Chapter 23: Emergency Drugs Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.

Chapter 23:Chapter 23:

Emergency DrugsEmergency Drugs

Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.

22Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.

Chapter 23 OutlineChapter 23 Outline

Emergency DrugsEmergency Drugs General measuresGeneral measures Categories of emergenciesCategories of emergencies Emergency kit for the dental officeEmergency kit for the dental office


Emergency DrugsEmergency Drugs

Haveles (p. 290)Haveles (p. 290) An increasing number of older patients who An increasing number of older patients who

are taking multiple drugs seek dental are taking multiple drugs seek dental treatment each yeartreatment each year Dental offices are administering more complicated Dental offices are administering more complicated

drug regimens, dental appointments are taking drug regimens, dental appointments are taking longer, and dental patients are getting sickerlonger, and dental patients are getting sicker

The chances of an emergency in a dental The chances of an emergency in a dental office continues to increaseoffice continues to increase


General MeasuresGeneral Measures

Haveles (pp. 290-291) (Boxes 23-1, 23-2)Haveles (pp. 290-291) (Boxes 23-1, 23-2) Train: before an emergency occurs, including Train: before an emergency occurs, including

cardiopulmonary resuscitation (CPR)cardiopulmonary resuscitation (CPR) Telephone number: post the number of the Telephone number: post the number of the

closest physician, emergency room, and 911closest physician, emergency room, and 911 Emergency kit: select items and keep up to Emergency kit: select items and keep up to

datedate


Preparation for TreatmentPreparation for Treatment

Haveles (p. 291)Haveles (p. 291) Before any emergency treatment can be Before any emergency treatment can be

administered, investigation of signs and administered, investigation of signs and symptoms must be donesymptoms must be done In most cases, maintenance of the airway, In most cases, maintenance of the airway,

breathing, circulation are of primary importancebreathing, circulation are of primary importance Drugs are Drugs are not not necessary for proper management necessary for proper management

of most emergenciesof most emergencies


Categories of EmergenciesCategories of Emergencies

Haveles (pp. 291-294)Haveles (pp. 291-294) Lost or altered consciousnessLost or altered consciousness Respiratory emergenciesRespiratory emergencies Cardiovascular system emergenciesCardiovascular system emergencies Other emergency situationsOther emergency situations Drug-related emergenciesDrug-related emergencies


Lost or Altered ConsciousnessLost or Altered Consciousness

Haveles (pp. 291-292)Haveles (pp. 291-292) SyncopeSyncope HypoglycemiaHypoglycemia Diabetic comaDiabetic coma Convulsions or seizuresConvulsions or seizures


SyncopeSyncope

Haveles (pp. 291-292)Haveles (pp. 291-292) The most common emergency in the dental The most common emergency in the dental

office is simple syncope (faint)office is simple syncope (faint) The skin becomes ashen-gray and diaphoresis occursThe skin becomes ashen-gray and diaphoresis occurs Due to anxiety, fear, or apprehensionDue to anxiety, fear, or apprehension

Treatment: involves placing the patient in the Treatment: involves placing the patient in the Trendelenburg position (feet elevated) causing Trendelenburg position (feet elevated) causing blood to rush to the headblood to rush to the head Spirits of ammonia can be administeredSpirits of ammonia can be administered


HypoglycemiaHypoglycemia(Insulin Reaction)(Insulin Reaction)

Haveles (p. 292)Haveles (p. 292) Most common cause is excessive dose of insulin in a Most common cause is excessive dose of insulin in a

diabeticdiabetic The person may not have eaten before the appointmentThe person may not have eaten before the appointment

The patient with hypoglycemia has a rapid pulse and The patient with hypoglycemia has a rapid pulse and decreased respiration and is loquaciousdecreased respiration and is loquacious Hunger, dizziness, weakness, and occasionally hand tremor Hunger, dizziness, weakness, and occasionally hand tremor

may occur; diaphoresis, nausea, and mental confusion are may occur; diaphoresis, nausea, and mental confusion are other signsother signs

