Download Chapter 23 outline

Chapter 23:
Emergency Drugs
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Chapter 23 Outline

Emergency Drugs

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
General measures
Categories of emergencies
Emergency kit for the dental office
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
2
Emergency Drugs
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An increasing number of older patients who
are taking multiple drugs seek dental
treatment each year


Haveles (p. 290)
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
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General Measures
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


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
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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
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Categories of Emergencies
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Haveles (pp. 291-294)
Lost or altered consciousness
Respiratory emergencies
Cardiovascular system emergencies
Other emergency situations
Drug-related emergencies
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6
Lost or Altered Consciousness
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Haveles (pp. 291-292)
Syncope
Hypoglycemia
Diabetic coma
Convulsions or seizures
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7
Syncope
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The most common emergency in the dental
office is simple syncope (faint)
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

Haveles (pp. 291-292)
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
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8
Hypoglycemia
(Insulin Reaction)
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Most common cause is excessive dose of insulin
in a diabetic
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The person may not have eaten before the appointment
The patient with hypoglycemia has a rapid pulse
and decreased respiration and is loquacious


Haveles (p. 292)
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
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9
Diabetic Coma
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Caused by elevated blood sugar
Symptoms include frequent urination, loss of
appetite, nausea, vomiting, and thirst
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
Haveles (p. 292)
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
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10
Convulsions or Seizures
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Convulsions are most commonly associated
with epilepsy but can also result from a toxic
reaction to a drug
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
Haveles (p. 292)
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
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11
Respiratory Emergencies
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
Haveles (p. 292)
Hyperventilation
Asthma
Anaphylactic shock
Acute airway obstruction
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12
Hyperventilation
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Rapid respiratory rate is often due to
emotional upset
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Haveles (p. 292)
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
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13
Asthma
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Patients who have acute asthma attacks have
a history of previous attacks and will have an
inhaler with them
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
Haveles (p. 292)
The most common sign is wheezing with prolonged
expiration
Treatment
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Patients can use their own ß2-agonist
If no response is noted, hospitalization for
aminophylline (parenteral or oral) and parenteral
corticosteroids and epinephrine should be
considered
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14
Anaphylactic Shock
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The reaction usually begins within 5 to 30 minutes
after ingestion or administration of the antigen
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

Haveles (p. 292)
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
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
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
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15
Acute Airway Obstruction
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Usually the result of a foreign body in the
pharynx or larynx; laryngospasm may be drug
induced
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
Haveles (p. 292)
Gasping for breath, coughing, gagging, acute
anxiety, and cyanosis are signs and symptoms
Treatment: Trendelenburg position on the right
side and encouraging coughing
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
Clearing the pharynx and pulling the tongue before
performing the Heimlich maneuver should be next
• Heimlich maneuver if necessary
A cricothyrotomy or tracheotomy are indicated if the
object cannot be dislodged by other methods
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16
Cardiovascular System
Emergencies
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
Haveles (pp. 292-293)
Angina pectoris
Acute myocardial infarction
Cardiac arrest
Other cardiovascular emergencies
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17
Angina Pectoris
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Often begins as substernal chest pain that
radiates across the chest to the left arm or the
mandible


Haveles (p. 293)
Pulse becomes rapid, and tachypnea (rapid
breathing) can occur
Treatment: the patient can premedicate with
sublingual nitroglycerin
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
An acute attack is treated with sublingual
nitroglycerin
Opioids or diazepam are used in hospitalized
patients
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18
Acute Myocardial Infarction
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
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…
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19
Acute Myocardial Infarction
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Treatment: includes administration of oxygen,
an aspirin tablet, and an opioid analgesic
agent and transfer to a hospital
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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
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20
Cardiac Arrest
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Generally, sudden circulatory and respiratory
collapse occur
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
Haveles (p. 293)
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
• Defibrillation is used to treat systole
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21
Other Cardiovascular
Emergencies
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
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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
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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…
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23
Other Emergency Situations
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Acute adrenocortical insufficiency: usually
occurs in patients who are taking enough
steroids to suppress the adrenal gland
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Cardiovascular collapse and irreversible shock
may result in a fatality
Treatment: parenteral hydrocortisone and oxygen
cont’d…
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24
Other Emergency Situations
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Thyroid storm: hyperthyroidism is out of control
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
Congestive heart failure and cardiovascular collapse
may follow
Treatment: includes tepid baths and aspirin, βblockers for cardiovascular symptoms, and possibly
hydrocortisone
cont’d…
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25
Other Emergency Situations

Malignant hyperthermia: genetically
determined reaction triggered by inhalation
general anesthetics or neuromuscular
blocking agents such as succinylcholine
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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
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26
Drug-Related Emergencies
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
Haveles (p. 294)
Opioid overdose: respiration can be
depressed or respiratory arrest may occur
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
Most common symptoms are shallow and slow
respiration and pinpoint pupils
Treatment: naloxone (Narcan), an opioid
antagonist
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27
Reaction to Local Anesthetic
Agents
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Reaction to local anesthetic agents: toxic
reaction from excessive level of the anesthetic

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Haveles (p. 294)
Both central nervous system stimulation and
depression can occur, exhibited as excitement or
convulsions
Treatment: symptomatic
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If convulsions are a prominent feature: diazepam
If hypotension is predominant: a pressor agent
If reflex bradycardia: atropine
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28
Epinephrine
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Due to excessive blood levels of epinephrine
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
Haveles (pp. 294-295 )
Symptoms range from nervousness to shaking
and can include tachycardia
Treatment: reassurance and time
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29
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
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30
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…
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31
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…
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32
Drugs
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
Haveles (p. 296)
Level 2 drugs
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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…
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33
Drugs


Haveles (pp. 296-297)
Other drugs
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Naloxone: opioid antagonist
Flumazenil: reversing most effects of
benzodiazepines
Antiarrhythmics: procainamide, lidocaine, verapamil,
and bretylium
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34
Equipment
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Level 1 (critical devices)
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Haveles (p. 297) (Box 23-3)
Syringes/needles
Tourniquets
System to give oxygen
Automated external defibrillator
Level 2 (secondary devices)
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Cricothyrotomy device
Endotracheal tube
Laryngoscope
System to give IV infusions
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35