Review and overview of common medical emergencies in the dental office and the care of these conditions

1. To Be Added
 Common meds used in dentistry that
can cause emergency
 Racemic epi
 Propanolol, MAOI’s , Tri cyclics, adderal
and other ADHD meds with epi.
 Throat pack to prevent aspiration
 Needle stick injury
 Organ degeneration by age and impact
on meds used and rx in dental setting
 Formula to calculate MRD & pediatric
assoc. recommendations
 Respiratory distress – add vaping
 Esthers in offices – topical, articane
(septocaine) – hybrid LA
 Depression, Panic Attack disorder,
Generalized Anxiety Disorder and CV,
epi, sugar, diet.
 The naturopath patient and AMA
(against medical advice) and
complicatins / compromises. Who
owns responsibility.
 ASA status

2. Medical Emergencies
In The Dental Office

3. Prevention
Update Medical History & Medications EVERY VISIT

4. PPT Organization
 Overview of emergencies
 Rapid Response Team
 Basic Emergency Equipment
 Local Anesthetic MRD / epi
 Emergency Meds / Kit
 CANAL Evaluation
 Core Drugs

5. Presentation Organization
117 slides total
Syncopy
Asthma
Angina
Allergic Reaction
Airway Management
Hypoglycemia
Seizure
Overdose
Bradycardia
Hypertension

6. Acute Medical Emergency
Prevention is the best care
Accurate medical history
Updated medical history EACH VISIT
Updated drug – prescription history
Naturopathic – vitamin / herb history

7. Preparation
Training & Review - RAPID RESPONSE TEAM

8. Acute Medical Emergency
 Recognition
Reaction
 Preparation
Provision

9. Type of Emergency
 Unexplained tachycardia >130
 Unexplained bradycardia <60
 Elevated respiratory rate >30 BPM
 Depressed resp. rate < 8 BPM
 Unexplained altered mental status
 Loss of consciousness
 Seizures
 Chest Pain
 Unexplained dyspnea
 Change in O2 Sat < 90% despite
supplemental Oxygen
 Staff worried about patient
 Apparent deterioration of patient
condition without any explanation or
above criteria
 Local anesthetic overdose
 Epinephrine overdose
 Drug interaction

10. Emergency Management Plan
 Emergency Checklist
 Staff members have specific assigned duties
 Contingency plans in place if staff member absent
 Staff trained for emergency management / BLS
 911 Caller, door holder, elevator guard, directions for EMS, recorder, 2 assistants to Dr.
 Gather Oxygen, AED, Med Kit, PO2 meter, BP cuff, stetheoscope
 Equipment & Medications Kit and checked weekly / monthly
 Placed in designated position
 Restocked as needed & immediately after use

11. Emergency Management Plan
One staff member assigned task of
ensuring that these procedures have
been completed and to document the
checklist review
 Unannounced emergency drills
conducted quarterly
 Appropriate emergency phone
numbers placed prominently near
telephones

12. Emergency Team
Rapid Response Team
7 Person Team
Preparing dental office staff members for emergencies Developing a basic action plan Daniel P
Haas, DDS, PhD.
1 Leader
1 Recorder / Scribe
2 perform CPR / Rescue Breathing (swith every 2 min.)
1 Emergency Drug manager- misc. help, sub for team member
1 AED
1 Direct EMS / hold door
Flow of personnel for brevity and smoothness reduces stress
Change out CPR - Cross Train

14. Role 1: Leader - Dentist
 Directs team members
 Positions patient and stays with him or her
 Performs emergency assessment
 Review mMd. Hx., current meds, meds administered
 ABC’s CPR
 Takes command & Keeps Calm & verifies team duties performed
 States instructions directly and clearly
 Requests feedback communication
 Fosters open exchange among team
 Concentrates on what is right for patient, not who is right
 Look for causes of emergency
Preparing dental office staff members for emergencies Developing a basic action plan
Daniel P Haas, DDS, PhD.

