APPENDIX
A
Guide to Management of Common Medical
Emergencies in the Dental Office*
GENERAL CONSIDERATIONS
The best management of a dental office medical emer-
gency is prevention. Dental practitioners must be pre-
pared to treat the seemingly well but chronically ill
patient whose condition is managed by a variety of
drugs. Prevention begins with the dental professional’s
awareness of the patient’s medical condition at the outset
of the dental visit. Knowledge of the type of condition,
its severity, and level of control provides a strong indica-
tor of the patient’s risk for experiencing a medical emer-
gency. Proper assessment that includes review of the
medical history, physical evaluation, and medical consul-
tation gives the practitioner the opportunity to take mea-
sures that could prevent such emergencies. If an
emergency does occur, an informed dentist will have a
better idea of the type of medical problem the patient is
experiencing. The dentist must also understand the
pathophysiologic factors regulating disease processes
and the pharmacodynamics of drug action and
interaction.
Patients frequently experience physical reactions
during treatment. Accordingly, considerable responsibil-
ity rests on the dentist first to recognize the signs and
symptoms of the problem and then to respond to any
emergency quickly, efficiently, and competently with
adequate resuscitative procedures. Obviously, important
precepts of good medical emergency management include
*Much of the material contained herein is modified from Malamed
SF: Medical emergencies in the dental office, ed 6, St Louis, 2007,
Mosby; Malamed SF: Emergency medicine in the dental office
(DVD), Edmonds, WA, HealthFirst Corporation, 2008, Joseph
Massad Productions; 2005 American Heart Association guidelines
for cardiopulmonary resuscitation and emergency cardiovascular
care, Circulation 112(Suppl 24):IV1-203, 2005; and Part 1: execu-
tive summary: 2010 American Heart Association guidelines for
cardiopulmonary resuscitation and emergency cardiovascular care,
Circulation 122(Suppl 3):S640-S656, 2010.
576
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
(1) being well prepared, (2) having confidence in selected
interventions, and (3) remaining calm in difficult circum-
stances. The health professional is responsible for
knowing and using techniques that are recognized to be
up to date, safe, and efficient. An unfamiliar or unreli-
able maneuver should never be attempted. The dentist
must be trained in providing basic cardiac life support
(BCLS) and in managing emergencies in the dental office.
Advanced cardiac life support (ACLS) training to include
intravenous (IV) drug administration may be useful in
dental practices that more often encounter medically
complex cases. The dental practitioner also should be
aware of the changes in basic cardiopulmonary resuscita-
tion (CPR) guidelines introduced in 2010.
Although dentists should be prepared to provide
resuscitation procedures in the dental setting, even more
consideration should be directed at preventing such situ-
ations. Prevention begins with obtaining an adequate
medical history of the patient, making an appropriate
physical evaluation, and ensuring that both patient and
environment are properly prepared before treatment
begins. Sometimes a potentially catastrophic event may
be prevented through recognition of physical conditions
or limitations before treatment begins.
Management of emergencies must begin long before
the point of occurrence. Preparation should include a
designated plan of action and an adequate armamen-
tarium to meet emergencies. To minimize largely unhelp-
ful emotional responses, the actions of the dental team
must be based on a thorough background in relevant
subject matter, continued study, and carefully prepared
and rehearsed emergency procedures in which each
person has specific duties and responsibilities. This
approach will require the availability of appropriate
resuscitative equipment and drugs to permit the team to
work together calmly and precisely. This teamwork must
be based on knowledge, practice, sound judgment, and
confidence. To this end, all members of the dental office
(dentist, hygienist, assistant, receptionist) should be
 APPENDIX A Guide to Management of Common Medical Emergencies in the Dental Office
trained in and be able to perform BCLS procedures prop-
erly when needed. Also, every dental office should have
a written plan that spells out specific duties for each
member of the office staff, covering areas such as who
will activate the emergency medical services (EMS)
system (i.e., call 911), start CPR, place an intravenous
line, and administer drugs. A staff member should be
designated to assist in necessary tasks during the emer-
gency situation, such as getting and preparing drugs and
recording every event and the time of each action.
Dental offices should have up-to-date emergency
drugs, oxygen, a pulse oximeter, and an automated
external defibrillator (AED). Electrocardiography is an
additional important adjunct modality for monitoring
the patient’s vital signs.
GENERAL PRINCIPLES OF
EMERGENCY CARE
Most life-threatening office emergencies are caused by
the patient’s inability to withstand physical or emotional
stress or the patient’s reaction to drugs. Emergencies
also can originate with a complication of a preexisting
systemic disease. Cardiopulmonary systems can be
involved, thereby necessitating some emergency support-
ive therapy.
Algorithms (i.e., standardized step-by-step proce-
dures) are recommended to be performed during emer-
gencies after the signs and symptoms of the condition
are recognized. Most often, the algorithm for medical
emergencies follows the sequence P-A-B-C-D, where P is
for positioning, A is for airway, B is for breathing, C is
for circulation, and D is for definitive care (e.g., diagno-
sis, drugs and defibrillator and other equipment). Of
note, however, in 2010, the American Heart Association
recommended use of a slightly different algorithm for
cardiac arrest, that is, P-C-A-B-D. Our own contribution
has been to add an E, for ensure proper patient response,
and an F, for facilitate next steps in medical/dental care,
for a more specific approach to this aspect of dental
management.
