Index

Introduction
Incidence and Prevalence
Kiss Principal
Components of the emergency kit
Types of Modules
Module - 1
Module - 2
Module - 3
Module - 4
Conclusion - Organization of the
Emergency Kit
EMERGENCY KITS
Introduction
In spite of efforts to prevent them, life-threatening emergencies can, and
do, occur inthe practice of dentistry. Prevention, as successful as it may be, is
not always enough. The entire dental office staff must be prepared to assist in
the recognition and management of any potential emergency situation. If every
staff member is not prepared, those few serious emergencies that all doctors
will encounter during their career may result in tragedy.

Incidence & Prevalence

Guidelines have been established to help doctors and staff members
adequately prepare for the immediate and effective management of life-
threatening situations. Most of these guidelines were developed by state boards
of dental examiners in connection with the certification of doctors who wish to
use parenteral sedation techniques, such as intramuscular (IM) or intravenous
(IV) sedation or general anesthesia, in their offices. Of late, many state dental
boards have enacted regulations controlling the use of orally administered
central nervous system (CNS) depressants. Guidelines for emergency
preparedness are included in all of these regulations. Speciality groups, such as
the American Association of Oral & Maxillofacial surgeons, the American
Academy of Pediatric Dentistry, and the American Association of Periodontists
have developed guidelines for their membership.

Those primarily affected by these guidelines are doctors who have

received advanced education and training degrees in various techniques of
CNS-depressant drug administration. The guidelines provide lists of
recommended personnel, equipment, and emergency drugs for the safe and
effective management of emergency situations.

Regardless of a doctor's level of training in emergency medicine, staff

members should be equally prepared to manage these situations. The doctor is
always expected to initiate emergency management and be capable of
sustaining a patient's life through application of the steps of basic life support
(BLS [also known as cardiopulmonary resuscitation, or CPR]) : P (positioning),
A (airway), B (breathing), and C (circulation). Management of D (definitive
treatment), which includes the administration of drugs, will be predicated on
the training level of the treating doctor.

Many of these practitioners state that they are their area's primary source
for emergency medical care because the nearest ambulance service is more than
1 hour away. Mny of them are trained in advanced cardiovascular life support
(ACLS) and certified in advanced trauma life support (ATLS), while others
possess varying degrees of training as emergency medical technicians (EMTs)
and paramedics. Morrow suggests appropriate levels of emergency training for
these doctors and recommends that they have immediate acess to emergency
kits, the design of which is based on the distance between the dental office and
nearest emergency medical facility. The greater this distance and the time
needed for travel, the more training and access to emergency drugs the doctor
requires.

Preparation of dental staff members and of the office for medical

emergencies should include the following minimal requirements :
1. Staff training should include BLS instruction for all members
of the dental office staff, recognition and management of
specific emergency situations, and emergency 'fire drills.'
2. Office preparation should include the posting of emergency
assistance numbers and the stocking of emergency drugs and
equipment.

EMERGENCY DRUG KITS

The dental office emergency kit need not and indeed should not be
complicated. It should be as simple as possible to use. The "KISS" principal is
important at this time: "Keep It Simple, Stupid." Pallasch's statement that
"complexity in a time of adversity breeds chaos" is as true today as it was when
written in 1976. The doctor should remember three things in preparing and
using emergency drug kits:

1. Drug administration is not necessary for the immediate

management of medical emergencies (BLS is always used, as
needed, first).
2. Primary management of ALL emergency situations involves
BLS.
3. When in doubt, don't medicate.

The emergency kit described in the following sections is a simple,

organized collection of drugs and equipment that has been highly effective in
the management of life-threatening situations that occur in dental offices.
However, proper management of a patient in almost all emergency situations
does not require drug administration. First and foremost in the management of
emergency situations are the steps of BLS (P ABC). Only after these
steps have been implemented should the doctor consider the administration of
drugs. Even in acute anaphylaxis, in which the patient experiences immediate
respiratory distress, circulatory collapse, or both, BLS remains the immediate
response, followed as rapidly as possible by the administration of epinephrine.
Management of all emergency situations follows the P ABCD
protocol (D .... definitive management: drugs and EMS).

Components of the emergency kit

Doctors should consider including items from each therapeutic category
in the emergency kit; however, doctors should select only those categories or
drugs with which they are familiar and able to use. Preferred drugs are listed,
with alternatives suggested in many instances. All doctors must evaluate
carefully every item that is included in their emergency drug kit. If a doctor has
any doubt about the categories or specific agents, consultation with a physician
(preferably a specialist in emergency medicine) or hospital pharmacist is
recommended-but above all determine their reason for suggesting a certain
drug or drug category over others.

All drugs come with drug-package inserts. Doctors should save this
information sheet from each drug included in their kit, read it, and take note of
important information about the drug, including its indications, usual doses
(pediatric, adult, and geriatric), adverse reactions, and expiration dates. Many
doctors transfer this information to an index card for quick reference. The
emergency drugs and equipment described in the following sections are
presented in four levels, or modules. The design of each module is based on the
doctor's level of training and experience in emergency medicine:
Module 1 : basic emergency kit (critical drugs and equipment)
Module 2 : noncritical drugs and equipment
 Module 3 : ACLS drugs
Module 4 : antidotal drugs

Two categories are described for each module injectable and

noninjectable drugs, as well as emergency equipment. Doctors always must
remember that the categories of drugs and equipment included in the
emergency kit must conform to the level of training of the office personnel who
will use it. Emergency kits should be simple but effective.