15. Emergency Team
--- 5 Assistants
 1 - Brings emergency kit, AED, Oxygen tank with Ambubag
 2&3 - Assists in CPR / Rescue Breathing
 4 --AED application, Activation, Use every 2 minutes / 5 cycles CPR
 Prepares drugs for administration
 5 - Keeps Chronological log of events
 Switch Out compressor / ventilator as needed
Preparing dental office staff members for emergencies Developing a basic action plan
Daniel P Haas, DDS, PhD.

16. Entire office is the TEAM
All For One -- The Patient
 Telephones EMS 911
 Meets paramedics at building entrance
 Prints out
 medical history
 treatment provided by dental team for EMS / ER
 May Assist / Switch Out with assistant for CPR as needed
Preparing dental office staff members for emergencies Developing a basic action plan
Daniel P Haas, DDS, PhD.

17. Basic Emergency Equipment
 Portable E size oxygen cylinder
 Ambubag with reservoir
 Oropharyngeal airways (size 7,8,9
adult)
 Magill Forceps
Preparing for medical emergencies The essential drugs and equipment for the dental office
Morton Rosenberg, DMD

18. Basic Emergency Equipment
 Stethoscope & Sphygmomanometer
 PO2 meter
 Glucometer
 Emergency Medicine kit
 AED
Preparing for medical emergencies The essential drugs and equipment for the dental office
Morton Rosenberg, DMD

19. Emergency Medicine kit
Medications to alleviate life-threatening emergency

20. Core Emergency Drugs
8 minimum
 Epinephrine for anaphylaxis, bronchospasm
 Benadryl for allergic reactions, anaphylaxis
 Albuterol for asthmatic attack,
bronchospasm
 Nitroglycerin for angina suspected MI
 Aspirin for suspected myocardial infarction
 Glucose source for diabetic emergency
(hypoglycemia)
 Ammonia inhalants for syncope
 Oxygen as supplemental adjunct
 Epinephrine .3-.5 mg q3-5 min prn IM
 Pedo ½ dose
 Benadryl 50 mg IM
 Albuterol 2 puffs inhaled
 Nitroglycerine .3 mg
 sublinual spray or tablet
 Aspirin 325 mg chew/swallow
 Glucose 1 tube
 Ammonia crush vial inhaled
 Oxygen 6 L/M face mask
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

21. Syncopy
most common dental emergency

22. Airway

23. Airway
 A = Airway
Foreign body obstruction:
airway techniques
Magill Forceps
Bronchospasm; albuterol, oxygen, epinephrine
Laryngospasm: oxygen, (epinephrine ??)
Hyperventilation
Aspiration/Emesis: airway techniques
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

24. OXYGEN
 USE: Almost any type of medical emergency
 DOSAGE: At least 5 liters/minute for patient
 CAUTION: Do not use with hyperventilation
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

26. Airway Management
 Sodium metabisulfite
 Sodium metabisulfite (MBS) is used as a preservative in food and wine and frequently
triggers attacks of asthma.
 Bronchoconstriction - Albuterol beta effect causes bronchodilation
 Asthma
 Chronic Bronchitis

27. Vasovagal Syncopy
 Eary signs
 Lightheadedness
 Nausea, sweating, pallor
 Blurred vision
 Hot or cold
 Ringing in ears
 Fuzzy thoughts
 Confusion
 Hard to speak
 Vagus nerve is stimulated
 excess acetylcholine is released
 Cardioinhibitory
 Drop in heart rate and
contractility
 Enhanced parasympathetic tone
 Drop in BP
 Vasodilation
 Panic, GAD, Stress, antihypertensives,
SSRI’s,
Risk of injury from falling

28. Vasovagal Syncopy
Tighten leg muscles
Tighten abdominal muscles
Elevate feet
Lower head
Oxygen
Not for hyperventilation

