INTRODUCTION Every dentist should realize that medical emergencies can, do and will happen during the course of practice. These emergencies could be related to dental treatment, patient risk factors or they could occur unexpectedly in the dental environment. A medical emergency could evolve into a life-threatening emergency without proper treatment. It is for these reasons emergency medications should be present in dental offices.
The majority of states require certain emergency medications if the dentist is performing any type of advanced anesthesia, such as minimal and moderate sedation (either oral or intravenous) as well as deep sedation/general anesthesia.
The ADA Council on Scientific Affairs in their 2002 report in the Journal of the American Dental Association, Volume 133, No 3, 364-365 titled “Office Emergencies and Emergency Kits” stated the following:
In designing an emergency drug kit, the Council suggests that the following drugs be included as a minimum: epinephrine 1:1,000 (injectable), histamine-blocker (injectable), oxygen with positive-pressure administration capability, nitroglycerin (sublingual tablet or aerosol spray), bronchodilator (asthma inhaler), sugar and aspirin. Other drugs may be included as the doctor’s training and needs mandate. It is particularly important that the dentist be knowledgeable about the indications, contraindications, dosages and methods of delivery for all items included in the emergency kit. Dentists are also urged to perform continual emergency kit maintenance by replacing soon-to-be-outdated drugs before their expiration. 1
Local anesthesia is the backbone of pain control in dentistry. Dentists realize and know that adverse events can occur before, during or after administration of local anesthesia. Package insert of all local anesthetics clearly illustrates the importance of the dental practitioner having the proper equipment and resuscitative drugs prior to administering any local anesthetic. Here is what the warnings section state:
“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.” 3
Emergency Drug Kit Key Facts
1. An emergency drug kit is critical in the dental setting. The ADA states that all dentists should have an emergency drug kit, equipment and knowledge to properly use all items.2. Emergency drugs, along with their actions and dosages, should be known by the dentist and his or her team.3. Know how to use your emergency drug kit BEFORE the emergency in your office.4. Know the location of your emergency drug kit.5. Develop an emergency drug logbook and review your drugs each month.6. Never give an expired drug.7. Know how to administer each emergency drug in your kit.
CANAL AcronymMedical emergencies happen in dental offices and we must be ready to react and respond. Here is an acronym that could assist you in trying to remember the many emergencies along with the emergency drugs that could potentially be used to treat them.
C = Cardiac
Chest pain: oxygen, nitroglycerin
Myocardial infarction: oxygen, aspirin
Dysrhythmias: ACLS drugs
Sudden Cardiac Arrest: AED
Ventricular Fibrillation: ACLS drugs
A = Airway
Foreign body obstruction: airway techniques
Bronchospasm; albuterol, oxygen, epinephrine
Larygnospasm: oxygen, succinylcholine
Aspiration/Emesis: airway techniques
N = Neurological
Transient ischemic attack
Panic attack: antianxiety agent
Anxiety: antianxiety agent
A = Allergic and drug reaction
Latex allergy: diphenhydramine
Anaphylaxis: epinephrine, diphenhydramine, albuterol, dexamethasone
Allergic reaction: diphenhydramine
Benzodiazepine Overdose: flumazenil
Local anesthetic overdose: oxygen
Narcotic Overdose: narcan
L = Loss of consciousness
Sudden Cardiac Arrest: AED
Understanding the Actions of the Sympathetic and Parasympathetic Receptor Sites
β1, (β2): increases
Sinoatrial node: heart rate ( HYPERLINK "http://en.wikipedia.org/wiki/Chronotropic" \o "Chronotropic" chronotropic)
β1, (β2): increases
Atrial cardiac muscle: contractility (inotropic)
β1, (β2): increases
Ventricular cardiac muscle
β1, (β2):increases contractility (inotropic)increases cardiac muscle automaticity
At atrioventricular node
β1:increases conductionincreases cardiac muscle automaticity
M2:decreases conductionAtrioventricular block
Vascular smooth muscle
α1: contracts; β2: relaxes
Larger coronary arteries
α1 and α2: constricts
Smaller coronary arteries
Arteries to viscera
Arteries to skin
Arteries to brain
Arteries to erectile tissue
Arteries to salivary glands
Arteries to skeletal muscle
α1 and α2: constrictsβ2: dilates
Mast cells: histamine
smooth muscles of bronchioles
β2: relaxes (major contribution)α1: contracts (minor contribution)
Pupil dilator muscle
α1: Relaxes(causes mydriasis)
M3: contracts circular muscle(causes miosis)
β2: relaxes(causes long-range focus)
M3: contracts(causes short-range focus)
Salivary glands: secretions
β: stimulates viscous, amylase secretionsα1: stimulates potassium cation
M3: stimulates watery secretions
Lacrimal glands (tears)
β: stimulates protein secretion
M1: Gastric acid secretion
α1, β2: glycogenolysis, gluconeogenesis
β1, β3: stimulates lipolysis
Gastrointestinal (GI) tract (smooth muscle) motility
α1, α2, β2: decreases
M3, (M1): increases
Sphincters of GI tract
α1, α2, β2: contracts
Glands of GI tract
α2: decreases secretion from beta cells, increases secretion from alpha cells
M3 increases stimulation from alpha cells and beta cells
N (nicotinic ACh receptor): secretes epinephrine and norepinephrine
Here is a suggested list of the core 8 emergency drugs needed for each dental office along with suggested other emergency medications for those doing advanced anesthesia. Check with your state dental board for the mandatory emergency medications you must have in your office.
