MEDICAL EMERGENCIES

IN THE
DENTAL OFFICE

November 23, 2018

Lecture Outline

DANIEL HAAS
DDS, PhD, FRCD(C)
Professor and Dean
Zwingenberger Decanal Chair
Faculty of Dentistry, University of Toronto

Schedule:
8:30 - 10:00 • Prevention: • Drug interactions
• The medically compromised patient
10:00 - 10:15 Break
10:15 – 12:00 • Basic principles of medical emergencies
• Resuscitative equipment
• Pharmacology of emergency drugs
12:00 – 1:00 Lunch Break
1:00 – 2:30 • Protocols for treatment of specific medical emergencies
2:30 – 2:45 Break
2:45 - 4:00 • Emergency kit preparation
• Staff roles
• Case review
4:00 – 4:30 • Question period
 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

MEDICAL EMERGENCIES

PREVENTION

systemic disease
  
  
dental treatment

PART I: POTENTIAL DRUG INTERACTIONS

VASOCONSTRICTORS
Indications
 increase depth of anaesthesia
 increase duration of anaesthesia
 reduce systemic toxicity
 hemostasis

Choices
 epinephrine
 levonordefrin

EPINEPHRINE

Pharmacology
 rapid onset
 exogenous epinephrine is metabolized by COMT
 short duration of action
 5 to 10 minutes if intravenous injection
 10 to 20 minutes if intraoral injection

 Mechanism of action: stimulates adrenoceptors, classified as alpha and beta

 Alpha agonist: vasoconstricts
 Beta-2 agonist: vasodilates
bronchodilates
 Beta-1 agonist: positive inotrope
positive chronotrope
increases automaticity

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Medical Emergencies November 23, 2018 Dr. D. Haas

The administration of local anaesthetic which contains epinephrine or levonordefrin to a

patient taking a drug from one of the following groups may lead to a cardiovascular emergency.

Non-selective ß-blockers, such as nadolol (Corgard™), oxprenolol (Trasicor™), pindolol

(Visken™), propranolol (Inderal™), sotalol (Sotacor™), timolol (Blocadren™),
bisoprolol.
 unopposed alpha effects may result
 blood pressure may increase
 should monitor BP and HR

Tricyclic antidepressants, such as, imipramine (Tofranil™), amitriptyline (Elavil™),

desipramine (Norpramin™), nortriptyline (Aventyl™), doxepin (Sinequan™) and
protriptyline (Vivactil™).
 sympathomimetic effects may be enhanced
 blood pressure may increase
 caution with epinephrine
 avoid levonordefrin

General Anaesthetic:
 vapors (primarily was with halothane) not with intravenous anaesthetics
 may lead to cardiac dysrhythmia
 limit epinephrine to < 1 µg/kg

Cocaine, Amphetamines
 may lead to cardiac dysrhythmia or BP increase
 avoid concurrent use
 slight caution with ADHD meds (Adderal™, Concerta™, Ritalin™ (methylphenidate))

COMT inhibitors
 Entacapone (Comtan)
 Parkinson’s disease adjunct
 similar precautions as above

If concern:
 monitor BP and HR pre-op
 minimize epinephrine/levonordefrin administration
 monitor BP and HR 5 minutes post-injection
 may re-administer epinephrine if BP and HR stable
 continue to monitor
 never use 1:50,000 concentration
 never use epinephrine-impregnated retraction cord
 consider limit of 0.04 mg (arbitrary)

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

1 cartridge of 1:200,000 epinephrine = 9 µg

1 cartridge of 1:100,000 epinephrine = 18 µg
1 cartridge of 1: 50,000 epinephrine = 36 µg
As well, for these patients, levonordefrin (Neo-Cobefrin™) should be restricted to 200 µg
(1 cartridge of 1: 20,000 levonordefrin = 90 µg).

Calculation of doses for vasoconstrictors:

Ratio concentrations represent grams per mL
1:100,000 = .01 mg/mL or 10 µg/mL
1:200,000 = .005 mg/mL or 5 µg/mL
1:50,000 = .02 mg/mL or 20 µg/mL
Therefore one cartridge of 1:100,000 epinephrine contains:
1.8 ml x .01 mg/mL = .018 mg (i.e. 18 µg)

Epinephrine interactions listed but NOT clinically relevant in dentistry:

Phenothiazines
 thioridazine (Mellaril)
 chlorpromazine (Thorazine)
 perphenazine (Trilafon)

Thyroid hormones
 levothyroxine (Synthroid)

Monoamine Oxidase Inhibitors

 no scientific evidence of interaction
 MAO is intraneuronal
 exogenously administered epinephrine and levonordefrin are metabolized by COMT
 Examples of MAOIs
 isocarboxazid (Marplan)
 phenelzine (Nardil)
 tranylcypromine (Parnate)
 selegiline (Eldepryl)

• Otherwise, local anaesthetics have no interaction of clinical significance.