30. AMMONIA INHALANTS
 DEFINITION: a respiratory stimulant
 USE: Syncope/fainting/loss of consciousness
 DOSAGE: one to 2 ampules
 SUGGESTED STOCK: One box of ammonia vaporules
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

31. CANAL Acronym
Conscious Patient
Determine What the Emergency Is
Cardiac
Airway
Neurological
Allergy
Loss of Consciousness
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

32. CANAL Acronym
C = Cardiac
Chest pain: oxygen, nitroglycerin
Myocardial infarction: oxygen, aspirin
Dysrhythmias: ACLS drugs?
Sudden Cardiac Arrest: AED
Ventricular Fibrillation: AED & ACLS drugs?
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

33. Patients presenting as
Cardiac Risk
 MI within 6 months
 Uncontrolled angina
 Cardiac dysrythmias
 Hyperthyroid state
 No physician of record…
 AMA against medical advice
 Untruthful medical history

34. Common Meds with epinephrine
that can induce a cardiac event
 Propanolol
 Nonselective beta blocker
 HTN with rebound bradycardia and
hypotension
 In the absence of a beta-blocker, a
systemic dose of epinephrine does not
have much effect on mean blood
pressure because it has both
 alphaadrenergic effects (producing
vasoconstriction) and beta-adrenergic
effects (producing vasodilation).
 If a patient on a nonselective beta-
blocker receives a systemic dose of
epinephrine, however, the beta-blocker
prevents the vasodilation, leaving
unopposed alpha vasoconstriction. The
resulting hypertensive reaction can be
large, with systolic pressure well over
200 mm Hg.
 Phenothiazines
 Phenothiazines block alpha-
adrenergic receptors.
Adrenaline/epinephrine should not
be used due to possible reversal of
adrenaline/epinephrine's pressor
effects resulting in exaggerated beta
effect (vasodilation & hypotension)
 Thyroid dysfunction
 elevated levels of thyroid hormones in
these patients make them sensitive to
sympathomimetic drugs such as
epinephrine, which is used in dentistry
as a vasoconstrictor in local anesthesia
and retraction cord (Racemic
epinephrine)

35. Common Meds with epinephrine
that can induce a cardiac event
 MAO inhibitors
 MAOIs act by inhibiting the activity of monoamine oxidase, thus
preventing the breakdown of monoamine neurotransmitters and
thereby increasing their availability
 Hypertension, possible dysrythmia
 Tricyclic antidepressants
 Tricyclic antidepressants increase levels of norepinephrine and
serotonin, two neurotransmitters, and block the action of
acetylcholine, another neurotransmitter.
 Dysrythmias, possible Hypertension

36. Medical Conditions with Epinephrine
That can induce a cardiac event
 Thyroid dysfunction
 Diabetes
 Sulfite allergy
 Pheochromocytoma
 Adrenal insufficiency
 Medical Conditions

37. Cardiac

38. Angina - Uncontrolled
ACS Acute Coronary Syndrome
MONA morphine, oxygen, nitroglycerin, aspirin

39. How Much Epi
Is Recommended?

40. Medically Compromised Cardiac
Patient
.04 mg
Two carpules
2% xylocaine with 1.8 ml 1:100.000 epi= .036 mg epi

41. Unstable Cardiac Patient
Contraindicated in ischemic patient

42. Angina

43. Unstable Angina can lead to
Acute Coronary Syndrome
 Heart Palpitations
 Chest Pain, which is usually described as pressure, squeezing, or a burning
sensation across the precordium and may radiate to the neck, shoulder, jaw, back,
upper abdomen, or either arm
 Exertional dyspnea that does not resolve the pain on rest
 Diaphoresis from sympathetic discharge
 Nausea from vagal stimulation
http://emedicine.medscape.com/article/1910735-overview

