Department of Pedodontic Department of Pedodontic & Preventive Dentistry & Preventive Dentistry

Medical Emergency Medical Emergency used in dentistryused in dentistry

Guided by – Guided by – Presented by - Presented by -

Dr. RANDHEER Abdul Wahab ModiDr. RANDHEER Abdul Wahab Modi

ContentContent

IntroductionIntroduction Common medical emergency in Common medical emergency in

dental officedental office Emergency kitEmergency kit Various drugsVarious drugs RefrencesRefrences

INTRODUCTIONINTRODUCTION Emergency is a life threatening situation Emergency is a life threatening situation

frequently occurring in dental office.frequently occurring in dental office. Many factors increase such incidence, that is:-Many factors increase such incidence, that is:-(1) Older person.(1) Older person.(2) Therapeutic advance in medical profession.(2) Therapeutic advance in medical profession.(3) Long dental appointment.(3) Long dental appointment.(4) Increase use & administration of drugs.(4) Increase use & administration of drugs. In dental office, these situations are stress In dental office, these situations are stress

related or involve preexisting conditions that related or involve preexisting conditions that are exuberated when patients are placed in are exuberated when patients are placed in stressful environment. stressful environment.

Common medical emergencies in dental Common medical emergencies in dental office –office –

1.1. UnconsciousnessUnconsciousness ––

Vasodepressor syncope.Vasodepressor syncope. Orthostatic hypotension.Orthostatic hypotension. Acute adrenal insufficiency.Acute adrenal insufficiency.

2. 2. Respiratory distress –Respiratory distress – Airway obstruction Airway obstruction Hyperventilation.Hyperventilation. Asthma.Asthma. Heart failure and acute pulmonary edema .Heart failure and acute pulmonary edema .

3. Altered consciousness - Diabetes mellitus , hyperglycemia and hypoglycemia.Thyroid gland dysfunction .Cerebrovascular accident

4. Seizures4. Seizures

5. drug related emergencies –5. drug related emergencies – Drug overdoseDrug overdose . . Allergy.Allergy.

6.chest pain –6.chest pain – Angina pectoris.Angina pectoris. Acute MIAcute MI ..

7. Sudden cardiac arrest .7. Sudden cardiac arrest .

Steps to prepare the dental Steps to prepare the dental office for emergencyoffice for emergency

Train all office personnel in emergency Train all office personnel in emergency procedures before an emergency occurs.procedures before an emergency occurs.

Post the contact no. of the closer physician , Post the contact no. of the closer physician , emergency services and ambulance.emergency services and ambulance.

Select the items including drugs and the Select the items including drugs and the devices for the emergency in the dental office devices for the emergency in the dental office and should check them after every 3 months.and should check them after every 3 months.

Methods to minimizing Methods to minimizing emergencies in the dental emergencies in the dental

officeoffice Take complete case history including past Take complete case history including past

medical, dental ,anesthetic experience and medical, dental ,anesthetic experience and medication.medication.

Observe the patients stature , built , gait , color , Observe the patients stature , built , gait , color , age , respiration .age , respiration .

Observe and record the amount of anxiety , use Observe and record the amount of anxiety , use active listening to determine hidden nervousness .active listening to determine hidden nervousness .

Record blood pressure and pulse.Record blood pressure and pulse. Perform any necessary lab investigations.Perform any necessary lab investigations. Request medical consultant as needed.Request medical consultant as needed. Prescribe pre - Medication & avoid drug interactionPrescribe pre - Medication & avoid drug interaction

Things to remember Things to remember Drugs are not necessary for the management of Drugs are not necessary for the management of

most emergencies .most emergencies . Primary management of all emergencies is Primary management of all emergencies is

basic life support.basic life support. When in doubt , never medicates.When in doubt , never medicates. Ideal route of emergency drugs administration Ideal route of emergency drugs administration

will be IV , as the onset is rapid and the effect will be IV , as the onset is rapid and the effect is most reliable using this route.is most reliable using this route.

