Management

of
Medical Emergencies
In the

Dental Office
 Hypertension
 Defined as blood pressure Greater Than
140/90
 Risk factors:
 CVA
 MI

 CHF

 Renal Failure

03/10/24 2
 Hypertension
 ASA Risk Status I
 <140 and < 90
 ASA Risk Status II
 140-160 and 90 to 95
 Routine dental
 Recheck BP for next
management
 Recheck in 6 months 3 appointments, if
elevated get medical
consultation
 Routine dental care

 Stress reducyion

03/10/24 3
 Hypertension
 ASA Risk Status III
 160-200 and 95 to 115
 Recheck BP in minutes
 If elevated, medical
consult before dental
treatment
 Stress reduction
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 ASA Risk Status IV
 >200/115
 Recheck BP in 5 minutes
 Immediate medical
consultation
 No routine treatment
 Emergency treatment in
hospital
 Rx for pain and infection
 Hypertension
Management
 Control BP before elective treatment

 Reasonable control of severe hypertension

before emergency treatment
 Medical consult before treatment for
uncontrolled hypertension

03/10/24 5
Management of Medical Emergencies

Common Medical
Emergencies
in the
Dental Office
 Vasovagal Syncope

Cause:
Loss of vasomotor tone due to a massive
parasympathetic discharge leading to
decreased pulse rate, and decreased blood
pressure which leads to cerebral hypoxia
and pooling of blood.
 Fainting: Vasovagal Syncope
In Dentistry

 The most common cause is psychogenic due to fear

and anxiety; especially from local anesthetic
 Most common between the ages of 16 and 35
 Males more prone than females
 Fainting is considered SERIOUS in PEDIATRIC
patients and patients OVER 40 years of age
 Vasovagal Syncope
Signs/Symptoms: Treatment:
1. Frightened anxious patient. 1. Place patient in

2. Decreased pulse rate. Trendelenberg’s position.

3. Decreased blood pressure. 2. Monitor vital signs.

4. Cool, moist, clammy skin. 3. Administer aromatic spirits

of ammonia.
5. Pale appearance.
4. Apply cold towel to
forehead.
5. Administer 100% oxygen.

6. Reassurance.
 Postural Hypotension
Cause:
 disorder of the autonomic nervous system in
which syncope occurs when the patient
assumes the upright position.
 Fainting: Postural Hypotension
 The second most common cause of transient
loss of consciousness.
 Not associated with fear an anxiety
 Predisposing factors
 Administration of Drugs
 Antihypertensives
 Psychotropics, Sedatives, and Tranquilizers.
 Age: increases with increasing age
 Prolonged recumbency
 Postural Hypotension
Signs/Symptoms: Treatment:
 Decrease in BP and loss of  Stop treatment
consciousness without  Assess consciousness
prodromal signs and  Place patient in the supine
symptoms
position with legs elevated
 Heart rate is normal, unlike
 Oxygen
Bradycardia in Vasovagal
 Monitor vital signs
Syncope.
 All manifestations of  Slowly reposition patient
unconsciousness
 When patient is placed in
the supine position,
consciousness rapidly
returns.
 Fainting: Postural Hypotension
Pregnancy (2 forms of hypotension)

1. Postural hypotension: during the first trimester

when getting out of bed in the morning; does not
reoccur during the day.

2. Supine hypotensive syndrome of pregnancy occurs

in the third trimester. If the patient is in the supine
position for more than 3 to 7 minutes, the uterus can
compress the inferior vena cava decreasing venous
return from the legs. Turning the patient on her left
or right side will alleviate the pressure and blood
flow returns to normal.
 Hyperventilation
Causes:
 Acute anxiety attack,

 Metabolic and endocrinologic disorders

(hypoglycemia, hyperthyroidism, Cushing’s
syndrome, pheochromocytoma).
 Hyperventilation
Signs/Symptoms: Treatment:
1. Tachypnea. 1. Assure patient airway.
2. Tachycardia. 2. Reassure patient.
3. Parasthesia around mouth 3. Have patient “re-breathe” in
and fingers. a paper bag.
4. Tetany, cramps.
5. Nausea.
6. Faintness.
7. Diaphoresis.
8. Acute anxiety.
9. Shortness of breath.
 Hypovolemic Syncope
Causes:
 External fluid loss;

 Internal sequestration of fluid;

 Decrease in cardiac output;

 Arrhythmias;

 Hypocapnia (hyperventilation);