44. Unstable Angina
Acute Coronary Syndrome
 Hypotension: Indicates ventricular dysfunction due to myocardial ischemia,
myocardial infarction (MI), or acute valvular dysfunction
 Hypertension: May precipitate angina or reflect elevated catecholamine levels due
to anxiety or to exogenous sympathomimetic stimulation
 Diaphoresis
 Jugular venous distention
 Cool, clammy skin and diaphoresis in patients with cardiogenic shock
http://emedicine.medscape.com/article/1910735-overview

46. NITROGLYCERIN
 DEFINITION: Antianginal—stimulates cGMP production which relaxes vascular
smooth muscle specifically in the coronary arteries in the presence of an anginal
attack
 USE: Chest pain (angina)
 DOSAGE: The usual dose of nitroglycerin is one sublingual (0.4 mg) tablet or one
spray (0.4 mg) from nitroglycerin spray atomizer administered every 5 minutes
 If pain does not resolve with 2 tablets it may be an impending MI
 Activate EMS
 CAUTION: Patients with low blood pressure
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

48. ASPIRIN
 Antiplatelet—inhibits prostaglandin synthesis and irreversibly inhibits platelet
aggregation
 USE: Suspected myocardial infarction
 DOSAGE: One 325 mg non-enteric, coated aspirin tablet, chewed and swallowed
or four-81 mg chewable tablets, chewed and swallowed
 CAUTION: Aspirin should not be given to persons who are allergic to it or have
active gastrointestinal bleeding
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

50. Bradycardia
antichlolinergic
Heart Rate < 60

51. Injectable Anticholinergic
 Atropine
 .5 mg
 Up to 3 mg total dose
 Anticholinergic:
 antagonizes acetylcholine at the muscarinic receptors, increasing the heart rate
 as well as having an antisialologue effect.
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

52. Injectable Atropine
 Bradycardia
 0.5 mg every 3-5 min for desired
response
 (max total dose: 3 m

53. Hypertensive Crisis

54. Injectable Antihypertensive
 Esmolol
 Beta-antagonist: is a cardioselective beta1 receptor blocker with
 rapid onset and a very short duration of action, with no significant intrinsic sympathomimetic or
membrane stabilizing activity at therapeutic dosages.
 It decreases the force and rate of heart contractions by blocking beta-adrenergic receptors of the
sympathetic nervous system
 Labetolol
 Beta-antagonist: is a mixed alpha/beta adrenergic antagonist, which is used to treat high blood
pressure.
 Hydralazine
 is a direct-acting smooth muscle relaxant used to treat hypertension by acting as a vasodilator
primarily in arteries and arterioles
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

55. Injectable Labetolol
 A loading dose of labetalol 20 mg
i.v. typically precedes either an
infusion or ongoing bolus doses of
labetalol.
 Labetalol as a single bolus dose has
an onset of action of 2–5 minutes,
with a duration of action lasting 2–4
minutes.[14]
 Incremental doses of 20–80 mg at
10-minute intervals continue until the
target BP is reached.
10 - 20 mg IV over 2 minutes initially
911 to ER
total dose not to exceed 300 mg

56. Neurological
 N = Neurological
Seizures: anticonvulsant
Transient ischemic attack - 911
Stroke - 911
Panic attack: antianxiety agent
Anxiety: antianxiety agent
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

58. Panic Attack Disorder
DSM – 5 Criteria
Psychological Symptoms
 Fear or losing control or “going crazy”
 Fear of dying
 A sense of being detached from yourself or your surroundings, or observing
yourself from outside your body

59. Panic Attack Disorder
Unexpected - out of the blue
 Panic disorder is a diagnosis given to people who experience recurrent
unexpected panic attacks. Learn about the condition and how to manage
panic attacks here
 a variety of psychological and physical symptoms occur. These symptoms include
rapid heart rate, sweating, shaking, shortness of breath, hot flashes, and
lightheadedness—as well as a sense of impending doom, chills, nausea, abdominal
pain, chest pain, headache, and numbness or tingling
 roughly 50% of people with panic disorder experience both unexpected and
expected panic attacks.
https://www.psycom.net/panic-attacks-panic-disorder-symptoms

