this presentation includes the various emergency drugs as well as emergency kits that we as dentists should keep in our dental clinics and hospitals for emergency purposes.

1. P R E S E N T E D B Y : -
D R M E E N A L A T H A R K A R
M D S
D E P T O F C O N S E R V A T I V E
D E N T I S T R Y A N D
E N D O D O N T I C S
EMERGENCY DRUGS
AND NSAID’s

2. CONTENTS:
 Emergency drugs
 Introduction
Purpose of emergency drugs
Category of emergency drugs
Modules of emergency drugs
 Emergency drug kit

3. INTRODUCTION:
 Everyone has personal experience pain in day to day
life.
 One of the greatest services, we as doctors can
provide to the society is to acquire skill in the
management of pain and to understand the
phenomenon of pain.
 Among the various novel methods for control of
pain, analgesics are most frequently used for pain
relief.

4. INTRODUCTION:
 Emergency drugs are those chemical entity used in
patients during life threatening conditions so that
the symptoms can be controlled and the life of a
patient can be saved.
 Emergency drugs are usually available in those kind
of dosage forms having short onset of action. i.e
rapid/prompt action.
 Emergency Drugs are used in those patients
requiring immediate attention.

5. PURPOSE OF DRUGS:
 To provide initial treatment for broad spectrum of
illness and injuries, most of which are life
threatening.
 To save life of patient.
 To control symptoms of patient.
 To reach the site of action as soon as possible.
 To normalize the vital body functions.
 To diverge the patient from possible risk.

6. CATEGORY OF EMERGENCY DRUGS:

7. ROUTES OF DRUG ADMINISTRATION, BY ONSET OF
ACTION (FASTEST TO SLOWEST)
 Endotracheal (ET) (when available): epinephrine,
lidocaine, atropine, naloxone, and flumazenil only
 Intravenous (IV)
 Sublingual or intralingual
 Intranasal (IN): midazolam
 Intramuscular (IM)
 Vastus lateralis
 Mid-deltoid
 Gluteal region

8. MODULES OF EMERGENCY DRUGS:
 four levels, or modules.
1. Module one: Basic emergency kit (critical drugs and
equipment)
2. Module two: Noncritical drugs and equipment
3. Module three: ACLS drugs
4. Module four: Antidotal drugs
 Two categories are described for each module—
injectable and noninjectable drugs, as well as
emergency equipment.

9. 1}Module One: Critical (Essential) Emergency
Drugs and Equipments
> INJECTABLE DRUGS
 Epinephrine
 Histamine blocker
> NONINJECTABLE
DRUGS
 Oxygen
 Vasodilator
 Bronchodilator
 Antihypoglycemics
 Aspirin
> EMERGENCY
EQUIPMENTS
1. O2 delivery system
2. Automated external
defibrillator
3. Syringes
4. Suction and suction tips
5. Tourniquets
6. Magill intubation forceps

10. 2}Module Two: Secondary (Noncritical)
Emergency Drugs and Equipments
 Injectable drugs
1. Anticonvulsant
2. Analgesic
3. Vasopressor
4. Antihypoglycemic
5. Corticosteroid
6. Antihypertensive
7. Anticholinergic
 Noninjectable drugs
1. Respiratory stimulant
2. Antihypertensives
 Emergency
equipments
1. Oropharyngeal and
nasopharyngeal
airways
2. Laryngeal mask
airway
3. Laryngoscope and
endotracheal tubes
4. Scalpel or
cricothyrotomy
needle

11. 3}Module Three: Advanced Cardiovascular Life
Support (ACLS)
 Epinephrine
 Oxygen
 Lidocaine
 Atropine
 Dopamine
 Morphine sulphate
 verapamil

12. 4}Module Four: Antidotal Drugs
1. Opioid antagonist- naloxane
2. Benzodiazepine antagonist- flumazenil
3. Antiemergence delirium drug- physostigmine
4. Vasodilator/ LA- procaine

13. Module 1: INJECTABLE DRUGS:
1. EPINEPHRINE:
 Drug class- natural cotecholamine
 Indications-Epinephrine in a 1:1000 or 1:2000
concentration is used to treat cases of acute allergic
reactions and bronchospasm.
 -1:10,000 concentration is recommended in
the management of cardiac arrest
 -angioedema and anaphylactic shock
 - open angle glaucoma
 Each kit should have two preloaded autoinjector
syringes of 1:1000 epinephrine

