In this presentation, Dr. H. Ryan Kazemi, oral surgeon in Bethesda, MD, discussed management of common medical emergencies in dental office.

1. Management of
Medical Emergencies in
Dental Office

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3. Emergency
Response Plan
Prevention
Basic Principles
of Medical
Emergencies
Airway
Management
Medical
Emergencies
Syncope
Anxiety
Attack
Asthma
Hypoglycemia Anaphylaxis Allergy
Angioneuro
Edema
Bronchospasm
/ COPD
Hyperventilation

4. Emergency Response Plan
Receptionist: Recognition of incident; Notification
of EMS; Crowd control
Administrative: Documentation
Team Leader: Dentist; Provides patient
assessment and treatment
Assistant: Airway management; Assist with patient
monitoring; Vital signs

5. Emergency Response Plan
Preparation
Every office should have a written emergency protocol utilizing a
team approach
Design policies to include:
Written guidelines defining those conditions that should be
referred to local EMS.
Directions for accessing EMS.
Easily accessible Hospital telephone numbers and directions to
ER
Staff training and role playing
CPR certification- Health care provider course

6. Prevention
Complete Past Medical & Surgical History
Careful Review of Current Medications
Allergies
Review of Systems
Proper preoperative Management
Pre-operative Consultation (not clearance) with
Patient’s Physician

7. 10 Core Questions
1.Are you now under a physician’s care or have you
been during the past 5 years, including
hospitalization and surgery?
2.Are you currently under a doctor’s orders or taking
any medications, including any BCP, OTC drugs, or
homeopathic preparations?
3.Do you have any allergies or are you sensitive to
any drugs or substances such as Penicillin,
novocaine, aspirin, latex or codeine?

8. 10 Core Questions
4. Have you ever bled excessively after a cut,
wound, or surgery? Have you ever received a
blood transfusion?
5. Are you subject to any fainting, dizziness, nervous
disorders, seizures, or epilepsy?
6. Have you or your family ever had any anesthesia
related problems

9. 10 Core Questions
7. Have you ever had any breathing difficulty
including asthma, emphysema, chronic cough,
pneumonia, tuberculosis, or any other lung
disorders? Do you use any tobacco products?
8. Do you have heart disease or a history of chest
pain or palpitations?

10. 10 Core Questions
9.Is there anything you would like to discuss alone
with the doctor?
10.Do you currently use or have a history of using
recreational drugs?

77. Anaphylaxis
Description: A catastrophic and potentially fatal type of allergic reaction, which
can occur within minutes after administration of drugs of non-human proteins
Key Signs & Symptoms:
–Laryngeal Edema: Stridor, Throat tightening, Choking
–Bronchospasm: Wheezing, Chest tightness
–Vascular collapse: Confusion, Syncope, Seizures, Hypotension, Tachycardia
Assessment Notations:
–Generalized urticaria or edema
–Sudden onset of symptoms
–Onset of shortness of breath

78. Anaphylaxis
Management
Position: comfortable, or lay down if hypotensive
Airway: 100% O2 by non-rebreather mask
Call Emergency Medical Services
Epinephrine: 1:1000, 0.3 to 0.5 cc SQ.
Pediatric: 0.01 ml/kg to maximum of 0.3 cc.
Repeat in 5-10 minutes.
Dosage should 0.1 - 0.2 mg SQ.
If severe, vascular Collapse or marked airway embarrassment and no
response to SQ epinephrine, then give Epinephrine ==>

79. Anaphylaxis
Management
==> 1:10,000, 0.3 to 0.5mg IVP over 3-5 minutes. (Pediatrics
0.1 cc/kg) Repeat Epinephrine as needed every 5 minutes
Without an IV, Epinephrine May be injected sublingually, 0.1
to 0.2 cc of 1:1000 concentration; (Pediatrics: Use 0.01 cc/
kg)
Obtain Vital Signs
Diphenhydramine (Benadryl) may also be given: 25-50 mg
IVP/IM. (Pediatrics: 20cc/kg IM)
Solumedrol: 125mg IVP/IM (Pediatrics: 2mg/kg IVP/IM)

