1. Chapter 23: Emergency Drugs Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.

2. 2 Chapter 23 Outline  Emergency Drugs  General measures  Categories of emergencies  Emergency kit for the dental office

3. 3Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Emergency Drugs  Haveles (p. 290)  An increasing number of older patients who are taking multiple drugs seek dental treatment each year  Dental offices are administering more complicated drug regimens, dental appointments are taking longer, and dental patients are getting sicker  The chances of an emergency in a dental office continues to increase

4. 4Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. General Measures  Haveles (pp. 290-291) (Boxes 23-1, 23-2)  Train: before an emergency occurs, including cardiopulmonary resuscitation (CPR)  Telephone number: post the number of the closest physician, emergency room, and 911  Emergency kit: select items and keep up to date

5. 5Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Preparation for Treatment  Haveles (p. 291)  Before any emergency treatment can be administered, investigation of signs and symptoms must be done  In most cases, maintenance of the airway, breathing, circulation are of primary importance  Drugs are not necessary for proper management of most emergencies

6. 6Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Categories of Emergencies  Haveles (pp. 291-294)  Lost or altered consciousness  Respiratory emergencies  Cardiovascular system emergencies  Other emergency situations  Drug-related emergencies

7. 7Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Lost or Altered Consciousness  Haveles (pp. 291-292)  Syncope  Hypoglycemia  Diabetic coma  Convulsions or seizures

8. 8Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Syncope  Haveles (pp. 291-292)  The most common emergency in the dental office is simple syncope (faint)  The skin becomes ashen-gray and diaphoresis occurs  Due to anxiety, fear, or apprehension  Treatment: involves placing the patient in the Trendelenburg position (feet elevated) causing blood to rush to the head  Spirits of ammonia can be administered

9. 9Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Hypoglycemia (Insulin Reaction)  Haveles (p. 292)  Most common cause is excessive dose of insulin in a diabetic  The person may not have eaten before the appointment  The patient with hypoglycemia has a rapid pulse and decreased respiration and is loquacious  Hunger, dizziness, weakness, and occasionally hand tremor may occur; diaphoresis, nausea, and mental confusion are other signs  Treatment: in conscious, a sugary drink or oral glucose  If unconscious, dextrose intravenously

10. 10Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Diabetic Coma  Haveles (p. 292)  Caused by elevated blood sugar  Symptoms include frequent urination, loss of appetite, nausea, vomiting, and thirst  Acetone breath, hypercapnia, warm and dry skin, rapid pulse and a decrease in blood pressure can occur  Treatment: requires hospitalization and includes insulin after laboratory results are obtained

11. 11Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Convulsions or Seizures  Haveles (p. 292)  Convulsions are most commonly associated with epilepsy but can also result from a toxic reaction to a drug  Convulsions are abnormal movements of parts of the body in clonic and/or tonic contractions and relaxations  Treatment should include protecting the patient from self-inflicted damage and turning the patient’s head to one side to prevent aspiration  Diazepam may be administered

12. 12Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Respiratory Emergencies  Haveles (p. 292)  Hyperventilation  Asthma  Anaphylactic shock  Acute airway obstruction

13. 13Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Hyperventilation  Haveles (p. 292)  Rapid respiratory rate is often due to emotional upset  Tachypnea, tachycardia, and paresthesia have been reported  Nausea, faintness, perspiration, acute anxiety, lightheadedness, and shortness of breath may occur  Treatment: encourage the patient to hold his or her breath or “rebreathe” into a paper bag

14. 14Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Asthma  Haveles (p. 292)  Patients who have acute asthma attacks have a history of previous attacks and will have an inhaler with them  The most common sign is wheezing with prolonged expiration  Treatment  Patients can use their own ß 2 -agonist  If no response is noted, hospitalization for aminophylline (parenteral or oral) and parenteral corticosteroids and epinephrine should be considered

15. 15Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Anaphylactic Shock  Haveles (p. 292)  The reaction usually begins within 5 to 30 minutes after ingestion or administration of the antigen  Usually, a weak, rapid pulse and profound decrease in blood pressure occur  Dyspnea and severe bronchial constriction occur  Treatment: parenteral epinephrine must be administered immediately in cases of severe anaphylactic shock  If bronchoconstriction predominates, albuterol administered by inhalation or nebulization may suffice  After life-threatening symptoms have been controlled, intravenous (IV) corticosteroids, intramuscular diphenhydramine, and aminophylline may be used

16. 16Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Acute Airway Obstruction  Haveles (p. 292)  Usually the result of a foreign body in the pharynx or larynx; laryngospasm may be drug induced  Gasping for breath, coughing, gagging, acute anxiety, and cyanosis are signs and symptoms  Treatment: Trendelenburg position on the right side and encouraging coughing  Clearing the pharynx and pulling the tongue before performing the Heimlich maneuver should be next Heimlich maneuver if necessary Heimlich maneuver if necessary  A cricothyrotomy or tracheotomy are indicated if the object cannot be dislodged by other methods

17. 17Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Cardiovascular System Emergencies  Haveles (pp. 292-293)  Angina pectoris  Acute myocardial infarction  Cardiac arrest  Other cardiovascular emergencies

18. 18Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Angina Pectoris  Haveles (p. 293)  Often begins as substernal chest pain that radiates across the chest to the left arm or the mandible  Pulse becomes rapid, and tachypnea (rapid breathing) can occur  Treatment: the patient can premedicate with sublingual nitroglycerin  An acute attack is treated with sublingual nitroglycerin  Opioids or diazepam are used in hospitalized patients