This appendix presents recommended management
protocols, following the algorithms just described, for
various medical emergencies likely to be encountered in
the dental office.
Key Points
The following elements are essential to the successful
treatment of medical emergencies:
1. Quick recognition of signs and symptoms and early
diagnosis of the underlying problem
2. Fast response time (4 to 6 minutes without oxygen
leads to irreversible brain damage)
3. Systematic monitoring of the patient’s well-being
using an algorithm such as P-A-B-C-D-E-F or, for
cardiac arrest, P-C-A-B-D-E-F
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
577
TYPES OF EMERGENCIES AND
THEIR TREATMENT
Unconsciousness
Syncope and Psychogenic Shock
Signs and Symptoms. Pallor, sweating, nausea, anxiety,
pupillary dilation, yawning, decreased blood pressure,
bradycardia (slow pulse), convulsive movements,
unconsciousness.
Cause. Cerebral hypoxia (reduced blood flow to brain),
sitting or standing stiff, anxiety.
Treatment
P: Positioning: Place patient in supine position; lower
head slightly and elevate legs (for pregnant women,
roll on left side)—assess consciousness.
A: Airway: Ensure open airway.
B: Breathing: Check breathing—should be adequate.
C: Circulation: Check carotid pulse—should be
adequate.
D: Dispense/administer:
• Oxygen at flow rate of 5-6 L/minute
• Aromatic ammonia (e.g., Vaporole)—“smelling
salts” (optional)
• Cold compresses applied to forehead
E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
recorded.
F: Facilitate next steps in medical/dental care and reas-
sure patient.
Low Blood Pressure/Slow Pulse
For low blood pressure or pulse (systolic is less than
previous diastolic), the following protocol is indicated:
Treatment: Low Blood Pressure
P: Positioning: Place patient in supine position; lower
head and raise legs.
A: Airway: Ensure open airway.
B: Breathing: Check breathing—should be adequate.
C: Circulation: Check pulse and ensure adequate circu-
lation, which may be weak.
D: Dispense/administer:
• Intravenous drip of 5% dextrose in lactated Ring-
er’s solution
• In unresponsive patient: a vasopressor drug such
as phenylephrine 10 mg/mL (1 ampule), or epi-
nephrine 0.3-0.5 mg given subcutaneously (SC) or
intramuscularly (IM), or intravenously (IV) with
ACLS training
E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
recorded.
578 APPENDIX A Guide to Management of Common Medical Emergencies in the Dental Office
F: Facilitate next steps in medical/dental care; reassure
patient.
Treatment: Slow Pulse. (Less than 60 beats/minute)
P: Positioning: Place patient in supine position; lower
head and raise arms and legs.
A: Airway: Ensure and maintain patent airway.
B: Breathing: Check breathing—should be adequate.
C: Circulation: Check—should be adequate in this
situation.
D: Dispense/administer:
• Oxygen at flow rate of 5-6 L/minute (if patient is
hypoxemic)
• Atropine 0.5 mg IV (to increase heart rate).
Repeat dose up to 3 mg; then consider use of
additional vasopressors (dopamine or
epinephrine).
E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
recorded.
F: Facilitate next steps in medical/dental care; reassure
patient.
Cardiac Arrest
Signs and Symptoms. No pulse or blood pressure,
sudden cessation of respiration (apnea), cyanosis, dilated
pupils.
Cause. Abrupt interruption of blood supply and oxygen
to the coronary arteries and heart muscle due to ischemia
(clot).
Treatment
For unresponsive cardiac arrest victim (adult):
P: Positioning: Place patient in supine position and
establish unresponsiveness (tap and shout). Call for
help, activate EMS (call 911), and get defibrillator.
C: Circulation and compressions: Health care provider
should assess pulse (carotid) for no more than 10
seconds. If no pulse is detected, and victim is not
breathing and is unresponsive, promptly initiate chest
compressions.
One operator: 30 compressions per every 2 ventila-
tions for a rate of 100 compressions/minute
(depth of 2 inches), until advanced airway is
placed
A: Airway: Establish airway by head tilt–chin lift, or by
jaw thrust if neck injury is suspected. Suction mouth/
pharynx if vomitus is blocking the airway.
B: Breathing: Ventilate lungs with mask Ambubag–
delivered positive-pressure oxygen (or mouth-to-
mask resuscitation); breathe every 6 to 8 seconds (8
to 10 breaths/minute).
If rescuer is ACLS-trained, perform endotracheal
intubation and provide positive-pressure oxygen.
NOTE: As of 2010: Ventilation technique uses slower
breaths with inspiration time of 1.5 to 2 seconds.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Two operators: 15 compressions per every 2 ventila-
tions (without pause for compressions), for a rate
of 100 compressions/minute. Continue resuscita-
tion until spontaneous pulse returns.
NOTE: The importance of technique for chest com-
pressions cannot be overemphasized; they must
be hard, fast, and maximally effective, with
minimal interruptions.
D: Defibrillator: Attach and use automated external
defibrillator (AED) as soon as available (ideally
within 3 to 5 minutes of collapse).
• Check rhythm and shock if indicated (repeated every
2 minutes).
