MEDICAL EMERGENCIES IN DENTAL

OFFICE AND THEIR MANAGEMENT

Presented by - Dr. Tamanna Kumari
Junior Resident-2
l Dept. Of Conservative Dentistry & Endodontics
• An emergency is a medical condition that demands
immediate attention and successful management. These are
the life‑threatening situations of which every practitioner
must be aware of so that needless morbidity can be avoided.
• Emergencies can be prevented to a certain extent by a
detailed medical history, physical examination, and patient
monitoring. Preparation for an emergency and sound
knowledge about the management of all emergencies in
general is of prime concern to dental specialists
 Incidence

The incidence of emergency events seen in the general practice

setting is rare but when an emergency does occur it can be life
threatening. The more common problems include vasovagal
syncope (faints), hypoglycaemic episodes, angina, seizures,
choking, asthmatic attack and anaphylaxis. Excluding syncope,
adverse medical events have been reported to occur at a rate of
0.7 cases per dentist per year.
 Medical Risk Assessment
• The recognition of ‘at-risk’ patients and subsequent
appropriate management is paramount in reducing the
probability of an adverse event. A thorough medical and drug
history is mandatory and should be undertaken by the dentist
in person. Patient-completed health questionnaires should be
confirmed by a verbal history.
• Identification of at-risk patients will allow modifications to be
made to treatment planning and may highlight those patients
whose treatment may be more appropriately conducted at
specific times or in specialist centres.
• Medical and drug records should be updated annually, and
any changes highlighted during ongoing treatment plans
should be re-assessed and recorded at every visit.
 EQUIPMENTS AND DRUGS

• Medical emergencies may require equipment, drugs or

both in order to manage them effectively. If these are
unavailable, patients should not be treated. It is also
important to check that the drugs are within their expiry
date.
Emergency Drugs In The General Dental Practice

• To manage the more common medical emergencies

encountered in general practice, the following drugs should be
available:
1 Oral glucose solution/tablets/gel/powder.
2 Glucagon injection 1mg IM.
3 Salbutamol aerosol inhaler (100 micrograms/actuation).
4 Adrenaline IM injection (1:1,000, 1mg/ml).
5 Glyceryl trinitrate (GTN) sublingual spray (400
micrograms/dose).
6 Aspirin dispersible (300mg)
7 Midazolam 5mg/ml or 10mg/ml (buccal or intranasal).
1. Oxygen
• Oxygen is indicated for all emergency conditions except
hyperventilation. A portable full “E” size cylinder should be
readily available for the patient oxygenation until the arrival
of emergency services.
• Oxygen is delivered with a clear full face mask at a flow rate of
10 l/min for the spontaneously breathing adult patient and 3-
5 l/min for breathing children.
• Bag-valve-mask device is required for the administration of
oxygen for the unconscious and apnoeic patient at a flow rate
of 10-15 l/min, and in case of positive pressure device usage,
the flow rate should not exceed 35 l/min for adults.
2. Adrenaline
• This is the drug of choice for the emergency treatment of
anaphylaxis, and also for asthma which does not respond to
the drug of first choice, albuterol or salbutamol.
• Adrenaline is also indicated for the management of cardiac
arrest, but in the dental setting, it may not likely be given,
since intravenous access may not be available.
• It has a very rapid onset and short duration of action, usually
5-10minutes, when given intravenously. However, it may be
associated with high risks if given to a patient with ischemic
heart disease
 For emergency purposes, it is available in two formulations: as
1:1,000 which equals 1mg per ml, for intramuscular, including
intralingual, injections, and 1:10,000, which equals 1 mg per
10 mL for intravenous injection.
 Initial dose for the management of anaphylaxis is 0.3 to 0.5
mg intramuscularly or 0.1 mg intravenously. These doses
should be repeated as necessary until resolution of the event.
Similar doses should be considered in asthmatic
bronchospasm which is unresponsive to a beta-2 agonist, such
as albuterol or salbutamol. The dose in cardiac arrest is 1mg
intravenously.
3. Nitroglycerin
• Nitroglycerin is the drug of choice to treat acute angina or
myocardial infarction. It has a rapid onset of action. It is
available as oral and transmucosal preparations,
transcutaneous patches, and IV solutions.
• Sublingual tablets or spray are suitable forms for dental office.
Sublingual tablets should be freshly opened because of short
shelf-life of opened bottle tablets.
• For Angina -1 tablet/metered spray (0.4 mg) should be
administered. If angina pain is not relieved within 1-2 min,
then repeat this dosage to 2-3 times at 5 min intervals.
4. Antihistamine