Emergency drugs may be administrated IM into Emergency drugs may be administrated IM into various sites like thigh , the upper outer various sites like thigh , the upper outer quadrant of the gluteal region and the deltoid quadrant of the gluteal region and the deltoid region.region.

Remember in the absence of effective Remember in the absence of effective circulation, these routes will not be effective.circulation, these routes will not be effective.

Emergency kit Emergency kit

Module one – basic emergency kit Module one – basic emergency kit ( critical drugs and equipment).( critical drugs and equipment).

Module two – non critical drugs and Module two – non critical drugs and equipment.equipment.

Module three – ACLS drugs.Module three – ACLS drugs. Module four – antidotal drugs.Module four – antidotal drugs.

Module oneModule one 1. Primary drugs 1. Primary drugs

Injectable NoninjectableInjectable Noninjectable

- Antiallergic Oxygen - Antiallergic Oxygen

-Histamine Vasodilator-Histamine Vasodilator

blockers Bronchodilatorblockers Bronchodilator

AntihypoglycemicAntihypoglycemic

AntiplateletAntiplatelet

1.Epinephrine

Action:- rapid onset of action, potent :- rapid onset of action, potent action as bronchial smooth muscle action as bronchial smooth muscle dilator , antihistaminic properties and dilator , antihistaminic properties and vasopressor properties , increase in vasopressor properties , increase in heart rate ,systolic blood pressure heart rate ,systolic blood pressure and cardiac output, decrease in and cardiac output, decrease in systolic blood pressure.systolic blood pressure.

Side effects Side effects – cardiac arrhythmias , – cardiac arrhythmias , short duration of action. short duration of action. Pregnancy ,as it reduces placental Pregnancy ,as it reduces placental blood flow and may lead to blood flow and may lead to premature laborpremature labor

.. IndicationsIndications – – cardiac arrest , cardiac arrest , anaphylaxis , acute asthmatic attackanaphylaxis , acute asthmatic attack

AvailabilityAvailability – for IV 1:1000 conc. – for IV 1:1000 conc. And 1:10,000 for IM ---- And 1:10,000 for IM ---- ADRENLINE ADRENLINE inj.inj.

Dentist may give into the frenulum Dentist may give into the frenulum under the tongue.under the tongue.

Dose – 0.3 – 0.5 mg of solution.Dose – 0.3 – 0.5 mg of solution.

2.chlorpheniramine , diphenhydramine 2.chlorpheniramine , diphenhydramine Action :- Action :- prevent histamine access –prevent histamine access –

receptor in cell----response in blockedreceptor in cell----response in blocked Indications Indications – Delayed onset allergic – Delayed onset allergic

reactions , definitive management of reactions , definitive management of acute allergic reactionacute allergic reaction

Side effects Side effects :-CNS depression, decrease :-CNS depression, decrease in blood pressure, thickening of in blood pressure, thickening of bronchial secretionbronchial secretion

ContraindicationsContraindications – acute asthmatic – acute asthmatic episodes (drying action.)episodes (drying action.)

AvailabilityAvailability – chlorpheniramine – 10 – chlorpheniramine – 10 mg /ml IV, diphenhydramine – 10 mg /ml IV, diphenhydramine – 10 mg / ml and phenramine maleate mg / ml and phenramine maleate ( Avil ) ( Avil ) – amp 1-2 ml IM .– amp 1-2 ml IM .

Noninjectable drugs ;-Noninjectable drugs ;- 1. Oxygen 1. Oxygen – important drug.– important drug. Supplied as Compressed gas cylinders Supplied as Compressed gas cylinders

( E cylinders),provide O2 for 30 min.( E cylinders),provide O2 for 30 min.Indication Indication :- in respiratory distress. :- in respiratory distress. Patient with COPD should be given Patient with COPD should be given

with caution because apnea may resultwith caution because apnea may result

2. nitroglycerine or amyl nitrate.2. nitroglycerine or amyl nitrate. Indications -Indications - acute anginal attack or acute anginal attack or

acute hypertensive episodesacute hypertensive episodes Contraindications Contraindications – in hypotensive – in hypotensive

patient .patient . Action Action – when it place sublingually , it – when it place sublingually , it

acts in 1-2 min.acts in 1-2 min. AvailabilityAvailability – tablet 0.1 , 0.3 , 0.6 mg. – tablet 0.1 , 0.3 , 0.6 mg.

nitroglycerine spray – 0.4 mg /dose and nitroglycerine spray – 0.4 mg /dose and amyl nitrate vaporous or – 0.3 ml.amyl nitrate vaporous or – 0.3 ml.