14.  Contraindications-
 Hyperthyroidism
 Hypertension
 Ischemic heart diseases
 Diabetes
 Angle closure glaucoma

16. 2. ANTIHISTAMINES
 Drug of choice- chlorpheniramine
 Alternative drug- diphenhydramine HCL (benadryl)
 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 on the cell, blocking the response of the
effector cell to histamine.
 Indications-Histamine blockers are recommended in
management of delayed-onset allergic reactions (only
involving skin)
 - in definitive management of acute life-
threatening allergic reactions (anaphylaxis).
 - for local anesthesia
 The emergency kit should contain a minimum of two
1-mL ampules of either diphenhydramine (50 mg/mL)
or chlorpheniramine (10 mg/mL).

17. NONINJECTABLE DRUGS:
1.OXYGEN:
 The most useful drug in the entire emergency kit is oxygen,
which is supplied in a variety of sizes of compressed gas
cylinders.
 In emergency situations an E cylinder provides O2 for
approximately 30 minutes (if the patient is apneic).
 Larger cylinders (H cylinders) provide significantly more O2
but are less portable; smaller cylinders (A through D
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.
 An E cylinder of O2 is quite portable and should be available
in dental offices even where centrally supplied nitrous oxide
(N2O) and O2 are used.

18. 2. VASODILATORS:
 1. nitroglycerine:
 Nitrolingual spray, Nitrostat tablets
 Indications-With onset of first-time chest pain,
nitroglycerin is used as an aid in differential diagnosis
and for the definitive management of angina pectoris,
the early management of acute myocardial infarction,
and the management of acute hypertensive episodes.
 Nitroglycerin is available in the following forms: 0.3-,
0.4-, 0.6-mg doses of sublingual tablets; 0.4- and 0.8-
mg doses of trans lingual spray.
 Act in 1-2 mins when placed sublingually.
 2. Amyl nitrite is available as 0.3-mL doses in yellow
vaporoles.
 Emergency drug kits should contain either one bottle
of sublingual tablets or one bottle of metered trans
lingual Nitroglycerin spray (0.4 mg).

19.  Contraindications-
 Obstructive hypertrophic cardiomyopathy
 Raised intracranial pressure
 Cardiac tamponade

21. 3.BRONCHODILATOR:
 Albuterol, Salbutamol
 Proprietary: Proventil, Ventolin, Proair, Respirol,
Volmax
 β2-adrenergic receptor agonists
 specific bronchial smooth muscle– relaxing
properties (β2) with little or no stimulatory action on
the cardiovascular and gastrointestinal systems (β1)
 indications:- Bronchodilators are used to treat
bronchospasm (acute asthmatic episodes) and
allergic reactions in which bronchospasm is a
component

23. 4.ANTIHYPOGLYCEMICS:
 Orange juice /Glucose Gel (Insta-Glucose™)
 Indications-
 Antihypoglycemics are useful in the
management of hypoglycemia in patients
with diabetes mellitus.
 Antihypoglycemics come in a variety of
forms, including Glucola, Gluco-Stat, Insta-
Glucose,
 Contraindications- oral carbohydrates
should not be administered to patients who
do not have an active gag reflex

24. 5. ANTIPLATELET:
 Aspirin:
 Standard doses range from 160 to 324 mg given orally.
Minimal side effects are noted, particularly with the 160
mg dose.
 Aspirin is available in 65-, 81-, 162-, and 325-mg tablets
under many brand names.
 Powdered forms of aspirin are available and are
preferred to tablets as their onset of action is more rapid
 Indication- Aspirin is recommended in the management
of patients with suspected myocardial infarction or
unstable angina.
 The emergency kit should include powdered or chewable
aspirin (325 mg)

26. CRITICAL EMERGENCY EQUIPMENTS:
1. O2 delivery system
2. Automated external defibrillator
3. Syringes
4. Suction and suction tips
5. Tourniquets
6. Magill intubation forceps