Most injectable emergency drugs are prepared in a 1-mL glass ampule or

vial. The number of milligrams of drug present in 1 mL of solution will vary
from drug to drug. For example, for diazepam the amount is 5mg/mL, whereas
for diphenhydramine the amount is 50 mg/mL and for ephedrine, 10 mg/mL,
The 1-mL form of the drug is known as its therapeutic dose, or unit dose.
Thus, 1 mL of solution is the usual dose of the drug administered to an adult
patient (8 years of age and older or a younger patient weighing in excess of 60
lbs [27 kg]) in an emergency situation. For pediatric patients (age 1 to 8
years), the therapeutic dose of an injectable drug is 0.5 mL, or half the adult
dose; for infants (under 1 year), the therapeutic dose is 0.25 mL, or one quarter
the adult dose.

However, epinephrine is the major exception to this basic rule of doses.

Although the 1-mL solution of 1:1000 epinephrine is considered the adult
therapeutic dose, a smaller initial dose-0.3 mL-is recommended, with
subsequent doses based on the patient's response. Initial pediatric and infant
epinephrine doses are reduced
accordingly (0.15 mL and 0.075 mL of a 1:1000 epinephrine solution).
 Noninjectable drugs are usually prepared so that one tablet or metered
spray is the adult therapeutic dose. Many noninjectable drugs are also prepared
in pediatric forms to simplify administration. Because both adults and children
are seen in most dental offices, a doctor treating many children should consider
including both drug forms in the emergency drug kit.

Other items of emergency equipment should be available in both adult

and pediatric forms. These include face masks and oropharyngeal and
nasopharyngeal airways (if warranted by training). Indeed the pediatric dentist
(and general dentist who treats many children) must provide a wider range of
equipment in both pediatric (for the patient) and adult (for the doctor or staff
patient)
sizes than the doctor who treats only adults.
Route of drug administration, by onset of action (fastest to slowest).
1. Endotracheal (ET) (when available); epinephrine, Lidocaine,
atropine, naloxone, and flumazenil only.
2. Intravenous (IV)
3. Intranasal (IN) : midazolam
4. Subligual or intralingual
5. Intramuscular (IM)
a) Vastus lateralis
b) Mid-deltoid
c) Gluteal region

MODULE ONE: CRITICAL (ESSENTIAL) EMERGENCY

DRUGS AND EQUIPMENT

Module one - critical (essential) emergency drugs

Category Generic drug Proprietary drug Alternative Quantity Availability
INJECTABLE
Allergy- Epinephrine Adrenalin None 1 Preloaded 1 : 1000
anaphylaxis syringe + (1 mg/mL)
3x1-mL
ampules
Allergy- Chlorphen- Chlor-Trimeton Diphenhy- 3x1-mL 10mg./mL
histamine- iramine dramine ampules
blocker (Benadryl)
NONINJECTABLE
Oxygen Oxygen Oxygen 1 'E' cylinder
Vasodilator Nitroglycerin Nitrolingual spray NitroStat 1 Metered 0.4 mg/ metered
sublingual spray bottle dose
tablets
Bronchodilator Albuterol Proventil, Ventolin Metaproterenol 1 metered- Metered-
dose inhaler aerosol inhaler
Antihypog- Sugar Orange juice, Insta-Glucose 1 bottle
lycemic Nondiet soft drink gel
Inhibitor of Aspirin Many None 2 packets 325 mg/
platelet tablet
aggregation

Equipment Recommended Alternative Quantity

Oxygen delivery system Positive pressure and O2 delivery system with Minimum
demand valve bag-value-mask device 1 large adult, 1 child

Pkcket mask 1 per employee

Automated electronic
defibrillatory (AED)
Syringes for drug
administration
Suction and suction tips
Tourniquets
Magill intubation forceps
Many
Plastic disposable syrings
with needles
High-volume suction
Large-diameter, round-
ended suction tips
Robber or Velcro
tourniquet; rubber tubing
Magill intubation forceps
Nonelectrical suction system Office suction system
Sphygmomanometer
1 AED
3 x 2-mL syringes with
needles for parenteral drug
administration
Minimum 2
3 tourniquets and 1
sphygmomanometer
1 pediatric Magill intubation
forceps
 What should be included in the minimum (absolutely basic) emergency
kit for a dental or medical office? As always, BLS training is the most
significant asset and the first management technique to he used in all
emergencies. However, a number of injectable and noninjectable drugs and
items of equipment should also be considered absolutely essential for inclusion
in the dental office emergency kit.