Treatment: in conscious, a sugary drink or oral glucoseTreatment: in conscious, a sugary drink or oral glucose If unconscious, dextrose intravenouslyIf unconscious, dextrose intravenously


Diabetic ComaDiabetic Coma

Haveles (p. 292)Haveles (p. 292) Caused by elevated blood sugarCaused by elevated blood sugar Symptoms include frequent urination, loss of Symptoms include frequent urination, loss of

appetite, nausea, vomiting, and thirstappetite, nausea, vomiting, and thirst Acetone breath, hypercapnia, warm and dry skin, Acetone breath, hypercapnia, warm and dry skin,

rapid pulse and a decrease in blood pressure can rapid pulse and a decrease in blood pressure can occuroccur

Treatment: requires hospitalization and Treatment: requires hospitalization and includes insulin after laboratory results are includes insulin after laboratory results are obtainedobtained


Convulsions or SeizuresConvulsions or Seizures

Haveles (p. 292)Haveles (p. 292) Convulsions are most commonly associated Convulsions are most commonly associated

with epilepsy but can also result from a toxic with epilepsy but can also result from a toxic reaction to a drugreaction to a drug Convulsions are abnormal movements of parts of Convulsions are abnormal movements of parts of

the body in clonic and/or tonic contractions and the body in clonic and/or tonic contractions and relaxationsrelaxations

Treatment should include protecting the Treatment should include protecting the patient from self-inflicted damage and turning patient from self-inflicted damage and turning the patient’s head to one side to prevent the patient’s head to one side to prevent aspirationaspiration Diazepam may be administeredDiazepam may be administered


Respiratory EmergenciesRespiratory Emergencies

Haveles (p. 292)Haveles (p. 292) HyperventilationHyperventilation AsthmaAsthma Anaphylactic shockAnaphylactic shock Acute airway obstructionAcute airway obstruction


HyperventilationHyperventilation

Haveles (p. 292)Haveles (p. 292) Rapid respiratory rate is often due to Rapid respiratory rate is often due to

emotional upsetemotional upset Tachypnea, tachycardia, and paresthesia have Tachypnea, tachycardia, and paresthesia have

been reportedbeen reported Nausea, faintness, perspiration, acute anxiety, Nausea, faintness, perspiration, acute anxiety,

lightheadedness, and shortness of breath may lightheadedness, and shortness of breath may occuroccur

Treatment: encourage the patient to hold his Treatment: encourage the patient to hold his or her breath or “rebreathe” into a paper bagor her breath or “rebreathe” into a paper bag


AsthmaAsthma

Haveles (p. 292)Haveles (p. 292) Patients who have acute asthma attacks have Patients who have acute asthma attacks have

a history of previous attacks and will have an a history of previous attacks and will have an inhaler with theminhaler with them The most common sign is wheezing with prolonged The most common sign is wheezing with prolonged

expirationexpiration Treatment Treatment

Patients can use their own Patients can use their own ßß22-agonist-agonist If no response is noted, hospitalization for If no response is noted, hospitalization for

aminophylline (parenteral or oral) and parenteral aminophylline (parenteral or oral) and parenteral corticosteroids and epinephrine should be corticosteroids and epinephrine should be consideredconsidered


Anaphylactic ShockAnaphylactic Shock Haveles (p. 292)Haveles (p. 292)

The reaction usually begins within 5 to 30 minutes The reaction usually begins within 5 to 30 minutes after ingestion or administration of the antigenafter ingestion or administration of the antigen Usually, a weak, rapid pulse and profound decrease in Usually, a weak, rapid pulse and profound decrease in

blood pressure occurblood pressure occur Dyspnea and severe bronchial constriction occurDyspnea and severe bronchial constriction occur

Treatment: parenteral epinephrine must be Treatment: parenteral epinephrine must be administered immediately in cases of severe administered immediately in cases of severe anaphylactic shockanaphylactic shock If bronchoconstriction predominates, albuterol If bronchoconstriction predominates, albuterol

administered by inhalation or nebulization may sufficeadministered by inhalation or nebulization may suffice After life-threatening symptoms have been controlled, After life-threatening symptoms have been controlled,

intravenous (IV) corticosteroids, intramuscular intravenous (IV) corticosteroids, intramuscular diphenhydramine, and aminophylline may be useddiphenhydramine, and aminophylline may be used


