Chapter 23 Outline. Chapter 23: Emergency Drugs. General Measures. Categories of Emergencies. Preparation for Treatment 12/12/2011.

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1 Chapter 23 Outline Chapter 23: Emergency General measures Categories of emergencies Emergency kit for the dental office Emergency 2 Emergency General Measures Haveles (p. 290) Haveles (pp ) (Boxes 23-1, 23-2) 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 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 3 4 Preparation for Treatment Categories of Emergencies Haveles (p. 291) Haveles (pp ) 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 are not necessary for proper management of most emergencies Lost or altered consciousness Respiratory emergencies Cardiovascular system emergencies Other emergency situations Drug-related emergencies 5 6 1

2 Lost or Altered Consciousness Haveles (pp ) Syncope Hypoglycemia Diabetic coma Convulsions or seizures Haveles (pp ) Syncope 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 7 8 Hypoglycemia (Insulin Reaction) 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 9 Diabetic Coma 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 10 Convulsions or Seizures Respiratory Emergencies 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 Hyperventilation Asthma Anaphylactic shock Acute airway obstruction

3 Hyperventilation Asthma 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 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 Anaphylactic Shock 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 Acute Airway Obstruction 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 A cricothyrotomy or tracheotomy are indicated if the object cannot be dislodged by other methods Cardiovascular System Emergencies Angina Pectoris Haveles (pp ) Angina pectoris Acute myocardial infarction Cardiac arrest Other cardiovascular emergencies 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

4 Acute Myocardial Infarction Acute Myocardial Infarction 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 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 Cardiac Arrest Other Cardiovascular Emergencies 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 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 Defibrillation is used to treat systole 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) 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

5 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 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 Drug-Related Emergencies Reaction to Local Anesthetic Agents Haveles (p. 294) 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 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 Epinephrine Emergency Kit for the Dental Office Haveles (pp ) Due to excessive blood levels of epinephrine Symptoms range from nervousness to shaking and can include tachycardia Treatment: reassurance and time Haveles (pp ) (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

6 Haveles (pp ) 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 Haveles (pp ) 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 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 Haveles (pp ) Other drugs Naloxone: opioid antagonist Flumazenil: reversing most effects of benzodiazepines Antiarrhythmics: procainamide, lidocaine, verapamil, and bretylium 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 35 6

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