A) Critical injectable drugs

The following two categories of injectable drugs are considered critical
in any emergency kit:
1. Epinephrine
2. Histamine blocker

Both drugs are used in the management of an acute allergic reaction, one
of the most feared of all emergency situations faced by the health care
professional.
1) Primary injectable: drug for acute allergic reaction
(anaphylaxis) Drug of choice. Epinephrine
Drug class - Catecholamine
Alternative drug - None

Proprietary
Ana-Guard, EpiPen, EpiPen Jr., Twinject Epinephrine (Adrenalin) is the
most important emergency drug in medicine. Epinephrine is the drug of choice
in the management of the acute (life-threatening) allergic reaction. Epinephrine
is valuable in the management of both the respiratory and cardiovascular
manifestations of acute allergic reactions.
Mode of Action
Desirable properties of epinephrine include
(1) a rapid onset of action;
(2) potent action as a bronchial smooth muscle dilator
(3) histamine-blocking properties;
(4) vasopressor actions; and
(5) cardiac effects :- which include
i) an increase in heart rate
ii) increased systolic blood pressure
iii) decreased diastolic blood pressure
iv) increased cardiac output
v) increased coronary blood flow.

Undesirable actions include epinephrine's tendency to predispose the

heart to dysrhythmias and its relatively short duration of action.
Therapeutic indications
Conc. Recommended
Acute allergic 1:1000
Acute asthmatic attack 1:1000
Cardiac arrest 1:10,000

Side effects, contraindications, and precautions

Tachydysrhythmias, both supraventricular and ventricular, may develop.
Epinephrine should be administered with caution to pregnant women because it
decreases placental blood flow and can induce premature labor. When it is
used, all vital signf should be monitored frequently. In the setting of the dental
office, epinephrine will usually be considered for administration in situations
felt to be acutely life-threatening, such as anaphylaxis and (possibly) cardiac
arrest. In such situations, the advantages of epinephrine administration clearly
outweigh any risks. No contraindications exist to epinephrine administration
under these conditions.

Availability
1) Epinephrine for parenteral administration is supplied in either a 1:1000
concentration, in which each milliliter contains 1 mg of the agent, or as a
1:10,000 concentration.
2) i) 1:1000 concentration for IM and subcutaneous
administration
ii) 1:10,000 concentration for IV administration.

3) Because of its short duration of action and because the dose administered
is 0.3 mg, multiple administrations are usually necessary during the
management of the acute phase of anaphylaxis.
Dose
Adult dose - 0.3 - 0.5 ml; im/s.c.
Pediatric dose - 0.15 ml

Suggested for emergency kit

1) One preloaded syringe
2) Three or four ampules of 1:1000 epinephrine

2) Primary injectable: drug for allergic, reaction

Drug of choice - Chlorpheniramine
Proprietary - Chlor-Trimeton
Drug class - Histamine blocker
(nonselective antihistamine)
Alternative drug. Diphenhydramine
Antihistamines now are categorized as histamineblockers, a term that
better describes their mode of clinical action. Histamine blockers are valuable
in the management of the more common delayed allergic response and in the
definitive management of the acute allergic reaction (administered after
epinephrine has resolved the life-threatening phase of the reaction).

Mode of Action
Histamine blockers are competitive antagonists of histamine; they do not
prevent the release of histamine from cells in response to injury, drugs, or
antigens but do prevent histamine's access to its receptor site in the cell,
blocking the response of the effector cell to histamine. Therefore, histamine-
blockers are more potent in preventing the actions of histamine than in
reversing these actions once they occur.
An interesting action of many histamine-blockers is that they are also
potent local anesthetics, especially diphenhydramine and tripelennamine.

Therapeutic indications
1) Delayed-onset allergic reactions
2) Definitive management 'of acute allergic reactions
3) Local anesthetics when the patient has a history of alleged
allergy to local anesthesia.

Side effects, contraindications, and precautions

Side effects of histamine-blockers include -
1) CNS depression
2) Decreased blood pressure
3) Thickening of bronchial secretions resulting from the drug's
drying action.
Because of this drying effect, histamine-blockers are contraindicated in
the management of acute asthmatic episodes.

Availability
1) Chlorpheniramine : Available as 10 mg/ mL in 1- and 2-mL
ampules and as 1-mL preloaded syringes.
2) Diphenhydramine : Available as 10 mg/mL in 10- and 30-
mL multidose vials, 50 mg/mL in 1-mL ampules and 10-mL
multidose vials, and 1 -mL preloaded syringes.

Suggested for emergency kit

Three or four 1-mL ampules of either chlorpheniramine (10 mg/mL) or
diphenhydramine (SO mg/mL).

B) Critical noninjectable drugs

The following five noninjectable drugs are also considered critical:
1. Oxygen
2. Vasodilator
3. Bronchodilator
4. Antihypoglycemic
5. Aspirin

1) Primary noninjectable: oxygen (O2)

Drug of choice. Oxygen
Drug class - None
Alternative drug - None

Proprietary
Recommended is the "E" cylinder, which is quite portable. In emergency
situations an E cylinder provides O 2 for approximately 30 minutes. Larger
cylinders provide significantly more O 2 but are less portable; smaller cylinders
contain too little O2 to be clinically effective for more than an extremely short
duration. O2 produced through a chemical reaction in small canisters is not
adequate for an emergency kit. A portable E cylinder of O 2 also should be
available in offices in which centrally located nitrous oxide and O 2 is available.
Because emergencies do occur in areas of the dental office other than in the
dental chair, the O2 delivery system must be portable.

Therapeutic indications
O2 administration is indicated in any emergency situation in which
respiratory distress is evident. Indeed O 2 should never be withheld from a
patient during a medical emergency.

