This document discusses the management of common medical emergencies that may occur in a dental office. It provides information on the causes, signs and symptoms, and treatment for various conditions including: hypertension, vasovagal syncope, postural hypotension, hyperventilation, hypovolemic syncope, angina pectoris, myocardial infarction, cardiopulmonary arrest, congestive heart failure, asthma attacks, seizures, insulin shock, diabetic coma, anaphylaxis, allergic reactions, and equipment needed in a dental office to treat emergencies. Emergency drugs like atropine sulfate, diazepam, and diphenhydramine HCl are also described.

1. Management
of
Medical Emergencies
In the
Dental Office
By
Dr .Hatem ELBitar

2. Hypertension
• Defined as blood pressure Greater Than
140/90
• Risk factors:
– CVA
– MI
– CHF
– Renal Failure
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3. Hypertension
• ASA Risk Status I
– <140 and < 90
– Routine dental
management
– Recheck in 6 months
• ASA Risk Status II
– 140-160 and 90 to 95
– Recheck BP for next
3 appointments, if
elevated get medical
consultation
– Routine dental care
– Stress reducyion
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4. Hypertension
• ASA Risk Status III
– 160-200 and 95 to 115
– Recheck BP in minutes
– If elevated, medical
consult before dental
treatment
– Stress reduction
• ASA Risk Status IV
– >200/115
– Recheck BP in 5 minutes
– Immediate medical
consultation
– No routine treatment
– Emergency treatment in
hospital
– Rx for pain and infection
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5. Hypertension
Management
• Control BP before elective treatment
• Reasonable control of severe hypertension
before emergency treatment
• Medical consult before treatment for
uncontrolled hypertension
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6. Management of Medical Emergencies
Common Medical Emergencies
in the
Dental Office

7. Vasovagal Syncope
Cause:
Loss of vasomotor tone due to a massive
parasympathetic discharge leading to
decreased pulse rate, and decreased
blood pressure which leads to cerebral
hypoxia and pooling of blood.

8. Fainting: Vasovagal Syncope
In Dentistry
• The most common cause is psychogenic due to fear
and anxiety; especially from local anesthetic
• Most common between the ages of 16 and 35
• Males more prone than females
• Fainting is considered SERIOUS in PEDIATRIC patients
and patients OVER 40 years of age

9. Vasovagal Syncope
Signs/Symptoms:
1. Frightened anxious patient.
2. Decreased pulse rate.
3. Decreased blood pressure.
4. Cool, moist, clammy skin.
5. Pale appearance.
Treatment:
1. Place patient in
Trendelenberg’s position.
2. Monitor vital signs.
3. Administer aromatic spirits
of ammonia.
4. Apply cold towel to
forehead.
5. Administer 100% oxygen.
6. Reassurance.

10. Postural Hypotension
Cause:
• disorder of the autonomic nervous system in
which syncope occurs when the patient
assumes the upright position.

11. Fainting: Postural Hypotension
• The second most common cause of transient
loss of consciousness.
• Not associated with fear an anxiety
• Predisposing factors
– Administration of Drugs
– Antihypertensives
– Psychotropics, Sedatives, and Tranquilizers.
– Age: increases with increasing age
– Prolonged recumbency

12. Postural Hypotension
Signs/Symptoms:
• Decrease in BP and loss of
consciousness without
prodromal signs and
symptoms
• Heart rate is normal, unlike
Bradycardia in Vasovagal
Syncope.
• All manifestations of
unconsciousness
• When patient is placed in
the supine position,
consciousness rapidly
returns.
Treatment:
• Stop treatment
• Assess consciousness
• Place patient in the supine
position with legs elevated
• Oxygen
• Monitor vital signs
• Slowly reposition patient

13. Fainting: Postural Hypotension
Pregnancy (2 forms of hypotension)
1. Postural hypotension: during the first trimester
when getting out of bed in the morning; does not
reoccur during the day.
2. Supine hypotensive syndrome of pregnancy occurs
in the third trimester. If the patient is in the supine
position for more than 3 to 7 minutes, the uterus
can compress the inferior vena cava decreasing
venous return from the legs. Turning the patient on
her left or right side will alleviate the pressure and
blood flow returns to normal.

14. Hyperventilation
Causes:
–Acute anxiety attack,
–Metabolic and endocrinologic disorders
(hypoglycemia, hyperthyroidism, Cushing’s
syndrome, pheochromocytoma).