Acute Airway ObstructionAcute Airway Obstruction

Haveles (p. 292)Haveles (p. 292) Usually the result of a foreign body in the Usually the result of a foreign body in the

pharynx or larynx; laryngospasm may be drug pharynx or larynx; laryngospasm may be drug inducedinduced Gasping for breath, coughing, gagging, acute Gasping for breath, coughing, gagging, acute

anxiety, and cyanosis are signs and symptomsanxiety, and cyanosis are signs and symptoms Treatment: Trendelenburg position on the right Treatment: Trendelenburg position on the right

side and encouraging coughingside and encouraging coughing Clearing the pharynx and pulling the tongue before Clearing the pharynx and pulling the tongue before

performing the Heimlich maneuver should be nextperforming the Heimlich maneuver should be next• Heimlich maneuver if necessaryHeimlich maneuver if necessary

A cricothyrotomy or tracheotomy are indicated if the A cricothyrotomy or tracheotomy are indicated if the object cannot be dislodged by other methodsobject cannot be dislodged by other methods


Cardiovascular System Cardiovascular System EmergenciesEmergencies

Haveles (pp. 292-293)Haveles (pp. 292-293) Angina pectorisAngina pectoris Acute myocardial infarctionAcute myocardial infarction Cardiac arrestCardiac arrest Other cardiovascular emergenciesOther cardiovascular emergencies


Angina PectorisAngina Pectoris

Haveles (p. 293)Haveles (p. 293) Often begins as substernal chest pain that Often begins as substernal chest pain that

radiates across the chest to the left arm or the radiates across the chest to the left arm or the mandiblemandible Pulse becomes rapid, and tachypnea (rapid Pulse becomes rapid, and tachypnea (rapid

breathing) can occurbreathing) can occur Treatment: the patient can premedicate with Treatment: the patient can premedicate with

sublingual nitroglycerin sublingual nitroglycerin An acute attack is treated with sublingual An acute attack is treated with sublingual

nitroglycerinnitroglycerin Opioids or diazepam are used in hospitalized Opioids or diazepam are used in hospitalized

patientspatients


Acute Myocardial InfarctionAcute Myocardial Infarction

Haveles (p. 293)Haveles (p. 293) Often begins as severe pain, pressure, or Often begins as severe pain, pressure, or

heaviness in the chest that radiates to other heaviness in the chest that radiates to other parts of the bodyparts of the body Sweating, nausea, and vomiting can occurSweating, nausea, and vomiting can occur Pain is unrelieved by rest or nitroglycerinPain is unrelieved by rest or nitroglycerin An irregular rapid pulse, shortness of breath, An irregular rapid pulse, shortness of breath,

diaphoresis (perspiration), and indigestion can diaphoresis (perspiration), and indigestion can occuroccur

cont’d…cont’d…


Acute Myocardial InfarctionAcute Myocardial Infarction

Treatment: includes administration of oxygen, Treatment: includes administration of oxygen, an aspirin tablet, and an opioid analgesic an aspirin tablet, and an opioid analgesic agent and transfer to a hospitalagent and transfer to a hospital In the hospital, patients are given lidocaine for In the hospital, patients are given lidocaine for

arrhythmias and vasopressor agents to maintain arrhythmias and vasopressor agents to maintain adequate blood pressureadequate blood pressure

New drugs that can dissolve clots are New drugs that can dissolve clots are administered soon after the event and may administered soon after the event and may reverse the clotreverse the clot


Cardiac ArrestCardiac Arrest

Haveles (p. 293)Haveles (p. 293) Generally, sudden circulatory and respiratory Generally, sudden circulatory and respiratory

collapse occurcollapse occur Permanent brain damage occurs within 4 minutesPermanent brain damage occurs within 4 minutes

Treatment: immediate CPRTreatment: immediate CPR Medications in a hospital include epinephrine for Medications in a hospital include epinephrine for

cardiac stimulation and lidocaine for arrhythmiascardiac stimulation and lidocaine for arrhythmias• Parenteral opioid analgesics are given for painParenteral opioid analgesics are given for pain