As As NITROCONTIN, NITROCONTIN, NITROCIN,NITROLINGUALNITROCIN,NITROLINGUAL…..…..

3. Albuterol/ Metaproterenol:- 3. Albuterol/ Metaproterenol:- Action Action :- Bronchial smooth muscle :- Bronchial smooth muscle

relaxant propertyrelaxant property IndicationIndication;- Acute asthmatic attack and ;- Acute asthmatic attack and

allergic reaction with bronchospsmallergic reaction with bronchospsm Availability:- Availability:- Albuterol inhaler Albuterol inhaler

(VENTOLIN, PROVENTIL)(VENTOLIN, PROVENTIL) Metaproterenol INHALER Metaproterenol INHALER ( ALUPENT)( ALUPENT)

4.Antihypoglycemic –4.Antihypoglycemic – Drug of choice Drug of choice – 50% dextrose solution .– 50% dextrose solution . Indications Indications – IV dextrose is used to – IV dextrose is used to

manage hypoglycemic episode when manage hypoglycemic episode when diabetic patient is unconscious and cant diabetic patient is unconscious and cant swallow.swallow.

AdministrationAdministration – can be given IM or IV. – can be given IM or IV.

5. Aspirin :-5. Aspirin :- Action :Action :- antiplatelet activity--- stop - antiplatelet activity--- stop

production of production of production of production of proaggregatory throboxane A2 and proaggregatory throboxane A2 and acylation of platelet cyclooxygenaseacylation of platelet cyclooxygenase

Indication ;- Indication ;- Myocardial infarction or Myocardial infarction or unstable anginaunstable angina

AvailabilityAvailability :- ASALITE, ASPENT, :- ASALITE, ASPENT, SPRIN…SPRIN…

50-100mg /day50-100mg /day

Module two Module two

A). Secondary Injectable drugsA). Secondary Injectable drugs

1.1. Midazolam :-Midazolam :-

actionaction :- anticonvulsant activity :- anticonvulsant activity

IndicationIndication :- Prolonged seizures, Local :- Prolonged seizures, Local anesthetic induced seizures, anesthetic induced seizures, hyperventilation ,thyroid stormhyperventilation ,thyroid storm

AvailabilityAvailability:- :- MIDAZ, MIDOSED, FULSEDMIDAZ, MIDOSED, FULSED....

5mg/ml in 1,2,35,10 ml vial5mg/ml in 1,2,35,10 ml vial

2. 2. Morphine sulphateMorphine sulphate IndicationsIndications – acute MI .also given in – acute MI .also given in

CHF and intense prolonged and CHF and intense prolonged and anxiety.anxiety.

Side effects Side effects – CNS and respiratory – CNS and respiratory depressantdepressant

Availability Availability – morphine sulfate 10 mg – morphine sulfate 10 mg / ml / ml

3. Methoxamine Action – i adrenergic agonist with almost exclusively alpha – adrenergic agonist , produces mild increase in BP due to peripheral vasoconstriction.Indications – treatment of acute adrenal insufficiency , Syncopal reactions , drug overdose reaction or allergy.Contra indication :-high blood pressure or ventricular tachycardiaAvailablity and dose – 10 mg /ml IV or IM as VASOXYSL

4. Antihypoglycemic:-4. Antihypoglycemic:- 5. Hydrocorticosone sodium 5. Hydrocorticosone sodium

succinate succinate .. Indication Indication – allergic reaction , – allergic reaction ,

anaphylaxis and adrenal crisis.anaphylaxis and adrenal crisis. Action Action – slow onset of action so – slow onset of action so

epinephrine is still the drug of choice epinephrine is still the drug of choice Availability :- Availability :- 50mg/ml 2 ml vial as50mg/ml 2 ml vial as SOLU- CORTEFSOLU- CORTEF