80. Drug-Induced Allergy
Symptoms:
– Uticaria: Red eruptions or hives & rashes
– Pruritus: Itching
Treatment:
– Withdraw drug in question
– Severe Reaction: Epinephrine 0.3 cc of 1:1000 I.M. or IV.; Oral
antihistamines;
– Mild-Moderate Reaction: Benadryl 50 mg orally or I.M. every 6-8
hours

81. Angioneurotic Edema
An IgE-mediated allergic painless swelling of an entire anatomic
part such as lips, eyelids, cheeks, or pharynx
– May be either drug or food induced
– Not painful
– Pruritus, Uticaria, hoarseness, stridor, cyanosis
Treatment:
– Antihistamines: Diphenhydramine 50mg P.O. or Hydroxyzine 25-100 mg
QID.
– In severe cases: 0.3 cc of 1:1000 Epinephrine SQ.

82. Asthma/Bronchospasm
A condition of acute narrowing, inflammation, and swelling of the
smaller airways.
Signs and Symptoms:
– Wheezing, dyspnea, breathlessness
– Cough
Assessment:
– Past Medical History
– Patient examination: Auscultation of lungs

83. Asthma/ Bronchospasm
Management
Position patient is a comfortable sitting position.
Administer supplemental 100%O2 at 15 LPM.
– Assist ventilation with bag-valve-mask if patient becomes cyanotic or develops
respiratory distress.
Administer nebulizer treatment of Albuterol (Proventil), 2 puffs; Repeat every 10-20
minutes if symptoms persist.
If symptoms are severe and no improvement after 2 treatments:
– Epinephrine 1:1000, 0.3-0.5 ml, SQ. (Ped.: 0.01 cc/kg); or terbutaline 0.25 mg
SQ.
If patient on steroids or remain symptomatic: Methylprednisolone, 125 mg IV push.

84. COPD
COPD (Chronic Obstructive Pulmonary disease)
involves loss of normal elasticity of the airways. It may
be the consequence of either chronic bronchitis or of
parenchymal disease represented by emphysema.
Airway obstruction is defined in terms of diminished
flow of air during forced expiration.
Signs and Symptoms: Shortness of breath; Cough

85. COPD
Management
Call Emergency Medical Services
Ascertain that the airway is open
Begin O2 at 2 liters per minute by nasal cannula. If
severely tachypneic and is cyanotic, place on 100%
Oxygen 15 LPM via non-rebreather mask.
Albuterol (Proventil)- Two puffs
Methylprednisolone, 125 mg IVP or Prednisone 40 mg
P.O.

86. Hyperventilation
Signs:
–Rapid breathing with a feeling that you can’t get enough air.
–Crying
–Convulsions
–Loss of consciousness
Management:
–Help patient breath in paper bag
–Calm and reassure patient
–Monitor BP and O2 saturation
–Consider sedation with Valium

87. Case #1
55 year old male, with history of heart murmur due to aortic
valve insufficiency, is scheduled for periodontal surgery.
Patient is given 2.0 g of Amoxicillin for prophylaxis
against bacterial endocarditis. Ten minutes later patient
begins to complain of SOB, and lightheadedness. He
then reports throat tightening and exhibits increased
wheezing. He also begins to show evidence of urticaria
over his chest and extremities.
Diagnosis?
Management?

88. Position: comfortable, or lay down if hypotensive
Airway: 100% O2 by non-rebreather mask
Call Emergency Medical Services
Epinephrine: 1:1000, 0.3 to 0.5 cc SQ.
Pediatric: 0.01 ml/kg to maximum of 0.3 cc.
Repeat in 5-10 minutes.
Dosage should 0.1 - 0.2 mg SQ.
If severe, vascular Collapse or marked airway embarrassment and
no response to SQ. epi, then give Epinephrine 1:10,000, 0.3 to
0.5mg IVP over 3-5 h (Pediatrics 0.1 cc/kg) Repeat Epinephrine as
needed every 5 minutes
Without an IV, Epinephrine May be injected sublingually, 0.1 to 0.2
cc of 1:1000 concentration; (Pediatrics: Use 0.01 cc/kg)
Obtain Vital Signs
Diphenhydramine (Benadryl) may also be given: 25-50 mg IVP/
IM. (Pediatrics: 20cc/kg IM)
Solumedrol: 125mg IVP/IM (Pediatrics: 2mg/kg IVP/IM)
Anaphylaxis

89. Case #2
45 year old obese male with history of coronary artery disease
and heavy smoking is undergoing general restorative
procedures. Patient is given 4 carpules of 2% lidocaine with
epinephrine for bilateral mandibular blocks. During the
procedure, patient begins to complain of chest tightness and
SOB. He also reports pain radiating to his left side of jaw and
arm.
Diagnosis?
Management?
Prevention?