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

DRUG-INDUCED ALLERGIC REACTIONS

Potential triggers in dentistry:
• penicillin family of drugs
• local anaesthetic formulations
• latex
• ASA

Pencillin allergy:
• Rate: 1 - 10% of patients
• 75% of anaphylaxis deaths
• 400 - 800 deaths/year in U.S.
• Mild anaphylaxis: 1/200 courses
• Severe anaphylaxis: ~1/2,000 courses
• Fatality rate: 1/60,000
• 96% of fatal reactions occur within 60 minutes

Contents of local anaesthetic cartridges:

• local anaesthetic: amide or ester
• vasoconstrictor: epinephrine or levonordefrin
• metabisulfite
• methylparaben (in the past)

Latex allergy:
• Noted risk groups: • spina bifida
• atopic patients
• health care workers

ASA Hypersensitivity:
• Anapylactoid reaction
• Patients with the following triad are pre-disposed:
• severe asthma, nasal polyps, multiple allergies

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

PREVENTION PART II:

PATIENT ASSESSMENT

Proper medical history

• known disorders
• current medications:
• prescription
• over-the-counter (OTC)

Physical evaluation:
• general appearance; ability to handle daily activities
• vital signs (BP, HR); ideally taken at initial visit and recalls

American Society of Anesthesiology Physical Status Classification System.

ASA I: A normal healthy patient.
ASA II: A patient with mild systemic disease.
ASA III: A patient with severe systemic disease that limits activity but is not
incapacitating.
ASA IV: A patient with incapacitating systemic disease that is a constant threat to life.
ASA V: A moribund patient not expected to survive 24 hours with or without
operation.
ASA E: Emergency operation of any variety; E precedes the number, indicating the
patient's physical status.

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

MANAGEMENT OF THE MEDICALLY COMPROMISED PATIENT:

CARDIOVASCULAR DISEASE
• Hypertension
• Ischemic heart disease
• Congestive heart disease
• Dysrhythmia
• Valvular heart disease

HYPERTENSION
 new guidelines published Nov 2017
 affects management of patients with hypertension
 new guidelines do not truly affect the dental management of hypertensive patients

Systolic Diastolic
Normal <120 and < 80
Elevated 120-129 and < 80
Stage 1 130-139 or 80-89
Stage 2 >140 or >90
Suggested guidelines
Systolic Diastolic Treatment alteration
<140 <90 may proceed with dental treatment

140-159 &/or 90-99 reassess in 5 minutes

if still ↑ encourage pt to see MD for assessment
may proceed with dental tx at that appt

160-179 &/or 100-109 reassess in 5 minutes

if still ↑ refer to MD within 1 month
may proceed with dental tx at that appt
intra-op monitoring of BP

180-200 &/or 110-115 reassess in 5 minutes

if still ↑ refer to MD in 1 wk
avoid elective tx
pain mgmt is a priority

>200 &/or >115 reassess in 5 minutes

if still ↑ refer to MD immediately, especially if the
patient is symptomatic
avoid elective tx
pain mgmt is a priority

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

Hypertension Protocol
• Pre-operative BP and heart rate
• Stress reduction:
-chairside manner
-profound local anaesthesia
-minimal or moderate sedation
• Monitor BP and HR 5 minutes post-injection
• Consider limiting epinephrine to 0.04 mg
• NEVER use retraction cord with epinephrine
• Be aware of orthostatic hypotension

ISCHEMIC HEART DISEASE

• Angina:-------> Stable or Unstable?
      
      
• Treatment? Yes No

Ischemic Heart Disease Protocol

• Pre-operative BP and heart rate
• Stress reduction:
-chairside manner
-profound local anaesthesia
- minimal or moderate sedation
• Monitor BP and HR 5 minutes post-injection
• Consider limiting epinephrine to 0.04 mg
• NEVER use retraction cord with epinephrine
 If recent MI, meaning less than 1 month ago, avoid elective dental care
 pain management is a priority

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

DYSRHYTHMIA OR CHD PROTOCOL

• Pre-operative BP and heart rate
• Stress reduction:
-chairside manner
-profound local anaesthesia
- minimal or moderate sedation
• Monitor BP and HR 5 minutes post-injection
• Consider limiting epinephrine to 0.04 mg
• NEVER use retraction cord with epinephrine

ASTHMA
Pre-operative evaluation of the asthmatic patient
Determine: • the frequency and severity of attacks
• effectiveness of medication
• current airway irritability
Consider: • Peak Expiratory Flow Rate (PEFR)
• should be more than 80% of expected value
Classify:
Historical asthma • asthma history without recent medication or attacks
Quiescent asthma • symptom free but currently on medication
Active asthma • on medication but still symptomatic

