Emergency medicines in dentistry / dental implant courses

Emergency medicines in dentistry
INDIAN DENTALACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

ANTHONY TROLLOPE
(1815-1882)
A man’s mind will
very gradually refuse
to make itself up until
it is driven and
compelled by an
Emergency…

INTRODUCTION
• Emergency
An Unforeseen Occurrence Or Combination Of
Circumstances That Calls For Immediate Action Or
Remedy; Pressing Necessity; Exigency
Mosby’s
• Drug
Any Substance Or Product That Is Used Or Is Intended To
Be Used To Modify Or Explore Physiological Systems Or
Pathological States For The Benefit Of The
Recipient(W.H.O.)

How An Emergency Occurs
• Dentist
• Dental Environment
• Dental Treatment
• Underlying Systemic
Conditions

Are U Prepared?
SYNCOPE
ANAPHYLAXIS
ALLERGIC REACTIONS
ANGINA PECTORIS
MYOCARDIAL INFARCTION
POSTURAL HYPOTENSION
SEIZURES
BRONCHOSPASM

Forewarned is forearmed
Preparation
• Train office personals
• Emergency numbers
• Emergency kits and
devices
• Vehicle
Prevention
• Observe patient
• Thorough history
• Monitor vital signs
• Test doses
• Lab investigations
• Medical consultation
• Premedications

DRUGS
Epinephrine Corticosteroids
Nitroglycerin Atropine
Bronchodilators Naloxone
Antihistamines Flumazenil
Anticonvulsive Aspirin
Morphine Hemostatics
Oxygen
Glycemic Agents
Aromatic Ammonia

EPINEPHRINE/ADRENALINE

INDICATION
• Anaphylaxis
• Severe Allergic Reactions
• Acute Asthmatic Attacks
• Cardiac Arrest

ACTIONS
• Antagonistic To Histamine
• Potent Bronchodilator
• B.P, Pulse Pressure
• Heart Rate
• C.O, force Of Contraction
• Oxygen Consumption

Dose and administration
DOSE:
0.2-0.5mg Subcutaneous, Intramuscular
(vastus Lateralis)
Intravenous: 1:10,000 1:100000
Ineffective Orally due to action of
Catechol-O-Methyl Transferase (COMT)
Mono Amine Oxidase(MAO)

Adverse Effects
• Palpitations
• Tachycardia
• Sweating
• Nausea And Vomiting
• Respiratory Difficulty
•Pallor
•Dizziness
•Weakness
•Tremor
•Headache
•Apprehension
•Nervousness
• Anxiety

PRECAUTIONS
Rapid IV Inj: Cerebral Hemorrhage
Transient Apnoea
Diabetics: Glycogenolysis
Pregnancy: Placental Blood Flow
Blood Glucose Level
Intra-arterial: Gangrene
Buttocks: Gas Gangrene
Hypertension: B.P.

ANTIHISTAMINES
• Competitive antagonist at h1

INDICATION
• Anaphylaxis
• Allergic Conditions
COMMONLY USED
• Chlorphenamine
• Diphenhydramine (benadryl)
• Pheniramine Maleate (avil)

ACTIONS
• Block Effect Of Released Histamines
• Controls Certain Immediate Type
• Itching , Urticaria
• Blocks Histamine Induced Bronchoconstriction
• Does Not Suppress Antigen Antibody Reaction

Diphenhydramine (benadryl)
25-50mg Oral
12.5mg/5ml Syr.IM
Pheniramine (avil)
25-50mg Oral
15mg/5ml I.M
Chlorphenamine (cadistin)
2-4mg Oral,IM.
Mild-oral
Moderate- parenteral
Severe- parenteral

Adverse effects
• Sedation,
• Alertness, concentration
• Motor In-coordination
• Dryness Of Mouth
• Urinary Hesitancy
• Headache, Epigastric Distress
Anticholinergic

PRECAUTIONS
Acute Asthma Attack-thickens
bronchial secretions
Operating
machines
Driving

NITROGLYCERIN
• Anti Anginal Drug
INDICATION
• Angina Pectoris
• M.I.
• C.H.F.