6. Esmolol/ Propanolol ;-6. Esmolol/ Propanolol ;- Action Action – beta adrenergic blocker – beta adrenergic blocker IndicationIndication:- Hypertension, angina :- Hypertension, angina

pectoris,pectoris,

cardiac arrhythmia, post myocardial cardiac arrhythmia, post myocardial tachycardia.tachycardia.

ContraindicationContraindication ;- COPD, Partial or ;- COPD, Partial or cmplete heart block. cmplete heart block.

AvailabilityAvailability :-2.5 mg in 10 ml ampule as :-2.5 mg in 10 ml ampule as ESOCARD, MINIBLOCK…. ESOCARD, MINIBLOCK….

7. Atropine :-7. Atropine :-

Action/IndicationAction/Indication:- in bradyarrythmias :- in bradyarrythmias and asystole that is refractory to and asystole that is refractory to epinephrine.epinephrine.

Side effects Side effects ;- large doses > 2 mg ---- ;- large doses > 2 mg ---- overdose ----hot, dry skin, headache, overdose ----hot, dry skin, headache, blurred vision, dry mouth and throat, blurred vision, dry mouth and throat, disorientation, hallucinationdisorientation, hallucination

AvailabilityAvailability:- .5 mg/ml in 1ml vial:- .5 mg/ml in 1ml vial

B. Secondary Injectable drugs :-B. Secondary Injectable drugs :- 1.1. Aromatic ammonia spiritAromatic ammonia spirit – – it is it is

used to treat syncope .used to treat syncope . ActionAction – it acts by irritating the membrane – it acts by irritating the membrane

of the upper respiratory tract ,resulting in of the upper respiratory tract ,resulting in stimulation of respiration and BP.stimulation of respiration and BP.

Contraindication Contraindication – in asthma or COPD may – in asthma or COPD may precipitate bronchspasmprecipitate bronchspasm

Availability Availability - in silver – grey vaporole 0.3 - in silver – grey vaporole 0.3 ml .ml .

2. Nifidepine:-2. Nifidepine:-

IndicationIndication:- :- Hypertension, acute Hypertension, acute anginal painanginal pain

Side effects Side effects :- Excessive hypotension:- Excessive hypotension

AvailabilityAvailability:- 10mg , 20 mg capsules:- 10mg , 20 mg capsules

as as PROCARDIA PROCARDIA

Module ThreeModule Three 1. oxygen1. oxygen 2.Lidocaine2.Lidocaine:-:- Action /indicationAction /indication.:- Local anesthetic .:- Local anesthetic

and antiarrhythmic action , used in and antiarrhythmic action , used in ventricular ventricular

Tachyarrhythmias 1mg/kg body wt.slow Tachyarrhythmias 1mg/kg body wt.slow iv bolus over 5-10 min.iv bolus over 5-10 min.

ContraindicationContraindication:- Hypersensitivity, :- Hypersensitivity, Bradycardia, Serious conduction Bradycardia, Serious conduction disturbance.disturbance.

AvailabilityAvailability:- :- GESICARD anhydrousGESICARD anhydrous

XYLOCARD XYLOCARD 3.Atropine:-3.Atropine:-

Action/Indication:Action/Indication:- in bradyarrythmias - in bradyarrythmias and asystole that is refractory to and asystole that is refractory to epinephrine.epinephrine.

4. Dopamine :-4. Dopamine :-

ActionAction :- stimulates alpha and beta :- stimulates alpha and beta adrenergic receptors , release of adrenergic receptors , release of norepinephrinenorepinephrine

IndicationIndication :-Hemodynamically significant :-Hemodynamically significant hypotension in absence of hypotension in absence of hypovolemia.hypovolemia.

Side effectSide effects :- Increase heart rate, s :- Increase heart rate, ventricular dysrhythmias, nausea , ventricular dysrhythmias, nausea , vomiting.vomiting.