• Oral administration of antihistamines is advisable for

mild non-life-threatening allergic reactions.
• Parenteral administration (IM) is required for life-
threatening reactions. Diphenhydramine (25-50 mg) or
chlorpheniramine - avil (10-20 mg) is administered by
oral or parenteral route.
• Pediatric dose of chlorpheniramine is 1-2 mg every 6 h
and diphenhydramine dose is 1-1.25 mg/kg every 6 h.
5. Albuterol (Salbutamol)
• A selective beta-2 agonist such as albuterol (salbutamol) is the
first choice for management of bronchospasm.
• When administered by means of an inhaler, it provides
selective bronchodilation with minimal systemic
cardiovascular effects. It has a peak effect in 30 to 60 minutes,
with a duration of effect of 4 to 6 hours.
• Adult dose is 2 sprays, to be repeated as necessary.
• Pediatric dose is 1 spray, repeated as necessary.
6. Aspirin
• Aspirin reduces overall mortality from acute myocardial
infarction by preventing further clot formation.
• Patient experiencing ischemic chest pain should chew and
swallow aspirin 325 mg tablet.
• For pediatric patients, 10-15 mg/kg is recommended.
• Aspirin is contraindicated in asthma, bleeding disorders, and
in known hypersensitivity to aspirin.
7. Oral Carbohydrate
• An oral carbohydrate source, such as juice or nondiet soft-
drink, should be readily available. Whereas this is not a drug,
and perhaps should not be included in this list, it should be
considered essential. Its use is indicated in the management
of hypoglycemia in conscious patients.
8. Aromatic Ammonia
It acts as respiratory stimulant for patients experiencing syncope.
It should be administered after maintaining patent airway of the
patient.
 ADDITIONAL DRUGS
• In addition to the drugs discussed, a number
of other drugs should be considered as part of
an emergency kit
1. Glucagon
• Glucagon intramuscular administration is required to manage
hypoglycaemia in unconscious patients. Glucagon acts within
10 min after administration.
• dosage for glucagon is 1 mg. Pediatric dose is 0.5 mg.
• Alternative for glucagon for severe hypoglycemia
management is 50% IV dextrose (glucose) 50-100 ml.
2. Atropine
• This anticholinergic drug is used to manage hypotension
accompanied with bradycardia. IV atropine in a dose of 0.5
mg for every 3-5 min is needed. Pediatric dose of atropine
sulfate: 0.02 mg/kg for IV route and 0.04 mg/kg for
intramuscular injection. Maximum dose for IV injection is 1
mg.
3. Ephedrine

• Ephedrine is like adrenaline but a less potent

vasopressor agent with prolonged action. For severe
hypotension, 5 mg IV or 10-25 mg IM should be
given.
4. Corticosteroid
• Corticosteroids such as hydrocortisone used to prevent
recurring anaphylaxis and manage adrenal insuffi ciency.
Onset of action is slow (1 h) on IV administration; for this
reason, their use in emergency is limited. Hydrocortisone 100-
200 mg IV/IM is administered for the management of acute
phase of these emergencies. Pediatric dose is 50-100 mg.
5. Morphine
• Morphine is used for the management of severe pain of
myocardial infarction. The dose involves titration in 1-3 mg
increments IV/5 mg increments intramuscularly until the relief
of pain. Lower doses should be considered for older patients.
6. Naloxone
• Naloxone is a specifi c opioid antidote that converses opioid-
induced respiratory depression. This should be used for the
emergency management of opioid (morphine) overdose. For
intramuscular injection, adult dose 0.4 mg and pediatric dose
of 0.01 mg/kg are advisable. The dose involves titration in 0.1
mg increments IV with slower administration for the benefi
cial effect.
7. Nitrous Oxide
• This is an alternative to morphine to manage pain of
myocardial infarction. It should be administered in a
concentration of approximately 65% with 35% oxygen.
8. Benzodiazepines