• Resume CPR beginning with compressions immedi-
ately after each shock.
NOTE: With intravenous drugs: Start normal saline
solution (with ACLS-trained rescuer).
• Epinephrine 1.0 mg 1 : 1000; repeat every 3 to 5
minutes as needed.
• Vasopressin 40 units can replace first or second
dose of epinephrine.
• Amiodarone—first dose: 300 mg bolus; second
dose: 150 mg
Other drugs used for treatment of cardiac arrest
(with ACLS-trained rescuer)
• Lidocaine (antiarrhythmic agent)
• Calcium chloride (increases myocardial
contractility)
• Morphine sulfate (for pain relief)
• Thrombolytic agents
E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
recorded.
F: Facilitate/ensure next steps in medical care (transport
to hospital); reassure patient.
Hypoglycemia (Insulin Shock)
Signs and Symptoms. Hunger, weakness, trembling,
tachycardia, pallor, sweating, paresthesias, uncoo-
perative, mental confusion (headache), incoherent,
uncooperative, belligerent, unconscious, tonic-clonic
movements, hypotension, hypothermia, rapid thready
pulse, coma.
Cause. Lack of blood glucose to the brain; taking insulin
and not eating.
Treatment
P: Position:
In conscious patient: place in upright sitting
position.
In unconscious patient: place in supine position.
A: Airway: Ensure open airway.
B: Breathing: Ensure that patient is breathing.
C: Circulation: Check pulse and confirm adequate
circulation; pulse could be weak.
 APPENDIX A Guide to Management of Common Medical Emergencies in the Dental Office
D: Dispense:
In conscious patient: Give a drink with high sugar
content such as orange juice, or a glucose paste
(cake icing) applied to the buccal mucosa.
In unconscious patient: Activate EMS by calling 911;
then administer:
• Oxygen at flow rate of 5-6 L/minute
• 5% dextrose in Ringer’s lactate (D5LR) IV: Run
the intravenous drip as fast as possible.
• Alternatively, give glucagon 1 mg SC or IM (or
IV), or epinephrine (for transient relief).
E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
recorded.
F: Facilitate/ensure next steps in medical care (trans-
port to hospital, if some improvement is not fairly
rapid). When patient regains consciousness, provide
reassurance and information about what happened,
because person is likely to have little memory of the
incident.
Acute Adrenal Insufficiency
Signs and Symptoms. Altered consciousness, wet,
clammy, confusion, weakness, fatigue, headache, pain in
abdomen or legs, nausea and vomiting, hypotension and
syncope, coma.
Cause. Adrenal suppression (low adrenocorticotropic
hormone) by exogenous steroids. The patient may be
medicated with steroids for many medical problems, or
the cause may be primary or secondary malfunction of
the adrenal cortex.
Treatment
P: Positioning: Place patient in semireclined position,
and raise feet slightly; call for help.
A: Airway: Ensure open airway.
B: Breathing: Should be adequate (i.e., predicted to be
adequate in this situation).
C: Circulation: Check pulse and confirm adequate
circulation.
D: Dispense:
In conscious patient:
• Provide oxygen at flow rate of 5-6 L/minute.
• Give hydrocortisone 100 mg, or dexamethasone
4 mg (IV).
In unconscious patient:
• Place in supine position.
• Activate EMS by calling 911.
• Administer oxygen at flow rate of 5-6 L/minute.
• Confirm diagnosis from review of medical history,
signs, and symptoms.
• Then start intravenous administration of 5%
dextrose in Ringer’s lactate (D5LR) and run the
intravenous drip as fast as possible.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
579
• Also provide hydrocortisone 100 mg, or dexa-
methasone 4 mg (IV).
• Give a vasopressor drug (e.g., epinephrine
1 : 1000, 0.5 mL).
E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
recorded.
F: Facilitate/ensure next steps in medical care (transport
to hospital); reassure patient.
Cerebrovascular Accident (Stroke)
Signs and Symptoms. Dizziness (patient may fall),
vertigo and vision changes, nausea and vomiting, tran-
sient paresthesia, unilateral weakness or paralysis, head-
ache, nausea, vomiting, convulsions, coma.
NOTE: Blood pressure and pulse generally are normal.
Raised blood pressure and body temperature and lowered
pulse and respiration indicate increased intracranial
pressure.
Cause. Interruption of blood supply and oxygen to the
brain occurring as a result of ischemia or hemorrhage.
Treatment
P: Positioning: Place patient in reclined, semisitting
position with the head elevated. Call for help and
activate EMS (call 911).
A: Airway: Ensure that airway is open and maintained
open.
B: Breathing: Ensure that breathing is adequate.
C: Circulation: Check pulse and confirm adequate
circulation.
D: Dispense/administer:
• Use pulse oximeter to determine oxygenation.
• Administer oxygen at flow rate of 5-6 L/minute if
needed.
E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
recorded.
• Keep patient quiet and still.
F: Facilitate/ensure next steps in medical care (transport
to hospital); reassure patients. (Seizure)
Convulsions (Seizure)
Signs and Symptoms. Aura (flash of light or sound, a
unusual smell), mental confusion, excessive salivation,
rolling back of eyes, loss of consciousness, tonic phase
(contractions—clenching of teeth) followed by clonic
phase (tremors, convulsive movements of extremities).