AvailabilityAvailability:- as :- as INTROPININTROPIN 200mg, 200mg, 400mg, 800mg in 5ml ampules400mg, 800mg in 5ml ampules

5. Morphine 5. Morphine :- for ischemic chest pain.:- for ischemic chest pain.

6. Verapamil :-6. Verapamil :-

ActionAction :- Ca blockade --- effect on smooth :- Ca blockade --- effect on smooth muscle of coronaries ---- increase muscle of coronaries ---- increase myocardial blood flow.----- decrease in myocardial blood flow.----- decrease in peripheral resistance.peripheral resistance.

Indication:Indication:-Paroxysmal supraventricular -Paroxysmal supraventricular tachycardiatachycardia

Side effectsSide effects :- transient decrease in blood :- transient decrease in blood pressure, nausea, constipation, pressure, nausea, constipation, headache, flushing. headache, flushing.

Avai labilityAvai lability:- as :- as CALAPTIN, VASOPTEN, CALAPTIN, VASOPTEN,

VERAMIL VERAMIL

Module fourModule four Antidotal drugs :-Antidotal drugs :-

1.1. NaloxaneNaloxane

ActionAction:-Reverses all action of :-Reverses all action of opoids…. Competitive at receptors. opoids…. Competitive at receptors.

IndicationIndication :- Antagonizes opiod action :- Antagonizes opiod action like respiratory depression, sedation .like respiratory depression, sedation .

AvailabilityAvailability :- .4-2mg/ml in 1ml :- .4-2mg/ml in 1ml ampule IV ,IM or SC every 2-3 min.ampule IV ,IM or SC every 2-3 min.

NALOXNALOX inj. inj.

ContraindicationContraindication:- Hypersensitivity:- Hypersensitivity

Alternative drug Alternative drug :- Nalbuphine.:- Nalbuphine.

Side effects Side effects :-:-

Nausea, vomiting, hypertension.Nausea, vomiting, hypertension.

2.Flumazenil:2.Flumazenil:

Action/ Indication Action/ Indication :- reverses excessive :- reverses excessive sedation caused by benzodiazepinesedation caused by benzodiazepine

Side effectsSide effects :- rebound anxiety :- rebound anxiety

AvailabilityAvailability:- .1 mg/ml in 5ml and 10ml :- .1 mg/ml in 5ml and 10ml multidose vial as multidose vial as ROMAZICONROMAZICON

3.Physostigmine:-3.Physostigmine:-

Action/ IndicationAction/ Indication:- reversible :- reversible cholinsterasecholinsterase

----crosses blood brain barrier---reverses ----crosses blood brain barrier---reverses emergence delirium.emergence delirium.

Side effects:-Side effects:-

-Increased salivation -bradycardia--Increased salivation -bradycardia-emesisemesis

-involuntary urination and defecation-involuntary urination and defecation

AvailabilityAvailability:- 1 mg/ml in 2ml ampule:- 1 mg/ml in 2ml ampule

as as ANTILIRIUMANTILIRIUM

4.Procaine :-4.Procaine :-

ActionAction :- Local anesthetic and :- Local anesthetic and vasodilatation.vasodilatation.

Indication :- Indication :- to manage vasospasm and to manage vasospasm and compromised circulation by compromised circulation by intrarterial inj. or by irritating drug intrarterial inj. or by irritating drug

AvailabilityAvailability:- 1% sol. In 2ml and 6ml :- 1% sol. In 2ml and 6ml ampules ampules as NOVACAINas NOVACAIN

CONCLUSIONCONCLUSION Proper management of a patient in Proper management of a patient in

almost all emergency situation does not almost all emergency situation does not require drug administration.require drug administration.

First & foremost in the management oe First & foremost in the management oe emergency situation are steps of basic emergency situation are steps of basic life support.life support.

ReferencesReferences

Medical emergencies in dental office Medical emergencies in dental office – malamed– malamed

Emedice.comEmedice.com Google.comGoogle.com