Layola, Venessa Anne Mei A.

Emergency Drugs

Table 1: Mandatory Emergency Drugs

Drugs Indications Preparations

For use in all medical
Steel cylinders (green); E tanks,
Oxygen emergencies where hypoxemia
690 L
may be present

Acute allergic reactions Acute Ampules: 1 mg

Epinephrine asthma (not responding to
adrenergic inhaler)
Angina pectoris, Acute
Nitroglycerin
myocardial infarction
Vials: 1 and 30 mg
Syringes: 0.3 and 1 mg
Tablets (sublingual): 0.15, 0.3, 0.4,
and 0.6 mg
Spray: 0.4 mg/actuation

Oxygen can be delivered to the spontaneously breathing patient via full face mask, nasal cannulae, or
nasal hood.

Epinephrine is mandatory for the treatment of cardiac arrest and overwhelming anaphylaxis.
However, it must be emphasized that these extreme conditions are the only situations that would
require its use in the dental office emergency. There are a few clinicians who maintain the mistaken
belief that epinephrine is the drug of choice in shock or shocklike states. There are three principal
reasons for disputing this belief.

First, in shock from almost any cause there is decreased venous return to the heart because of
peripheral venous pooling. Because the peripheral action of epinephrine is primarily on the arterial
side, there is little gain in promoting peripheral vasoconstrictions, which is already present because of
the massive release of endogenous catecholamines (epinephrine and norepinephrine). At this point
administration of epinephrine may further decrease venous return and tissue perfusion. Second, a
possible deleterious effect is an increase in selective ischemia that takes place in certain viscera such as
the kidney. Here, as in peripheral vessels, the blood supply is constricted in a compensatory effort to
increase blood flow to the more vital brain and heart tissues. Perpetuation of this condition could be
undesirable. Third, the possible precipitation of ventricular fibrillation in the ischemic and irritable
myocardium is an important factor. This could be especially disastrous in the dental office where
defibrillation equipment is usually not available. In early treatment of shock states the patient will
benefit more from measures aimed at correction of the primary cause such as hypovolemia rather than
misdirected attempts at pharmacologic correction.

Desirable properties of this agent include a rapid onset of action; potent action as a bronchial smooth
muscle dilator (beta2 properties); antihistaminic actions; vasopressor actions; and its actions on the
heart, which include an increased heart rate (21%), increased systolic blood pressure (5%), decreased
diastolic blood pressure (14%), increased cardiac output (51%), and increased coronary blood flow.
Undesirable actions include its tendency to predispose the heart to dysrhythmias and its relatively short
duration of action.

Epinephrine is an important drug during cardiac arrest because no other drug is capable of maintaining
coronary artery blood flow while CPR is in progress, which is essential for preserving the chances of
survival from cardiac arrest. Epinephrine also preserves blood flow to the brain. In the absence of drug
therapy, cerebral blood flow during CPR is minimal; most blood enters the common carotid artery and
flows into the external carotid branch, not the internal carotid artery. Following administration of a
drug with a-adrenergic properties, such as epinephrine, cerebral blood flow is significantly increased.

Because of its profound bronchodilating effects, epinephrine is also indicated for the treatment of acute
asthmatic attacks unrelieved by b2-adrenergic sprays or aerosols.

Side effects, contraindications, and precautions: Tachydysrhythmias, both supraventricular and

ventricular, may develop. Epinephrine should be used with caution in pregnant women because it
decreases placental blood flow and may induce premature labor. When used, all vital signs must be
monitored frequently.

Antihistamines will be of value in the treatment of the delayed allergic response and in the definitive
management of the acute allergic reaction (administered after epinephrine has terminated the acute life-
threatening phase of the reaction). Antihistamines act as competitive antagonists of histamine. They do
not prevent the release of histamine from cells in response to injury, drugs, or antigens, but do prevent
access of histamine to its receptor site in the cell and thereby block the response of the effector cell to
histamine. Thus, antihistamines are more potent in preventing the actions of histamine than in
reversing these actions once they develop.

Nitroglycerin Vasodilators are used in the immediate management of chest pain (such as may occur
with angina pectoris or acute myocardial infarction). Two varieties of vasodilator are available:
nitroglycerin (TNG) as a tablet and a spray, and an inhalant, amyl nitrite. A patient with a history of
angina pectoris will usually carry a supply of nitroglycerin. Tablets remain the most popular form of
TNG, although most patients prefer the translingual spray once they have used it. .

Amyl nitrite, another vasodilator, is available for use as an inhalant. It is supplied in a yellow vaporole
or a gray cardboard vaporole with yellow printing in a dose of 0.3 mL, which when crushed between
one's finger and held under the victim's nose will act in about 10 seconds to produce a profound
vasodilation. The duration of action of amyl nitrite is shorter than that of TNG; however, the shelf life
of the vaporole is considerably longer. Side effects occur with all vasodilators but they are more
significant with amyl nitrite.