ACTIONS
• Direct Nonspecific Smooth Muscle Relaxation
Preload Reduction
• Venous Return
• Oxygen Consumption
• C.O
Afterload Reduction
• Total Peripheral Resistance
• Blood Pressure

……Redistribution of coronary blood flow
• Dilation of large coronary vessels
• Relaxing bigger conducting
coronary arteries
• Perfusion to ischemic myocardium

• 0.5 mg tabs (ANGISED)
• 0.4-0.8 mg spray (GTN SPRAY)
• 5-15 mg oral (ANGISPAN-TR)
• 5-10 µg/min I.V (NITROJECT)
• Transdermal patch:1 for 14-16hours/day
(NITRODERM-TTS)

Adverse Effects
• Fullness of head
• Throbbing headache
• Flushing, weakness
• Sweating
• Palpitation
• Dizziness
• Fainting,Hypotension

Precautions
• Rest in supine or sitting position
• Monitor B.P
• Caution in Hypotensive state

 Sympathomimetic
 Bronchodilator
ACTIONS
 Stimulation of β receptors
 Relaxes smooth muscles

 2-4 Mg Oral
 0.25-0.5 Mg I.M./S.C.
 100-200 Mcg Inhalational(M.D.I.)
Asthalin
Ventorlin
Croysal
1puff /Min Followed By 4 Puffs

SIDE EFFECTS
Muscle tremors-dose related
Palpitation
Restlessness
Nervousness
Throat irritation

ASPIRIN
NSAIDs
Acetyl salicylic acid
Indicated
• Myocardial Infarction
Actions
• Irreversible inhibition of thromboxane a2
• Interfere with platelet aggregation
• Prolongs bleeding time

160-325 mg tabs
Chew -30 seconds and swallow
Aspirin
Ecospirin
Disprin

Side effects
• Peptic ulceration
• Vomiting
• Abdominal cramps
• Salicylism-(3-6gms)
Tinnitus
Vertigo
Dizziness
Mental confusion

Reye’s syndrome
• Hepatic
Encephalopathy
• Children
with Viral infection
Rheumatic arthritis
• SGOT

Acute salicylate poisoning
Children
Fatal Dose:15-30 gms
Vomiting, dehydration
Petechial Hemorrhages
Coma
Death-Resp:depression

Rx
External Cooling,IV Fluid
Gastric Lavage
Forced Alkaline Diuresis
Blood Transfusion
Vit K Therapy

DIAZEPAM
Benzodiazepine derivative
Indications
Seizures
Actions
 Anti anxiety
 Anticonvulsive
 Centrally mediated muscle relaxation

DOSE AND ADMINISTRATION
 0.2-0.5 mg/kg-I.V to a max 100
mg/day
 Valium 2,5,10mg tabs
10 mg/2 ml inj I.V.,I.M.
 Calmpose 5,10 mg tabs
 10 mg/2 ml inj

SIDE EFFECTS
 Dizziness
 Vertigo
 Ataxia
 Amnesia
 Disorientation
 Dry mouth, weakness
 Blurring of vision
 Depression and Sedation

FLUMAZENIL
Antagonist to diazepam
 Depression and sedation
 BZD anesthesia
 0.2mg/min-I.V.-overdose
 0.3-1mg,I.V.,inj-regains BZD anesthesia within 1 minute
Mazicon
Romazicon
Side effects
 Agitation
 anxiety

MORPHINE
• Opioid Analgesic
Indicated
– Acute Myocardial Infarction
Actions
– Strong Analgesic
– Perception And Reaction To Pain Is Reduced
– Release Of Sub P From Spinal Cord Is
Inhibited
– Sedative Effectwww.indiandentalacademy.com

• 10-15 mg I.M., S.C.
• 2-10 mg I.V.
Morcontin
Rilimorph

Side effects
• Sedation
• Hypotension
• Local reaction at injection site-histamine
• Vomiting
• Constipation
• Urinary retention
• Euphoric effect