Asthma Severity Based on Treatment

Mild intermittent: inhaled ß-2 agonist symptomatically
Mild persistent: inhaled low-dose steroid or leukotriene antagonist or cromolyn daily + inhaled
ß-2 agonist for symptoms
Moderate persistent: inhaled medium-dose steroid daily + possible long-acting ß-2 agonist or
leukotriene antagonist or theophylline daily + inhaled ß-2 agonist for symptoms
Severe persistent: oral steroids + inhaled high-dose steroid daily + long-acting ß-2 agonist or
leukotriene antagonist or theophylline daily + inhaled ß-2 agonist for symptoms

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

ASTHMA PROTOCOL
 continue with usual meds prior to appointment
 stress reduction protocol
 avoid ASA
 if active or persistent; also avoid other NSAIDs

PATIENTS ON STEROIDS
• current recommendations vary
• physiologic release = ~25 mg of cortisol is released daily
• stress can increase release to 300 mg
• exogenous steroids can suppress endogenous release
Steroid Equivalent dose in mg
Hydrocortisone (cortisol) 20
Prednisone 5
Prednisolone 5
Methylprednisolone 4
Triamcinolone 4
Dexamethasone 0.75
Betamethasone 0.6
Coverage is required if:
• stressful procedure such as extraction, surgery, or general anaesthesia and
• patient is on a physiologic dose or greater, currently or in the past 2 weeks and
• patient has risk factors such as: -poor health
-long-term steroid use (>4 years)
-pain
-infection
Management:
 Monitor BP
 Patient should have equivalent of 100 – 150 mg hydrocortisone on day of procedure
and the following day.

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

DIABETES MELLITUS
 Type 1
o Beta cell destruction or defect
o Usually absolute insulin deficiency

 Type 2
o Insulin resistance with relative insulin deficiency

HYPOGLYCEMIA HYPERGLYCEMIA
rapid onset: minutes slow onset: hours or days
cool, wet hot, dry
pallor flushed
weak, dizzy malaise
hunger, nausea nausea, vomiting
mental confusion stupor
lethargy drowsy
belligerence irritable
paraesthesias headache
normal or  resp acetone odor, deep respiration
 HR  HR
BP (BP)  BP
LOC LOC
seizure

PROTOCOL FOR THE DIABETIC PATIENT

 confirm control, medical care
 glycosylated hemoglobin (HbA1c) <7%
 review of systems, especially for CVS
 appointment should not interfere with usual meal or snack intake
 take glucometer readings if symptomatic
 oral glucose source ready

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

MALIGNANT HYPERTHERMIA
Known Triggers
• Inhalational vapor general anaesthetics (isoflurane, desflurane, sevoflurane)
• Succinylcholine (muscle paralyzing agent)
• Role of stress is controversial
What is safe?
• Routine dentistry for an awake non-anxious patient
• All local anaesthetics used in dentistry
• Minimal/moderate sedation. Nitrous oxide (in a clean system) or benzodiazepines are not
triggers.
Management
Awake, non-anxious patient:
• Usual treatment
• Pre-op and post-op BP and HR
Highly stressful dentistry :
• Consider minimal/moderate sedation
• Referral out if minimal/moderate sedation is not adequate

CEREBROVASCULAR ACCIDENT
 Stroke
 Defer elective dental treatment for at least 1 month following a stroke
 Be aware of potential bleeding issues depending on medication

CVA Management
 Pre-operative vital signs
 Stress reduction
o chairside manner
o profound local anaesthesia
o minimal or moderate sedation
 Monitor BP and HR 5 minutes post-injection
 Consider limiting epinephrine to 0.04 mg
 NEVER use retraction cord with epinephrine
 Be aware of orthostatic hypotension

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

THE ELDERLY

Increased incidence of:

CVS concerns
CVA
Pharmacotherapeutic changes

Pharmacotherapeutics in the elderly:

• Pharmacokinetic changes
• Pharmacodynamic changes
• Systemic disease
• Polypharmacy

Clinical presentations of adverse drug reactions:

• restlesness • incontinence
• falls • constipation
• depression • parkinsonism
• confusion • akathisia
• memory loss • tardive dyskinesia

Goals of pharmacotherapy for the older patient.

• Simplify.
• Decrease the: • number of drugs you give.
• initial dose of drugs you give.
• frequency of drugs being taken.
• Monitor the patient after prescribing a medication.
• Review the patient’s medication list.

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

BASIC PRINCIPLES

Most medical emergencies in the dental office are secondary to

INSUFFICIENT TISSUE OXYGENATION.
Your treatment should be directed at correcting this problem. If you remember
this, you will treat the patient appropriately.