19. 19Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Acute Myocardial Infarction  Haveles (p. 293)  Often begins as severe pain, pressure, or heaviness in the chest that radiates to other parts of the body  Sweating, nausea, and vomiting can occur  Pain is unrelieved by rest or nitroglycerin  An irregular rapid pulse, shortness of breath, diaphoresis (perspiration), and indigestion can occur cont’d…

20. 20Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Acute Myocardial Infarction  Treatment: includes administration of oxygen, an aspirin tablet, and an opioid analgesic agent and transfer to a hospital  In the hospital, patients are given lidocaine for arrhythmias and vasopressor agents to maintain adequate blood pressure  New drugs that can dissolve clots are administered soon after the event and may reverse the clot

21. 21Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Cardiac Arrest  Haveles (p. 293)  Generally, sudden circulatory and respiratory collapse occur  Permanent brain damage occurs within 4 minutes  Treatment: immediate CPR  Medications in a hospital include epinephrine for cardiac stimulation and lidocaine for arrhythmias Parenteral opioid analgesics are given for pain Parenteral opioid analgesics are given for pain Defibrillation is used to treat systole Defibrillation is used to treat systole

22. 22Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Other Cardiovascular Emergencies  Haveles (p. 293)  Arrhythmias: depend on an electrocardiogram for diagnosis before treatment  A cerebrovascular accident (CVA): treated with oxygen and “clot busters” in the hospital  Hypertensive crisis: treated with antihypertensive agents given intravenously

23. 23Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Other Emergency Situations  Haveles (p. 294)  Extrapyramidal reactions: can be produced by antipsychotic agents  prochlorperazine (Compazine) used for nausea and vomiting can produce this type of reaction  Treatment: IV diphenhydramine (Benadryl) cont’d…

24. 24Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Other Emergency Situations  Acute adrenocortical insufficiency: usually occurs in patients who are taking enough steroids to suppress the adrenal gland  Cardiovascular collapse and irreversible shock may result in a fatality  Treatment: parenteral hydrocortisone and oxygen cont’d…

25. 25Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Other Emergency Situations  Thyroid storm: hyperthyroidism is out of control  Congestive heart failure and cardiovascular collapse may follow  Treatment: includes tepid baths and aspirin, β- blockers for cardiovascular symptoms, and possibly hydrocortisone cont’d…

26. 26Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Other Emergency Situations  Malignant hyperthermia: genetically determined reaction triggered by inhalation general anesthetics or neuromuscular blocking agents such as succinylcholine  Treatment: baths and aspirin are used to control elevated temperature dantrolene (Dantrium) can control acidosis and body temperature by reducing calcium released into muscles during contractile response dantrolene (Dantrium) can control acidosis and body temperature by reducing calcium released into muscles during contractile response

27. 27Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Drug-Related Emergencies  Haveles (p. 294)  Opioid overdose: respiration can be depressed or respiratory arrest may occur  Most common symptoms are shallow and slow respiration and pinpoint pupils  Treatment: naloxone (Narcan), an opioid antagonist

28. 28Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Reaction to Local Anesthetic Agents  Haveles (p. 294)  Reaction to local anesthetic agents: toxic reaction from excessive level of the anesthetic  Both central nervous system stimulation and depression can occur, exhibited as excitement or convulsions  Treatment: symptomatic  If convulsions are a prominent feature: diazepam  If hypotension is predominant: a pressor agent  If reflex bradycardia: atropine

29. 29Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Epinephrine  Haveles (pp. 294-295 )  Due to excessive blood levels of epinephrine  Symptoms range from nervousness to shaking and can include tachycardia  Treatment: reassurance and time

30. 30Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Emergency Kit for the Dental Office  Haveles (pp. 294-297) (Table 23-1)  Choice of drugs will depend on individual circumstances, experience, and personal preference  Other drugs that may be used if personnel are trained in advanced cardiac life support (ACLS) include level 2 drugs, atropine and lidocaine, and calcium chloride

31. 31Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Drugs  Haveles (pp. 294-297)  Drugs may vary, depending on the preference and experience of the practitioner  Some equipment and drugs are kept in the emergency kit for use by a physician or for those with ACLS training in an emergency cont’d…

32. 32Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Drugs  Haveles (pp. 294-296)  Level 1 (critical) drugs  Epinephrine: cardiac arrest, anaphylaxis, or acute asthmatic attack  Diphenhydramine: some allergic reactions  Oxygen: indicated in most emergencies  Nitroglycerin: acute anginal attack  Glucose: hypoglycemia  Albuterol: bronchodilation cont’d…

33. 33Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Drugs  Haveles (p. 296)  Level 2 drugs  Benzodiazepines: convulsions  Aromatic ammonia spirits: syncope  Morphine: an acute myocardial infarction  Methoxamine: hypotension  Hydrocortisone: allergic reactions, anaphylaxis, and adrenal crisis  Dextrose: unconscious hypoglycemia  Glucagon: severe hypoglycemia  Atropine: preoperative antisialagogue and to increase cardiac rate  β-Blockers: tachycardia or hypertension cont’d…

34. 34Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Drugs  Haveles (pp. 296-297)  Other drugs  Naloxone: opioid antagonist  Flumazenil: reversing most effects of benzodiazepines  Antiarrhythmics: procainamide, lidocaine, verapamil, and bretylium

35. 35Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Equipment  Haveles (p. 297) (Box 23-3)  Level 1 (critical devices)  Syringes/needles  Tourniquets  System to give oxygen  Automated external defibrillator  Level 2 (secondary devices)  Cricothyrotomy device  Endotracheal tube  Laryngoscope  System to give IV infusions