31. MODULE 2: INJECTABLE:
1. ANTICONVULSANTS-
 MIDAZOLAM:
 Midazolam (Hypnovel and Dormicum [Europe, Great
Britain]) is available as 5 mg/mL in 1-, 2-, 5-, and 10-mL
vials and in 2-mL preloaded syringes, and 1 mg/mL in 2-,
5-, and 10-mL vials.
 The well-known proprietary name of midazolam—Versed—
is no longer marketed.
 Diazepam is available as 5 mg/mL in 2-mL ampules and
10-mL vials and in 2-mL preloaded syringes.
 Indication-Midazolam is used to treat prolonged seizures ,
local anesthetic-induced seizures, hyperventilation, and
thyroid storm.
 emergency kit-- One 5-mL vial of midazolam (5 mg/mL)

32.  Drug of choice- diazepam-benzodiazepine
 Alternative drug- barbiturates(thiopentane)
 Seizure disorders may occur in dental office in several
circumstances:
 Overdose reactions of LA.
 Epileptic seizures
 Febrile convulsions
 Indications- termination of prolonged seizures
 - local anesthetic seizures
 - hyperventilation syndrome
 - thyroid storm
 Avaliability- diazepam(valium)-5 mg/ml(2ml preloaded
syringe)

33. 2.ANALGESIC :
Morphine sulfate
 Alternative drug-- Nitrous oxide and oxygen (N2O-
O2)/ meperidine
 Narcotic analgesic action
 Morphine sulfate is available 8, 10, and 15 mg/mL
(in 2-mL ampules and 20-mL vials)
 Indications-Intense, prolonged pain or anxiety;
 acute myocardial infarction;
congestive heart failure
 Emergency kits may contain 10 mg/mL morphine
sulfate (two 2-mL ampules).

34.  Contraindications-
 In victims of head injury and multiple trauma
 Patients with compromised respiration

35. 3. VASOPRESSORS:
 Drug of choice-methoxamine
 Alternative drug-phenylephrine
 Pure alpha adrenoceptor agonist
 Vasopressors are used to manage clinically
significant hypotension.
 Possible uses include the following:
1. Syncopal reactions
2. Drug overdose reactions
3. Postseizure states
4. Acute adrenal insufficiency
5. Allergy
 Availability- methoxamine- 10 mg/ml, 20 mg/ml
 - phenylephrine-10 mg/ml(1 ml ampule).

36.  Contraindications-
 Hyperthyroidism
 Bradycardia
 Partial heart block
 Myocardial disease
 Severe artherosclerosis

37. 4.ANTIHYPOGLYCEMIC:
 Dextrose, 50% solution /Glucagon
 1 mg/mL (two or three 1-mL vials) of glucagon for
IV or IM administration
 indications-Antihypoglycemics are used in the
treatment of hypoglycemia and as a diagnostic aid in
unconsciousness or seizures of unknown origin
 Contraindications- in starvation state
 Chronic hypoglycemia

38. 5.CORTICOSTEROID
 Drug of choice- hydrocortisone sodium succinate
 Alternative drug- methyl prednisolone sodium
succinate
 Primary value- in prevention of recurrent episodes of
anaphylaxis
 Adrenal glucocorticosteroid
 Availability- Hydrocortisone sodium succinate-
50mg/ml(one 2-mL vial).
 - methyl prednisolone- 50mg/ml (1ml vial)

39.  Indications- definitive management of acute allergy
 - status asthamaticus
 - apthous ulcer
 - acute adrenal insufficiency
 - congenital adrenal hyperplasia
 Contraindications- when administered for an
emergency treatment there are many factors to be
considered such as presence of pre-existing injection,
peptic ulcer and hyperglycemia

40. 6.ANTIHYPERTENSIVES:
 Drug of choice- esmolol, propanolol
 β-adrenergic blocker
 Alternative drug :Labetalol
 Indications-Acute hypertensive episodes
 Availability-Esmolol is available as 2.5 g in a 10-mL
ampule, which is diluted to a 10-mg/mL concentration
prior to infusion, and as a 100-mg/mL solution, which is
also diluted to 10-mg/mL prior to administration.
 Emergency kit- Two ampules 100 mg/mL with diluent.

41. 7.PARASYMPATHETIC BLOCKING
AGENT/ANTICHOLINERGIC DRUG:
 Atropine is a parasympatholytic drug that decreases
vagal tone through its vagolytic action, thereby
increasing the rate of discharge of sinoatrial node.
 Atropine is used to treat bradycardia and
hemodynamically significant bradydysrhythmias
 Emergency kit-Two or three ampules of 0.5 mg/mL
(for IM administration) or two 10-mL syringes with 1
mg per syringe (for IV administration).