The first step for an unresponsive patient:

 C-A-B vs A-B-C. Lay provider vs Health-care professional

A - AIRWAY (ensure patency; head and chin position)

B - BREATHING (“look, listen and feel” replaced by check for responsiveness)
C - CIRCULATION (check pulse and blood pressure)

 Compression: rate of 100/minute – “push hard, push fast”

 Compression:ventilation ratio 30:2

Maintenance of Respiratory function

Respiratory physiology is essentially the action of gas exchange, specifically being the
ability of delivering oxygen from the atmosphere to the cells and removing carbon dioxide from
the cells and out into the atmosphere.
Minute ventilation = Respiratory rate x tidal volume
For most adults ~ 12 breaths/minute x 500 ml = 6 litres per minute

Maintenance of Cardiovascular function

An important objective of cardiovascular function is to perfuse tissues with oxygenated
blood. A basal level mean blood pressure is required to ensure adequate perfusion.
Blood pressure
Blood pressure is comprised of cardiac output (CO) and total peripheral resistance (TPR).
Cardiac output, in turn, is comprised of stroke volume (SV) and heart rate (HR).

Blood Pressure
     
CO TPR
        
HR SV arterial diameter, elasticity, viscosity

Assessment of Circulation
• heart rate and rhythm
• blood pressure
• cardiac output influences systolic blood pressure
• arterial resistance influences diastolic blood pressure
• perfusion
• orientation (to time, place and person)
• colour and capillary filling

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

ADJUNCTIVE EQUIPMENT
• Blood pressure cuff.
• Stethoscope.
• Oxygen delivery system:
• “E” cylinder of oxygen
• clear face mask
• for spontaneously breathing patients: conscious or unconscious
• administer 6 - 10 L/Min
• FiO2 = 60 + 5 for each L/min above 6 (therefore 60 – 80% inspired O2)
• pocket mask
• for unconscious patients
• allows mouth-to-mask ventilation
• bag-valve-mask device (Ambu-bag) or positive pressure delivery
• for unconscious patients, not breathing
• administer 10 - 15 L/Min
• 75 – 95% inspired O2
• nasal cannula
• for conscious patients
• inspired O2 = 20 + 4 x L/min
• therefore inspired O2 = 24 - 44 L/min
• Oropharyngeal airways (multiple sizes).
• for apneic and unconscious patients
• Disposable syringes (3 mL) with needles (~20 -22 gauge).
• Drugs in ampules, vials, or pre-loaded syringes
• Glucose replacement
• Tonsillar suction (optional)
• Magill forceps (optional)
• Cricothyrotomy capability could be considered (commercial system or use of 12g
intravenous catheter) - optional
• AED: see discussion later in presentation

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

DRUGS USED FOR

THE MANAGEMENT OF MEDICAL EMERGENCIES
IN THE DENTAL OFFICE

There are numerous suggestions for drugs which a dentist should have readily available
for the treatment of medical emergencies. These suggestions often differ, but ultimately it is the
individual dentist's own decision as to which drugs are appropriate for his/her particular practice.
Each dentist must decide which group of drugs and resuscitative equipment will allow them to
practise to the standard of care they wish to achieve. The following is one synopsis of
recommended drugs that could comprise part of an "emergency kit" in a dental office.
The dentist's role in the handling of any medical emergency is prevention, recognition,
activation of emergency measures (call 911), initiation of treatment and stabilization. It is
essential that the dentist is trained and competent in basic life support (BLS) (cardiopulmonary
resuscitation (CPR)). The treatment of any medical emergency must include the assessment and
necessary treatment of airway, breathing and circulation (ABCs of CPR). Usually, only after
these basics are addressed should the dentist consider the use of emergency drugs.
Drugs that should be readily available to the dentist can be divided into 2 categories;
A. Essential (strongly advised) and B. Additionally recommended. Whereas the intravenous
route may be considered ideal for emergencies, unless it is already present, it is not expected that
dentists would have the expertise to quickly accomplish venipuncture. Therefore, intravenous
and intramuscular doses are suggested. Where "i.m." is listed, the dentist should consider using
the sublingual/intralingual injection, if possible.

A. Essential (strongly advised):

DRUG INDICATION ADULT DOSE
1. Oxygen Most medical emergencies 100%: inhalation

2. Epinephrine anaphylaxis 0.3-0.5mg i.m.

asthma unresponsive to salbutamol 0.3-0.5mg i.m.
cardiac arrest 1 mg, i.v.

3. Nitroglycerin pain of angina 0.3 - 0.4 mg sublingual

4. Diphenhydramine allergic reactions 50 mg i.m.

5. Salbutamol asthmatic bronchospasm 2 puffs (200 µg): inhalation

6. ASA (Aspirin) myocardial infarction 325 mg

 A sugar source such as fruit juice or a non-diet soft drink should be readily available.