90. Place patient in a comfortable semi-inclining position.
Ascertain that the airway is open & breathing is unlabored.
Administer 100% Oxygen at 4 liters via nasal cannula.
Monitor vital signs: Blood pressure, pulse, & respiration.
Administer Nitroglycerin, 1/150 sublingually (0.4 mg).
Repeat Nitroglycerin every 5 minutes, until pain resolves or blood
pressure becomes <90, or a maximum of 3 doses.
IF PAIN DOES NOT RESOLVE, SUSPECT MYOCARDIAL
INFARCTION
Administer Morphine Sulfate, 2-5mg IV. if pain persists after 3
doses of NTG.
Transfer to Hospital
Angina Pectoris

91. Case #2 (Continued)
Patient is now on 100% oxygen and has been given 3
doses of Nitroglycerin in 5 minute intervals. At this
time, patient loses consciousness and becomes
unresponsive.
Diagnosis?
Management?

92. ABC now changed to CAB sequence
Chain of Survival”:
Immediate recognition of cardiac arrest and activation of
emergency response system
Early CPR with emphasis on chest compressions
Rapid defibrillation
Effective advanced life support
Integrated post-cardiac arrest care
Call First, Call Fast, Call 911
Position patient comfortably (Semi-sitting)
Start chest compressions
Open Airway
Rescue breaths (100% O2 via mask; IV started)
Compression / breaths in 30:2 ratio for 100 compressions per
minute
Vital signs: EKG, Oximeter, and BP
Nitroglycerin- Sublingual 0.4 mg; repeat Q5min up to three doses;
or spray inhaler, repeat every 5 minutes
Morphine Sulfate 1 to 3 mg IV q5 to 30 min.
Myocardial Infarction

93. Case #3
25 year old female is undergoing impression of implant tooth #18.
During placement of the impression coping, the patient suddenly
coughs, and the operator loses the screw driver toward the back
of the throat. The patient sits up and begins to cough violently.
What action should the dentist take?
Next the patient stops coughing and is no longer able to speak.
While he is holding his neck, he becomes unconscious.
What action should the dentist take?

94. Position: Conscious adult and child: Standing
Conscious adult or child: Perform Heimlich maneuver
Unconscious adult or child: Perform Abdominal thrusts; then
visualize airway for obstruction. DO NOT PERFORM BLIND
FINGER SWEEPS ON PEDIATRIC PATIENTS
Attempt to ventilate patient, look for chest rise. If none, reposition
head and try again; Repeat steps until successful.
Circulation: Check for pulse. If none, refer to cardiac arrest
protocol. If pulse is present, maintain airway and monitor patient
Airway FB Obstruction

95. Case #3 (Continued)
While performing abdominal thrusts, a rush of air is
felt as the patient’s airway becomes open and the
patient is now breathing. The oral cavity is then
inspected, but the screwdriver can not be seen.
Patient now begins to regain consciousness.
Diagnosis?
Management?
Prevention?

96. Direct patient to hospital ER for chest X-ray
Need to rule out aspiration
Use preventive measures: ‘throat pack’, floss around small
components, high suction
FB Aspiration

97. Case #4
17 year old female is about to undergo removal of
impacted third molars under local anesthesia. The
patient appears quite anxious, diaphoretic and pallor.
As the dentist begins to administer local anesthesia, the
patient becomes unconscious and unresponsive. Her
pulse is 45 beats per minute.
Diagnosis?
Management?
Prevention?