60. Panic Attack Disorder
DSM – 5 Criteria
Physical Symptoms
 Palpitations, pounding heart, or accelerated heart rate
 Sweating
 Trembling or shaking
 Shortness of breath
 Feelings of choking
 Chest pain or discomfort
 Feeling dizzy, unsteady, light-headed, or faint
 Chills or heat sensations
 Numbing or tingling sensations (commonly referred to as “pins and needles”)

61. Panic Attack
 people who suffer from panic attacks and panic disorder may be at higher risk of
heart attack and heart disease later in life.
 compared to individuals without panic disorder, sufferers were found to have
 up to a 36% higher risk of heart attack and
 up to 47% higher risk of heart disease
https://www.psycom.net/panic-attacks-panic-disorder-symptoms
Psychology Medicine

62. How to stop a panic attack
 Plan in place – take person out of current environment if possible
 Distract patient from symptoms, and help them calm down
 Practice deep breathing and hold for a second and release for four seconds (have
patient count to 4 exhaling
 gives patient control, focus on count and not panic
 Progressive muscle relaxation
 Clench fist, or feet and totally count to 10 and then totally relax
 Repeat a mantra
 “This is temporary”, “ I am going to be ok”
 find an object and focus on it (distracting from panic)
 What color is your shirt, pants, where did you get it, is that your favorite color

63. Panic Attack Treatment
 Cognitive behavioral therapy
 Stress reduction
 Life style changes
 Medication
 SSRI, - serotonin reuptake inhibitors
 fluoxetine (Prozac), paroxetine (paxil), sertraline (Zoloft)
 SNRI – serotonin -norepinephrine reuptake inhibitors
 venlafaxine, (Effexor) Wellbutrin (buproprion)
 Benzodiazepines
 Valium,
 Ativan

64. Anxiety Attack
 symptoms that result from being in a state of anxiety—such as restlessness,
shortness of breath, increased heart rate, and difficulty concentrating
 generally less intense than those experienced at the height of a panic attack

65. Allergic Drug Reaction
 A = Allergic and drug reaction
 Latex allergy: diphenhydramine
 Anaphylaxis: epinephrine, diphenhydramine, albuterol, dexamethasone
 Allergic reaction: diphenhydramine, epinephrine, hydrocortisone
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

66. Loss of Consciousness
 L = Loss of consciousness
Syncope: ammonia
Hyperventilation
Sudden Cardiac Arrest: 911 & AED
Hypoglycemia: glucose
Stroke - 911
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

67. Asthma
Bronchospasm
Allergic Rxn

68. Asthma

69. Asthma
 a chronic inflammatory disease that narrows the airways
 wheezing, chest tightness, shortness of breath, and coughing
 As the airways react, the bronchial muscles contract.
 Cells in the airways may produce more mucus
 Chronically the bronchial smooth muscle may hypertrophy along with an
increase in the numbers of mucous glands
https://www.nhlbi.nih.gov/health/health-topics/topics/asthma

70. Asthma Triggers
potential triggers include
medications such as aspirin and beta blockers
Seasonal
Exercise induced
Stress

71. Asthma Diagnosis
 Diagnosis is usually based on the
 pattern of symptoms
 response to therapy over time
 and spirometry]
 Asthma is classified according to the
 frequency of symptoms
 forced expiratory volume in one second (FEV1)
 and peak expiratory flow rate
 It may also be classified as atopic or non-atopic where atopy refers to a predisposition toward
developing a type 1 hypersensitivity reaction.

