Primary Survey

When faced with an emerging perioperative medical event, the following hierarchical steps must be implemented in every situation: (1) assess responsiveness, (2) check airway, (3) and, simultaneously, check breathing and pulse. These fundamental activities comprise the primary survey (Box D), which identifies those problems that are immediately life-threatening and must be promptly acted upon, i.e., obstructed airway, respiratory arrest, or cardiac arrest.

Box D. Primary Survey: Every Patient.

Assess responsiveness (level of consciousness):

Tap the patient on the shoulder and shout – “Are you OK?” (Figure 1)
- Responsive patient
  - Alert
    - Awake and able to speak
  - Disoriented
    - May moan, cry, or make other sounds
    - Responds to verbal and/or painful stimuli. i.e., moves
Place responsive patient in the dental chair in an upright/semi-reclining position (Figure 2)
Unresponsive patient
- Silent, does not respond to verbal and painful stimuli
  - Place unresponsive patient in the dental chair in a supine position on a firm, flat board (e.g., EMS board) to allow for adequate compressions later (Figure 3)
    - SUMMON THE OFFICE EMERGENCY TEAM
    - NOTIFY EMERGENCY MEDICAL SERVICES TEAM (EMS)

Figure 1.

Figure 2.

Figure 3.

Box D. Primary Survey: Every Patient.

Assess responsiveness (level of consciousness):

Tap the patient on the shoulder and shout – “Are you OK?” (Figure 1)
- Responsive patient
  - Alert
    - Awake and able to speak
  - Disoriented
    - May moan, cry, or make other sounds
    - Responds to verbal and/or painful stimuli. i.e., moves
Place responsive patient in the dental chair in an upright/semi-reclining position (Figure 2)
Unresponsive patient
- Silent, does not respond to verbal and painful stimuli
  - Place unresponsive patient in the dental chair in a supine position on a firm, flat board (e.g., EMS board) to allow for adequate compressions later (Figure 3)
    - SUMMON THE OFFICE EMERGENCY TEAM
    - NOTIFY EMERGENCY MEDICAL SERVICES TEAM (EMS)

*If alone, the AED should be used as soon as it is determined that the patient is in cardiac arrest

Check airway:

If the patient is responsive (i.e., alert and talking, even in a whisper) the airway is open, at least partially, at this time
If the patient is unresponsive (i.e., does not respond to verbal and painful stimuli) evaluate airway
- If the airway is not open, it may be due to relaxation of the soft tissues of the oropharynx
  - Perform head-tilt/chin-lift (Figure 4)
- If obstruction is caused by foreign material it must be cleared
  - Suction thick, frothy, bloody saliva and vomitus
  - Foreign object must be removed (see Airway obstruction (foreign body)

Check airway:

If the patient is responsive (i.e., alert and talking, even in a whisper) the airway is open, at least partially, at this time
If the patient is unresponsive (i.e., does not respond to verbal and painful stimuli) evaluate airway
- If the airway is not open, it may be due to relaxation of the soft tissues of the oropharynx
  - Perform head-tilt/chin-lift (Figure 4)
- If obstruction is caused by foreign material it must be cleared
  - Suction thick, frothy, bloody saliva and vomitus
  - Foreign object must be removed (see Airway obstruction (foreign body)

Figure 4.

Look for breathing and check pulse (minimum 5 seconds; maximum 10 seconds):

Simultaneously, see if the patient’s chest rises and falls, listen for escaping air, and feel the airflow against the side of your cheek (Figure 5); and palpate the carotid artery (Figure 6)
- Unresponsive patient
  - Normal breathing (quiet, regular and effortless) and has definite pulse
    - Monitor vital signs until EMS arrives
  - No normal breathing, but has definite pulse
    - Initiate rescue breathing
      - 1 breath every 5-6 seconds (10 to 12 breaths/min.)
      - Check pulse every 2 minutes
  - If no pulse, begin cardiopulmonary resuscitation (CPR) and prepare for
    - automated external defibrillation (AED) in accordance with currentAmerican Heart Association and/or American Red Cross Guidelines.^20,21
- No breathing or only agonal breaths (i.e., isolated or infrequent gasping) and no pulse
  - Begin CPR – cycles of 30 compressions and 2 breaths
    - Continue CPR until AED is turned on, the AED pads are applied, and the AED is ready to analyze the heart rhythm*
      - Ensure that everyone, including the rescuer performing CPR, is clear of the patient during AED rhythm analysis and shock
        If the AED advises that a shock is not indicated
        Resume the CPR immediately until prompted by AED to allow rhythm check (about 2 minutes)
        If the AED advises that a shock is indicated press the shock button
        Resume CPR immediately until prompted by AED to allow rhythm check (about 2 minutes)
  - Continue with CPR and defibrillation until EMS takes over or the patient starts to move

Figure 5.

Figure 6.

*If alone, the AED should be used as soon as it is determined that the patient is in cardiac arrest

The unresponsive patient in an oral healthcare setting depend on the office emergency team for (1) early recognition of airway obstruction, respiratory and/or cardiac arrest and notification of EMS, (2) early high-quality CPR to delay brain damage from lack of oxygen, (3) early defibrillation to restore an effective heart rhythm, and (4) early advanced life support and post-arrest care. For each minute CPR and/or defibrillation is delayed, the patient’s chance of survival is reduced by 7 to 10 percent.

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