• Benzodiazepine is administered to manage prolonged or

recurrent seizures (status epilepticus).
• IV diazepam 5-10 mg is rapid in stopping all types of seizures.
An alternative treatment for status epilepticus is midazolam
or lorazepam IM/IV. Patients should be monitored carefully
after administration since respiratory depression and sedation
are the side effects of these drugs which can be reversed by
antidote drug.
• Adult doses for lorazepam are 4 mg IM or midazolam 5-10 mg
IM. A repeat dose can be given if necessary for a normally
breathing patient. Pediatric dose of diazepam is 0.5 mg/kg for
2-5 year olds and 0.3 mg for 6-11-year-old children.
• Pediatric dose for lorazepam is 0.05-0.1 mg/kg. Pediatric dose
of midazolam is 0.1-0.3 mg/kg. For IV administration, these
drugs should be slowly titrated for the favorable effect.
Recently, buccal midazolam is also recommended to treat
seizures.
9. Flumazenil
• The benzodiazepine antagonist flumazenil antagonizes the
side effects of sedation and respiratory depression induced by
benzodiazepines administration.
• Dosage is 0.1-0.2 mg IV increments with a maximum dose of 1
mg.
10. Calcium Channel Blockers
• This group of drugs is indicated for the management of
hypertension, angina, and supraventricular tachycardia.
• Nifedipine 10-20 mg sublingual administration is
recommended for a known patient of coronary artery spasm.
• Verapamil IV (5-10 mg) administration is primarily indicated
for paroxysmal supraventricular tachycardia.
 EMERGENCY EQUIPMENT FOR THE
DENTAL OFFICE
1. Portable oxygen cylinder (E size) with regulator (supplemental
oxygen-delivering devices - oxygen therapy mask, nasal cannula,
pocket mask, and bag valve mask unit).
2. Oropharyngeal airways (sizes 1-4).
3. Portable suction with suction catheters.
4. Intravenous (IV) fl uids/lines, syringes, needles, and tourniquets.
5. Automated blood glucose measurement device.
6. Stethoscope.
7. Sphygmomanometer.
8. A spacer device for inhaled bronchodilators.
9. Magill intubation forceps.
10. Pulse oximeter with audible alarm.
11. Automated external defibrillator (AED).
 Basic Principles of Management of
Medical Emergencies
The golden rule in managing any emergency is rendering basic
life support (BLS) measures and cardiopulmonary resuscitation
(CPR). This is done by following the basic principles:
• Position (P),
• Airway (A),
• Breathing (B), Circulation (C), and
• Definitive therapy (D).
 Position of the Patient

• The primary positions during emergency situations are

a) Supine for seizures.
b) Supine position with elevated legs for syncope and cardiac
arrest.
c) Semi erect and upright position for angina, myocardial
infarction, heart failure and asthma
 Airway
• Assess airway patency: Try to maintain a patent airway in
unconscious patients by head tilt–chin lift technique or jaw
thrust maneuver.
Opening Airway Technique:
The rescuer must stand behind the victim’s head to perform this
procedure.
• Head tilt: Place one hand on patient’s forehead and apply
backward pressure with the palm to rotate the head upward
and backward.
• Chin lift: Place the tips of middle and index fi ngers on the
symphysis of the mandible to lift the mandible.
• Jaw thrust technique: Place the fi ngers on the angle of the
mandible and displace the mandible forward.
 Breathing
• Using the “look – listen – and – feel” technique, the rescuer
can determine the victim’s breathing status. The rescuer must
place his ear 1 inch from the nose and mouth while looking
toward the victim’s chest. If airway is obstructed, signs may be
gurgling, “stridor,” expiratory “wheeze,” or silent chest with no
breath sounds.
• Count respiratory rate (RR): Normal adult RR is 12-20
breaths/min and child RR is 20-30 breaths/min. To assess
depth and symmetry of inspiration by observing chest
expansion.
The signs of respiratory distress are sweating, central cyanosis
(tongue and mucous membranes), use of accessory muscles of
respiration (neck muscles), and abdominal breathing.
Oxygen must be administered if the patient is not ventilating
adequately
This can be done by three ways:
• Exhaled air ventilation
• Atmospheric air ventilation
• O2 Enriched ventilation.
Exhaled air ventilation: This can be given by 2 methods.
• Mouth-to-mouth breathing
• Mouth-to-nose breathing.

Atmospheric air ventilation: Manually operated self-

inflating bag-valve-mask device is used to deliver atmospheric air
to the victim’s lungs (trained person only).