73. ALBUTEROL
 Bronchodilator:
 stimulates beta-2 adrenergic receptors causing bronchodilation
(agonist)
 DOSAGE: one to 2 puffs
 No contraindications to using albuterol in acute episodes of bronchospasm
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

74. Neurological

75. Seizure
Epilepsy
Local Anesthetic Overdose
Drug Withdrawl / Delerium Tremens

76. Injectable Anti Convulsant
 Diazepam:
 5 mg IV / IM
 facilitation of the action of gamma aminobutyric acid (GABA), an inhibitory
neurotransmitter in the central nervous system
 produce sedation, anti-anxiety effect and skeletal muscle relaxation
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

77. Injectable Diazepam
 Status Epilepticus
 5-10 mg IV/IM q5-10min; not to
exceed 30 mg, OR

78. Allergic Reaction

79. Allergic Reaction
Mild - PO Benadryl 25mg - 50 mg. Qid
Severe IM Benadryl 50 mg
Anyphylaxsis - Epipen, Benadryl, 911, ? corticosteroid

80. Histamine Release

82. Histamine Release
 IgE is an antibody that is released in large amounts to battle
the allergens.
 When the allergen attaches to IgE it triggers a chain of
reactions
results in histamine being released by mast cells or
basophils.

83. Histamine
 Bronchoconstriction by stimulation of H1 receptors on smooth muscles.
 Mucosal edema from increased microvascular permeability (H1)
 leading to transudation of fluid and macromolecules
 through wide intercellular gaps (> 12 nm).

84. Allergic Reaction
Life Threatening
Anaphylaxsis

85. Anaphylaxsis
 Immediate or delayed severe allergic
reaction may be life threatening
• Trouble breathing
• Hives or swelling
• Tightness of the throat
• Hoarse voice
• Nausea
• Vomiting
• Abdominal pain
• Diarrhea
• Dizziness
• Fainting
• Low blood pressure
• Rapid heart beat
• Feeling of doom
• Cardiac arrest

86. Anyphylaxsis
 Administer epipen
 Activate 911
 Administer Benadryl 50 mg
 Send to ER
 Possible rx for Medrol dose pack

87. Injectable Corticosteriod
 Hydrocortisone (Solu-Cortef)
 Dexamethasone – Anti-inflammatory:
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

88. Injectable corticosteroid
 Inject hydrocortisone slowly IV or IM.
 Adults 200 mg
 Children 6 – 12 years 100 mg,
children
 6 months to 6 years 50 mg,
 children less than 6 months 25 mg.

89. Pharmacothearpy
 Adrenergic agonists (eg, epinephrine)
 Antihistamines (eg, diphenhydramine, hydroxyzine)
 Bronchodilators (eg, albuterol)
 Corticosteroids (eg, methylprednisolone, prednisone)
 Positive inotropic agents (eg, glucagon)
 Vasopressors (eg, dopamine)

91. EPINEPHRINE 1:1,000
 DEFINITION: Cardiac stimulant/anaphylaxis—activates alpha and beta-adrenergic
receptors increasing heart rate, myocardial contractility, bronchial dilation and
decreases peripheral vascular resistance
 USE: Anaphylaxis/bronchospasm
 DOSAGE: 0.3 mg intramuscular every 5 minutes (adult)
 Child 0.15 mg epi
 No contraindications to giving epinephrine during anaphylaxis
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

92. Activation of EMS
911 ----- call for help

93. DIPHENHYDRAMINE
 DEFINITION: Antihistamine—antagonizes histamine at the H-1 receptor, causes
sedation and has an anticholinergic effect
 USE Allergic reaction/anaphylaxis
 DOSE: 50 mg intramuscular or intravenous
 CAUTION: No contraindications to giving diphenhydramine during an allergic
reaction unless noted allergy or hypersensitivity to diphenhydramine
 SUGGESTED STOCK:
 Two 1-mL ampules or vials of diphenhydramine 50 mg/mL
 Diphenhydramine hydrochloride capsules 25 mg
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