• Defibrillation is used to treat systoleDefibrillation is used to treat systole


Other Cardiovascular Other Cardiovascular EmergenciesEmergencies

Haveles (p. 293)Haveles (p. 293) Arrhythmias: depend on an electrocardiogram Arrhythmias: depend on an electrocardiogram

for diagnosis before treatmentfor diagnosis before treatment A cerebrovascular accident (CVA): treated A cerebrovascular accident (CVA): treated

with oxygen and “clot busters” in the hospitalwith oxygen and “clot busters” in the hospital Hypertensive crisis: treated with Hypertensive crisis: treated with

antihypertensive agents given intravenouslyantihypertensive agents given intravenously


Other Emergency SituationsOther Emergency Situations

Haveles (p. 294)Haveles (p. 294) Extrapyramidal reactions: can be produced Extrapyramidal reactions: can be produced

by antipsychotic agentsby antipsychotic agents prochlorperazine (Compazine) used for nausea prochlorperazine (Compazine) used for nausea

and vomiting can produce this type of reactionand vomiting can produce this type of reaction Treatment: IV diphenhydramine (Benadryl)Treatment: IV diphenhydramine (Benadryl)




Acute adrenocortical insufficiency: usually Acute adrenocortical insufficiency: usually occurs in patients who are taking enough occurs in patients who are taking enough steroids to suppress the adrenal glandsteroids to suppress the adrenal gland Cardiovascular collapse and irreversible shock Cardiovascular collapse and irreversible shock

may result in a fatalitymay result in a fatality Treatment: parenteral hydrocortisone and oxygenTreatment: parenteral hydrocortisone and oxygen




Thyroid storm: hyperthyroidism is out of controlThyroid storm: hyperthyroidism is out of control Congestive heart failure and cardiovascular collapse Congestive heart failure and cardiovascular collapse

may followmay follow Treatment: includes tepid baths and aspirin, Treatment: includes tepid baths and aspirin, ββ--

blockers for cardiovascular symptoms, and possibly blockers for cardiovascular symptoms, and possibly hydrocortisonehydrocortisone




Malignant hyperthermia: genetically Malignant hyperthermia: genetically determined reaction triggered by inhalation determined reaction triggered by inhalation general anesthetics or neuromuscular general anesthetics or neuromuscular blocking agents such as succinylcholineblocking agents such as succinylcholine Treatment: baths and aspirin are used to control Treatment: baths and aspirin are used to control

elevated temperatureelevated temperature• dantrolene (Dantrium) can control acidosis and body dantrolene (Dantrium) can control acidosis and body

temperature by reducing calcium released into muscles temperature by reducing calcium released into muscles during contractile responseduring contractile response


Drug-Related EmergenciesDrug-Related Emergencies

Haveles (p. 294)Haveles (p. 294) Opioid overdose: respiration can be Opioid overdose: respiration can be

depressed or respiratory arrest may occurdepressed or respiratory arrest may occur Most common symptoms are shallow and slow Most common symptoms are shallow and slow

respiration and pinpoint pupilsrespiration and pinpoint pupils Treatment: naloxone (Narcan), an opioid Treatment: naloxone (Narcan), an opioid

antagonistantagonist


Reaction to Local Anesthetic Reaction to Local Anesthetic AgentsAgents

Haveles (p. 294)Haveles (p. 294) Reaction to local anesthetic agents: toxic Reaction to local anesthetic agents: toxic

reaction from excessive level of the anestheticreaction from excessive level of the anesthetic Both central nervous system stimulation and Both central nervous system stimulation and

depression can occur, exhibited as excitement or depression can occur, exhibited as excitement or convulsionsconvulsions

Treatment: symptomaticTreatment: symptomatic If convulsions are a prominent feature: diazepamIf convulsions are a prominent feature: diazepam If hypotension is predominant: a pressor agentIf hypotension is predominant: a pressor agent If reflex bradycardia: atropineIf reflex bradycardia: atropine