Paediatric doses (These are approximate, not to exceed the adult doses listed above):
• epinephrine = 0.01 mg/kg
• diphenhydramine = 1 mg/kg
• salbutamol = 1 puff (100 µg)

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

ESSENTIAL EMERGENCY DRUGS

OXYGEN
• for every emergency (except hyperventilation; equivocal need if acute MI)
• should be in a portable source: "E"-size cylinder
• deliver by • full face mask if patient is conscious, or unconscious yet breathing
• bag-valve-mask device if patient is unconscious, not breathing

The percentage of oxygen delivered depends on technique used:

Technique Percent Oxygen
Mouth to mouth or mouth to mask 16%
Bag-valve-mask 21%
Nasal cannula with oxygen 24 - 44%
Face mask with oxygen 60 - 80%
Bag-valve-mask with oxygen 75 - 95%

EPINEPHRINE
• Drug of choice for the emergency treatment of:
• anaphylaxis
• asthma which does not respond to salbutamol
• cardiac arrest
• Pharmacology: • alpha agonist: vasoconstricts
• beta-1 agonist: stimulates the heart; • positive inotrope
• positive chronotrope
• increases automaticity
• beta-2 agonist: dilates bronchioles and vasculature
• Availability:
1:1,000 = 1 mg per ml (for intramuscular or sublingual injection)
or 1:10,000 = 1 mg per 10 ml (for intravenous injection)
or autoinjector systems for i.m. such as:
EpiPen™, 1 dose of 0.3 mg (0.3 ml of 1:1,000)
EpiPen Jr™, 1 dose of 0.15 mg (0.3 ml of 1:2,000)

NITROGLYCERIN
• Indications: acute angina or myocardial infarction
• Pharmacology: rapid onset
venodilator: decreases venous return to heart
reduces myocardial O2 consumption
***Important, always check BP before using: concern over RV involvement.
Do not use if: systolic BP < 90,
or, if erectile dysfunction agents used within 24hr (Viagra or Levitra) or 48hr (Cialis)

Availability: 0.3, 0.4, 0.6 mg sublingual tablets (short shelf-life once bottle opened) or
0.4 mg sublingual spray (better shelf-life)

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

ANTIHISTAMINE
• Indications: allergic reactions
• Pharmacology: blocks H-1 receptors, therefore blocks action of histamine
• Availability: • diphenhydramine (Benadryl™, 50 mg/ml)

SALBUTAMOL
• Indications: drug of first choice for bronchospasm
• Pharmacology: • ß-2 agonist: bronchodilates
• peak effect in 30 - 60 minutes; duration of effect: 4 - 6 hours
• Availability: inhaler (Ventolin™)

ASA
 Blocks cyclooxygenase and therefore formation of thromboxane A2
 Inhibits platelet aggregation
 Reduces overall mortality from acute MI
 Aim is to prevent progression from ischemia  injury  infarction
 325 mg tablet should be given STAT to any patient with pain suggestive of acute MI
 Chewing is preferable to swallowing (can consider 4 x 81 mg chewable tabs)
 contraindicated if known hypersensitivity to ASA

B. Additional drugs to consider:

DRUG INDICATION DOSE

1. Glucagon hypoglycemia in unconscious patient 1 mg i.m.

2. Atropine clinically significant bradycardia 0.6 mg i.v. or i.m.

3. Steroid (hydrocortisone) adrenal insufficiency 100 mg i.v. or i.m.

recurrent anaphylaxis "

4. Ephedrine clinically significant hypotension 5 mg i.v.prn or 10-25 mg i.m.

5. Analgesic (morphine) angina-like pain unresponsive nitro. titrate 2 mg prn i.v., 5 mg i.m.
(or nitrous oxide) " up to 50%, inhalation

6. Lorazepam or Midazolam convulsions that are not self-limiting 4mg(loraz)- 5mg(midaz) i.m.

7. Fluids (a) Ringer's lactate clinically significant hypotension titrate i.v.

(b) 50% dextrose hypoglycemia titrate i.v.

The final composition of the readily-available emergency drugs will depend on the
individual dentist's needs and the nature of the practice. The drugs listed above should be
considered. Dental offices that provide minimal sedation, moderate sedation, deep sedation and /
or general anaesthesia require additional drugs and equipment.

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

TREATMENT ALGORITHMS

SYNCOPE
 most common emergency
 sudden, transient loss of consciousness
 caused by:
 psychogenic factors
 fear
 stress
 non-psychogenic factors
 decreased blood flow to brain
 Signs which may precede LOC:
 warmth, cold sweat, feels unwell, nausea
 loss of consciousness
 breathing may be irregular or cease
 convulsive movements, twitching
 Signs which follow:
 pallor, weakness, sweating, nausea

Management:
• Position
• ABC's
• Oxygen
• Begin management of all unresponsive patients with this protocol
• Consider oral glucose, when conscious

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

ANAPHYLAXIS
Major signs: bronchospasm
hypotension
laryngeal edema

Minor signs: urticarial rash

generalized flush
nausea
abdominal pain

Treatment of anaphylaxis:
• ABCs as necessary & O2
• call 911

• Epinephrine
• initial dose of 0.3 - 0.5 mg i.m.
(paediatric dose of 0.01 mg/kg)
• repeat every 5 - 10 minutes as necessary

• Antihistamine

diphenhydramine (Benadryl™) 50 mg i.m.