Causes. There are several potential causes of convul-
sions and seizures including syncope, drug reactions
(local anesthetic overdose), hypoglycemia, hyperventila-
tion, cerebrovascular accident, and convulsive seizure
disorder.
580 APPENDIX A Guide to Management of Common Medical Emergencies in the Dental Office
Treatment
P: Positioning: Place patient in supine position; clear
instruments and protect patient from injury (i.e.,
lightly restrain arms and legs from gross movements).
Call for help.
After convulsion ceases:
A: Airway: Ensure that airway is open. Suction mouth
along buccal surfaces of teeth if excessive secretions
are making breathing difficult.
B: Breathing: Ensure that breathing is adequate.
C: Circulation: Check pulse and confirm adequate
circulation.
D: Dispense/administer:
• Oxygen at flow of 5-6 L/minute
For status epilepticus (a seizure lasting more than 5
minutes):
• Activate EMS (call 911).
• For adult, give diazepam (Valium) 5-20 mg IV or
intranasal lorazepam 2-4 mg or intranasal mid-
azolam 5 mg, one-half volume per nostril (may
not be readily available—ask pharmacist)
If convulsions persist for 5 minutes after treating,
repeat with one-half dose.
E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
recorded.
• Support respiration (seizure may precipitate respi-
ratory arrest).
F: Facilitate/ensure next steps in medical care (transport
to hospital, if needed), and reassure patient.
Local Anesthesia Drug Toxicity
Signs and Symptoms. Confusion, talkative, restless,
apprehensive state, excited manner, headache, lighthead-
ness, convulsions, increase in blood pressure and pulse
rate. NOTE: Stimulation is followed by depression of the
central nervous system.
Late features can include drowsiness, disorientation,
convulsions followed by depression, drop in blood pres-
sure, weak or rapid pulse or bradycardia, apnea, uncon-
sciousness, death. NOTE: Lidocaine toxicity is documented
to occasionally exhibit depression only, without the
usual prodromal of the excitatory phase.
Causes. Too-large a dose of local anesthetic per body
weight, rapid absorption of drug or inadvertent intrave-
nous injection, slow detoxification or elimination
of drug
Treatment
P: Positioning: Place patient in comfortable position;
convulsing or unconscious patient should be in supine
position.
If patient is convulsing:
• Clear instruments and protect patient from injury.
• Call for help.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
After convulsion ceases:
A: Airway: ensure airway is open.
B: Breathing: Ensure that breathing is adequate.
C: Circulation: Check pulse and confirm adequate
circulation.
D: Dispense/administer:
• Oxygen at flow rate of 5-6 L/minute
• If local anesthesia overdose results in seizure, a
benzodiazepine (diazepam, lorazepam, or mid-
azolam) as described in the seizure algorithm may
be administered.
E: Ensure vital signs, drug administration are properly
monitored and recorded; maintain blood pressure
F: Facilitate/ensure next steps in medical care (provide
supportive therapy):
• Treat bradycardia (0.4 mg atropine IV, with
ACLS-trained rescuer).
• Transport to hospital.
• Reassure patient.
NOTE: If patient becomes unconscious, maintain
airway, administer CPR, and activate EMS (call 911).
Respiratory Difficulty
Hyperventilation
Signs and Symptoms. Rapid and shallow breathing,
confusion, dizziness, paresthesias, cold hands, carpal-
pedal spasms; can progress to seizure.
Cause. Anxiety-induced excessive loss of CO2 from
deep and rapid breathing; also respiratory alkalosis.
Treatment
P: Positioning: Place patient in an upright position.
Explain the problem and reassure the patient.
A: Airway: Maintain open airway by talking with
patient.
B: Breathing: Instruct the patient to be calm and breathe
slowly into a paper bag or into the cupped hands over
the nose and mouth (i.e., rebreathe carbon dioxide).
C: Circulation: No treatment required.
D: Dispense (i.e., provide) reassurance.
E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
recorded.
F: Facilitate/ensure next steps in medical/dental care:
Consider rescheduling appointment with antianxiety
measures/presedation.
Aspiration or Swallowing a
Foreign Object
Signs and Symptoms. Coughing or gagging associated
with a foreign object; inability to speak; possible cyano-
sis from airway obstruction; violent respiratory effort;
suprasternal retraction; rapid pulse.
Cause. Foreign body in larynx or pharynx.
 APPENDIX A Guide to Management of Common Medical Emergencies in the Dental Office
Treatment. With conscious victim:
P: Positioning: Keep the patient standing, or sitting
leaning forward. Ask: “Can you speak?” or “Are you
choking?” Patient may indicate need for help by dem-
onstrating the “universal choking sign”—clutching
hands wrapping around the neck or nodding.
A: Airway: Open airway by placing arms around patient
and applying Heimlich maneuver.
B: Breathing: Repeat maneuver until object is cleared
and breathing is reestablished, or until patient
becomes unconscious.
With unconscious or unresponsive victim:
P: Positioning: Place victim in supine position. Activate
EMS (call 911); then initiate CPR in C-A-B sequence.
C: Circulation: Check pulse; begin CPR if no pulse is
felt. Provide chest compressions in ratio of 30 per 2
ventilations. (NOTE: Chest compressions provide
pressure to dislodge foreign object.)
