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EMERGENCIES
WHAT IF??
Marvin Leventer DDS
Dentist Anesthesiologist
General Dentist
University of Maryland Dental
BASIC EMERGENCY DRUGS
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Oxygen
Epinephrine
Diphenhydramine
Sugar
Albuterol
Nitroglycerin
Aspirin
Ammonia
EMERGENCY EQUIPMENT
 Positive pressure oxygen
 Ambu bag
 Appropriate size masks
 Oral and nasal airway
 Syringes: 1cc, 3cc, 5cc
 Yankaur suction tips, tubing, connectors
 Magill intubation forceps
 AED
 Blood Pressure cuff/machine
 Pulse Oximeter (for sedation)
OXYGEN THERAPY
 Used for All patients
especially
 cardiopulmonary arrest
 acute chest pain
 suspected hypoxemia.
 Flow rate of 3-15L/min
 E-tank with regulator
 At least 1/2 full
OXYGEN THERAPY
Nasal cannula
2-4 L/min
Nasal Hood
6-10 L/min
Face mask
6-10 L/min
Ambu-bag
10 L/min
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NASAL CANNULA
FACE MASK
Attach tubing to Etank or Nitrous
machine
Attach to E-tank or Nitrous machine
Can use Nasal Mask
AMBU BAG
Attach to E-tank or Nitrous machine
Face masks of different sizes
SYRINGES
1 CC
3 CC
For benadryl or
epinephrine
SUCTION
Battery backup
Manual backup
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SUCTION TIPS
Yankaur- high
volume, wide bore
Tubing connector to
vacuum
MAGILL FORCEPS
Intubation forceps
Reach objects from back of mouth/throat
Advanced airway
Oral airway
Nasal airway
Measure sizes appropriately
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Epinephrine
Catecholamine, Vasopressor, Inotrope
Indications: Anaphylaxis, asthma,
symptomatic bradycardia, croup,
pulseless arrest, hypotensive shock,
beta blocker overdose, ca channel
blocker overdose
Epinephrine
Stimulates B2-adrenergic receptors
Bronchodilation
Vasodilation of arterioles, decreases
diastolic BP, primarily in skeletal muscle.
Epinephrine
Actions:
Stimulates alpha receptors
Increases SVR
Stimulates B1-adrenergic receptors
Inc. heart rate (SA node)
Inc. contractility, automaticity, conduction
velocity
Epinephrine
Adverse effects:
Tremors, anxiety, headache,
intracranial hemmorhage
Dyspnea
Arrhythmias (SVT, VT), palpitations,
hypertension, poss. MI?
Nausea, vomiting
Hyperglycemia
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Epinephrine
Onset IM : 5-10 min
Peak IM: ?
Peak IV/IO: 1 min
Half life 2-4 min
EPINEPHRINE
Pre-filled for use with IV line
Ampules to be admns with 1cc syringe
Epinephrine
Forms:
Injection 1:1000 (1mg/ml)
Glass ampul
Injection 1:10,000 (.1mg/ml)
ANAPHYLAXIS ADULT
 1:1000 epipen .3mg deep IM/thigh
 1:1000 ampul .3-.5mg in 1cc syringe deep IM
 1:10,000 prefilled 10cc syringe: titrate .1mg
increments IV or 3-5mls IM.
Prefilled 10cc syringe
Epipen Adult .3 mg (.3ml 1:1000 soln)
Epipen Child (10-30 kgs), .15 mg (.3mls 1:2000
soln)
Racemic solution 2.25%
ANAPHYLAXIS CHILD
 Best in thigh
 IM: .01mg/kg (1:1000) in thigh Q 15min PRN, max
dose .5mg
 IM auto injector: .3mg >30kgs, or .15mg <30kgs.
 IV/IO: .01mg/kg, 1:10,000, .1mg at a time, q 3-5
min, max dose 1mg
 IV/IO infusion: .1-1 ug/kg/min for resistant
hypotension
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BRONCHOSPASM/ EPI
 Dose is .3 to .5 mg SQ/IM
 1:1000 epi-pen
 Single or double dose
 Adult or pediatric (.15mg)
 1:1000 ampul
 1cc syringe .3-.5 mls
 1/10,000 solution (pre-filled 10cc syringe)
 3-5ml IM??, (intraoral or deltoid), or titrate .1mg
increments IV.