• If available, give steroid: hydrocortisone (Solu-Cortef™) 100 mg i.m.

Less Severe Allergic response

Antihistamine:
diphenhydramine (Benadryl™) 50 mg i.m. (paediatric dose = 1 mg/kg)

BRONCHOSPASM (ASTHMATIC ATTACK)

1. Salbutamol (Ventolin™) 2 puffs (200 µg)

(paediatric dose of 1 puff [100 µg] )
• repeat as necessary
• if no response then go to Epinephrine

2. Epinephrine
• initial dose of 0.3 - 0.5 mg i.m.
(paediatric dose of 0.01 mg/kg)

• repeat every 5 - 10 minutes as necessary

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

CARDIAC ARREST
 NO PULSE
Management
 Call 911: when it is indicated, early defibrillation is crucial
 Compression: rate of 100/minute
 Compression:ventilation ratio 30:2
 Defibrillate as soon as possible
 AED if available
 Airway
 Breathing: 2 breaths
 100% oxygen with BVM
 Epinephrine 1 mg i.v., only if CPR is not interrupted – airway control and ventilation
support (and early defibrillation if indicated) are more important than medications
 4 possible ECG rhythms
o VENTRICULAR FIBRILLATION
o PULSELESS VENTRICULAR TACHYCARDIA
o ASYSTOLE
o PULSELESS ELECTRICAL ACTIVITY
CPR Survival Rate
 Out-of-hospital sudden cardiac arrests result in 250,000 deaths in the U.S. every year
 Mortality increases 7 - 10% with every one-minute delay
 Mortality of 3 - 4% with every minute if CPR-BLS is administered

AUTOMATED EXTERNAL DEFRIBILLATORS

 Allows early defibrillation
 No need for ECG recognition
 Allows lay use of defibrillator
 Voice prompts
 If SCA out-of-hospital--> survival rate 6%
 If witnessed SCA and if AED used within 5 min:
o survival rates have increased to 49 - 74%, when lay rescuer CPR and AED
programs have been in place in airports and casinos

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

Management of Cardiac Arrest if AED available

 verify cardiac arrest
 if witnessed SCA, start CPR until AED placed
 if not witnessed, do 2 minutes (5 cycles) of CPR, then use AED
 turn on AED
 place electrodes
 analyze rhythm
 deliver shock if advised
 If no shock advised, resume CPR

AEDs
 High first shock efficacy: VF terminated ~90% of the time
 Therefore no need for 3 stacked shocks
 After VF is terminated, most patients have a non-perfusing rhythm at first
o PEA or asystole
 Therefore CPR should be given immediately after the first shock
 Carry out 5 cycles (2 minutes) – then do pulse check
 Biphasic preferred over monophasic
 Lower energy have equivalent or greater success for terminating VF
 Machine-specific: 120 - 200 joules
 Monophasic still acceptable: 360 joules: If older AED, it should be re-programmed to
new guidelines of 1 shock at 360 joules, not 200 - 300 - 360 as before

Conclusions
 Stay current in BLS-CPR
 Consider training in AED
 Consider if AED is appropriate for your office
 Not yet standard of care (as of today)

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

ANGINA
If positive history of angina If no history of angina – assume MI
1. ABCs & O2 1. ABCs
2. call 911
2. nitroglycerin 0.3/0.4 mg 3. nitroglycerin 0.3/0.4 mg if BP > 90/60
if no relief after 3 - 5 minutes: 4. ASA 162- 325 mg
3. repeat 5. analgesic
if no relief after 3 - 5 minutes: • morphine
4. repeat or • N2O:O2
if no relief after 3 - 5 minutes: **Do NOT give epinephrine**
5. call 911 (assume MI)
6. ASA 162-325 mg
7. analgesic;
• morphine 2 mg iv or 5 mg im
or • N2O:O2
(if elderly, nitrous oxide may be preferable over morphine)

**Do NOT give epinephrine**

HYPERTENSIVE CRISIS
Diagnosis: • systolic BP >200 or diastolic BP >115
and • symptomatic (headache, visual disturbances, palpitations)
Management: • transfer to physician immediately

HYPOTENSION
Diagnosis: • If symptomatic and systolic BP < 90, or BP drops 15 - 20%.
Management: • Syncope protocol --> position; ABCs; & oxygen
• then reassess BP and perfusion.
• I.V. fluids if possible (Ringer's Lactate)
• Heart rate < 60: consider atropine 0.6 mg
• Heart rate > 60: consider ephedrine 5 to 25 mg; use cautiously

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

CEREBROVASCULAR ACCIDENT
Diagnosis:
 Sudden severe headache
 Dizziness
 Weakness or numbness of
 Confusion
 Trouble speaking, understanding, seeing, walking

Assessment:
 Facial droop
 Arm drift
 Abnormal speech

Management:
• Symptomatic
• Transfer to hospital

ADRENAL CRISIS
Diagnosis: History of steroid use combined with the following signs and symptoms:
-confusion
-nausea and vomiting
-abdominal pain
-hypotension
Management: • treat as hypotension protocol listed above, and:
• add hydrocortisone (Solu-Cortef) 100 mg.