Oxygen enriched ventilation: Portable E cylinder with

adjustable O2 flow (10-15 L/min) and a face mask.
 Circulation
• To record heart rate by assessing carotid pulse in neck. If
carotid pulse is not palpable, the rescuer has to start
cardiopulmonary resuscitation (CPR) immediately.
• Look at the hands and fingers for color changes. Touch the
patient’s hand to assess the upper limb temperature. Apply
blanching pressure for 5 s on the fingertip at heart level to
assess capillary refill time. Normal refill time is <3s. Dentist
should record and monitor all vital signs.
 Definitive Management
• If patient is unconscious, the initial steps to be followed are
P-C (position of the patient - assessing circulation).
• Next step is A-B (airway maintenance - adequate breathing)
- if carotid pulse is not palpable, then the team must
immediately start CPR.
• After achievement of adequate ventilation, diagnosis must
be made, and definite treatment must be provided.
• The basic procedures are same for all the age groups of the
patients, but for the adults, the main effort is to bring early
defibrillation, and for children, the focus should be on early
ventilation.
CPR Guidelines
• Call 108 (emergency management of India) or call adjacent
hospital ambulance number.
• Call for assistance.
• Open air way by head tilt–chin lift procedure.
• Give 2 breaths and make the chest rise.
• Check the person’s responsiveness; if patient is unconscious,
then start chest compressions.
• The lower half of the sternum is compressed, with care taken
not to compress the xiphoid process.
• Place the heel of your hand on the center of the victim’s chest and
keep your other hands on top of the fi rst with the interlaced fingers.
• Press down so you compress the chest at least 2 inches deep in
adults and children and 1.5 inches deep in infants (Rate of
compression 100/mn).
• 30 compressions with short pause (10 s or less) between the
compressions.
• After each compression, the chest must be allowed to recoil fully.
• After 30 compressions, the rescuer must start to ventilate the
patient, by mouth-to-mouth/mouth-tomask breath (1 s breath 2 with
a gap of 3 s).
• Continue compressions and breaths - 30 compressions, two breaths
- until help arrives
• For a pediatric patient, start with 30 chest compressions and
two rescue breaths should be given if there is absent of palpable
pulse.
• 15 chest compressions and 2 rescue breath are advised for
children with the presence of two rescuers.
• If palpable pulse >60/mn give rescue breath 12-20/mn (1
breath lasting for 1 s for every 3-5 s).
 Medical Emergencies in the Dental
Practice
Most frequently occurring medical emergencies that develop
during the course of dental treatment are as follows.
• Vasovagal syncope
• Postural hypotension
• Allergies/ Hypersensititvity reactions
• Acute Adrenal Insufficiency
• Diabetic emergencies
• Hyperventilation
• Asthma- Status Asthmaticus
• Cardiac chest pain-Myocardial infarction
• Epilepsy- Status Epilepticus
 VASOVAGAL SYNCOPE (Common Faint)

• Most common medical emergency. It is described as sudden,

transient loss of consciousness due to cerebral hypoperfusion.
Predisposing factors:
• They can be presented as psychogenic factors including
extreme anxiety, fear and pain. Non psychogenic factors
comprise of sitting or upright position, hunger, poor physical
condition and hot, humid and crowded environment.
Signs and symptoms:
Light headedness, headache, pallor, dizziness, nausea, sweating,
visual disturbances i.e. pupil dilation and blurred vision.[1,14,19]
Prevention:
a) Thorough pre treatment medical evaluation and grading an
individual on the ability to tolerate psychological stress.
b) Stress reduction protocols.
c) Good communication.
d) Reassurance.
Management of syncope