Epinephrine
 Asthma:
 SQ: .01mg/kg (.01ml/kg 1:1000), Q15min, max dose .5mg
 Bradycardia:
 IV/IO: .01mg/kg (.1ml/kg 1:10,000), q 3-5 min, max dose
1mg
 Croup:
 Nebulizer: .25ml racemic soln (2.25%) in 3 mls saline, up to
.5 mls in 3mls saline older kids.
CARDIAC ARREST/ EPI
1mg IV (ACLS protocol) every 3-5
minutes.
Ventricular fibrillation
Ventricular tachycardia no pulse
Pulseless electrical activity
Asystole
Diphenhydramine
Side effects:
Dizziness, drowsiness, anxiety, dystonic
Blurred vision, pupil dilation, dry mouth
Hypotension, tachycardia
DIPHENHYDRAMINE
 H1 blocker
 Antihistamine
 Antinausea
 Drying
 sedating
 Oral liquid
 IV/IM solution
 50mg/ml
ANAPHYLACTOID (MILD)/
BENADRYL
Delayed type allergic reaction
Hives, rash, itching
25-50mg
1/2 - 1 ml: IV/IM
Liquid Benadryl 12.5mg/5ml
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Diphenhydramine
 Anaphylactic shock (after epinephrine)
 1-2 mg/kg IV/IM/IO q4-6 hrs, max 50mg
 Liquid dose: 2x IM dose, max 50mg
 Onset: 30 min. IM
 Peak: 1-4 hrs. IM
 Duration: 4-8 hrs. IM
 Half Life: 2-8 hrs. IM
ANAPHYLAXIS/ BENADRYL
50mg IV/IM
Following
epinephrine
ALBUTEROL
Beta 2 agonist,
minimal beta 1
Bronchodilator
Asthma
Aspiration with
hypoxia
Metered Dose
Inhaler
Albuterol
Onset: 5-15min
Peak: 1-1.5 hrs.
Duration: 4-6 hrs.
Half life: 3-8 hrs.
2-10 puffs
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Albuterol
Adverse effects:
Tremors, anxiety,insomnia, dizziness
Dry nose & throat,
Palpitations, tachycardia
Flushing, sweating
Albuterol
Mild/Mod asthma, anaphylaxis
MDI: 4-8 puffs q 20min.
Nebulizer:
Albuterol
Forms:
Nebulized solution .5%
Prediluted nebulized soln. .083%
MDI, metered dose inhaler 90 ug/puff
Albuterol
Asthma anaphylaxis severe
Nebulizer: .5mg/kg/hr, max 20mg/hr
MDI: 4-8 puffs Q20 min (if intubated)
<20kg 2.5mg/dose q20min
>20kg, 5mg/dose q 20min
SUGAR
Glucose paste or orange juice
25-50gms
What if unconscious
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Dextrose/ Glucose
Carbohydrate
Indication: Hypoglycemia
Needed for cellular respiration and ATP
formation.
IV / Oral
Dose: .5-1 g/kg IV/IO
D5W: 10-20 ml/kg
D50: 1-2 ml/kg
NITROGLYCERIN
Tabs or spray
.4mg/dose
Dilates coronary
arteries
Decreases
myocardial work
3 doses and call 911
Oral: >2yrs old: 10-20g as single dose
NITROGLYCERIN
Dilates systemic veins
Lowers blood pressure
1/2 tab for uncontrolled HTN?
1/2 tab to aid in diagnosis of MI
Nitroglycerin
Dose:
Angina, AMI: .4mg X 3 over 15 min
1-2 sprays under tongue, X3 over 15
min.
Nitroglycerin
Forms:
Injection: .5, 5, 10 mg/ml.