DIABETIC EMERGENCIES
HYPOGLYCEMIA or HYPERGLYCEMIA
1. if conscious: 1. if conscious:
• oral carbohydrates • hospitalize
2. if unconscious: 2. if unconscious:
• ABCs • ABCs
• oxygen • oxygen
• call 911 • call 911
• 50% dextrose i.v. or
• 1 mg glucagon i.m.

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

LOCAL ANAESTHETIC EMERGENCIES

• psychogenic reactions
• allergic reactions
• toxicity: -overdose of local anaesthetic
-overdose of vasoconstrictor
Psychogenic reactions
• syncope
• nausea, vomiting
• alterations in heart rate or blood pressure
• hyperventilation
• mimic an allergic reaction
Possible Allergens
• esters
• methylparaben
• metabisulfite
• specific amide (rare)
Local Anaesthetic Toxicity
Level: Signs
Low: sedation, analgesia, antiarrhythmic activity
Intermediate: lightheadedness, slurred speech, drowsiness, euphoria/dysphoria, diplopia,
sensory disturbances, muscle twitching
High: disorientation, tremors, respiratory depression, tonic/clonic seizures
Lethal: coma, respiratory arrest, cardiovascular collapse

Recommended maximum doses of local anaesthetic, with vasoconstrictor.

Drug Maximum dose Max. # of cartridges
articaine 7 mg/kg (up to 500 mg) 7
bupivacaine 2 mg/kg (up to 90 mg) 10
lidocaine 7 mg/kg (up to 500 mg) 13
mepivacaine 6.6 mg/kg (up to 400 mg) 11 (or 7 if plain)
prilocaine 8 mg/kg (up to 500 mg) 8

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

Calculations of Doses
Local anaesthetics:
Percent solutions represent grams per 100 mL.
Move the decimal place to the right and this value = mg/mL
i.e. 2% lidocaine = 20 mg/mL
Most cartridges = 1.8 mL.
Therefore one cartridge of 2% lidocaine contains 1.8 ml x 20 mg/mL = 36 mg

Example : Prilocaine for a 20kg child (44lb) Example : Lidocaine for a 20kg child (44lb)
8 mg/kg X 20 kg = 160 mg 7 mg/kg X 20 kg = 140 mg
4% prilocaine = 40 mg/ml 2% lidocaine = 20 mg/ml
160 mg / (40 mg/ml) = 4 ml 140 mg / (20 mg/ml) = 7 ml
Each cartridge = 1.8 ml Each cartridge = 1.8 ml
Therefore 2.2 cartridges may be used. Therefore 3.9 cartridges may be used.

MAXIMUM NUMBER OF CARTRIDGES#

Child’s Age--> 3 yr old 5 yr old 7 yr old
If weight is 50th percentile for that age 14kg 18kg 23kg

articaine with epinephrine 1.4 1.8 2.2

lidocaine with epinephrine 2.7 3.5 4.5
mepivacaine plain 1.7 2.2 2.8
mepivacaine with vasoconstrictor 2.6 3.3 4.2
prilocaine with epinephrine 1.6 2 2.6
# using the 50th percentile weight for age.
Calculations should be based on the child’s body weight and not his or her age.

Methemoglobinemia
 Condition in which cyanosis develops in the absence of cardiac or respiratory abnormalities
 May be congenital or acquired through drugs or chemicals
 MetHb is normally <1%
 Cyanosis and respiratory distress may occur with MetHb >10%
 Associated with prilocaine overdose
 or severe benzocaine overdose
 Prilocaine’s metabolite o-toluidine can block MetHb reductase, leading to  MetHb
 Appears 3 - 4 hours after administration
 Avoid prilocaine or benzocaine if congenital methemoglobinemia
 Unresponsive to O2
 Pulse oximeter readings are abnormal
 Blood is chocolate brown
 Treated by 1% methylene blue I.V.

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

SEIZURES
• protect patient; no drugs needed unless it becomes Status Epilepticus
• if Status Epilepticus: • call 911
•Lorazepam (Ativan™) 4 mg i.m. or
•Midazolam (Versed™) 5 mg i.m.
(if given, monitor for deep sedation (ABC's)

HYPERVENTILATION

Manifestations

Cardiovascular Musculoskeletal Neurologic

-palpitations -muscle pains and cramps -dizziness
-tachycardia -tremors -lightheadedness
-precordial pain -stiffness -tingling or numbness of extremities

Management:
•Calm the patient
•Correct alkalosis (re-breathe into paper bag)