Emergency drugs should be available in all dental offices ready to address the medical emergency that they would be used for. These 8 emergency drugs should be the minimum in dental offices. They are:
Epinephrine for anaphylaxis, bronchospasm
Benadryl for allergic reactions, anaphylaxis
Albuterol for asthmatic attack, bronchospasm
Nitroglycerin for angina
Aspirin for suspected myocardial infarction
Glucose source for diabetic emergency (hypoglycemia)
Ammonia inhalants for syncope
Oxygen as supplemental adjunct
The Core 8 Emergency Drugs
1. ALBUTEROLDEFINITION—Bronchodilator: stimulates beta-2 adrenergic receptors causing bronchodilation USE: Bronchospasm (acute asthmatic attack)DOSAGE: one to 2 puffs per doseCAUTION: No contraindications to using albuterol in acute episodes of bronchospasmSUGGESTED STOCK: One albuterol Metered-dose inhaler
2. AMMONIA INHALANTSDEFINITION: a respiratory stimulantUSE: Syncope/fainting/loss of consciousnessDOSAGE: one to 2 vaporulesSUGGESTED STOCK: One box of ammonia vaporules
3. ASPIRIN DEFINITION: Antiplatelet—inhibits prostaglandin synthesis and inhibits platelet aggregation irreversibly USE: Suspected myocardial infarction DOSAGE: One 325 mg nonenteric, coated aspirin tablet, chewed and swallowed or four-81 mg chewable tablets, chewed and swallowedCAUTION: Aspirin should not be given to persons who are allergic to it or have active gastrointestinal bleedingSUGGESTED STOCK: One or 2 packets of chewable 325 mg nonenteric, coated aspirin or four 81-mg chewable tablets
4. DIPHENHYDRAMINE DEFINITION: Antihistamine—antagonizes histamine at the H-1 receptor, causes sedation and has an anticholinergic effect USE Allergic reaction/anaphylaxisDOSE: 50 mg intramuscular or intravenous CAUTION: No contraindications to giving diphenhydramine during an allergic reaction unless noted allergy or hypersensitivity to diphenhydramineSUGGESTED STOCK: 1. Two 1-mL ampules or vials of diphenhydramine 50 mg/mL and/or2. Diphenhydramine hydrochloride capsules 25 mg
5. EPINEPHRINE 1:1,000DEFINITION: Cardiac stimulant/anaphylaxis—activates alpha and beta-adrenergic receptors increasing heart rate, myocardial contractility, bronchial dilation and decreases peripheral vascular resistanceUSE: Anaphylaxis/bronchospasm DOSAGE: 0.3 mg intramuscular every 5 minutes.CATUION: No contraindications to giving epinephrine during anaphylaxisSUGGESTED STOCK: 1. Two autoinjectors of epinephrine in adult form and pediatric form (EpiPen and EpiPen Jr)2. Two 1-mL ampules or vials of epinephrine 1:1,000
6. GLUCOSE SOURCEDEFINITION: 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. SUGGESTED STOCK: 1. Three tubes of glucose gel (InstaGlucose)2. Three tubes of glucose tablets
7. NITROGLYCERINDEFINITION: 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 minutesCAUTION: Patients with low blood pressure
8. OXYGENUSE: Almost any type of medical emergencyDOSAGE: At least 2 liters/minute for patientCAUTION: Do not use with hyperventilationSUGGESTED STOCK: One portable “E” cylinder of oxygen with regulator and the equipment necessary to deliver O2 to the victim (nasal cannula and ambu-bag)
Additional MedicationsReversal Agent—Benzodiazepine
Flumazenil (Romazicon)—Benzodiazepine Antagonist: Reverses effect of benzodiazepines by inhibiting the gamma amino butyric acid (GABA) receptors
Reversal Agent—Narcotics Naloxone (Narcan)—Narcotic Antagonist: Reverses the effect of narcotics by competively inhibiting narcotic receptor sites
Injectable AntiConvulsantMidazolam or diazepam: A benzodiazepine that acts on the inhibitory neurotransmitter GABA, limbic system, hypothalamus and thalamus to produce sedation, anti-anxiety effect and skeletal muscle relaxation
Injectable AntihypoglycemicsDextrose (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 reactionGlucagon (GlucoGen)—Antihypoglycemic: causes a rise in blood glucose levels by promoting hepatic glycogenolysis and gluconeogenesis.