Acute morphine poisoning
Features
• Coma
• Cyanosis
• Flaccidity
• Fall in B.P.
• Pulmonary edema
• Shock
• Death-respiratory failure
50 mg I.M.
Lethal dose
250 mg

Treatment
• Maintain Respiration, B.P.
• I.V. Fluid
• Gastric Lavage-Pottasium Permanganate
• Antidote-Naloxone
0.4-0.8 mg I.V.
Repeated every 2-3 min

precautions
• Children And Elderly –Respiratory Depression
• Asthma-Histamine Release
• Head Injury
↑Intracranial Pressure
Respiratory Depression
Vomiting, altered Mentation
• Hypovolemia And Hypotension

NALOXONE
Pure antagonist
Inj I.V.-0.4-0.8 mg
• I.V.2-3 mg till 10mg
• Respiration stimulated
• Analgesia relieved
Narcotan 0.4 mg in 1 ml

Corticosteroids
• Hydrocortisone Sodium Succinate
• Dexamethasone
Indicated
• Anaphylaxis
• Allergic Conditions
• Acute Adrenal Insufficiency
• Asthma

Actions
• Suppresses Signs Of Inflammation
• Suppresses All Types Of Hyper
Sensitization
• Suppression Of CMI
• Reduces Bronchial Hyperactivity
• Influences Airway Remodeling
• Retard Disease Progression

• In Acute Adrenal Insufficiency
100 mg I.V. Bolus+100 mg 8 Hour
Infusion
• In Anaphylaxis And Allergies
50-100mg,I.V.-4 Times
• In Asthmatic Attacks
200 mg. I.V.

• Hyperglycemia
• Delayed healing
• Peptic ulcer
• Hirsutism
• Growth retardation
• Oropharyngeal candidiasis

HPA axis suppression
• Stoppage Of Exogenous Steroids
• Precipitation Of Withdrawal Symptoms
Fever
Malaise
Muscle Pain
Weakness
• Stress-adrenal Crisis
Prevention:
Gradual Reduction Of Dose
↑Dose During Infections Or Stress
Short Acting Steroids At Low Possible Dose
Shortest Period Of Time

ATROPINE
• Anticholinergic
Indicated
Hypotensive States
Counteract Bradycardia
Actions
• Tachycardia Due To Blockade Of M2 Receptor On SA Node
• Thus Decreases Vagal activity
Dose
• 0.6-2 Mg ,I.M.,I.V.
• Atropine Sulphate

Side effects
• Dry mouth
• Dry skin
• Excitement
• Hallucination
• Restlessness
• CVS collapsewww.indiandentalacademy.com

HEMOSTATICS
 Ethamsylate
 Adenochrome monosemicarbazone
Indication
 Hemorrhagic states after tooth extraction
Action
 Reduces capillary fragility
 Control oozing of blood
 Prevent micro vessel bleeding
 Antihyaluronidase actionwww.indiandentalacademy.com

Adenochrome
1-5 mg,oral,i.m.,
styptochrome 3mg/2ml inj
styptocid 2 mg/2 ml inj
Ethamsylate
250-500 mg tds,oral,I.V., I.M.
Ethamsyl,dicynene
Side effects
 Nausea
 Rashes
 headache

ANTIFIBRINOLYTICS
 Epsilon Amino Caproic Acid
 Tranexamic Acid
Indication
 Excessive Bleeding-haemophilics
Actions
 Inhibit Plasminogen Activation
 Prevent Dissolution Of Clot
Dose And Administration
 EACA:- 5 gm Oral/I.V., Followed By 1 gm Till
Bleeding Stops(max:30 Gms/24 Hrs)
Hemocid,Hamostat
 Tranexamic Acid:- 0.5-1g Tds I.V.
10-15 Mg/Kg 2-3 Times/Day
Cyclokapron

Aromatic ammonia
Indication
 Vasodepressor Syncope
Action
 Production Of Noxious Odor
 Irritation Of Respiratory Membrane
 Stimulation Of Respiratory And Vasomotor
Centers Of Medulla
 ↑ B.P.,Heart Rate
Available: - Silver Gray Vaporole 0.3 Mg
Caution: Asthma

