthesia risk may be significantly increased in patients who fall outside the healthy, young adult category typically treated in the oral surgical/dental outpatient setting.

Pharmacologic desensitization for dental phobias: clinical observations.

The elimination of the extreme fear reported by dental phobic patients traditionally involves psychologic interventions such as systematic desensitization. Observations resulting from a conscious sedation approach, as outlined in two case histories, suggest that a desensitization phenomena is occurring. This pharmacologic desensitization appears to mimic elements of systematic desensitization. Optimal management of fearful patients may sometimes require conjunctive support from both dental behavioral scientists and dental anesthesiologists.

Intraoperative management of a partially severed endotracheal tube during orthognathic surgery.

A potential hazard of orthognathic surgery is disruption to the endotracheal tube as it passes through the nasal cavity. Instrumentation necessary to the surgical procedure can inadvertently sever the tube either partially or completely necessitating one of several procedures to correct the situation. A case report is presented which describes a situation where the patient's endotracheal tube had been partially lacerated intraoperatively. Due to lack of patency in one nostril, a method for replacement was required that allowed the new tube to pass through the same nostril as the original tube without placing excessive forces on a surgically fractured maxilla. The mechanism for the replacement procedure as well as consideration of alternative approaches is discussed.