Injectable AnticholinergicAtropine—Anticholinergic: antagonizes acetylcholine at the muscarinic receptors, increasing the heart rate as well as having an antisialagogue effect.
Injectable Corticosteriod Hydrocortisone (Solu-Cortef)—Anti-inflammatory: a corticosteroid secreted by the adrenal cortex which has anti-inflammatory, anti-allergic, mineralocorticord activity and stimulates gluconeogenesis.Dexamethasone – Anti-inflammatory: a corticosteroid secreted by the adrenal cortex which has anti-inflammatory, anti-allergic, glucocorticord activity, and stimulates gluconeogenesis.
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 systemLabetolol—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
Advanced Cardiovascular Life Support and Pediatric Advanced Life Support Emergency Medications: NOTE: Practitioners may vary on what they carry in their office with these medications as well as the dosing dependent upon the training they received related to advanced cardiovascular life support (ACLS) and pediatric advanced life support (PALS).
Drugs for ventricular fibrillation/pulseless ventricular tachycardia
Drugs for asystole and pulseless electrical activity
Drugs for bradycardia
Drugs for tachycardia
Drugs for acute coronary syndrome
Adenosine (Adenocard)—Antiarrhythmic: used for treatment of paroxysmal supraventricular tachycardia by slowing conduction time through the atrioventricular (AV) node as well as interrupting the re-entry pathways through the AV node.
Amiodarone (Cordarone)—Antiarrhythmic: a Class III agent that inhibits adrenergic stimulation which prolongs the action potential, decreases AV conduction and sinus node function which is used for life-threatening recurrent ventricular fibrillation or hemdynamically-unstable ventricular tachycardia.
Atropine (Atropine)—Anticholinergic: antagonizes acetylcholine at the muscarinic receptors, increasing the heart rate as well as having an anti-sialagogue effect.
Lidocaine—Antiarrhythmic: is a Class IB antiarrhythmic drug which is used intravenously for the treatment of ventricular arrhythmias.
Vasopressin (Pitressin)—Antidiuretic hormone: adjunctive treatment used in pulseless ventricular tachycardia/ventricular fibrillation.
Verapamil (Isoptin/Calan)—Antiarrhythmic: used for the treatment of paroxysmal supraventricular tachycardia, atrial flutter and atrial fibrillation.
Development of an Emergency Drug Kit for your Office
Dentists can make their own emergency drug kit.
First, know which drugs you will need in your office. Do you need the Core 8 drugs? Do you need more advanced medications such as used in ACLS or PALS protocols? Dentists should be thoroughly knowledgeable on the emergency drugs they have in their office.
Second, purchase those drugs and then maintain them in some type of container whether it is a plastic container/box or a metal crash cart.
Third, place these emergency medications in ziploc bags or smaller plastic containers with color coded labels for easy identification.
Fourth, know the medical emergencies for which these emergency drugs are used for.
Finally, develop an emergency drug logbook and keep up with your drugs and their expiration dates.
In conclusion, the emergency drug kit is essential for the practice of dentistry. No practitioner is able to determine when he or she will be faced with a medical emergency that will require the use of emergency drugs. It is for that reason alone, dental healthcare practitioners should stay up-to-date on medical emergencies as well as the drugs used to treat them. Develop a regular protocol to where you and your staff are able to rehearse various emergencies using your emergency drugs. Know their actions along with the route of administration. You and your staff should always know the location of your emergency drugs. Assign a staff member the role of reviewing your emergency drugs each month to prevent expiration of these drugs.
None of us know when our patient’s life may depend on our readiness as well as having the proper emergency drugs.
ReferencesJournal of the American Dental Association, Volume 133, No 3, 364-365 titled “Office Emergencies and Emergency Kits”
Journal of the American Dental Association, May 2010, Supplement on Medical Emergencies
Package Insert on Local Anesthesia, “WARNINGS” section
Wikipedia: Central Nervous System
American Heart Association
Advanced Cardiovascular Life Support (ACLS)
Pediatric Advanced Life Support (PALS)
CRASH CART, SAJITH KUMAR. RN, RM, MScN / Emergency Medicine; www.emergencymedicinemims.com
Emergency Drug Tracker, compliments of Emergency Drug Resource. buildyourowndrugkit.com