42.  Availability- 5 mg/ml (0.1 mg/ml preloaded syringe)
 Indications-management of severe sinus bradycardia
accompanied by symptomatic hypotension
 - anesthetic premedication
 - inhibition of cardiac reflexes
 - opthalmic use
 Contraindication- glaucoma
 - chronic lung disease
 Conventional dose in adults- 300-600 mg

43. SECONDARY NONINJECTABLE DRUGS
1. Respiratory stimulant
2. Antihypertensives

44. 1.RESPIRATORY STIMULANT:
 Drug of choice- Aromatic ammonia
 Aromatic ammonia has a noxious odor and irritates the
mucous membrane of the upper respiratory tract,
stimulating the respiratory and vasomotor centers of the
medulla. This action in turn increases respiration and
blood pressure.
 Indication-Aromatic ammonia is used to treat
vasodepressor syncope as well as respiratory depression
not induced by opioid analgesics
 Contraindication- chronic obstructive pulmonary
disease, asthama
 Availability- Silver-gray vaporoles containing 0.3 mL of
aromatic ammonia

45. 2. ANTIHYPERTENSIVE
 Hydralazine:
 used in the management of high blood pressure.
 It is a peripheral vasodilator, causing relaxation of
arteriolar smooth muscle via a direct effect.
 Availability- One bottle 25-mg tablets.

46. SECONDARY EMERGENCY EQUIPMENT
1. Oropharyngeal and nasopharyngeal airways
2. Laryngeal mask airway
3. Laryngoscope and endotracheal tubes
4. Scalpel or cricothyrotomy needle

47. Plastic or rubber
oropharyngeal or
nasopharyngeal
airways are used to
help maintain a
patent airway in the
unconscious patient

51. MODULE THREE: ADVANCED
CARDIOVASCULAR LIFE SUPPORT (ACLS)

52. 1. SODIUM BICARBONATE(NAHCO3)
 During cardiopulmonary arrest, both metabolic and
respiratory acidosis occur.
 NAHCO3 is effective in management of metabolic
acidosis.
 Availability- ( 50 ml ampule)
 Indications-reversal of metabolic acidosis occurring
during anaerobic metabolism in cardiopulmonary
arrest.
 - management of metabolic acidosis in
uncontrolled diabetes, circulatory insufficiency from
shock or dehydration, alkanization of urine.

53.  Contraindications- in hypoventilatory states
- metabolic or
respiratory acidosis
- hypocalcemia
- chloride depletion

55. BASIC EMERGENCY EQUIPMENTS:
 Tourniquets
 Syringes
 Ambu bag
 Oropharyngeal and nasopharyngeal airways
 Normal saline 0.9%, 1000-mL bags
 18-and 20-gauge angiocatheters
 Yankauer suction tip
 Portable oxygen system (E cylinder size)
 Stethoscope
 Sphygmomanometer (child and adult sizes)
 ECG/defibrillator (AED)
 Sterile water for injection

56. EMERGENCY DRUG KIT
 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.
 Management of all emergency situations follows the
(P → A → B →C D) protocol (D = definitive
management: diagnosis, drugs, and defibrillation).

57.  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 implemented, as needed, first).
 2. Primary management of all emergency situations
involves BLS.
 3. When in doubt, don’t medicate (there will be a
very specific exception to this in the case of
presumed anaphylaxis

58. BASIC DRUG EMERGENCY KIT
 Epinephrine 1mg/mL (1:1000 dilution)
 Dextrose 50% of 50 mL ampule 0.5g/mL
 Oxygen
 Nitro-glycerine tablets or spray 0.4 mg per tablet
 Albuterol; metered inhaler
 Hydrocortisone 300 mg ampule
 Spirits of ammonia (vaporable)

61. Self made emergency drug kit

62. CONCLUSION:
 Based on the knowledge of the pharmacology of the drugs it is
necessary to choose the right kind of analgesic suitable to a patient
that delivers the desired effect with minimal side effects and provide
the best achievable comfort to the patient.
 Medical emergencies can, and do happen in the practice of dentistry.
 The essential emergency drug kit and emergency equipment should be
kept always in the dental office.

63. REFERENCES:
 Essentials of pharmacology :K.D .Tripathi
 Medical emergencies: Malamed
 Wikipedia