15. Hyperventilation
Signs/Symptoms:
1. Tachypnea.
2. Tachycardia.
3. Parasthesia around mouth
and fingers.
4. Tetany, cramps.
5. Nausea.
6. Faintness.
7. Diaphoresis.
8. Acute anxiety.
9. Shortness of breath.
Treatment:
1. Assure patient airway.
2. Reassure patient.
3. Have patient “re-breathe” in
a paper bag.

16. Hypovolemic Syncope
Causes:
–External fluid loss;
–Internal sequestration of fluid;
–Decrease in cardiac output;
–Arrhythmias;
–Hypocapnia (hyperventilation);
–Hypoglycemia.

17. Hypovolemic Syncope
Signs/Symptoms:
1. Blood pressure low
normal or elevated;
Tachycardia.
2. Orthostatic
hypotension and
increased pulse rate.
3. Altered mental states;
anorexia; apathy,
weakness.
4. Cold clammy skin.
Treatment:
1. Maintain patient airway –
turn head to one side to
prevent aspiration.
2. Administer 100% oxygen.
3. DO NOT use aromatic
spirits of ammonia because
it stimulates the
sympathetic system and
augments
arrythmogenicity.

18. Acute Angina Pectoris
Cause:
Diminished blood supply to myocardium
due to an imbalance between myocardial
oxygen supply and demand.

19. Acute Angina Pectoris
Signs/Symptoms:
1.Chest pain –
substernal pressure
or crushing
sensation. May
radiate to neck, left
shoulder and down
arm, and left side of
jaw.
Treatment:
1. Place patient in supine position.
2. Assure patient airway.
3. Administer nitroglycerine – if patient’s
prescription not available – administer
0.3 mg sublingually.
4. If pain persists five minutes after
nitroglycerine dose, repeat
administration.
5. If still no response, repeat
nitroglycerine and administer 100%
oxygen.
6. If angina does not subside – concerned
that myocardial infarction is
developing. Transfer to emergency
room.

20. Myocardial Infarction
Cause:
Inadequate supply of oxygen to
myocardium.

21. Myocardial Infarction
Signs/Symptoms:
1. Chest pain – substernal pressure
or crushing sensation, may
radiate to neck, left shoulder,
down arm, left side of jaw.
2. Feeling of impending doom;
3. Nausea.
4. Pale and diaphoretic.
Treatment:
1. Usually does not respond to
nitroglycerine.
2. Administer 100% oxygen.
3. Position patient in semi-sitting
position.
4. Transport to medical facility
immediately.
• Note: Narcotics for pain should
be avoided initially, so as not to
interfere with differential
diagnosis, but if desired give
Demerol 25-75 mg IM or IV.

22. Cardiopulmonary Arrest
Causes:
–Hypoxia;
–myocardial infarction;
–anesthesia – local or general;
–anaphylaxis;
–excessive vagal tone.

23. Cardiopulmonary Arrest
Signs/Symptoms:
1. Absence of pulse.
2. Absence of blood pressure.
3. Absence of heart beat.
4. Absence of respiration.
5. Coma.
6. Cyanosis.
7. Dilated pupils.
Treatment:
1. Rule out aspiration.
2. “Precordial Thump” within
one minute of arrest.
3. Assure patient airway.
4. Provide CPR – do not
interrupt CPR for more
than 5 seconds, for any
reason.
5. Transport to medical
facility.

24. Acute Congestive Heart Failure
Cause:
Primary “pump” problem.

25. Acute Congestive Heart Failure
Signs/Symptoms:
1. Right Sided CHF
a. Systemic congestion
b. Ankle swelling
c. Jugular vein distention
d. Pleural effusion
e. Dsypnea
f. Accumulation of fluids in
peritoneum.
2. Left Sided CHF
a. Pulmonary congestion
b. Dsypnea
c. Orthopnea
d. Great anxiety
e. Very labored breathing
f. Productive cough
g. Cyanosis
Treatment:
1. Place patient in semi-sitting position.
2. Assure patient airway.
3. Administer 100% oxygen.
4. Transport to medical facility
immediately.

26. Asthmatic Attack
Cause:
Reversible bronchospasm.
Two Subtypes:
–Extrinsic or allergic type is caused by
environmental allergens.
–Intrinsic (endogenous) type – mechanism
inducing attacks is unknown.