A: Airway: Open airway by administering quick upward
abdomen thrusts (up to 5).
B: Breathing: Check airway for breathing and attempt
to ventilate. Each time the airway is opened, the
rescuer should look for an object in the victim’s
mouth and remove it if found.
• Do not delay the 30 chest compressions for
longer than 10 sec while looking for object.
• Continue chest compressions and ventilation
attempts until EMS unit arrives.
NOTE: If cricothyrotomy is necessary (i.e., rescuer is
unable to ventilate for 4 to 5 minutes), refer to “Crico-
thyroid Membrane Puncture” procedure that follows.
Once breathing has been reestablished:
D: Dispense/administer:
• Oxygen at flow rate of 5-6 L/minute
E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
recorded.
F: Facilitate/ensure next steps in medical care (maintain
supine position and transport to hospital); reassure
patient.
• Inform patient and request radiographs to locate
foreign object or trauma to chest cavity is sus-
pected, if needed (posterior-anterior chest view,
lateral chest view, flat plane abdominal).
NOTE: If foreign object is in gastrointestinal tract,
track with x-ray examination. Foreign object in
trachea or lung requires removal using bronchos-
copy or thoracotomy. If foreign object has occluded
the airway, the Heimlich maneuver may be of
benefit before initiation of a cricothyrotomy.
Cricothyroid Membrane Puncture
The approach to a patient with acute airway obstruction
should consist of the following steps:
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
581
• Recognition of obstruction
• Use of nonsurgical maneuvers to relieve obstruction
(i.e., back blows, Heimlich maneuver).
• Administration of mouth-to-mouth breathing to
bypass obstruction or to diagnose obstruction
• Activation of EMS with 911 call
• Establishment of an emergency surgical airway (cri-
cothyrotomy) if Heimlich maneuver is unsuccessful
Cricothyrotomy
1. Place patient in head-down position with neck
hyperextended.
2. Ensure that chin and sternal notch are held in median
plane.
3. Cut skin or puncture with very-large-bore needle over
cricothyroid cartilage.
4. Insert cricothyrotomy canula (Portex Mini-Trach II)
or very-large-bore needle through skin over cricothy-
roid cartilage. Insert pointed end caudally to avoid
damage to the vocal cords.
If cannula is not available:
a. Insert small scissors or hemostats through crico-
thyroid membrane and into the tracheal space, or
use large (8-gauge) needle.
b. Expand instrument and dilate transversely.
c. Insert tube into trachea between beaks of dilating
instrument.
d. Remove scissors or hemostats.
e. Tape tube into place.
5. Use positive pressure or enriched oxygen flow if
patient is breathing independently.
6. Arrange for rapid transfer of patient to the
hospital.
Bronchial Asthma
Signs and Symptoms. Sense of suffocation, pressure in
chest, nonproductive cough, expiratory wheezes, pro-
longed expiratory phase, increased respiratory effort,
chest distension, thick, stringy mucous sputum, cyanosis
(in severe cases).
Causes. Can be induced by allergy, infection, exercise,
anxiety leading to bronchial inflammation, bronchocon-
striction, vascular permeability, occlusion of bronchioles
by thick mucous plugs, and bronchospasm.
Treatment
P: Positioning: Place patient in an upright comfortable
position.
A: Airway: Ensure that airway is open by removing
dental materials and listening to breath sounds.
B: Breathing: Encourage relaxed slow breathing.
C: Circulation and communication: generally circula-
tion is adequate if patient is conscious. Com-
municate with patient and/or staff to get a rapid
582 APPENDIX A Guide to Management of Common Medical Emergencies in the Dental Office
bronchodilator for use. Calm the patient and the
staff.
D: Dispense/administer:
• Two deep inhalations of fast-acting, β2-
agonist bronchodilator (e.g., albuterol, Isuprel
mistometer)
• Repeat with two additional deep inhalations of
bronchodilator if attack persists 5 minutes.
• Oxygen at flow rate of 5-6 L/minute, if needed
E: Ensure that vital signs are properly monitored and
recorded.
• If attack persists, activate EMS (call 911).
F: Facilitate next steps in medical care (transport to
hospital); reassure patient.
• Maintain oxygen at flow rate of 5-6 L/minute.
• With unresponsive Patient: administer epineph-
rine 1 : 1000 (0.3-0.5 mL SC); repeat every 20
minutes as needed.
If transport to hospital is pending:
• Give theophylline ethylenediamine (aminophyl-
line) 250-500 mg IV slowly over a 10-minute
period.
• Administer hydrocortisone sodium succinate
(Solu-Cortef), 100 mg IV.
NOTE: Because aminophylline may cause hypoten-
sion, it should be given with extreme caution to patients
with asthma who are hypotensive.
Mild (Delayed Onset)
Allergic Reaction
Signs and Symptoms. Mild pruritus (itching)—slow
appearance; and mild urticaria (rash)—slow
appearance.
Cause. Overreaction to allergens such as drugs, pollens,
or food in which mast cells degranulate and release his-
tamine, often in skin or mucosa.
Treatment
P: Positioning: Place patient in comfortable position
(upright).
A: Airway: Ensure that airway is open by talking with
patient.
B: Breathing: Ensure that breathing is adequate.