Tabs: .4mg
Spray: .4mg/spray
Nitroglycerin
Onset: 1-2 min
Duration: 3-5 min
Half Life: 1-4 min
Side Effects:
Headache, dizziness, postural
hypotension, flushing
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ASPIRIN
 Antiplatelet
 Acute Myocardial Infarction
(if not contraindicated)
 Regular aspirin or
 2 chewable x (162mg) =
325mg
 First check for bleeding
disorders, ulcers, blood
thinners
FLUMAZENIL/ ROMAZICON
Reversal for BDZ
overdose
Concentration
.1mg/ml
Necessary with oral
sedation?
Route of
administration?
IV, IM, SL
FLUMAZENIL/ROMAZICON
What is nature of emergency
Delayed drowsiness but safe
Unable to maintain own airway but chin lift
works
Unable to maintain airway even with chin
lift, but still breathing some
Apnea/complete obstruction
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FLUMAZENIL/ ROMAZICON
Unable to maintain saturation >92% even
with chin lift, jaw thrust, 100% O2
.2mg initially IV, .1mg/min up to 1mg
.5mg IM right arm +.5mg IM left arm
Prepare for resedation in 20-40 min
FLUMAZENIL/ ROMAZICON
Child dose IV:
.01mg/kg up to
.5mg
Flumazenil
Monitor for re-sedation, repeat doses at
20 min intervals
Max 3mg/hr.
Mechanism: Antagonizes effect of BDZ
at GABA receptor
Does not antagonize non BDZ GABA
agonists, I.e., ethanol, barbiturates.
Naloxone
Classification: Opoid receptor
antagonist
Use: Narcotic reversal
Form: injection .4mg/ml
Dose: 1-5ug/kg IV/IM/IO/SQ titrate to
effect, max .01mg/kg
Peds dosing .1mg/kg??
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Naloxone
Onset: IV/IO 1 min
Duration: 20-60 min
Half Life: 1 hour
Adverse effects:
Seizures, pulmonary edema, hypertension,
tachycardia
NOTE
Drugs are not necessary for the proper
management of most emergencies.
Primary Management of all emergency
situations is BLS.
When in doubt, do not medicate.
Consider repeat dosing
LARYNGOSPASM
Reflex closure of
vocal cords to
protect lungs from
foreign matter.
Must be in DEEP
SEDATION to occur
COMPLETE LARYNGOSPASM
No breathing at all
O2 sat is falling below 90%
Airway maneuvers as previously
Flumazenil??
Call for help
PARTIAL LARYNGOSPASM
Still making some breathing noises but unable
to maintain >92% O2 sat with or without
airway maneuvers
Suction
Chin lift, jaw thrust
100%O2
Positive pressure with BVM (bag valve mask)
do NOT inflate stomach
Flumazenil??
FOREIGN BODY AIRWAY
OBSTRUCTION
Where is the obstruction
BLS protocol, Heimlich
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EMESIS
 Can cause airway obstruction
 If awake with airway reflexes: low risk
 If sedated, YANKAUR suction, turn to right, trendelenburg
position.
 Prevention?
ASPIRATION
 Must have lost airway reflexes
 Deep sedation
 Elderly, infirm
 If aspiration of low pH stomach contents: leads
to pneumonia, deterioration of lung tissue,
hypoxia.
 >25mls of pH <2.5
 Prevention?
ISCHEMIC HEART DISEASE
PTS W/ CHEST PAIN
Monitor and vital signs
Nitroglycerin sub lingual q5min x3
100% Oxygen nasal hood or face mask
Aspirin 160-325mg chewed unless
contraindicated
If no relief, call 911 and transport to ER
ASPIRATION
What is O2 saturation?
Listen to lungs
If wheezing: Albuterol
100% O2
911
UNCONSCIOUS MI CARDIAC
ARREST
Ventricular
fibrillation
Ventricular
tachycardia
Immediate CPR and
AED defibrillator
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CONDITIONS REQUIRING
ADVANCED CARDIAC LIFE
SUPPORT
Need an experienced trained team to
provide ACLS
Need IV
EKG monitor required for proper
diagnosis
Necessary for oral sedation?