27. Asthmatic Attack
Signs/Symptoms:
1. Wheezing
2. Effortless inspiration, prolonged
expiration.
3. Distended chest.
4. Severe attack:
a. Tachypnea (>35) or
Bradypnea (<12) Tachycardia
(>30)
b. Exhaustion; altered
consciousness
c. Use of accessory muscles of
respiration.
d. Cyanosis.
e. Silent chest (i.e. no wheezing
with dyspnea and tachypnea)
5. Hydration
Treatment:
1. Put patient in sitting position;
assure patient airway; give 100%
oxygen.
2. Two inhalations of isoproterenol
HCl.
3. If no response to isoproterenol,
and in severe attacks, administer
epinephrine (1:1,000),
sublingually, 0.3 to 0.5 ml over 5
minutes. May be repeated every
30 minutes up to 3 doses.
Children’s dose: epinephrine
(1:1,000) 0.01 mg/kg (0.02 mg/lb)
repeat only once after one hour.
4. Contact patient’s physician.

28. Seizures
Causes:
–Neurologic disorders;
–Syncope;
–Drug toxicity;
–Hypoxia.

29. Seizures
Signs/Symptoms:
1. Involuntary or bizarre
movements.
2. Tongue biting.
3. Loss of consciousness
Treatment:
1. Assure patient airway.
2. Administer 100%
oxygen.
3. Place soft/padded bite
protector.
4. Transport to medical
facility.

30. Insulin Shock
Cause:
Hypoglycemia

31. Insulin Shock
Signs/Symptoms:
1. Rapid fall in blood glucose level.
A. May see parasympathetic
response: hunger, nausea
B. Catecholamine release
a. Anxiety
b. Tachycardia
c. Palpitation
d. Diaphoresis
2. Slow fall in blood glucose level.
A. Increasing lethargy
B. Slurred speech
C. Lassitude
D. Progressive decreasing mental
status
Treatment:
1. If conscious – give oral
glucose (orange juice,
candy, sugar cubes).
2. If unconscious – patient is
in need of IV administration
of 50% dextrose – transport
to medical facility
immediately.

32. Diabetic Coma
Cause:
Hyperglycemia

33. Diabetic Coma
Signs/Symptoms:
1. Frequent urination.
2. Loss of appetite.
3. Thirst.
4. Acetone odor of breath.
5. Hyperpnea.
6. Nausea and vomiting.
7. Warm, dry skin.
8. Rapid pulse.
9. Decreased blood pressure.
10.Coma.
Treatment:
1. Place patient in supine
position.
2. Assure patient airway.
3. Administer 100% oxygen.
4. Call 911.
5. Transport to medical
facility.

34. Anaphylaxis
Cause:
Antigen interaction with antibody coated
target cells.

35. Anaphylaxis
Signs/Symptoms:
1. Sense of impending doom;
2. Bronchial obstruction: wheezing,
laryngeal edema.
3. Hypoxia.
4. Hypotension.
5. Prutitis, urticaria, angioedema.
6. Nausea, vomiting, diarrhea,
abdominal pain.
7. Convulsions may occur.
Treatment:
1. Place patient in Trendelenberg
position.
2. Airway maintenance.
3. Administer 100% oxygen.
4. Administer epinephrine 1:1,000
sublingually 0.3 to 0.5 ml over 5
minutes. May be repeated every
30 minutes up to 3 doses.
Children: epinephrine 1:1,000
sublingually 0.01 mg/kg (0.02
mg/lb). Repeat only once after
one hour.
5. Transport to medical facility.

36. Allergic Reaction
Cause:
Delayed hypersensitivity reactions.

37. Allergic Reaction
Signs/Symptoms:
1. Mild Reaction
a. Urticaria
b. Pruritis
c. Skin eruptions
d. Mild angioneurotic
edema
2. Severe Reaction
a. Bronchial congestion
b. Respiratory depression
c. Edema
Treatment:
1. Place patient in supine
position.
2. Assure patient airway.
3. Give 100% oxygen.
4. Mild reaction: 50mg
diphenhydramine HCl
(Benadryl) orally.
5. Severe reaction: 50mg
diphenhydramine HCl
(Benadryl) intramuscularly.
6. Transport to medical
facility.