• Discontinue the procedure. Patients should be placed in

supine position with elevated legs (Trendelenburg position) to
facilitate blood flow to brain.
• Check circulation, airway, breathing and maintain airway by
Head tilt – Chin Lift technique (Jaw thrust maneuver if
necessary).
• Administer 100% oxygen (8-10 litres/mn via mask and
reservoir bag).
• Monitor vital signs and check medical history for associated
illness.
• NH3 ampules inhalant is used as respiratory stimulant. If
patient feels cold, provide blanket or provide cold towel for
warm patients.
• If bradycardia persists, administer 0.5–1mg Intramuscular (IM)
or Intravenous (IV) atropine.
• For hypoglycaemic patients, administration of soft drinks or
50% IV glucose or IM glucagon is advisable. Patient once
recovered should be discharged with attendant.
• If patients do not recover initiate Cardio Pulmonary
Resuscitation (CPR) and immediately transfer to hospital
 Angina
• Angina pectoris is the result of myocardial ischaemia caused
by an imbalance between myocardial blood supply and
oxygen demand. Typically, angina is precipitated by exertion,
eating, exposure to cold, or emotional stress. It lasts for
approximately one to five minutes and is relieved by rest or
glyceryl trinitrate.
• It can be classified as:
 Stable: induced by effort and relieved by rest.
 Unstable: occurring at increasing frequency or severity or at
rest.
 Decubitus: precipitated by lying flat.
 Variant: caused by coronary artery spasm (rare).
Management
• Stop the procedure, position the patient upright and reduce
anxiety. Supine position may increase the subjective intensity
of pain.
• Monitor vital signs and provide 100% Oxygen.
• Administer Glyceryl trynitrate (GTN) 400μg spray or sublingual
tabs as needed. Spray 1 or 2 metered doses with no more
than 3 metered doses within a 15 mn period.
• Sublingual tablets 0.3–0.6 mg every 5 mn with no more than
three tablets for 15 minutes.
• For known angina patient administer aspirin. If GTN is not
available then calcium channel blockers like nifedipine 10-
20mg sublingual administration is required.
• If pain is not relieved by 2 doses of GTN over a 10-minute
period then suspect for MI and call EMS immediately
 Myocardial Infarction
 MI is caused by deficient coronary arterial blood supply to a
region of myocardium due to obstruction from atherosclerotic
coronary artery that results in cellular death and necrosis.
 Suspect MI when radiating anginal pain is not relieved by
GTN. There may be weakness, nausea, sweating, pallor, cold /
sweaty skin, restlessness, dizziness, dyspnoea and syncope.
Associated pump failure results in hypotension, palpitations,
slow pulse to tachycardia and pulmonary edema.
 Myocardial infarction (MI) is the irreversible necrosis of heart
muscle secondary to prolonged ischaemia. This usually results
from an imbalance of oxygen supply and demand.
• Approximately 90% of MIs result from an acute thrombus that
obstructs an atherosclerotic coronary artery, resulting in
complete occlusion of the vessel.
Management

• Call EMS for help.

• Position the patient upright / flat if faint. Assess circulation,
airway and breathing. Administer high flow oxygen for pain
relief (15 L/min). Administer GTN and repeat in 5 mn up to 3
tablets (Not advised for hypotensive patients).
• Aspirin 325 mg with or without Clopidogrel 300 mg can be
given orally (if there is no aspirin allergy).
• If pain continues, administer Morphine 2 to 5 mg IM / IV with
High Flow Oxygen. In place of Morphine and Oxygen a
mixture of 50% N2O and 50% O2 can be used.
• Record vital signs of the patient. If unconsciousness persists
initiate CPR and transfer the patient to nearest hospital.
 Epilepsy
• This is a recurrent tendency to spontaneous, intermittent,
abnormal electrical activity in a part of the brain, manifesting
as seizures.
• Seizure types are characterised firstly according to whether
the source of the seizure
1. within the brain is localised (partial or focal seizure) or
2. widely distributed (generalised seizures).
• Partial seizures are further divided on the extent to which
consciousness is affected. If it is unaffected, then it is termed
a simple partial seizure; otherwise, it is a complex partial
seizure.

• A partial seizure may spread within the brain and become a

secondary generalised seizure. Generalised seizures are
divided according to the effect on the body but all involve loss
of consciousness. These include absence (petit mal),
myoclonic, clonic, tonic, tonic-clonic (grand mal) and atonic
seizures.
 Status Epilepticus
• Traditionally, status epilepticus was characterised by 30
minutes of continuous seizure activity or by multiple
consecutive seizures without return to full consciousness
between the seizures.

• It is now thought that a shorter period of seizure activity

causes neuronal injury and that seizure self-termination is
unlikely after five minutes. As a result, some specialists
suggest times as brief as five minutes to define status
epilepticus.
• The Resuscitation Council (UK) guidelines from 2006
recommend that medications should only be administered if
convulsive movements occur for greater than five minutes or
recur in quick succession.

