Management of

Medical Emergencies
in the Dental Office
2017

MOHAMMED KHAN
BDS

ABDUSALAM ALRMALI
BDS DDS imp MDS FICOI

Designed by

Clinical guide
 INDEX
ESSENTIAL EMERGENCY DRUGS 5
ADDITIONAL DRUGS 12
PRINCIPLES OF MANAGEMENT OF
MEDICAL EMERGENCIES
14
AIRWAY OBSTRUCTION 15
SYNCOPE 17
ASTHMATIC ATTACK 18
CHEST PAIN 19
SEIZURES 21
ALLERGY 22
LOCAL ANESTHETIC TOXICITY 23
HYPERVENTILATION 24
HYPOGLYCEMIA VS HYPERGLYCEMIA 25
SUMMARY 26


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ABDUSALAM ALRMALI
BDS DDS imp MDS FICOI
ESSENTIAL EMERGENCY DRUGS
5
Oxygen
- Oxygen is indicated for every emergency except Hyperventilation

- 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.

Recomend oxygen cylinder:

- Recomended size ( E )
- can be used up to 30 min
- versitile and portable

bag-valve-mask
ESSENTIAL EMERGENCY DRUGS
6
Epinephrine
Epinephrine now considered is the first drug of choice for emergency
treatment of anaphylaxis , asthma and cardiac arrest

- IM route for ANAPHYLAXISIS

- IV route for CARDIAC ARREST

Epinephrine has a very rapid onset and short

duration of action, usually 5 to 10 minutes when
given intravenously.
Available in two formulations:

- 1 : 1,000, which equals 1 mg per ml - for intramuscular injection

- 1 : 10,000, which equals 1 mg per 10 ml - for intravenous injection

Adult dose : 0.3 mg as 0.3 mL of 1 : 1,000

Pediatric dose: 0.15 mg as 0.3 mL of 1 : 2,000

Autoinjector systems are also present for intramuscular use

such as the ( EpiPen)
ESSENTIAL EMERGENCY DRUGS
7
Injectable Antihistamine ( Benadryl )
Diphenhydramine
Indicated for the management of allergic reactions.

Mild non-life threatening allergic reactions may be managed by oral

administration, life-threatening reactions necessitate parenteral
administration.

Injectable agents considered, diphenhydramine or chlorpheniramine

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.

1:1000 recommend to allergic reaction

1:10.000 recommend to cardiac arrest
Adult dose from 0.3 - 0.5 ml of solution

Can be used as LA when the pt has allergy to LA agents

ESSENTIAL EMERGENCY DRUGS
8
Nitroglycerin
Indicated for Acute angina or Myocardial infarction. It is characterized
by a rapid onset of action.

Available as sublingual tablets or a sublingual spray

Important point to be aware of :

- Tablets have a short shelf-life of approximately 3 months

once the bottle has been opened and the tablets exposed to
air or light.

- Systolic blood pressures below 90 mmHg contraindicate the use

of this drug.
- Adult Dose 0.4mg
ESSENTIAL EMERGENCY DRUGS
9
Albuterol (Salbutamol)
A selective beta-2 agonist such as albuterol (salbutamol) is the first
choice for management of bronchospasm

Provides selective bronchodilation with minimal systemic

cardiovascular effects.

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.
ESSENTIAL EMERGENCY DRUGS
10
Aspirin (acetylsalicylic acid)
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 are relatively few contraindications:

- hypersensitivity to aspirin
- severe asthma
- significant gastric bleeding

Minimum of 162 mg should be given immediately to any patient with pain

suggestive of acute myocardial infarction.

Aspirin does not increase bleeding significantly

ESSENTIAL EMERGENCY DRUGS 11
Oral Carbohydrate
Oral carbohydrate source, such as orange juice or non-diet soft-drink,
should be readily available

Its use is indicated in the management of hypoglycemia in conscious

patients.
ADDITIONAL DRUGS 12
Glucagon
Allows intramuscular management of hypoglycemia in an unconscious
patient.

Atropine
This anti-muscarinic, anti-cholinergic drug is indicated for the management
of hypotension, which is accompanied by bradycardia.

Ephedrine
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

Corticosteroid
Hydrocortisone may be indicated for the prevention of anaphylaxis.
Hydrocortisone may also play a role in the management of an adrenal crisis.

Relatively slow onset of action, which approaches one hour even when
administered intravenously
ADDITIONAL
ADDITIONALDRUGS
DRUGS 13
Morphine
Indicated for the management of severe pain which occurs with
a myocardial infarction.
Extreme caution should be used in the elderly

Nitrous Oxide
Reasonable second choice if morphine is not available to manage pain
from a myocardial infarction.

Injectable Benzodiazepine
Management of seizures which are prolonged or recurrent,
also known as status epilepticus

Lorazepam has been reported as the drug of choice for status epilepticus
and can be administered intramuscularly.