38. Equipment List
In order to successfully manage a dental emergency in the dental office you
must be properly equipped with the necessary armamentarium which should
include:
1. Sphygmomanometer with
various cuff sizes: a.) children,
b.) average adult, c.) large
adult.
2. Stethoscope.
3. 100% oxygen, E size
compressed cylinder, portable
unit, flow rate indicator.
4. Clear resuscitation face masks
(to allow for recognition of
vomiting) of various sizes: a.)
children, b.) average adult, c.)
large adult.
5. Self-inflating resuscitation bag
(amber type bag).
6. Small paper bags.
7. Gauze 4x4.
8. Alcohol pads.
10.1” adhesive tape.
11.Tourniquet.
12.Oropharyngeal airways – various
sizes.
13.Soft plastic bite protector.
14.Backboard for CPR in dental chair.
15.Medical emergency kit (Benadryl,
Epinephrine, glucose,
Isoproterenol Inhaler,
Nitroglycerin, and Aspirin).

39. Emergency Drugs and Equipments
A. ATROPINE SULFATE
1. Actions
– Parasympatholytic agent
2. Indications
– Symptomatic bradycardia
– Sinus bradycardia with hypotension
3. Dosage
– 0.5 to 1 mg IV bolus (every 5 minutes)
– Total dose is 2.0 mg for cardiac patients
4. Side effects
– Dry mouth
– Blurred vision
– Aggravates blindness in patients with glaucoma
– Difficulty in urination with older males
5. Contraindications
– Atrial flutter or fibrillation with rapid ventricular response
– Patients with closed angle glaucoma
– Tachycardia
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40. Emergency Drugs and Equipments
B. Diazepam
1. Actions
– Minor tranquilizer
– CNS Depressant
– Anticonvulsant
– Muscle relaxant
2. Indications
– Status epilepticus
– Hysteria/anxiety
3. Dosage
– 2 to 15 mg slowly IV(5mg/min maximum in larger veins)
– Given in small doses initially
– May give more if patient’s condition requires
4. Side effects
– Respiratory depression
– Sleepiness
– Hypotension
– CNS depression
– Dysrhythmias
5. Contraindications
– Hypotension
– Ventilatory insufficiency
– Pregnancy
– Alcohol intoxication
– Narrow angle glaucoma
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41. Emergency Drugs and Equipments
C. Diphenhydramine HCI
1. Actions
– Antihistamine – binds to histamine receptor sites to prevent further action
– Antiemetic
– Mild central nervous system depressant
– Reverses actions of phenothiazines
2. Indications
– Anaphylaxis
i. Preferred before encountering allergen to keep reaction from occurring
ii. Will not reverse effects of histamine once histamine is active in system, but will keep from further histamine effects
– Delayed hypersensitivity reactions
3. Dosage
– 25 to 50 mg IM or IV
4. Side effects
– Drowsiness
– Blurring of vision
– Respiratory depression
– Dry mouth
– Wheezing
– Urinary retention
– Hypotension
5. Contraindications
– Hypotension
– Alcohol intoxication
– Closed angle glaucoma
– Ulcer disease with GI obstruction
– Pregnancy
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42. Emergency Drugs and Equipments
D. Epinephrine
1. Action – alpha and beta sympathomimetic drug
– Increases heart rate
– Increases contractile state of heart
– Bronchodilates
– Vasoconstricts
– Increases blood pressure
2. Indications
– Cardiac arrest
i. Ventricular fibrillation
ii. Asystole
– Asthma
– Anaphylaxis
3. Dosage
– Cardiac arrest
i. 0.5 to 1.0 mg of a 1:10,000 concentration IV
ii. May be repeated every 5 to 10 minutes
– Asthma
i. 0.3 to 0.5 mg of a 1:1,000 concentration SQ
ii. May be repeated every 10 minutes as necessary
– Anaphylaxis
i. 0.5 mg of a 1:1,000 concentration SQ
ii. May be repeated as required
4. Side effects
– Ventricular dysrhythmias
– Angina
– Hypertension
– Ectopic beats
– Nausea
– Dilated pupils
5. Contraindications
– Angina
– Hypertension
– Hyperthyroidism
– No contraindications for patients in cardiac arrest or anaphylaxis
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43. Emergency Drugs and Equipments
E. Morphine Sulfate
1. Actions
– Analgesic
– Vasodilator
i. Reduces preload
ii. Reduces afterload
– Stimulates parasympathetic nervous system
2. Indications
– To reduce pain and anxiety associated with acute myocardial infraction
– Pulmonary edema from congestive heart failure
3. Dosage
– 2.0 to 5.0 mg IV bolus
4. Side effects
– Respiratory depression or arrest
– Hypotension
– Sleepiness
– Bradycardia
– Increased intracranial pressure
5. Contraindications
– Respiratory depression
– Head injuries
– Trauma to chest or abdomen
– Uncontrolled bleeding
– Alcohol intoxication
– Use with caution when giving to patients with inferior or posterior wall myocardial infarction as morphine may cause
bradycardia
9/5/2022 43