EpinephrineEpinephrine

Haveles (pp. 294-295 )Haveles (pp. 294-295 ) Due to excessive blood levels of epinephrineDue to excessive blood levels of epinephrine

Symptoms range from nervousness to shaking Symptoms range from nervousness to shaking and can include tachycardiaand can include tachycardia

Treatment: reassurance and timeTreatment: reassurance and time


Emergency Kit for the Dental Emergency Kit for the Dental OfficeOffice

Haveles (pp. 294-297) (Table 23-1)Haveles (pp. 294-297) (Table 23-1) Choice of drugs will depend on individual Choice of drugs will depend on individual

circumstances, experience, and personal circumstances, experience, and personal preferencepreference Other drugs that may be used if personnel are Other drugs that may be used if personnel are

trained in advanced cardiac life support (ACLS) trained in advanced cardiac life support (ACLS) include level 2 drugs, atropine and lidocaine, and include level 2 drugs, atropine and lidocaine, and calcium chloridecalcium chloride


Drugs Drugs

Haveles (pp. 294-297)Haveles (pp. 294-297) Drugs may vary, depending on the Drugs may vary, depending on the

preference and experience of the practitionerpreference and experience of the practitioner Some equipment and drugs are kept in the Some equipment and drugs are kept in the

emergency kit for use by a physician or for those emergency kit for use by a physician or for those with ACLS training in an emergencywith ACLS training in an emergency



DrugsDrugs

Haveles (pp. 294-296)Haveles (pp. 294-296) Level 1 (critical) drugsLevel 1 (critical) drugs

Epinephrine: cardiac arrest, anaphylaxis, or acute Epinephrine: cardiac arrest, anaphylaxis, or acute asthmatic attackasthmatic attack

Diphenhydramine: some allergic reactionsDiphenhydramine: some allergic reactions Oxygen: indicated in most emergenciesOxygen: indicated in most emergencies Nitroglycerin: acute anginal attackNitroglycerin: acute anginal attack Glucose: hypoglycemiaGlucose: hypoglycemia Albuterol: bronchodilationAlbuterol: bronchodilation



DrugsDrugs Haveles (p. 296)Haveles (p. 296)

Level 2 drugs Level 2 drugs Benzodiazepines: convulsionsBenzodiazepines: convulsions Aromatic ammonia spirits: syncopeAromatic ammonia spirits: syncope Morphine: an acute myocardial infarctionMorphine: an acute myocardial infarction Methoxamine: hypotensionMethoxamine: hypotension Hydrocortisone: allergic reactions, anaphylaxis, and Hydrocortisone: allergic reactions, anaphylaxis, and

adrenal crisisadrenal crisis Dextrose: unconscious hypoglycemiaDextrose: unconscious hypoglycemia Glucagon: severe hypoglycemiaGlucagon: severe hypoglycemia Atropine: preoperative antisialagogue and to increase Atropine: preoperative antisialagogue and to increase

cardiac ratecardiac rate ββ-Blockers: tachycardia or hypertension-Blockers: tachycardia or hypertension



DrugsDrugs

Haveles (pp. 296-297)Haveles (pp. 296-297) Other drugsOther drugs

Naloxone: opioid antagonistNaloxone: opioid antagonist Flumazenil: reversing most effects of Flumazenil: reversing most effects of

benzodiazepinesbenzodiazepines Antiarrhythmics: procainamide, lidocaine, verapamil, Antiarrhythmics: procainamide, lidocaine, verapamil,

and bretyliumand bretylium


EquipmentEquipment

Haveles (p. 297) (Box 23-3)Haveles (p. 297) (Box 23-3) Level 1 (critical devices)Level 1 (critical devices)

Syringes/needlesSyringes/needles TourniquetsTourniquets System to give oxygenSystem to give oxygen Automated external defibrillatorAutomated external defibrillator

Level 2 (secondary devices)Level 2 (secondary devices) Cricothyrotomy deviceCricothyrotomy device Endotracheal tubeEndotracheal tube LaryngoscopeLaryngoscope System to give IV infusionsSystem to give IV infusions

Chapter 23: Emergency Drugs Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.

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