Midazolam is another alternative which is water soluble and

could be considered
PRINCIPLES OF MANAGEMENT OF MEDICAL
EMERGENCIES 14
The golden rule in managing any emergency is basic life support (BLS)
and cardiopulmonary resuscitation (CPR).

This is done by following the basic principles:

Position (P)
Primary positions to manage an emergency are supine position,
Trendelenburg position, and semi-erect position

Avoid supine position in pregnancy

Airway (A)
Maintaining functioning airwayachieved usually by the head tilt-chin lift
manoeuvre , invasive procedures like direct laryngoscopy and cricothyrotomy can
be followed

Breathing (B)
If spontaneous breathing is not evident then rescue breathing should be accomplished
immediately either by the mouth-to-mouth technique or the bag-valve-mask technique

Circulation (C)
The most rapid and reliable method is by palpating the carotid pulse at the region
of the sternocleidomastoid muscle. If pulse is absent, then CPR is initiated immediately.

Definitive therapy (D)

Involves administration of drug when indicated and contacting for emergency care.
 AIRWAY OBSTRUCTION 15
Caused due to accidental slippage, aspiration of foreign objects.

Patient manifests with inability to speak, grasps the throat

coughs, inability to exchange air , cyanosis, and loss of
consciousness.
These might eventually lead to cardiac arrest finally.
Management:

clear the airway

If the patient is conscious: sit straight, support chest with one hand,
and deliver five sharp back blows between the shoulder blades with
the heel of the other hand.

If the patient is choking:

an attempt is made to expel the object with upward thrusts using
Heimlich thrust . It acts as artificial cough that produces
a rapid increase in intra-thoracic pressure thus helping to expel the
foreign body .
 AIRWAY OBSTRUCTION 16
Prevented by measures such as use of rubber dams or gauze,
throat screens, or floss ligatures.
SYNCOPE 17
Syncope is caused due to inadequate cerebral perfusion

Causes: Manifestations

- fear - nausea
- hypotension - warmth
- adrenal crisis - perspiration
- anaphylaxis - baseline blood pressure
- cardiac arrest - tachycardia
- diabetic collapse
- hypoglycemia
- epileptic seizure
- fainting
- stroke

Prevented by:

Ensuring that the patient has had their meal before

treatment in case of systemic diseases like diabetes and also
making the patient lie in the supine position before administering
local anesthetics
Management:

- supine position
- maintain airway
- Give oxygen
- check pulse
- Give oral Glucose
- Call for assistantance if no improvment
ASTHMATIC ATTACK 18
Anxiety, infection, exposure to an allergen or drugs
can precipitate an asthmic attack

Presents with :

- Heaviness in the chest,

- Difficulty in breathing,
- Spasmodic and unproductive cough,
- Expiratory wheeze,
- Anxious behavior.

Management:

2 puffs of albuterol, If no improvement is seen in 15 seconds

then administer 1:1000 adrenaline 0.5 ml SC/IM
if still no response is observed in 2-3 min then salbutamol
slow IV injection is advised
CHEST PAIN 19
Factors precipitate chest pain include:

- Angina
- Acute myocardial infarction
- Gastrointestinal reflux disease
- Anxiety
- Costochondritis
- Paroxysmal supraventricular tachycardia

Present with :

- Tightness
- Fullness
- Constriction or heavy weight on the chest.

Angina pectoris and acute myocardial infarction

(AMI) are the two commonly occurring cardiac
problems in a conscious patient.
Quality of pain can also indicate whether the patient is having an
angina or acute myocardial infarction.

Angina pectoris pain is significant but not severe

acute myocardial infarction pain generally radiates to
left side of the body-left shoulder, left mandible, left arm.

Unexplained chest pain should be considered as an MI until this

has been excluded
CHEST PAIN 20
Management:

For angina pectoris, drug of choice is nitroglycerine,

sublingual tablet, translingual or transmucosal spray.

Management of a patient with suspected acute myocardial infarction

involves administration of:

- Morphine
- Oxygen
- Nitroglycerine ( self medicate )
- Aspirin (MONA) in addition to emergency medical service.

If morphine is unavailable, the specialist can also substitute nitrous

oxide/oxygen in a 50:50 concentration.

Prevention:
- Stress reduction protocol
- Decrease amount of adrenaline in LA
SEIZURES 21
Patients who convulse in dental office generally have a seizure
history and are often characterized as having epilepsy.
Management:

If the patients experiencing seizure is unconscious,

they should primarily be placed in the supine position and the head
tilt-chin lift manoeuvre is performed.

Doctor should remove all instruments from patient's mouth

and protect the patient Clear airway loosen clothing and help
patient breath adequately.

If seizure continues for long, then the condition is known

as status epilepticus.

This is a life-threatening emergency and is best managed

with I.V. diazepam 5 mg IV/IM or by maintaining BLS till
patient is shifted to emergency care.