GLYCEMIC AGENTS
To Increase Blood Glucose Level
Oral Glucose
Conscious Patients And Those Who Can
Swallow
Use A Palatable Agent
15 gms Oral,15 -20 mins
Repeated Administration-hyperglycemia

Dextrose
Unconscious Patients
Cannot Swallow
I.V.,-Onset Of 5-10 Mins
50 % In Water-25 gms (Ampule)
Caution:
-Rapid Extravasation Into Skin Causes Necrosis
-Administration Of Dextrose To Alcohol Dependent
Patients With Thiamine Deficiency-
Wernicks Encephalopathy
Prevention By 100 mg I.V., Thiamine Before
Dextrose

Glucagon
•Pancreatic Hormone
•Lyophilised Powder(1mg) Mixed With 1 ml
Of Normal Saline For Injection
•0.5-1 mg ,I.M.,
Hyperglycemic
Glycogenolysis And Gluconeogenesis
Efficiency Depends On
Hepatic Glycogen Storage
Status Of Nutritional Deprivationwww.indiandentalacademy.com

Side Effects
Nausea With Vomiting
Exacerbation Of Hypoglycemia In Type 2
Dm By Stimulating Release Of Insulin

XYGEN THERAPY
O2
O2
O2
O2

Oxygen therapy
 Almost all emergencies
 Respiratory deficient
Portable oxygen cylinder
Not indicated
 Hyperventilation syndrome
 O₂ flushes away co₂ and counters the desired
treatment of increasing co₂ level

OXYGEN REGULATOR

OXYGEN CYLINDER WRENCH

NASAL CANNULAE

FACE MASK
 Breathing
 Non Rebreathing

E-NEBULIZER

NEBULIZER

USED
Drugs
I.V insertion
Rapid onset
Peak effect
I.V. insertion
Complication
Hematoma
Nerve injury
Embolism
Phlebitis

•To summarise

Emergency Drugs Dose
Hypoglycemia Oral Glucose
Dextrose
Glucagon
10-15gms
5%
0.5-1 mg,IM
Acute Myocardial Infarction Morphine
Aspirin
10-15mg,I.M,s.c,2-10 mg,IV
160-325 mg oral
Anaphylaxis Epinephrine
Antihistamines
Hydrocortisone
0.3-0.5 ml,I.M
10-20 mg,I.V
50-100 mg,I.V
Angina Pectoris Nitroglycerin 0.4 mg sublingual
Seizures Diazepam 10 mg/2ml inj
Acute Adrenal Crisis Hydrocortisone 100-200 mg I.V.
Acute Asthmatic Attack Salbutamol
Hydrocortisone
Adrenaline
100-200 mg MDI
200 mg I.V
0.3-0.5 mg I.M
Vasovagal Syncope Atropine 0.5 mg,I.V,I.M
Excessive Bleeding Ethamsylate
Adenochrome
250-500 mg,oral,I.V
1-5mg,oral,I.M
Morphine Overdose Naloxone 0.4-0.8 mg,I.V
BZD Overdose Flumazenil 0.3-1 mg/min I.Vwww.indiandentalacademy.com

EMERGENCIES ARE UNPREDICTIVE, TO BE
PREPARED IS THE BEST…

BIBILOGRAPHY
MEDICAL EMERGENCIES IN DENTAL OFFCE-
MALAMED(5TH EDI)
MEDICAL PROBLEMS IN DENTISTRY-
SCULLY,CAWSON(5TH EDI)
MEDICAL EMERGENCIES IN DENTISTRY-
BENNETT,ROSENBERG
ESSENTIALS OF MED PHARMACOLOGY-
KD TRIPATHI(6TH EDI)
GENERAL MEDICINE- GEORGE MATHEW(2ND EDI)
TEXT BOOK OF ORAL MEDICINE -GHOM
PREPARING FOR MEDICAL EMERGENCIES-
JADA2010
MANAGEMENT OF MEDICAL EMERGENCIES IN
DENTAL OFFICE-JDSA-2006

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