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

EMERGENCY DRUG KIT

The intention of providing this material is to facilitate the development of your own
customized emergency kit. The drugs supplied are to be used consistent with the principles
discussed in this course. The addition of an E-cylinder of oxygen with means for delivery is
considered essential. Additional drugs and equipment could be added, based on your judgment.
Please make note of the expiry dates and arrange to replace the drugs as necessary, through any
pharmacy you deal with.
Each emergency kit is contained within one large freezer bag or Tupperware-like container,
and contains the following:
 4 small zipper sandwich bags
 4 file cards
 4 syringes (3 mL)
 2 epinephrine ampules
 1 atropine ampule
 1 diphenhydramine vial
 1 salbutamol inhaler
 1 bottle of nitroglycerin
 ASA

CONTENTS OF BAGS
It is suggested that they be arranged as follows:

Allergy / Anaphylaxis bag:

 Epinephrine ampule (1 mL of
1:1,000)
 Diphenhydramine vial (50 mg/ml)
 syringe x 2 Angina/MI bag
 card  Nitroglycerin
 ASA
 card
Asthma bag
 Salbutamol inhaler Syncope/Hypotension bag
 Epinephrine ampule  Atropine 0.6 mg/mL
 syringe  syringe
 card  card

Not provided, but to be considered:

Diabetes bag
 Orange juice
 Glucagon (optional)
 Card

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

CARDS

SYNCOPE / HYPOTENSION

 ABC's
 Position
 O2
 consider oral glucose when conscious
 if BP and HR<60: consider atropine 0.6 mg, 1 mL i.m.

ALLERGY

SEVERE / ANAPHYLAXIS:
 ABCs, O2 , call 911
 Epinephrine 1:1,000, 0.5 mL i.m.
 repeat epinephrine q10 min prn
 Diphenhydramine 50 mg 1 mL i.m.

LESS SEVERE REACTION:

 Diphenhydramine 50 mg 1 mL i.m.

ASTHMA (ACUTE ATTACK)

 Salbutamol inhaler, 2 puffs

 repeat as necessary
 O2

if symptoms worsen then add:

 Epinephrine 1:1,000 0.5 mL i.m.
 repeat q10 min prn

ANGINA / MI ANGINA / MI
Known history of angina:
 ABCs, O2 No history of angina
 nitroglycerin, allow 3 minutes  call 911
 if no relief, repeat nitro, allow 3 minutes  ABCs
 if no relief, repeat nitro, allow 3 minutes  nitroglycerin, if BP above 90/60
 if no relief after 3 doses, call 911  ASA 162 - 325 mg
 ASA 162 - 325 mg  consider morphine or N2O:O2
 consider morphine or N2O:O2

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

EMERGENCY PREPARATION
 Key office staff should have CPR training
 In-office review of roles
 In-office drills
 Review kit periodically
 Emergency number should be posted
 Have a written emergency protocol in place in the office.

Assign duties: (as an example; modify as appropriate for your office)

 Member #1: Team Leader
 Takes command
 Appears calm
 States and directs clear commands
 Closed loop approach
 Requests acknowledgment
 Open exchange
 Concentrate on what is right for the patient – not who is right

 Member #2
 Brings emergency kit
 Brings O2 tank and attaches appropriate delivery system
 Brings AED
 Assists with ABCs of CPR
 Checks oxygen tank regularly
 Checks emergency kit regularly
 Prepares drugs for administration

 Member #3
 Calls EMS (9-1-1)
 Meets paramedics at entrance of building
 Keeps chronological log of events
 Assists with ABCs of CPR

 Member #4
 Takes vital signs
 Assists with ABCs of CPR
 Assists with other duties as needed

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 University of Toronto Continuing Dental Education
Medical Emergencies November 23, 2018 Dr. D. Haas

 Info for 911 call

 Have portable phone so that the dentist in the operatory can speak directly
 Key information to give:
 Patient is:
 Conscious
 Or not
 Patient is:
 Breathing
 Or not
 Preliminary diagnosis
 Example: “Possible myocardial infarction.”
 Information on the patient
 Example: “66-year old female with chest pain. Conscious. Blood pressure of 164 over
92. Heart rate of 82 per minute
 What is being done for the patient
 Example: “The patient is currently being given 6 liters per minute of oxygen by face-
mask.”
 Location. Provide exact street address with office number. Provide names of cross
streets if possible.
 Example: “Dr. Smith’s dental office at 124 Edward St., suite 171, 1 block east of
University Ave and 1 block north of Dundas”)
 Telephone number from which the call is being made

EMERGENCY KIT
 Readily accessible
 Simple organization
 Expiry date notation
 Consider: • Group drugs by emergency
• “Baggie” approach
• Group purchasing

SUGGESTED READING
Malamed, S.F. Medical Emergencies in the Dental Office. 7th ed., Mosby, 2015.
Haas, D.A. Emergency Drugs. In, Dental Clinics of North America, Vol 46: October 2002.
Haas D.A. Preparing dental office staff members for emergencies. Developing a basic action
plan. Journal of the American Dental Association, 141:8S-13S, May 2010.

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