• Intravenous diazepam is considered first-line treatment for

control of prolonged seizures; however, it may be more
appropriate to administer a single dose of midazolam via the
buccal or intranasal route in a dental practice setting
depending on the experience of the dental clinician in gaining
IV access.
Management

 Recognize the problem (lack of response to stimulation). Place

the patient's supine position in the dental chair. Once the seizure
ceases (<5 minutes) reassure the patient.
 If intravenous access is available diazepam (Valium) IV is
administered at a dose of 0.2-0.5mg for Child lesser than 5
years 0.2-0.5 mg slowly every 2-5 minutes with a maximum of
5mg, above 5 years.
 When the episode terminates allow the patient to recover,
discharge the patient with attender, postpone dental
procedures. If the condition pertains to more than 5mins
activate EMS and start with BLS until the medical help reaches
 Hypoglycaemia

• Plasma glucose is normally maintained at levels between 3.6

and 5.8mmol/l. Cognitive function deteriorates at levels
<3mmol/l.
• In people with diabetes, the most common cause is a relative
imbalance of the administered versus required insulin or oral
hypoglycaemic drugs.
Clinical symptoms

Weakness, sweating, slurred speech, blurred vision, trembling,

pale, cold and clammy skin (Hypothermia), nausea & hunger,
depressed respiration, rapid pulse, hypotension, head ache,
irritability, bizarre behaviour, disorientation, drowsiness,
unconsciousness, seizure and coma.
Management
• Conscious patients can normally be treated with 10-20mg of
oral glucose/ 200ml of fruit juice or sublingual “Gluco-gel”.
• After 10 minutes repeat, oral glucose till symptoms subside.
• If the patient is unconscious, patient placed in Trendelenburg
position.
• Monitor circulation, airway and breathing.
• Administer Glucagon 1mg SC/IM/IV and give IV Glucose 50%.
For children below 8 years give 0.5mg Glucagon.
• Oxygen may be administered for unconscious patient.
• Transfer the patient to hospital
 Asthmatic attack
• Asthma is characterised by recurrent episodes of dyspnoea,
cough, and wheeze caused by reversible airway obstruction.

• Its prevalence in 13- to 14-year-old school children increased

by 40% between 1995 and 2003 (15.2% to 21.6%).
Management
 Ask the patient to remain calm and sit upright. (supine
position worsens dyspnea).
 Ask the patient to inhale 2 puffs from albuterol inhaler. If
patient is unable to inhale, then use volumetric spacer (100
mgs/ puff) and give 4-6 puffs and allow 6 breaths for each puff
or use nebulizer.
 For young children give up to 10 puffs via spacer device. If
there is no improvement in 15 seconds, then consider SC/IM
administration of 1:1000 dilution of adrenaline 0.3 ml.
 If no response is observed in 2‑3 min oral or IV administration
of hydrocortisone sodium succinate 100 to 200 mg should be
considered.
 If condition persists administer IV aminophylline and call EMS
to transfer the patient to hospital. High flow 100% O2(8-10
L/min)can be delivered whilst waiting for ambulance.
 For paediatric patients 3-5 L/mn O2 administration is
advisable
 Foreign Body – Upper Airway
Obstruction ( Choking)

Severe or complete upper airway obstruction due to a

foreign body rapidly progresses to unconsciousness and
cardiac arrest within minutes and presents with distress,
choking, coughing and cessation of breathing.
Management

• Partial obstruction: Encourage the patient to cough up

or spit out. If there is poor air entry, increasing high
pitched stridor or respiratory distress, manage as for
complete airway obstruction.