Side effects, contraindications, and precautions

None with the emergency use of O 2, although O2 administration is not
indicated in the treatment of hyperventilation.

Availability
Compressed gas cylinders come in a variety of sizes. Portability of the
emergency O2 cylinder is desirable.

Suggested for emergency kit

 One E cylinder is the minimum requirement for an emergency kit.

2) Primary noninjectable: vasodilator

Nitroglycerin
Proprietary - Nitro lingual spray, Nitro stat tablets
Drug class - Vasodilator

Alternative drug. Amyl nitrite

Vasodilators are used in the immediate management of chest pain as may
occur with angina pectoris or acute myocardial infarction. Two varieties of
vasodilator are available: (1) nitroglycerin as a tablet and a spray and (2) an
inhalant, amyl nitrite. A patient with a history of angina pectoris usually carries
a supply of nitroglycerin.

Therapeutic Indications
1) With chest pain, vasodilators are used as an aid in differential
diagnosis.
2) Definitive management of angina pectoris
3) Early management of acute myocardial infarction
4) Management of acute hypertensive episodes.

Side effects, contraindications, and precautions

1) Nitroglycerin
Side effects of nitroglycerin include a transient, pulsating headache;
facial flushing; and a degree of hypotension, 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.
Because nitroglycerin as a tablet is an unstable drug, it usually must be replaced
within 12 weeks after its initial use.

2) Amyl Nitrite
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
seated in upright positions because significant postural changes develop.
2) Sildenafil, Tadalfil, Vardenafil
The recent introduction of sildenafil, tadalafil, and vardenafil to treat
erectile dysfunction has created another drug-drug interaction. The combination
of these drugs with nitrates may increase the risk of severe hypotension,
tachycardia, and cardiovascular collapse, representing a synergistic effect. Men
who have received nitroglycerin for the treatment of ischemic heart disease
have died after ingesting these drugs.

Availability
Nitroglycerin is available in three forms:
1) 0.3-, 0.4-, 0.6-mg doses of sublingual tablets
2) 0.4- and 0.8-mg/dose translingual spray
3) 0.3-mL doses of amyl nitrate yellow vaporoles.

Suggested for emergency kit

Kits should contain one bottle of metered translingual nitroglycerin spray
(0.4 mg).

3) Primary noninjectable: bronchodilator Drug of choice

Albuterol
Proprietary - Proventil, Ventolin

Drug class - Bronchodilator

Side effects, contraindications, and precautions

Albuterol, like other (B2 agonists, can have clinically significant cardiac
effects in some patients. This response is less likely to develop with albuterol
than with other bronchodilators, hence its selection for the emergency kit.

Metaproterenol, epinephrine, and isoproterenol mistometers are more

likely to produce cardiovascular side effects, including tachycardia and
ventricular dysrhythmias. Administration of these latter drugs is contraindicated
in patients with preexisting tachydysrhythmias from prior use of the drug.

Availability
1) Albuterol inhalers
2) Metaproterenol inhalers
3) Epinephrine mistometers
4) Isoproterenol mistometers

Suggested for emergency kit. One metered albuterol inhaler.

4) Primary noninjectable: antihypoglycemic Drug of choice

Orange juice
Drug class : Antihypoglycemic

Alternative drug : Soft drink (nondiet)

THERAPEUTIC INDICATIONS
Hypoglycemic states secondary to diabetes mellitus or fasting
hypoglycemia in the conscious patient; emergency management of unconscious
hypoglycemic states in the absence of both parenteral medications and rapid
access to emergency medical assistance.

Side effects, contraindications, and precautions

1) Liquid or viscous oral carbohydrates should not be administered to a
patient who does not have an active gag reflex or is unable to drink without
assistance.
2) Parenteral administration of antihypoglycemics is recommended in these
situations.
3) There are no side effects when oral carbohydrates are administered as
directed.

Availability
Antihypoglycemics come in a variety of forms, including Glucola,
Gluco-Stat, Insta-Glucose, nondiet cola beverages, fruit juices, granulated
sugar, and tubes of decorative icing.

Suggested for emergency kit

Any of the previously mentioned sources can be included in the
emergency kit.

5) Primary noninjectable: antiplatelet Drug of choice. Aspirin

Drug class - Antiplatelet

Alternative drug. None

Mode of Action
Aspirin has become a recommended antithrombotic drug in the
prehospital phase of suspected myocardial infarction. Considered to be the
standard antiplatelet agent, aspirin represents the most cost-effective treatment
available for patients with acute ischemic coronary syndromes. Aspirin
irreversibly acetylates platelet cyclooxygenase, removing all cyclooxygenase
activity for the life span of the platelet (8 to 10 days). Aspirin stops production
of proaggregatory thromboxane A 2 and is also an indirect antithrombotic agent.
Aspirin also has important nonplatelet effects because it likewise inactivates
cyclooxygenase in the vascular endothelium and thereby diminishes formation
of antiaggregatory
prostacyclin.

Therapeutic indications
Aspirin is recommended in management of patients with suspected
myocardial infarction or unstable angina.

Side effects, contraindications, and precautions.

Definite contraindications to aspirin therapy include ongoing major or
life-threatening hemorrhage; a significant predisposition to such hemorrhage,
such as a recent bleeding peptic ulcer; or a history of aspirin allergy.