Side effects, contraindications, and precautions: Side effects of nitroglycerin include a transient
pulsating headache, facial flushing, and a degree of hypotension (noted especially if the patient is in an
upright position). Because of its mild hypotensive actions, nitroglycerin is contraindicated in patients
who are hypotensive, but may be used with some degree of effectiveness in the management of acute
hypertensive episodes. Side effects of amyl nitrite are similar to but more intense than those of
nitroglycerin. These include facial flushing, pounding pulse, dizziness, intense headache, and
hypotension. Amyl nitrite should not be administered to patients who are in an upright position because
the patient may feel dizzy and suffer a fall.

Table 2: Emergency Support Drugs

Category Generic Proprietary Alternative

Injectable
Anticonvulsant Midazolam Versed Diazepam
Analgesic Morphine Meperidine
Vasopressor Methoxamine Vasoxyl Phenylephrine
Antihypoglycemic 50% Dextrose sol. Glucagon
Hydrocortisone Solu-
Corticosteroid Dexamethasone
Cortef sodium succinate
Antihypertensive Labetalol HCl Normodyne
Anticholinergic Atropine

Noninjectables
Respiratory stimulant Aromatic Ammonia
Carbohydrate Decorative
Antihypoglycemic Many
icing
Bronchodilator Albuterol Ventolin, Proventil Metaproterenol
Antihypertensive Nifedipine Procardia

Anticonvulsant Seizures that may require acute medical intervention may be associated with epilepsy,
hyperventilation episodes, cerebrovascular accidents, hypoglycemic reactions, or vasodepressor
syncope. Local anesthetic overdoses or accidental intravascular injection may also require the
administration of an anticonvulsant. Current management of a seizure that interferes with ventilation or
persists for longer than 5 minutes includes the use of an intravenous benzodiazepine such as diazepam
or midazolam.

With its introduction, diazepam became the preferred anticonvulsant. Because seizure disorders are
characterized by a stimulation of the central nervous and cardiorespiratory and cardiovascular systems,
followed by a period of depression of these same systems, drugs that depress the systems at therapeutic
does are more likely to produce postseizure complications. When barbiturates are administered to
terminate seizure activity, the degree of postseizure depression is accentuated and its duration
prolonged because of the pharmcologic action of the barbiturate.
If the doctor is not adapt at recognizing and managing this situation, the patient may be worse off after
the seizure than during it. The benzodiazepines, unlike barbiturates, will usually terminate seizure
activity without the pronounced depression of the respiratory and cardiovascular systems.

Analgesic medications will be useful during emergency situations in which acute pain or anxiety is
present. In most instances the presence of pain or anxiety will cause an increase in the workload of the
heart (and an increased myocardial oxygen requirement) that may prove detrimental to the well-being
of the patient. Two such circumstances are acute myocardial infarction and congestive heart failure.
The choice of analgesic drugs includes the narcotic agonists morphine sulfate and meperidine
(Demerol).

Side effects, contraindications, and precautions: Narcotic agonists are potent CNS and respiratory
depressants. Vigilant monitoring of vital signs is mandatory whenever these agents are used. Use of
narcotic agonists is contraindicated in victims of head injury and multiple trauma; they should be used
with care in persons with compromised respiratory function.

Vasopressor In most emergency situations in which a vasopressor is indicated in the dental office, an
agent such as epinephrine will not be the drug of choice. Epinephrine will be used primarily in the
management of acute allergic reactions and is rarely employed in cases of clinically mild to moderate
hypotension. One reason for this is that epinephrine elicits an extreme antihypotensive response. In
addition to an increase in blood pressure, epinephrine causes an increase in the workload of the heart
through its effect on heart rate and cardiac contraction; it also increases the irritability of the
myocardium by sensitizing it to dysrhythmias.

Vasopressors such as methoxamine (Vasoxyl) and phenylephrine (Neo-Synephrine) are drugs that
produce moderate blood pressure elevations through peripheral vasoconstriction.

Methoxamine is a clinically useful vasopressor with sustained action and little effect on the
myocardium or central nervous system. Its vasopressor action is associated with a marked increase in
peripheral resistance and no increase in cardiac output. A compensatory bradycardia accompanies the
rise in blood pressure produced by methoxamine. The onset of the pressor action is almost immediate
following IV administration and may persist for up to 60 minutes. After IM injection the response
occurs within 15 minutes and persists for 90 minutes.

Phenylephrine acts in a similar fashion, with a 5-mg IM dose causing a 30-mm Hg elevation of systolic
blood pressure and a 20-mm Hg elevation of diastolic blood pressure, with the response persisting for
50 minutes. As with methoxamine, a pronounced and persistent bradycardia will be noted (average
decline in heart rate from 70 to 44 beats per minute).