• Complete obstruction: The victim cannot speak,

breathe or cough. If he is in the dental chair sit him up,
turn patient side on in chair. Support the chest with one
hand and deliver five sharp back blows between the
shoulder blades with the heel of the other hand. If back
blows fail, five abdominal thrusts (Heimlich) should be
done.
• Unconscious obstruction: Commence CPR with
finger sweep between each cycle. It is important to
consider cricothryoidotomy if there is no air entry at
all.
 ALLERGY /HYPERSENSITIVITY REACTIONS
 Allergy is a hypersensitive state acquired through exposure to
a particular allergen, reexposure to which produces a
heightened capacity to react.
 A patient‟s history is a major factor in determining the risk of
allergy, the specific drug to be employed is of extreme
importance.
 Antibiotics like penicillin or sulfonamides, analgesics like
codeine and ester containing local anesthetics like procaine,
tetracaine provoke allergic reponse very frequently.
• Anaphylaxis is a Type 1 hypersensitivity reaction involving IgE
to which free antigen binds leading to the release of
vasoactive peptides and histamine.
• Management of a patient with suspected anaphyalxis during
anesthesia
• Stop administration of all agents likely to cause anaphylaxis.
• P- Position- the patient should be placed flat with legs
elevated.
• A-B-C- Airway, Breathing, Circulation.
Definitve care:
 Epinephrine intramuscularly (IM) 0.3 -0.5mg of 1:1000
dilution in the anterolateral aaspect of the thigh. Repeat it
every 10 minutes should be administered
 .If the patient is conscious, or unconscious yet spontaneously
breathing, oxygen should be delivered by a full face mask,
where a flow rate of 6 to 10 liters per minute is appropriate
formost adults. If the patient is unconscious and apneic, it
should be delivered by a bag-valvemask device where a flow
rate of 10 to 15 liters per minute.
Monitor vital signs
Additional drug therapy- histamine blocker- diphenhydramine
(50 mg for adults, 25 mg for children) IM/IV or
chlorpheneramine 10-20 mg by slow IV infusion) should be
adminstered
corticosteroid – 100-500 mg hydrocortisone slowly IV should be
given.
 Hyperventilation
• Hyperventilation is breathing occurring more deeply and
rapidly than normal. The normal adult respiratory rate is
11-18/min but anxiety can result in a hyperventilatory
state. CO2 is ‘blown off’ and results in a decrease in
arterial pCO2.
• The resultant fall in arterial CO2 concentration causes
cerebral vasoconstriction and respiratory alkalosis.
Management:
 Terminate all procedure and ask the patient to relax.
 Position the patient in comfortable position (Sitting) and
encourage the patient to rebreathe the expired air since expired
air is rich in CO2.
 Ask the patient to breathe in and out slowly in the full-face
mask or hands cupped over face closing mouth and nose for 10
times. Ask the patient to repeat the cycle until the relief of
symptoms.
 Do not administer O2 for hyperventilating patients. No drugs
are usually required but if symptoms persist administer IM/Oral
Diazepam 10 mg or IM Midazolam 3 -5 mg.
 If the patient becomes unconscious, place him in supine
position, maintain airway and initiate CPR until the patient
recovers consciousness
 Adrenal crisis
• The adrenal cortex produces three steroid hormones, which
include glucocorticoids (cortisol), mineralocorticoids and
androgens. Cortisol is the most important human
glucocorticoid. It is essential for life, and regulates or supports
many important metabolic, cardiovascular, immunologic and
homeostatic functions in the body.
• An acute exacerbation of chronic cortisol insufficiency results
in ‘adrenal crisis’, and is most commonly precipitated by
surgical stress or sepsis. Primary adrenal insufficiency is rare
and is due to adrenal gland destruction.
• It may occur as a consequence of hypothalamic–pituitary
disease, or more commonly due to suppression of the
hypothalamic–pituitary axis by exogenous steroid therapy.
Cortisol production is increased as a response to stress;
however, if the adrenal cortex is unable to synthesise an
adequate quantity of cortisol, required to meet increased
demands, a crisis may be precipitated and a potentially
lifethreatening medical emergency may develop.
Management
• Place the patient in supine position.
• Maintain patent airway.
• Manage symptoms. If patient is having seizure, then
administer IV Diazepam 1 ml/min up to 2.5 - 5 mg or
Midazolam IM/IV injections.
• If patient is Hypotensive give IV fluids. If patient is
unconscious administer high flow Oxygen and monitor vital
signs.
• If patient is unconscious with signs of allergy, then administer
IM/IV epinephrine or antihistamine or corticosteroids. Initiate
CPR if necessary and call EMS immediately
 Conclusion
Staff must undergo training in the management of emergencies
to a level based on their clinical responsibilities. Skills learned
should be refreshed annually and training can be undertaken
within the general practice or at designated training centres. All
new staff members must undergo resuscitation training as part
of their induction.
 REFRENCES
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Dental Association · January 2008
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Rawat1, Vanshika Agarwal2, Nitin Bhagat3, Pallav Prakash4,
Shashank Agarwal5, Aprajita Dhawan6. European Journal of
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Issue 08, 2020
• JDSA ARTICLE.Management of Medical Emergencies in the
Dental Office: Conditions in Each Country, the Extent of
Treatment by the Dentist Daniel A. Haas
• World Journal of Pharmaceutical and Life Sciences. MEDICAL
EMERGENCIES IN DENTAL PRACTICE: A REVIEW Siddharth
Tevatia*1, Vaibhav Mukund2, Shivam Agarwal3and Vivek
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