Dentists must be prepared to manage medical emergencies which may arise in practice.
I. ESSENTIAL EMERGENCY DRUGS
Medical emergencies were most likely to occur during and after local anesthesia, primarily during tooth extraction and endodontics. In the United States and Canada, studies have also shown that syncope is the most common medical emergency seen by dentists.
The extent of treatment by the dentist requires preparation, prevention and then management, as necessary. Prevention is accomplished by conducting a thorough medical history with appropriate alterations to dental treatment as required.
The most important aspect of nearly all medical emergencies in the dental office is to prevent, or correct, insufficient oxygenation of the brain and heart.
Medical Emergencies in the Dental Office
Therefore, the management of all medical emergencies should include ensuring that oxygenated blood is being delivered to these critical organs. This is consistent with basic cardiopulmonary resuscitation, with which the dentist must be competent. This provides the skills to manage most medical emergencies, which begin with the assessment, and if necessary the treatment of airway, breathing and circulation the ABCs of CPR. Usually, only after these ABCs are addressed should the dentist consider the use of emergency drugs.
Drugs that should be promptly available to the dentist can be divided into two categories. These drugs are summarized in Table 1. The second category contains drugs which are also very helpful and should be considered as part of the emergency kit. These supplementary drugs are summarized in Table 2.
Medical emergencies in the dental office
The precise composition of the drug kit can vary as the presence of the drugs in this latter group may depend on the nature of the dental practice. The following will summarize the drugs which should be part of a dentist's emergency kit.
Oxygen is indicated for every emergency except hyper-ventilation. This should be done with a clear full face mask for the spontaneously breathing patient and a bag-valve-mask device for the apneic patient.
Therefore whenever possible, with the exception of the patient who is hyperventilating, oxygen should be administered. For the management of a medical emergency it should not be withheld for the patient with chronic obstructive lung disease, even though they may be dependent on low oxygen levels to breathe if they are chronic carbon dioxide retainers.
Short term administration of oxygen to get them through the emergency should not depress their drive to breathe. This should allow for more than enough oxygen to be available for the patient until resolution of the event or transfer to a hospital.
If the typical adult has a minute volume of 6 liters per minute, then this flow rate should be given as a minimum. If the patient is conscious, or unconscious yet spontaneously breathing, oxygen should be delivered by a full face mask, where a flow rate of 6 to 10 liters per minute is appropriate for most adults.
If the patient is unconscious and apneic, it should be delivered by a bag-valve-mask device where a flow rate of 10 to 15 liters per minute is appropriate. A positive pressure device may be used in adults, provided that the flow rate does not exceed 35 liters per minute.
Epinephrine is the drug of choice for the emergency treatment of anaphylaxis and asthma which does not respond to its drug of first choice, albuterol or salbutamol. Epinephrine is also indicated for the management of cardiac arrest, but in the dental office setting, it may not be as likely to be given, since intravenous access may not be available. Its administration intramuscularly is not as likely to be very effective in this latter emergency, where adequate oxygenation and early defibrillation is most important for the cardiac arrest dysrhythmias with the relatively best prognoses, namely ventricular fibrillation or pulseless ventricular tachycardia.
As a drug, epinephrine has a very rapid onset and short duration of action, usually 5 to 10 minutes when given intravenously. For emergency purposes, epinephrine is available in two formulations.
It is prepared as 1 : 1,, which equals 1 mg per m l, for intramuscular, including intralingual, injections. More than one ampule or pre-filled syringe should be present as multiple administrations may be necessary. It is also available as 1 : 10,, which equals 1 mg per 10 mL for intravenous injection. Autoinjector systems are also present for intramuscular use such as the EpiPen which provides one dose of 0.
Initial doses for the management of anaphylaxis are 0. These doses should be repeated as necessary until resolution of the event. Similar doses should be considered in asthmatic bronchospasm which is unresponsive to a beta-2 agonist, such as albuterol or salbutamol.
The dose in cardiac arrest is 1 mg intravenously. Intramuscular administration during cardiac arrest has not been studied, but would appear to be unlikely to render significant effect.
Epiniphrine is clearly a highly beneficial drug in these emergencies. Concurrently, however, it can be a drug with a high risk if given to a patient with ischemic heart disease.
II. ADDITIONAL DRUGS
Nevertheless, it is the primary drug needed to reverse the life-threatening signs and symptoms of anaphylaxis or persistent asthmatic bronchospasm. This drug is indicated for acute angina or myocardial infarction. It is characterized by a rapid onset of action. For emergency purposes it is available as sublingual tablets or a sublingual spray.