Availability
Aspirin is available in 65-, 81-, 162-, and 325-mg tablets under many
brand names.
Suggested for emergency kit
The emergency kit should include three or four "baby" chewable aspirin
(162 mg). Two tablets should be taken as directed by a doctor if a heart attack is
suspected.

C) Critical emergency equipment

Critical items of emergency equipment include the following:
1. O2 delivery system
2. Automated external defibrillator
3. Syringes
4. Suction and suction tips
5. Tourniquets
6. Magill intubation forceps

1) O2 Delivery System
Table compares several methods of ventilation.

Comparison of Ventilation Methods

Technique % oxygen delivered
Mouth-to-mouth 16
Mouth-to-mask 16
Bag-valve-mask 21
Bag-valve-mask + supplemental >21 to <100
O2
Positive pressure O2 100

i) Positive pressurre
 An O2 delivery system adaptable to the E cylinder allows for the delivery
of O2 under positive pressure to the patient. Examples of this device include the
positive-pressure/demand valve and the reservoir bag on many inhalation
sedation units. The devices should be fitted with a clear face mask, allowing for
the efficient delivery of 100% O 2 while permitting the rescuer to visually
inspect the victim's mouth for the presence of foreign matter (e.g., vomitus,
blood, saliva, water). Face masks should be available in child, small-adult, and
large-adult sizes.

ii) Bag-valve-mask device

A portable, self-inflating bag-valve-mask device (Ambu-bag, PMR is a
self-contained unit that may be easily transported to any site within a dental
office. This is an important feature since not all emergencies will develop
within the dental operatory and it may be necessary to resuscitate a person in
other areas, such as the waiting room or restroom. A source of positive-pressure
oxygen or ambient air or enriched O 2 attached to an oxygen delivery tube
should be available in these areas. With either device the rescuer must be able
to maintain both an airtight seal and a patent airway with one hand while using
the other hand to activate the device and ventilate the victim.

iii) Pocket mask

The pocket mask is a clear full-face mask, identical in shape and
application to the positivepressure and bag-valve-mask devices. Unlike these
devices, however, the rescuer must apply exhaled air ventilation into the inlet
on top of the mask to ventilate the victim. Exhalation occurs passively through
a one-way valve located on the side of the mask. In this way, the rescuer does
not rebreathe the victim's exhaled air. The pocket mask also is available with a
supplemental O2 port, permitting attachment of the mask to an O 2 tube, and
deliver enriched O2 ventilation.

Small enough to fit easily into a pocket or purse, the pocket mask enables
the rescuer to provide mouth-to mask ventilation to the apneic victim in place
of mouthto-mouth ventilation. The pocket mask also helps individuals
overcome the "yuck" factor, which refers to the fact that a significant
percentage of victims requiring artificial ventilation regurgitate, presenting with
a pharynx and oral cavity filled with vomitus ("yuck").

The rescuer can also use the pocket mask to ventilate a pediatric patient
by simply inverting the mask, holding the narrow nose side of the rnask in the
cleft of the chin and the wider chin side on the bridge of the child's nose.
Because of concern in the health professions about the transmission of hepatitis
viruses and HIV as a result of direct physical contact with bodily fluids, the
pocket mask (or any other mask or "barrier" technique for that matter) is an
ideal choice to provide the rescuer positive psychological support.

In addition, the low cost of the mask is another reason that all dental
office personnel should have their own pocket mask.

Suggested for emergency kit

One portable O2 cylinder (E cylinder) with a positive-pressure mask, one
portable self-inflating bag-valve-mask device, and one pocket mask for each
staff member. Several sizes-child, small-adult, and large-adult-of clear full-face
masks also should be available; specialty practices should stock additional
mask sizes.
2) Automated external defibrillator
Though rare in the dental environment, sudden cardiac arrest does occur.
Successful resuscitation from sudden cardiac arrest depends on many factors
collectively known as the "chain of survival." The adult chain of survival has
four links: (1) early access to EMS; (2) early BLS; (3) early defibrillation; and
(4) early ACLS.

The most important component in the chain of survival is the elapsed

time between collapse and defibrillation. The shorter this span of time, the
greater the chance of successful resuscitation. The likelihood of successful
resuscitation from out-of-hospital sudden cardiac arrest decreases at a rate of
approximately 7% to 10% per minute, even if basic life support is administered
effectively.

Basic life support (CPR) certification is mandated for dental licensure in

many states and provinces. "BLS for health care providers," as now defined by
the American Heart Association, includes defibrillation (P ABCD).
Therefore, all jurisdictions requiring BLS for dental licensure should mandate
the on-site availability of an AED to fulfill the requirements of BLS for health
care providers.

3) Suggested for emergency kit. One AED

Syringes
Plastic disposable syringes equipped with an 18- or 21-gauge needle are
used in parenteral drug administration. Although many sizes are available, the
2-mL syringe is adequate for the delivery of emergency drugs.
Suggested for emergency kit
Two to four 2-mL disposable syringes with 18- or 21-gauge needles.