98. Place patient in supine position with feet elevated.
Administer 100% Oxygen via mask.
Ascertain airway is open and breathing is unlabored.
Assist ventilation with bag-valve-mask if patent is unresponsive to
O2 therapy, has marked respiratory distress, altered LOC, or apnea.
Monitor vital signs: If Hypotensive, give 300-500 cc Fluid
Permit patient to inhale aromatic ammonia vaporole
Determine etiologies: Hypoglycemia, Hypovolemia (hypotension),
Arrhythmia, psychogenic, seizure
Consider transfer to hospital with prolonged symptoms
Syncope

99. Case #5
40 year old male with history of COPD (Chronic
Obstructive Pulmonary Disease) is undergoing root
canal treatment of tooth #3 under local anesthesia.
During the procedure, patient begins to complain of
heart palpations. His breathing becomes more
labored at this time, with increased wheezing.
Diagnosis?
Management?

100. Call Emergency Medical Services
Ascertain that the airway is open
Begin O2 at 2 liters per minute by nasal cannula. If severely
tachypneic and is cyanotic, place on 100% Oxygen 15 LPM via non-
rebreather mask.
Albuterol (Proventil)- Two puffs
Methylprednisolone, 125 mg IVP or Prednisone 40 mg P.O.
Asthma

101. Clinical Condition
Step 1 Verify unresponsiveness. Call for emergency equipment. Monitor patient.
Step 2 Open the airway with head tilt, chin lift, and jaw thrust. Ammonia vaporole
respiratory stimulant (optional). Supplemental oxygen with Non-rebreathing face
mask 15 L/minute or Nasal cannula/Nasal hood 4 L/minute. Raise the legs.
Step 3 Reversal agent(s) if indicated.
Step 4 Respiratory deterioration. Raise the legs.
Clinical Condition
Step 1 Verify unresponsiveness. Call for emergency equipment. Monitor patient.
Step 2 Open the airway with head tilt, chin lift, and jaw thrust. Ammonia vaporole
respiratory stimulant. Raise the legs.
Step 3 Reversal agent(s) if indicated.
Clinical Condition
Step 1 Verify unresponsiveness. Call for emergency equipment. Monitor patient.
Step 2 Open the airway with head tilt, chin lift, and jaw thrust. Verify not breathing. Check
Pulse oximeter (BP >80 systolic) and/or Carotid pulse present (BP >60 systolic)
which indicate chest compressions not needed.
Step 3 Raise the legs.
Step 4 Reversal agent(s) if indicated.
Ventilation Management - Apnea / Hypoventilation / Obstruction
Apnea without Carotid Pulse - see Adult Cardiac Management
Action
Action
Action
Respiratory rate 0
Apnea with Carotid Pulse
Ten Minutes Saves A Life! is a registered trademark of the ADSA Anesthesia Research Foundation / © 2013 EmergSim LLC / 10Min Resp Mgmt 131108 (1)
Step 6 Confirm supraglottic airway placement with chest rise.
Step 7 If no chest rise seen after advanced airway placement, continue with evaluation for larynospasm, foreign body, bronchospasm,
or chest wall rigidity.
Step 5 Consider advanced supraglottic airway with gastric venting capacity if unable to ventilate with bag mask easily.
Step 1 Open the airway with head tilt, chin lift, and jaw thrust.
Step 2 Consider oral or nasal airway if apneic.
Step 3 Bag Mask ventilation - preferably two person. One breath every 6 seconds, breath volume 400-800 mL, pressure <20 cm H 2O,
oxygen flow 15 L/minute.
Step 4 Confirm chest rise with each breath.
Adult Respiratory Distress - The Unresponsive Patient
Ten Minutes Saves A Life!®
Monitoring (blood pressure, heart rate, pulse oximetry, respiratory rate) ongoing throughout evaluation and management. All initial
actions are performed simultaneously after verification of unresponsiveness by stimulating the patient including head tilt and jaw lift.
Reversal agents (naloxone and flumazenil) may be administered at any time.
Respiratory rate >10 and
Oxygen saturation > 95%
Respiratory rate <10 and/or
Oxygen saturation <95%
Breathing Normally and Unresponsive
Respiratory Depression and Unresponsive
Ventilation Management (see below)
Ventilation Management (see below)
Ventilation Management (see below)
Ten Minutes Saves A Life
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