C: Circulation and communication: Should be adequate
in this situation. Request blood pressure cuff. There
should be no tachycardia, hypotension, dizziness,
dyspnea, or wheezing. Inform the patient that an
antihistamine drug will be administered.
D: Dispense/administer:
• Diphenhydramine (Benadryl) 25-50 mg PO, or
IM (or IV if dentist has ACLS or advanced
training).
• Repeat dose up to 50 mg every 6 hours orally for
2 days, if needed.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
recorded.
F: Facilitate/ensure next steps in medical care.
• In this case, allergy testing should be considered,
and dentist should initiate discussion with physi-
cian to withdraw offending drug.
Severe (Immediate Onset)
Allergic Reaction
Signs and Symptoms. Skin reactions—rapid appear-
ance such as severe pruritus (itching of skin, throat,
palate); severe urticaria (rash); swelling of lips, eyelids,
cheeks, pharynx, and larynx (angioneurotic edema); and
anaphylactic shock (cardiovascular—fall in blood pres-
sure), (respiratory—wheezing, choking, cyanosis, hoarse-
ness), (central nervous system—loss of consciousness,
dilation of pupils).
Cause. Overreaction to allergens such as drugs, pollens,
food where mast cells degranulate and release histamine
in cardiopulmonary system.
Treatment
P: Positioning
With conscious patient: place in upright (most com-
fortable) position.
With unconscious patient: place in supine position
and activate EMS (call 911).
A: Airway: Assess to ensure that airway is open.
B: Breathing: Ensure breathing is adequate by talking to
and reassuring patient.
C: Circulation: No immediate requirement. Apply blood
pressure cuff (pulse oximeter) to assess circulation
within 5 minutes.
D: Dispense/administer:
• Epinephrine 0.3-0.5 mg 1 : 1000 SC or IM, or IV
if dentist has ACLS training
• Oxygen maintained at flow rate of 5-6 L/
minute
• Repeat epinephrine 0.3-0.5 mg 1 : 000 SC or IM,
every 5-10 minutes as needed.
E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
recorded. NOTE: Monitor blood pressure to ensure
hypertension is not occurring.
F: Facilitate/ensure next steps in medical care (transport
to hospital); reassure patient.
If transport to hospital is pending:
• Give repeat doses of epinephrine 0.3-0.5 mg
1 : 1000 SC or IM, every 5-10 minutes as needed.
• Also administer 25 to 50 mg diphenhydramine
(Benadryl), once patient’s life is no longer in
danger.
If dentist has ACLS training and laryngeal edema is
involved:
 APPENDIX A Guide to Management of Common Medical Emergencies in the Dental Office
• Provide steroids—hydrocortisone sodium succi-
nate (Solu-Cortef), 100 mg SC or IM or IV
• Perform CPR if patient stops breathing and has
no pulse, including use of automated external
defibrillator (AED).
• Use cricothyrotomy if needed.
NOTE: Aminophylline may cause hypotension and
should be used with extreme caution in patients with
asthma who also are hypotensive.
Respiratory Arrest
Signs and Symptoms. Cessation of breathing,
cyanosis.
Cause. Physical obstruction of airway (tongue or foreign
object), drug-induced apnea.
Treatment
P: Positioning: Place patient in supine position, and acti-
vate EMS (call 911).
A: Airway: Maintain open airway, tilting the patient’s
head back as indicated.
B: Breathing: Respirations will be absent.
• Open mouth to see if foreign object is
readily accessible; remove object if visible (in
adult).
• If foreign object cannot be removed, perform Heim-
lich maneuver (abdominal thrusts) until object is
removed or no pulse is detected. If no pulse is felt,
initiate CPR (using the C-A-B sequence) and chest
compressions in a ratio of 30 per 2 ventilations.
• Once airway is open, ventilate patient 12 to 15
times per minute.
C: Circulation: Support blood pressure through position
of patient, parenteral fluids, and vasopressors.
D: Dispense/administer appropriate drug:
• Give oxygen or artificial respiration.
If apnea is secondary to sedative/benzodiazepine
(e.g., diazepam) overdose: administer reversal
agent:
• Flumazenil (0.2 mg IV over 15 sec) if diazepam
was used to sedate (with ACLS-trained rescuer);
repeat 0.2 mg every minute up to 1 mg.
If apnea is secondary to narcotic/opioid overdose:
administer reversal agent:
• 0.4 mg naloxone hydrochloride (Narcan) IV, IM,
or SC plus oxygen
• Keep patient awake.
E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
recorded.
F: Facilitate/ensure next steps in medical/dental
care (transport to hospital, if necessary); reassure
patient.
NOTE: Monitor patient carefully for the duration of
action of reversal agent (e.g., naloxone), which may be
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
583
less than that of the narcotic. No reversal agent exists
for barbiturate overdose.
Chest Pain
Angina Pectoris
Signs and Symptoms. Substernal myocardial pain that
can radiate to arms, neck, jaw, or abdomen; myocardial
pain lasting less than 15 minutes and possibly radiating
to the left shoulder; pain relieved by nitroglycerin; patient
usually has a history of the condition.
NOTE: Vital signs are normal; no hypotension, sweat-
ing, or nausea occurs.