4) Suction and aspirating apparatus

A strong suction system and a number of large-diameter suction tips are
essential items of emergency equipment. The disposable saliva ejector,
commonly found in dental offices, is entirely inadequate in situations in which
anything other than the tiniest object must be evacuated from a patient's mouth.
Aspirator tips should be rounded to ensure that there is little risk of bleeding
should it become necessary to suction the hypopharynx. Plastic evacuators and
tonsil suction tips are quite adequate for this purpose.

Suggested for emergency kit

A minimum of two plastic evacuators or tonsil suction tips should be
available in the emergency kit.

5) Tourniquets
A tourniquet will be required if IV drugs are to be administered. In
addition, three tourniquets are needed to perform a bloodless phlebotomy in the
management of acute pulmonary edema. A sphygmomanometer (blood pressure
cuff) can be used as a tourniquet, as may a simple piece of latex tubing.

Suggested for emergency kit

Three tourniquets and a sphygmomanometer should be included in each
kit.

6) Magill intubation forceps

 The Magill intubation forceps is designed to aid in the placement of an
endotracheal tube during nasal intubation. The Magill intubation forceps is a
blunt-endcd scissors with a right-angle bend. This design permits the forceps to
grasp objects deep in the hypopharynx such as the endotracheal tube.
Published reports have described the ingestion or aspiration of dental
items such as crowns and endodontic files."," Just before being "swallowed,"
these items lie in the posterior region of the patient's oral cavity. There is
usually nothing readily available on an instrument tgray that can be easilyi used
to retrieve such objects. The Magill intubation forceps is designed to
perform this function and is highly recommended for inclusion in every
emergency kit.

Suggested for emergency kit

One pediatric-size Magill intubation forceps.
Module Two - secondary (noncritical) drugs and equipment
Category Generic drug Proprietary drug Alternative Quantity Availability
INJECTABLE
Anticonvulsant Midazolam Versed Diazepam 1x5-mL vial 5 mg./mL
Analgesic Morphine sulfate Generic Mepridine 3x1-mL ampules 10 mg./mL
Vasopressor Phenylephrine Generic 3x1-mL ampules 10 mg/mL
Antihypogl- 50% dextrose Glucagon 1 vial 50-mL ampule
ycenic
Corticosteroid Hydrocortisone Solu-Cortef Dexamethasone 2x2-mL 50 mg./mL
sodium succinate mix-o-vial
Antihyper- Esmolol Brevibloc Propranolol 2x100-mg./ 100 mg./mL
tensive mL vial
Anticholinergic Atropine Generic Scopolamine 3x1-mL ampules 0.5 mg./mL
NONINJECTABLE
Respiratory Aromatic Generic 2 boxes 0.3 mL/Vaporole
Stimulant ammonia
Antihyper- Nifedipine Procardia 1 bottle 10mg/capsule
tensive

MODULE THREE : ACLS

 A third category of injectable drugs that should be included in the
emergency kit are those classified as essential in the performance of ACLS.
These drugs should be considered for inclusion only by doctors who have
completed a course in ACLS.

Module Three - advanced cardiac life support : essential drugs

Category Generic drug Proprietary drug Alternative Quantity Availability
INJECTABLE
Cardiac arrest Epinephrine Adrenalin 3x10-mL 1:10,000
preloaded syringes (1 mg/10mL
Syringe)
Analgesic Morphine sulfate N2O-O2 3x1-mL ampules 10mg/mL
Antidysrhythmic Lidocaine Xylocaine Procainamide 1 preloaded syringe 100 mg/syringe
and 2 x 5-mL
ampules
Symptomatic Verapamil Isoptin 2x10-mL syringes 1.0 mg/10 mL
bradycardia
Paroxysmal Verapamil Isoptin 2x4-mL ampules 2.5 mg/mL
supraventricular
tachycardia

ACLS essential drugs

In recent years a number of ACLS drugs previously considered essential
have been deemphasized. These include sodium bicarbonate, calcium chloride,
bretylium tosylate, and isoproterenol. Essential ACLS drugs include the
following:
1. Epinephrine
2. Oxygen (O2)
3. Lidocaine
4. Atropine
5. Dopamine
6. Morphine sulfate
 7. Verapamil
1) ACLS essential: cardiac arrest Drug of choice - Epinephrine
Proprietary - Adrenalin
Drug class - Endogenous catecholamine

Alternative drug - None

Three items form the essentials of ACLS-epinephrine, O 2, and
defibrillation. Epinephrine (Adrenalin) previously has been discussed as an
essential injectable drug in the management of anaphylaxis. Epinephrine is
available as a 1-mg dose in preloaded syringes containing either 1 mL (1:1000
concentration) or 10 mL (1:10,000) of solution. The 1:10,000 concentration is
for IV or endotracheal administration, whereas the 1:1000 solution is designed
for subcutaneous, sublingual, or IM administration.

Epinephrine's importance in cardiac arrest lies in the fact that no other

drug can maintain coronary artery blood flow while CPR is in progress, which
is essential for preserving a chance of survival in cardiac arrest. Epinephrine
also preserves blood flow to the brain. In the absence of drug therapy, cerebral
blood flow during CPR is minimal, with most blood entering into the common
carotid artery and flowing into the external carotid branch, not into the internal
carotid artery. 64 After the administration of a drug such as epinephrine, with a-
adrenergic properties, cerebral blood flow increases significantly.