95. Loss Of Consciousness

96. Airway management

97. Oropharyngeal Airway
 measured from the corner
of the patient’s mouth to
the angle of the mandible.

99. Nasopharyngeal Airway
measure from the tip of
your patient’s nose to
the tip of their earlobe.

101. Loss of Consciousness (LOC)
 Activate 911
 Call for help / get AED
 Bag Mask / Ambubag ventilation
with 5 L O2
 CPR / AED
 Review history and meds
 2 minute interval CPR teams

102. Diabetic Hypoglycemia
Insulin dependent patient that rushed and did not eat…

103. Blood Glucose Meter
 High 200 mg/dl
 Low < 70 mg/dl

104. GLUCOSE SOURCE
 DEFINITION: Antihypoglycemic—increases glucose level for treatment of
hypoglycemia
 USE: Hypoglycemia
 DOSAGE: One tube of glucose gel.
 CAUTION: Unconsciousness. Never place anything orally into an unconscious
person.
 Glucagon would be needed for LOC
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

106. Injectable Antihypoglycemics
 Dextrose (50% Dextrose)
 Antihypoglycemic: a source of calories and fluid for patients that are not able to take
oral fluids in the event of a hypoglycemic reaction
 Glucagon (GlucoGen)
 Antihypoglycemic: causes a rise in blood glucose levels by promoting hepatic
glycogenolysis and gluconeogenesis.
 Positive inotropic cardiac effect
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

107. Dextrose 50% Injection
 In insulin-induced hypoglycemia,
intravenous injection of 10 to 25
grams of dextrose (20 to 50 mL of
50% dextrose) is usually adequate
 Each mL of fluid contains 0.5 g
dextrose

108. Overdose

109. OVERDOSE
Local anesthetic overdose
Benzodiazepine Overdose: flumazenil
Local anesthetic overdose: oxygen
Narcotic Overdose: narcan

110. Package insert of Local Anesthetics
Drug Insert Warnings Section
 Dental practitioners who employ local
anesthetic agents should be well
versed in diagnosis and management
of emergencies which may arise from
their use.
 Resuscitative equipment,
oxygen and other resuscitative
drugs should be available for
immediate use
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

113. Reversal Agent for
Benzodiazepine
 Flumazenil (Romazicon)
 Benzodiazepine Antagonist: 0.2 mg IV over 15-30 sec
 IF no response after 30 sec, administer 0.3 mg over 30 sec 1 min later; IF no
response, repeat dose of 0.5 mg IV over 30 sec at 1-min intervals to max
cumulative dose of 3 mg/hr
 Reverses effect of benzodiazepines by inhibiting the gamma amino butyric acid
GABA receptors
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

114. Flumazenil (Romazicon)
Flumazenil is only approved for intravenous (IV) administration
 0.2 mg IV over 15 sec
 IF after 45 sec no response,
administer 0.2 mg again over 1 min;
may repeat at 1 min intervals; not to
exceed 4 doses (1 mg)
 IF re-sedation occurs, may repeat
doses at 20-min intervals; not to
exceed 1 mg/dose or 3 mg/hr

115. Reversal Agent—Narcotics
 Naloxone (Narcan)
 Narcotic Antagonist:
 Reverses the effect of narcotics by
 competitively inhibiting narcotic opioid receptor sites
 stable airway and adequate ventilation established before the administration of
naloxone
 adults, an initial naloxone dose of 0.4 mg to 2 mg is recommended
 selection of dose determined by the patient's respiratory status
 and likelihood of precipitating opioid withdrawal
Emergency Drug Kit Strategies For The Dental Office Written by John B. Roberson, DMD

116. Naloxone (Narcan)
 0.4 to 2 mg/dose
IV/IM/subcutaneously.
 May repeat every 2 to 3 minutes as
needed.
 Therapy may need to be reassessed
if no response is seen after a
cumulative dose of 10 mg.

118. Prevention Is
Better Than Treating !!!