Cause. Blood supply to the cardiac muscle is insufficient
for oxygen demand (atherosclerosis or coronary artery
spasm). Angina episode may be precipitated by stress,
anxiety, or physical activity.
Treatment
P: Positioning: Place patient in sitting-up or semi-sitting-
up (comfortable) position with head elevated.
A: Airway: Ensure open airway.
B: Breathing: Ensure that breathing is adequate.
C: Circulation and communication: Check pulse and
communicate with patient and staff to get the
nitroglycerin.
D: Dispense/administer:
• Nitroglycerin 0.4-mg tablet sublingually or one or
two metered spray doses (0.3-0.6 mg) of nitro-
glycerin sublingually
• Repeat 1 nitroglycerin tablet every 5 minutes up
to a total of 3 tablets or 3 sprays in 15-minute
period.
• Oxygen at flow rate of 5-6 L/minute
• If pain is not relieved with 3 doses of nitroglyc-
erin, give one aspirin 325 mg, and call 911.
E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
recorded.
F: Facilitate next steps in medical care (transport to
hospital if needed); reassure patient.
NOTE: If any doubt exists about whether angina or
myocardial infarction exists (i.e., pain continues, worsens
or subsides but then returns), activate EMS (call 911) or
transport patient to hospital. Once the nitroglycerin
tablet container has been opened, the remaining tablets
have a poor shelf life (30 days); a new supply should be
stocked.
Myocardial Infarction
Signs and Symptoms. Development of chest pain,
sometimes manifested as a crushing, squeezing, or heavy
feeling, that is more severe than with angina, possibly
radiating to the neck, shoulder, or jaw; lasting longer
584 APPENDIX A Guide to Management of Common Medical Emergencies in the Dental Office
than 15 minutes; and not relieved by nitroglycerin
tablets, in a conscious patient. Cyanotic, pale, or ashen
appearance; weakness, cold sweat, nausea, vomiting, air
hunger and sense of impending death; increased, irregu-
lar pulse beat of poor quality with palpitations, feeling
of impending doom.
Cause. Interruption of blood supply to the heart, most
commonly due to occlusion of coronary vessels. Anoxia,
ischemia, and infarct are present.
Treatment. (For adult victim who is conscious and
responsive)
P: Positioning: Place patient in a comfortable position.
Call for help and activate EMS (call 911).
A: Airway: Ensure open airway.
B: Breathing: Ensure that breathing is adequate by com-
municating with and reassuring patient.
C: Circulation: Request equipment to check pulse and
blood pressure.
D: Dispense/administer:
• Aspirin 325-mg tablet in conscious patient
• Oxygen at flow rate of 5-6 L/minute
E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
recorded.
F: Facilitate/ensure next steps in medical/dental care
(transport to hospital); reassure patient.
NOTE: Maintain patient in most comfortable position;
this may not be the supine position, because the air
hunger may be associated with orthopnea.
• Administer nitrous oxide–oxygen (N2O 30%, O2
70%), if available.
• Alternatively, demerol (50 mg IV) or morphine
(10 mg IV) may be administered if the dentist has
ACLS training.
The condition may progress to cardiac arrest.
With unresponsive patient: Initiate CPR, including use
of automated external defibrillator (AED).
Other Reactions
Intraarterial Injection of Drug into
the Arm
Signs and Symptoms. Pain and burning sensation
distal to the injection site; cold and blanching skin on
hand or fingers distal to the injection site.
Cause. Intraarterial injection of drug into the arm.
Treatment
P: Positioning: Place patient in supine position.
A: Airway: Administer oxygen at flow rate of 5-6 L/
minute.
B: Breathing: Ask patient to breathe slowly.
C: Circulation and communication: Leave needle in
place and communicate next steps to patient.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
D: Dispense:
• 40-60 mg 2% lidocaine (2-3 mL)
• 100 mg hydrocortisone sodium succinate (Solu-
Cortef) IM
E: Ensure that vital signs (obtained on other arm), drug
administration, and patient responses are properly
monitored and recorded.
F: Facilitate/ensure next steps in medical care (transport
to hospital), which may include heparinization and
brachial plexus block.
Extrapyramidal Reactions
Antipsychotic Drugs Producing Side Reactions. Phe-
nothiazines (Compazine, Thorazine, Phenergan, Sparine,
Stelazine, Trilafon, Mellaril); butyrophenones (Haldol,
Innovar [general anesthetic]); thioxanthenes (Navane,
Taractan).
Signs and Symptoms. Acute dystonic reaction (more
frequent in young people, women): rapid onset, involun-
tary movement of tongue, muscles of mastication, and
muscles of facial expression; neck muscles affected
frequently (torticollis), arms and legs less frequently;
akathisia (constant motion); parkinsonism, tardive dyski-
nesia (involving buccolinguomasticatory triad—sucking,
smacking, chewing, fly-catching movements of tongue).
Cause. Adverse effects of drug.
Treatment
P: Positioning: Place patient in semiupright position.
A: Airway: Ensure open airway.
B: Breathing: Ensure that breathing is adequate by
talking with and reassuring patient.
C: Circulation: Request blood pressure equipment or
pulse oximeter to check circulation.
D: Dispense/administer:
• Diphenhydramine HCl (Benadryl) 25-50 mg
orally, or IV if dentist has ACLS training
• Oxygen at flow rate of 5-6 L/minute
E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
recorded.