911
BRADYCARDIA
Below 60 bpm
Symptomatic
Altered consciousness, low blood pressure,
chest pain
100% O2 via nasal or face mask
Associated with fainting
ammonia
BRADYCARDIA
Increased parasympathetic tone due to
intense pain
Decrease painful stimulus
Healthy heart
No treatment
MI
911
Atropine
TACHYCARDIA
Over 100 bpm
What is blood pressure?
Predisposition to tachycardia?
Etiology: endogenous/exogenous epinephrine
Wait (epi has short 1/2 life)
Inform patient transient feeling
Pain, anxiety
More local, or Nitrous oxide
TACHYCARDIA
Hypovolemia
NPO and blood loss
Trendelenberg position, fluids
Drug interactions
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SUPRA VENTRICULAR
TACHYCARDIA
Sudden onset above 150
Predisposition
Symptomatic
Dizziness, lightheaded, hypotension
TX: carotid massage, valsalva, cold
water on face
Consider 911
HYPOTENSION
TREATMENT:
Oxygen
Supine /trendelenberg
Fluids
HYPOTENSION
 >20% Below baseline OR <80/40
 Symptomatic?
 Dehydration, NPO status, vasodilation
 Sedation and/or local anesthesia overdose
 Drug interactions
 Capillary refill > 3sec.
 Vagal
 Myocardial ischemia
HYPERTENSION
Systolic > 160 or Diastolic>95
Increases bleeding, risk of CVA
Leads to cardiac arrhythmias
Increases myocardial oxygen
consumption
HYPERTENSION
TREATMENT
Fluid overload: empty bladder
Pain: Increase analgesia
Myocardial ischemia may require
Nitrates
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SEIZURE/STATUS
EPILEPTICUS
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Repeated seizures over a short time without a recovery period.
Drug toxicity, disease, injuries
Pt may become hypoxic with acidosis
Diazepam 5MG IV, 10MG IM
Midazolam 2-5MG IV, 5MG IM
911
OVERDOSE/ EXESSIVE
SEDATION
Benzodiazepines
Local anesthetics
Poly-pharmacy/ synergism
Antihistamines
Narcotics
Nitrous oxide
Self medication/ all other prescription
meds
OVERDOSE/ EXCESSIVE
SEDATION
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Airway: head tilt, chin lift, jaw thrust
Breathing: Oxygen, assist with face mask
Circulation: Vital signs: Spo2, BP, Pulse
Position: supine
Reduce level of sedation
SYNCOPE
Signs and Symptoms: Fainting,
convulsions, bradycardia, sweating
Inadequate O2 and Glucose to brain
TX: supine, O2, ABC, sugar, ammonia
OVERDOSE/ EXCESSIVE
SEDATION
Hypoventilation
Rapid shallow breathing
Disorientation
Lack of cooperation
Hysterical/ disinhibition
LOCAL ANESTHETICS
Additive with other CNS depressants
Max dose may be less for adverse
effects
Use proper mg/kg dose
Don’t administer all local at once
 Nitrous oxide- off
 Reverse BDZ?
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LOCAL ANESTHETIC MAX
DOSES
drug
mg/kg
max dose mg
Articaine
7.0
600
Lidocaine
4.4 (> w/ epi)
300
Mepivicaine
4.4
300
Prilocaine
6.0
600
Bupivicaine
2.0
90
Etidocaine
8.0
400
HYPERGLYCEMIA
HYPOGLYCEMIA
 S/S:Hunger, weakness, trembling, tachycardia, pallor, sweating;
incoherent, uncooperative, belligerent; unconsciousness
 Glucose <60mg/dl
 If conscious, give glucose or sugar by mouth
Type 1: Diabetic
Coma
Hyperglycemia,
ketoacidosis,
hyperosmolar coma.
>450
911
 Drink or viscous
 If unconscious give 25g glucose or 50ml D50W IV push.
 Recheck glucose
THANK YOU
AIRWAY AIRWAY AIRWAY
YOU CAN ALWAYS GIVE MORE BUT
YOU CANT TAKE IT BACK
WHAT IF
LESS IS MORE
HEAD TILT, JAW THRUST, TONGUE
PULL
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QUESTIONS
[email protected]
410 706 2470
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