Antihypoglycemic Glucose preparations are used to treat hypoglycemia that results either from fasting
or insulin use in a patient with diabetes mellitus. If the patient is conscious, oral carbohydrates such as
chocolate bar, cake icing, or cola drink will act rapidly to restore circulating blood sugar. On the other
hand, if the patient is unconscious and acute hypoglycemia is suspected, intravenous administration of
50% dextrose solution is the treatment of choice.

Corticosteroids will be administered in the management of an acute allergic reaction, but only after
the acute phase has been brought under control through the use of basic life support, epinephrine, and
antihistamines. The primary value of the corticosteroids is in the prevention of recurrent episodes of
anaphylaxis. Corticosteroids are also important in the management of acute adrenal insufficiency.

The onset of intravenous corticosteroids, such as hydrocortisone sodium succinate, is delayed, but the
drugs can be useful in halting the progression of a major allergic or anaphylactoid reaction. There is
also the potential for encountering what appears initially to be a syncopal episode but is in reality the
more serious problem of acute adrenal insufficiency in a patient chronically taking systemic
corticosteroids to treat a medical condition. For this life-threatening emergency, only the prompt
diagnosis and infusion of corticosteroids will be curative.

Hydrocortisone sodium succinate is considered the drug of choice for the dental emergency kit.
Corticosteroids are considered second-line drugs primarily because of their slow onset of action.

Antihypertensive The need to administer drugs to decrease excessive elevations in blood pressure is
extremely uncommon. First, the incidence of extreme acute blood pressure elevation is quite rare and,
second, there are other means of decreasing blood pressure without resorting to parenteral
antihypertensive drugs.

Emergency Drugs
Oral drugs, such as nifedipine or nitroglycerin, may be administered in most situations to provide a
minor depression of blood pressure. The inclusion of a drug in this category is in response to state
requirements for general anesthesia permits (and in a few states for parenteral sedation, too).

Anticholinergic Atropine, a parasympathetic blocking agent, is recommended for the management of

symptomatic bradycardia (adult heart rate of <60 beats per minute). By enhancing discharge from the
sinoatrial (SA) node, atropine may provoke tachycardia (adult heart rate>100 beats per minute).
Atropine will be of benefit in situations in which the patient has an overload of parasympathetic
activity on the heart. Extremely fearful patients are likely candidates for this response.

Atropine is also considered an essential drug in advanced cardiac life support (ACLS), in which it is
employed in the management of bradydysrhythmias (hemodynamically significant heart block and
asystole).

Side effects, contraindications, and precautions: Large doses of atropine (>2.0 mg) may produce
clinical signs of overdosage, including: hot, dry skin; headache; blurred near vision; dryness of the
mouth and throat; disorientation; and hallucination. Administration of atropine is contraindicated in
patients with glaucoma or prostatic hypertrophy. However, in life-threatening situations the benefits of
atropine administration usually outweigh the possible risks.

Respiratory stimulant After oxygen, aromatic ammonia is the most commonly used drug in the
emergency situation. It is available in a silver-gray vaporole, which is crushed and placed under the
victim's nose until respiratory stimulation is effected. Aromatic ammonia has a noxious odor and acts
by irritating the mucous membrane of the upper respiratory tract, thereby stimulating the respiratory
and vasomotor centers of the medulla; this in turn increases respiration and blood pressure. Movement
of the arms and legs often occurs in response to inhalation of ammonia. This too acts to increase the
return of blood from the periphery and aids in raising blood pressure, especially if the patient has been
positioned properly.
Side effects, contraindications, and precautions: Ammonia should be employed with caution in
persons with chronic obstructive pulmonary disease (COPD) or asthma because its irritating effects on
the mucous membranes of the upper respiratory tract may precipitate bronchospasm.

Antihypoglycemic agents will be useful in the management of hypoglycemic reactions occurring in

patients with diabetes mellitus or in the nondiabetic patient with hypoglycemia (low blood sugar). The
diabetic patient will usually carry a ready source of carbohydrate such as a candy bar or hard candy.
Such items should also be available in the dental office for use in the conscious patient with
hypoglycemia.

Bronchodilator Asthmatic patients and patients with allergic reactions manifested primarily by
respiratory difficulty will require the use of bronchodilator drugs. Although epinephrine remains the
drug of choice in the management of bronchospasm, its wide ranging actions on systems other than the
respiratory tract has resulted in the introduction of newer, more specific agents known as b2-adrenergic
agonists. These agents, of which albuterol is an example, have specific bronchial smooth muscle-
relaxing properties (b2) with little or no stimulatory effect on the cardiovascular and gastrointestinal
systems (b1) . In the dental situation in which the patient's true cardiovascular status may be unknown,
b2 agonists appear more attractive for management of the acute asthmatic episode than agents that have
both b1 and b2 agonist properties, such as epinephrine and isoproterenol.