F: Facilitate/ensure next steps in medical care (transport
to hospital); reassure patient.
Response to Unknown Cause
When a likely cause for the patient’s response cannot be
identified, a period of observation is justified.
P: Positioning: Place patient in supine position and acti-
vate EMS (call 911).
A: Airway: Ensure open airway, support respiration,
and administer oxygen.
B: Breathing: Ensure that breathing is adequate.
 APPENDIX A Guide to Management of Common Medical Emergencies in the Dental Office
C: Circulation: Request blood pressure equipment or
pulse oximeter to check blood pressure and
circulation.
D: Dispense/administer intravenous 5% dextrose with
lactated Ringer’s solution.
E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
recorded.
F: Facilitate/ensure next steps in medical/dental care:
• Keep patient off all medication.
• Reassure patient.
• Transfer to hospital if patient’s condition is
serious.
• Be prepared to do CPR and use the AED, if
needed.
Emergency Kit
Review contents, expiration date, and appearance of all
drugs periodically (at least monthly). Ensure that kit
contains the following:
1. Oxygen tank and setup
2. Blood pressure cuff
3. Stethoscope
4. Syringes (1, 5, 10, and 20 mL)
5. Lacrimal pocket mask
6. Disposable airway, No. 2, 3, and 4
7. Butterfly needles, No. 3, 21 gauge
8. 22-gauge needles
9. Intravenous tubing set, long No. 880-35
10. 250 mL dextrose, lactated Ringer’s solution
11. Paper tape roll
12. Alcohol sponges
13. Drugs
a. Atropine: 0.5 mg/1-mL ampule
b. Aspirin: 325-mg tablets
c. Benadryl (diphenhydramine): 50-mg tablets or
50 mg/1 mL syringe/22 gauge, 1-inch needle
d. Aminophylline (theophylline ethylenediamine):
250 mg/1 mL syringe/22 gauge, 1-inch needle
e. Hydrocortisone sodium succinate (Solu-Cortef):
100 mg/2 mL syringe/22 gauge, 1-inch needle
f. Epinephrine 1 : 1000
i. Twinject: two doses of 0.3 mg
ii. EpiPen: auto-injector 0.3 mg
iii. 1.0-mL ampules
g. Glucagon: 1 mg/mL ampule
h. Naloxone hydrochloride (Narcan): 0.4 mg/1-
mL ampule/tuberculin syringe
i. Nitroglycerin: 0.4-mg tabs (packed as 30/bottle),
or nitroglycerin pump spray (400 μg/spray)
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
585
j. Phenylephrine: 10 mg/mL (two or three 1-mL
ampules)
k. Two ammonia inhalant buds (Vaporole)
l. Orange juice, glucose paste, or dextrose 50%:
100 mL
m. Diazepam (Valium): 5 mg/mL (Alternatively,
stock lorazepem 2 mg/mL or midazolam
1 mg/mL)
n. Lidocaine 2%, 2-mL ampules
14. Curved cricothyrotomy cannula
15. Padded tongue blade
16. Pulse oximeter/ECG unit (medical resources)
17. Automated external defibrillator (AED) (e.g., Heart-
stream FR-2, Medtronic Physio-control, Surviv-
alink)
NOTE: Commercial medical emergency kits for den-
tistry are available from companies such as Banyan Inter-
national (Abilene, Texas), Dixie Medical Inc. (Franklin,
Tennessee), and HealthFirst (Mountlake Terrace,
Washington).
Pediatric Drug Doses
Pediatric doses are presented on a weight basis, which
can be simply multiplied based on the patients weight.
Although nomograms using weight, surface area, and
other factors may be more accurate, use of the following
method is suggested in an emergency situation.
1. Diphenhydramine HCl (Benadryl): 1-1.25 mg/kg,
up to 50 mg maximum, IV; then 1-1.25 mg/kg q6h
orally or parenterally
2. Atropine sulfate: 0.01 mg/kg, up to 0.4 mg maximum,
IV or SC
3. Theophylline ethylenediamine (aminophylline):
3-5 mg/kg IV slowly—20 mg/minute maximum
4. Epinephrine (adrenaline) 1 : 1000
a. 0.05 mg-0.3 mg maximum SC or IM (diluted to
1 : 10,000 for intravenous administration)
b. EpiPen Junior—autoinjector 0.15 mg
5. Ammonia inhalants (e.g., Vaporole): Same as for
adults
6. Hydrocortisone sodium succinate:: Adult dose IV—
50 mg, 100 mg, and above
7. Naloxone HCl (Narcan): No pediatric doses clearly
established; 0.01 mg/kg IV (preferably) every
2-3 minutes for 2-3 doses maximum
8. 50% dextrose injection: 0.5 mg/kg or 1 mL/kg
9. Diazepam (Valium): Dose not clearly established in
patients younger than 12 years of age but in the
range of 0.1-0.5 mg/kg for intractable seizures
586 APPENDIX A Guide to Management of Common Medical Emergencies in the Dental Office

Record of Emergency Treatment

Patient Name
Chart #
Time BP Pulse Drug(s) delivered, Patient Response
amount, concentration (comments)

Copyright © 2013 by Mosby, an imprint of Elsevier Inc.