Reduction of anxiety is a key feature of prevention

 ALLERGY 22
A hypersensitive state of skin and various mucosae acquired through
exposure to a particular allergen, reexposure to which produces a
heightened emergent capacity to react

MANAGEMENT :

- Reassure pt.
- Initiate basic life support as needed ( P. A .B. C. D )
- Administer antihistaminics (diphenhydramine 50mg)
- Epinephrine 0.123-0.3ml of 1:1000 i.m /s.c
- Monitor vital signs regularly
LOCAL ANESTHETIC TOXICITY 23
Toxicity is usually either due to the local anesthetic itself or
the vasoconstrictor

Toxicity can be due to rapid infusion or failure to aspirate before

injection.

Generally, the reactions are self limiting.

Toxicity presents with:

- Talkativeness
- Slurred speech
- Anxiety
- Confusion
- Drowsiness
- Seizure and cardiac arrhythmias in extreme cases.

Management:

- Stop ttt ( Treatment )

- Reassure the pt
- monitor vital signs.
- Administer oxygen
- In adverse cases administration of diazepam 5 mg slowly is advised
 Instrument for controlling hemorrhage
HYPERVENTILATION 24
Hyperventilation is breathing occurring more deeply and rapidly than
normal. The normal adult respiratory rate is 11-18/min but anxiety
can result in a hyperventilatory state. CO2 is blown off and results in
a decrease in arterial CO2. The resultant fall in arterial CO2
concentration causes cerebral vasoconstriction and respiratory
alkalosis.

RING FINGER
 Instrument for controlling hemorrhage
HYPOGLYCEMIA VS HYPERGLYCEMIA 25
HYPOGLYCEMIA HYPERGLYCEMIA
occurs when blood glucose levels
It occurs when concentration of
are abnormally high.
blood glucose drops below 60 mg/dl
This can occur anytime when there is not enough
insulin in the bloodstream
or the body is not using insulin properly.

Sign and symptoms Sign and symptoms

- Tremors
- High levels of sugar in the urine
- Confusion - Frequent urination
- Restlessness - Increased thirst
- Fatigue
- Sweating
- Blurred vision
- Tachycardia

Managment
Due to the similarity of the signs and symptoms of hyper and hypoglycemia
we always treat the symptoms as a hypoglycemia because it is more common and
more fatal and can lead to death

- P.A.B.C
- If the patient is conscious and she is able to take her food by mouth give
15 g of the carbohydrate in the following form orange juice

- In unconscious patient take 50ml of the dextrose in 50% of the

concentration or 1mg of the glucagon I/V Or 1mg of the glucagon
intramuscularly.
- The signs and symptoms of hypoglycemia should be resolved in 10 to
15 mins , The patient should be observed for 30 to 60 min after the recovery.
The normal blood glucose level is confirmed by the glucometer before
the patient leaves.
Instrument for controlling hemorrhage
SUMMARY 26
ESSENTIAL EMERGENCY DRUGS

Drug Treatment Adult Dose

OXYGEN Almost any medical emergency 100% inhalation

EPINEPHRINE Anaphylaxis 0.1mg IV OR 0.3-0.5 IM

Asthma unresponsive to salbutamol 0.1mg IV OR 0.3-0.5 IM
Cardiac arrest 0.1 IV

NITROGLYCERIN Pain of angina 0.3 - 0.4 mg sublingual

DIPHENHYDRAMINE Allergic reactions 25 - 55 mg IV or IM

ALBUTEROL/SALBUTAMOL Asthmatic bronchospasm 2 sprays inhalation

ASPRIN Myocardial infarction 160 - 325mg

Instrument
Instrument for
REFERENCES
SUMMARY
for controlling
controlling hemorrhage
hemorrhage
27
ADDITIONAL EMERGENCY DRUGS

Drug Treatment Adult Dose

GLUCAGON Hypoglycemia in unconscious paitent 1 mg IM

ATROPINE Clinically significant bradycardia 0.5mg IV OR IM

EPHIDRINE Clinically significant hypotension 5mg IV -10-25mg IM

HYDROCORTISONE Adrenal insufficiency - recurrent anaphylaxis 100 mg IV or IM

MORPHINE Angina like pain unresponsive to nitroglycirine 2mg IV - 5mg IM

NIXROUS OXIDE Angina like pain unresponsive to nitroglycirine 35% inhalation

LORAZEPAM OR
MIDAZOLAM Status epliptcus 4mg IM or IV
Instrument for controlling hemorrhage
REFERENCES 28
1- Malamed SF. Medical Emergencies in the Dental Office. 5th ed.
St Louis: Mosby; 2000. pp. 5891.

2- Scully's : medical problem in dentistry 7th eduction 2014

3- Oxford Handbook of Oral and Maxillofacial Surgery