Bronchodilators must be administered precisely as directed. One to two inhalations every 4 to 6 hours
is the recommended dosage for albuterol. Nebulized epinephrine (e.g., Primatene-Mist â ) should be
administered one to two inhalations per hour. In situations in which these nebulized agents fail to
terminate the attack, other bronchodilators (e.g., epinephrine, aminophylline, isoproterenol) must be
administered parenterally (intramuscularly or subcutaneously).

Side effects, contraindications, and precautions: Albuterol, like other b2 agonists, may have a clinically
significant cardiac effect in some patients. This response is less likely to develop with albuterol than
with other bronchodilators, thus its selection for the emergency kit. Metaproterenol, epinephrine, and
isoproterenol mistometers are more likely to produce cardiovascular side effects, including tachycardia
and ventricular dysrhythmias.

Table 3: Advanced Cardiac Life Support Drugs

Drug Indication
Antiarrhythmics
Ventricular tachycardia, pulseless, ventricular
Lidocaine
tachycardia, or ventricular fibrillation
Ventricular tachycardia, pulseless ventricular
Procainamide
tachycardia or ventricular fibrillation
Ventricular tachycardia, pulseless ventricular
Bretylium
tachycardia or ventricular fibrillation
 Atrial flutter or atrial fibrillation, paroxysmal
Verapamil, diltiazem
supraventricular tachycardia
Adenosine Paroxysmal supraventricular tachycardia
Bradycardia, asystole, first-degree and Mobitz type
Atropine I atrioventricular block, Mobitz type II and third-
degree block
Magnesium Torsades de pointes, ventricular fibrillation
Atrial flutter or atrial fibrillation, refractory
ß blockers (e.g., propranolol)
ventricular tachycardia or ventricular fibrillation
Inotropes
Ventricular fibrillation, asystole, pulseless,
Epinephrine
electrical activity, bradycardia
Norepinephrine Refractory hypotension
Dopamine Bradycardia, hypotension
Dobutamine Congestive heart failure
Isoproterenol Refractory bradycardia
Digitalis Atrial flutter, fibrillation
Amrinone Refractory congestive heart failure
Vasodilators/Antihypertensives
Nitroprusside Hypertension, acute heart failure
Nitroglycerin Hypertension, acte heart failure, anginal pain
Others
Hyperkalemia, metabolic acidosis with bicarbonate
Sodium bicarbonate
loss, hypoxic lactic acidosis
Furosemide Acute pulmonary edema
Morphine Acute pulmonary edema, pain and anxiety
Thrombolytic agents (e.g., anistreplase) Acute myocardial thrombosis

Table 4: Antidotal Drugs

Category Generic Proprietary Alternative

Narcotic antagonist Naloxone Narcan Nalbuphine
Benzodiazepine
Flumazenil Mazicon
antagonist
Antiemergence delirium Physostigmine Antilirium
Vasodilator Procaine Novocain

Table 5: Emergency Drug Kit

Adult Dosage and Route of

Drug Indications
Administration
Epinephrine (Adrenalin)-1:1000 anaphylaxis, cardiac arrest 0.5 ml intravenously
Methylprednisolone sodium
cardiac arrest, anaphylaxis, acute 125 mg intravenously, given
succinate (Solu-Medrol)-125 mg
adrenocortical insufficiency slowly
Monovile
1 mEq/kg intravenously initially,
Sodium bicarbonate–7.5% cardiac arrest
then half this every 10 minutes
acute allergic reaction,
Diphenhydramine (Benadryl) 10
extrapyramidal reaction to 5 ml intravenously
mg/ml
phenothiazine
Aromatic spirits of ammonia-
syncope one ampule, by inhalation
crush ampules
Glyceryl trinitrate–0.6 mg tablet angina pectoris one tablet sublingually
1 ml subcutaneously or
Morphine sulfate–15mg/ml myocardial infarction
intravenously
Phenylephrine hydrochloride
(Neo-Synephrine Hydrochloride) toxic reaction to local anesthetic 1 to 2 ml intravenously
– 1:500
hypovolemia, IV route for drug
Dextrose in water–5% 1000 ml IV drip
administration
severe or prolonged convulsion
Diazepam– 5 mg/ml as in toxic reaction to local 1 to 8 ml intravenously (titrated)
anesthetic
Naloxone hydrochloride(Narcan) 1 ml intravenously or
narcotic depression
–0.4 mg/ml intramuscularly
Isoproterenol hydrochloride
bronchospasm one or two inhalations
aerosol–0.25%
Physostigmine salicylate – CNS depression following 0.5 to 2 ml intravenously (slow
1mg/ml diazepam administration titration)
Atropine sulphate–0.1 mg/ml bradycardia with hypotension 0.5 - 1.0 mg IV