Therapeutic indications
Cardiac arrest (including ventricular fibrillation, pulseless ventricular
tachycardia, asystole, and pulseless electrical activity).
Side effects, contraindications, and precautions
 In those situations requiring epinephrine, no contraindications to its
administration exist. However, doctors should be aware that when large doses
are administered to patients not receiving CPR, hypertension frequently results.
In addition, epinephrine may induce or exacerbate ventricular ectopy,
especially in patients who are receiving digitalis.

Availability
Epinephrine is available at a 1:10,000 concentration in preloaded 10-mL
syringes.

Suggested for emergency kit

Two or three preloaded syringes may be included in the kit.

2) ACLS essential : O2
Drug of choice : O2
Proprietary : None
Drug class : None

Alternative drug. None

O2 already is included in the emergency kit as an essential noninjectable
drug. It is essential in cardiac resuscitation and emergency cardiac care.
Although exhaled air ventilation provides 16% to 17% O 2and ambient air
ventilation provides 21% O2, enriched O2 ventilation, or 100% O2 ventilation,
precludes the possibility of the development of hypoxia if ventilation is
adequate.
Absolutely no contraindications exist to the administration of O 2in emergency
situations. Long-term administration of high O 2, concentrations can produce O 2
toxicity, but the duration required for the development of such a situation far
exceeds the duration of almost all emergency situations. O 2 must never be
withheld or diluted during resuscitation because of the mistaken belief that it is
harmful.

3) ACLS essential: antidysrhythmic Drug of choice. Lidocaine

Proprietary. Xylocaine
Drug class. Local anesthetic, antidysrhythmic

Alternative drug. Procainamide

Lidocaine (Xylocaine) is used extensively in the management of cardiac
dysrhythmias, especially those of ventricular origin that develop after acute
myocardial infarction. Lidocaine is considered the primary antidysrhythmic
drug in ACLS. Procainamide also effectively suppresses ventricular ectopy and
is recommended for administration when lidocaine has not effectively
suppressed life-threatening ventricular dysrhythmias.

Therapeutic Indications
Lidocaine is administered when premature ventricular contractions
(PVCs) occur more than six times per minute or with the presence of closely
coupled PVCs, multifocal PVCs, or those occurring in bursts of two or more in
succession. Lidocaine administration also is indicated in sustained ventricular
tachycardia (where a palpable pulse is present) and in ventricular fibrillation
that is refractory to electrical defibrillation.
Side effects, contraindications, and precautions
Excessive doses of lidocaine produce myocardial, circulatory, and CNS
depression. Clinical signs and symptoms of lidocaine overdose include
drowsiness, paresthesias, and muscle twitching. More severe overdoses may
produce tonic-clonic seizure activity. Decreased hepatic function or hepatic
blood flow slows the rate of lidocaine biotransformation, producing prolonged
elevated blood levels and a greater risk of lidocaine overdose. Impaired hepatic
blood flow frequently is observed in the presence of acute reductions in cardiac
output.

Availability
Lidocaine is available for IV injection in 5-mL prefilled syringes
containing either SO or 100 mg and in 5-mL ampules of 100 mg.

Suggested for emergency kit

One 100-mg preloaded syringe and one 5-nil- ampule.

4) ACLS essential: symptomatic bradycardia

Drug of choice. - Atropine

Proprietary. Atropine
Drug class. Parasympatholytic

Alternative drug. Isoproterenol

Atropine is the drug of choice for hemodynamically significant
bradydysrhythmias and also is administered during asystole that is refractory to
epinephrine administration. A bradydysrhythmia is considered to be
hemodynamically unstable when the following conditions are preset :

Symptoms:
1. Chest pain
2. Shortness of breath
3. Decreased level of consciousness
4. Weakness, fatigue
5. Exercise intolerance
6. Lightheadedness, dizziness, and "spells"

Signs:
1. Hypotension
2. Drop in blood pressure upon standing
3. Diaphoresis
4. Pulmonary congestion upon physical examination
or chest x-ray
5. Frank congestive heart failure or pulmonary edema
6. Chest pain
7. Acute coronary syndrome (unstable angina, angina, or other
symptoms of acute myocardial infarction)
8. PVCs

Isoproterenol is a synthetic sympathomitnetic amine with nearly pure

beta-adrenergic receptor activity. Despite producing a decrease in mean blood
pressure, isoproterenol provides increased cardiac output. However, it also
markedly increases myocardial O2, consumption and may therefore induce or
exacerbate myocardial ischemia. Although still considered for administration in
the management of hemodynamically significant and atropine refractory
bradycardia, isoproterenol is no longer the drug of choice. Electronic pacing of
the heart has proven more effective than isoproterenol, and does not increase
myocardial O2 requirements. Atropine is one of four drugs that may be
administered endotracheally (see discussion on secondary injectable drugs).
5) ACLS essential: symptomatic hypotension
Drug of choice. Dopamine
Proprietary. Intropin
Drug Class. Sympathomirnetic amine
Alternative drug. Dobutamine

Mode of Action
1) Dopamine
Dopamine is a chemical precursor of norepinephrine. In large doses it
stimulates both a- and (3-adrenergic receptors. At lower doses it dilates renal,
mesenteric, and cerebral arteries. Dopamine also stimulates the release of
norepinephrine; it is indicated for administration in hemodynamically
significant hypotension in the absence of hypovolemia. When administered, the
dose of dopamine should be kept as low as possible to ensure adequate
perfusion of vital organs.