One important point to be aware of is that the tablets have a short shelf-life of approximately 3 months once the bottle has been opened and the tablets exposed to air or light. The spray has the advantage of having a shelf-life which corresponds to that listed on the bottle.
This supports the need for the dentist to always having a fresh supply available. With signs of angina pectoris, one tablet or spray 0. Relief of pain should occur within minutes. If necessary, this dose can be repeated twice more in 5-minute intervals. Systolic blood pressures below 90 mmHg contraindicate the use of this drug. An antihistamine is indicated for the management of allergic reactions. Whereas mild non-life threatening allergic reactions may be managed by oral administration, life-threatening reactions necessitate parenteral administration.
Two injectable agents may be considered, either diphenhydramine or chlorpheniramine. They may be administered as part of the management of anaphylaxis or as the sole management of less severe allergic reactions, particularly those with primarily dermatologic signs and symptoms such as urticaria.
Recommended doses for adults are 25 to 50 mg of diphenhydramine or 10 to 20 mg of chlorpheniramine. A selective beta-2 agonist such as albuterol salbutamol is the first choice for management of bronchospasm. When administered by means of an inhaler, it provides selective bronchodilation with minimal systemic cardiovascular effects.
It has a peak effect in 30 to 60 minutes, with a duration of effect of 4 to 6 hours. Adult dose is 2 sprays, to be repeated as necessary.
Pediatric dose is 1 spray, repeated as necessary. Aspirin acetylsalicylic acid is one of the more newly recognized life-saving drugs, as it has been shown to reduce overall mortality from acute myocardial infarction.
The purpose of its administration during an acute myocardial infarction is to prevent the progression from cardiac ischemia to injury to infarction.
There is a brief period of time early on during a myocardial infarction where aspirin can show this benefit.
Medical Emergencies in the Dental Office
For emergency use there are relatively few contraindications. These would include known hypersensitivity to aspirin, severe asthma or history of significant gastric bleeding. The lowest effective dose is not known with certainty, but a minimum of mg should be given immediately to any patient with pain suggestive of acute myocardial infarction. An oral carbohydrate source, such as fruit juice or non-diet soft-drink, should be readily available.
Whereas this is not a drug, and perhaps should not be included in this list, it should be considered essential. If this sugar source is kept in a refrigerator it may not be appreciated that it is a key part of the emergency equipment.
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Therefore, consideration should be given to making this part of the emergency kit. Its use is indicated in the management of hypoglycemia in conscious patients. In addition to the 6 drugs discussed above, a number of other drugs should be considered as part of an emergency kit, as shown in Table 2.
The presence of this drug allows intramuscular management of hypoglycemia in an unconscious patient. Glucagon is indicated if an intravenous line is not in place and venipuncture is not expected to be accomplished, as may often be the case in a dental office. The dose for an adult is 1 mg. If the patient is less than 20 kg, the recommended dose is 0.
Glucagon is available as 1 mg formulation, which requires reconstitution with its diluent immediately prior to use.
Handbook of medical emergencies in the dental office
This anti-muscarinic, anti-cholinergic drug is indicated for the management of hypotension, which is accompanied by bradycardia. The dose recommended is 0. Paradoxically, doses of less than 0. This drug is a vassopressor which may be used to manage significant hypotension. It has similar cardiovascular actions compared with epinephrine, except that ephedrine is less potent and has a prolonged duration of action, lasting from 60 to 90 minutes. Similar precautions as noted with epinephrine administration should be considered when given to a patient with ischemic heart disease.
For the treatment of severe hypotenson, it is ideally administered in 5 mg increments intravenously. Intramuscularly it should be given in a dose of 10 to 25 mg. Administration of a corticosteroid such as hydrocortisone may be indicated for the prevention of recurrent anaphylaxis. Hydrocortisone may also play a role in the management of an adrenal crisis. The notable drawback in their use in emergencies is their relatively slow onset of action, which approaches one hour even when administered intravenously.
This is the reason why these drugs are not considered essential, as they are of minimal benefit in the acute phase of the emergency. There is low likelihood of an adverse response with one dose.
The prototype for this group is hydrocortisone, which may be administered in a dose of mg as part of the management of these emergencies. Morphine is indicated for the management of severe pain which occurs with a myocardial infarction.
Advanced Cardiac Life support recommendations list morphine as the analgesic of choice for this purpose. This should be guided by a decrease in blood pressure and respiratory depression. Extreme caution should be used in the elderly. If an intravenous is not in place, consideration can be given to administering morphine in a dose of approximately 5 mg intramuscularly.