44. Emergency Drugs and Equipments
F. Naloxone
1. Actions
– Narcotic antagonist; blocks the effects of narcotics on the central nervous system
2. Indications
– Overdose of opiate and opioid drugs
Common opiates and opioids:
Morphine
Heroine
Codeine
Darvon
Lomotil
Percodan
Methadone
3. Dosage
– 0.4 to 2.0 mg initially given only to point of stimulating patient’s respiratory rate
4. Side effects
– May precipitate withdrawal in patients who are addicted to narcotics
– When it wears off, patient may lapse back into coma
5. Contraindications
– None
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45. Emergency Drugs and Equipments
G. Nitroglycerin
1. Actions
– Vasodilator – dilates both arteries and veins
– Reduces cardiac workload
i. Reduces preload
ii. Reduces afterload
– Reduces oxygen demand by myocardium
2. Indication
– Angina
– Acute myocardial infarction
– Congestive heart failure with pulmonary edema
3. Dosage
– 0.3 mg given SL, and may be repeated at 5 minute intervals three times
4. Side effects
– Headache
– Burning under the tongue
– Hypotension
– Weakness
– Dizziness
5. Contraindications
– Myocardial infarction with hypotension
– Hypotension
– Increased intracranial pressure
– Glaucoma
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46. Emergency Drugs and Equipments
H. Nitrous Oxide
1. Actions
– Analgesic
2. Indications
– Pain related to acute myocardial infarction
3. Dosage
– Mixture of 50% nitrous oxide and 50% oxygen
– Patient self-administers to prevent overdose
4. Side effects
– Light-headedness
– Drowsiness
– Nausea and vomiting
5. Contraindications
– Head injuries
– COPD
– Pulmonary edema
– Abdominal distention
– Shock
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47. Emergency Drugs and Equipments
I. Oxygen
1. Actions
– Increased arterial oxygen tension
– Increased hemoglobin saturation
– Increased oxygen delivery to tissues
2. Indications
– Hypoxemia of any cause
– Acute myocardial infarction
– Trauma
– Shock
– Cardiopulmonary arrest
3. Dosage
– Nasal cannula – 2 to 6 liters per minute
– Simple mask – not less than 6 liters per minute
– Reservoir mask – 10-15 liters per minute
4. Side effects
– Decreased rate and depth of ventilations if patient has COPD
– No side effects when given in high concentrations over short periods of time
– Drying of mucous membranes if not humidified
5. Contraindications
– None
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48. REFERENCES
1. Medical Emergencies: Prepare Your Team for A Quick Response. Fast, T.B. Dental
Management. Jan. 1987, 32-6.
2. Managing Emergencies in the Dental Office. Terezhlamy, G.T.
3. When the Patient’s Life in Your Hands. Dental Management. Aug. 1976.
4. Medical Emergencies: The Team Approach. Malamed, S.F. Alpha Omega. Fall 1984,
29-36.
5. Medical Emergencies in Dental Practice Part I – Preparation. Gobetti, J.P., et al.
Journal of Michigan Dental Assoc. Vol. 61, Feb. 1979.
6. Emergency Preparedness: A Survey of Dental Practitioners. Fast, T.B., et al. JADA.
Vol. 112, Apr. 1986, 499-501.
7. Emergency Kits for the Dental Practitioner. Jastak, J.T. J. Oreg. Dentl. Assoc. Winter
1983/84.
8. Medical Emergencies in Dental Practice Part III – Cardiovascular Emergencies.
Dworin, A.M. and Gobetti, J.P. J. of Michigan Dental Assoc. Vol. 61, July-Aug. 1979.
9. Medical Emergencies in Dental Practice Part V: Miscellaneous Medical Emergencies.
Dworin, A.M. and Gobetti, J.P. J. of Michigan Dental Assoc. Vol. 61, July-Aug. 1979.
10. Office Emergencies: An Outline of Causes, Symptoms, and Treatment. Freeman, N.S.
et al. JADA. Vol. 94, Jan. 1977, 91-96.
11. Emergency Medical Therapy. Eisenberg and Copass. W.B. Saunders 2nd Ed. 1982.
12. Medical Emergencies in Dental Practice Part IV: The Dyspenic Patient. Dworin, A.M.
and Gobetti, J.P. J. of Michigan Dental Assoc. Vol. 61, July-Aug. 1979.