2) Dobutamine
Dobutamine is a synthetic sympathomimetic amine that exerts significant
inotropic effects by stimulating B 1- and a-adrenergic receptors in the
myocardium."' Its P-stimulatory actions greatly outweigh its a-stimulatory
actions, usually resulting in a mild vasodilation. In its usual dose, dobutamine
is less likely than isoproterenol or dopamine to induce tachycardias. Dopamine
is administered via an IV infusion, with the infusion rate altered according to
the response of the patient.

Therapeutic indications
The primary therapeutic indication for dopamine is to treat
hemodynamically significant hypotension in the absence of hypovolemia.
Side effects, contraindications, and precautions
Because dopamine produces an increase in heart rate, it may induce or
exacerbate supraventricular or ventricular dysrhythmias. In addition, dopamine
may alter the imbalance between supply and demand of the myocardium for O 2,
inducing or exacerbating myocardial ischemia.

Nausea and vomiting frequently are noted with dopamine administration.

In patients receiving monoamine oxidase inhibitors (isocarboxazid, pargyline,
tranylcypromine, or phenelzine), dopamine activity may be augmented. These
patients should receive no more than one tenth the usual dose of dopamine.

Availability
Dopamine is available as 200 mg, 400 mg, and 800 mg in 5-mL ampules
and syringes.

Suggested for emergency kit

One or two ampules of 400-mg dopamine (80 mg/mL).

6) ACLS essential: analgesia

Drug of choice. Morphine
Proprietary. Morphine
Drug class. Opioid agonist

Alternative drug. Meperidine

The management of pain and anxiety during ischetnic chest pain is a
critical part of overall patient care. Although a number of analgesics are
available, morphine is the drug of choice.
7) ACLS essential: paroxysmal
supraventricular tachycardia
Drug of choice. Verapamil
Proprietary. Isoptin
Drug class. Calcium channel blocker

Alternative drug. None

Verapamil (Isoptin) is the second calcium channel blocker discussed in
this section. Verapamil is included in the ACLS category because it is
extremely effective in the management of supraventricular tachycardia.
Verapamil slows conduction through the atrioventricular node, reducing
ventricular response to atrial flutter and fibrillation.

Therapeutic indications
In emergency cardiac care, verapamil is used primarily to treat
paroxysmal supraventricular tachycardia that does not require cardioversion.
When verapamil proves ineffective in the management of PSVT, synchronized
cardioversion is recommended.

Side effects, contraindications, and precautions

A transient decrease in arterial pressure may be noted because of
peripheral vasodilation in response to verapamiL7s Verapamil is not indicated
for ventricular tachycardia; it may induce severe hypotension and predispose a
patient to ventricular fibrillation.76
Availability
Verapamil is available for injection as 2.5 mg/mL in 2-mL and 4-mL
ampules.

Suggested for emergency kit

One or two 4-mL ampules.

MODULE - 4 ANTIDOTAL DRUGS

Module four - antidotal drugs

Category Generic drug Proprietary drug Alternative Quantity Availability
INJECTABLE
Opioid antagonist Naloxone Narcan Nalbuphine 2x1-mL 0.4 mg/mL
ampules
Benzodiazepine Flumazenil Romazicon - 1x10-mL vial 0.1 mg/mL
antagonist
Anticholinergic Physostigmine Antilirium - 3x2-mL 1 mg/mL
toxicity ampules

ORGANIZATION OF THE EMERGENCY KIT

The emergency drug kit need not and indeed should not be complicated.
Adherence to the KISS (Keep It Simple, Stupid) principle is suggested. Four
levels or modules of drugs and equipment were presented:
1. Module One: basic emergency kit (critical drugs and
equipment)
2. Module Two: noncritical drugs and equipment
3. Module Three: ACLS
4. Module Four: antidotal drugs
 Doctors should match their educational backgrounds and clinical
experiences with these different levels and drugs before considering them for
inclusion in the office emergency kit. Only those drugs and items of equipment
with which the doctor is familiar should be included. Minimally, Module One
(critical drugs and equipment) should be available in all offices.

A simple place in which to store emergency drugs and equipment is in a

fishing tackle box or plastic box with several compartments. Larger kits may be
stored in mobile tool cabinets . Labels should be applied to each compartment
in which a drug is stored, listing the drug's generic and proprietary names to
avoid possible confusion during an emergency as well as its dosage emergency
indication and expiry date.

A written record of the expiration dates of each of the drugs in the

emergency kit must be kept and the drug replaced prior to that date. Expired
drugs and empty O2 cylinders are ineffective in the management of any
emergency situation. An office staff member should be assigned to check the
emergency drug kit at least once a week and all emergency equipment daily-
especially the O2 cylinders-to ensure that all emergency items are ready for use.
Records of all emergency drug and equipment inspections should be
maintained in a bound (not a loose-leaf) notebook. The emergency kit and
equipment must be kept in a readily accessible area. The back of a storage
cabinet or a ked closet is not the place for life-saving equipment.
 References

1) Medical Emergencies in the Dental Office (6th edition)

- Stanley F. Malamed, DDS
2) www.google.com