 Hypoglycemia.
 Hypovolemic Syncope
Signs/Symptoms: Treatment:
1. Maintain patient airway –
1. Blood pressure low
turn head to one side to
normal or elevated; prevent aspiration.
Tachycardia.
2. Administer 100% oxygen.
2. Orthostatic 3. DO NOT use aromatic
hypotension and spirits of ammonia because
increased pulse rate. it stimulates the
3. Altered mental states;
sympathetic system and
augments
anorexia; apathy, arrythmogenicity.
weakness.
4. Cold clammy skin.
 Acute Angina Pectoris
Cause:
Diminished blood supply to myocardium
due to an imbalance between myocardial
oxygen supply and demand.
 Acute Angina Pectoris
Treatment:
Signs/Symptoms: 1. Place patient in supine position.
1. Chest pain – 2. Assure patient airway.
3. Administer nitroglycerine – if patient’s
substernal pressure prescription not available – administer
0.3 mg sublingually.
or crushing 4. If pain persists five minutes after
sensation. May nitroglycerine dose, repeat
administration.
radiate to neck, left 5. If still no response, repeat nitroglycerine
and administer 100% oxygen.
shoulder and down 6. If angina does not subside – concerned
that myocardial infarction is developing.
arm, and left side of Transfer to emergency room.
jaw.
 Myocardial Infarction
Cause:
Inadequate supply of oxygen to
myocardium.
 Myocardial Infarction
Signs/Symptoms:
1. Chest pain – substernal pressure
or crushing sensation, may
radiate to neck, left shoulder,
down arm, left side of jaw.
2. Feeling of impending doom;
3. Nausea.
4. Pale and diaphoretic.
Treatment:
1. Usually does not respond to
nitroglycerine.
2. Administer 100% oxygen.
3. Position patient in semi-sitting
position.
4. Transport to medical facility
immediately.
 Note: Narcotics for pain should
be avoided initially, so as not to
interfere with differential
diagnosis, but if desired give
Demerol 25-75 mg IM or IV.
 Cardiopulmonary Arrest
Causes:
 Hypoxia;

 myocardial infarction;

 anesthesia – local or general;

 anaphylaxis;

 excessive vagal tone.

 Cardiopulmonary Arrest
Signs/Symptoms: Treatment:
1. Absence of pulse. 1. Rule out aspiration.

2. Absence of blood pressure. 2. “Precordial Thump” within

3. Absence of heart beat. one minute of arrest.

4. Absence of respiration. 3. Assure patient airway.

5. Coma. 4. Provide CPR – do not

interrupt CPR for more
6. Cyanosis.
than 5 seconds, for any
7. Dilated pupils.
reason.
5. Transport to medical
facility.
 Acute Congestive Heart Failure
Cause:
Primary “pump” problem.
 Acute Congestive Heart Failure
Signs/Symptoms: Treatment:
1. Right Sided CHF 1. Place patient in semi-sitting position.
a. Systemic congestion 2. Assure patient airway.
b. Ankle swelling 3. Administer 100% oxygen.
c. Jugular vein distention 4. Transport to medical facility
d. Pleural effusion immediately.
e. Dsypnea
f. Accumulation of fluids in
peritoneum.
2. Left Sided CHF
a. Pulmonary congestion
b. Dsypnea
c. Orthopnea
d. Great anxiety
e. Very labored breathing
f. Productive cough
g. Cyanosis
 Asthmatic Attack
Cause:
Reversible bronchospasm.
Two Subtypes:
 Extrinsic or allergic type is caused by
environmental allergens.
 Intrinsic (endogenous) type – mechanism
inducing attacks is unknown.
 Asthmatic Attack
Signs/Symptoms: Treatment:
1. Wheezing 1. Put patient in sitting position;
2. Effortless inspiration, prolonged assure patient airway; give 100%
expiration. oxygen.
3. Distended chest. 2. Two inhalations of isoproterenol
4. Severe attack: HCl.
a. Tachypnea (>35) or Bradypnea 3. If no response to isoproterenol,
(<12) Tachycardia (>30) and in severe attacks, administer
b. Exhaustion; altered
epinephrine (1:1,000),
consciousness sublingually, 0.3 to 0.5 ml over 5
minutes. May be repeated every
c. Use of accessory muscles of 30 minutes up to 3 doses.
respiration. Children’s dose: epinephrine
d. Cyanosis. (1:1,000) 0.01 mg/kg (0.02
e. Silent chest (i.e. no wheezing mg/lb) repeat only once after one
with dyspnea and tachypnea) hour.
5. Hydration 4. Contact patient’s physician.
 Seizures
Causes:
 Neurologic disorders;

 Syncope;

 Drug toxicity;

 Hypoxia.
 Seizures
Signs/Symptoms: Treatment:
1. Involuntary or bizarre 1. Assure patient airway.
movements. 2. Administer 100%
2. Tongue biting. oxygen.
3. Loss of consciousness 3. Place soft/padded bite
protector.
4. Transport to medical
facility.
 Insulin Shock
Cause:
Hypoglycemia
 Insulin Shock
Signs/Symptoms: Treatment:
1. Rapid fall in blood glucose level.
1. If conscious – give oral
A. May see parasympathetic glucose (orange juice,
response: hunger, nausea
candy, sugar cubes).
B. Catecholamine release
2. If unconscious – patient is
a. Anxiety
b. Tachycardia
in need of IV administration
c. Palpitation
of 50% dextrose – transport
to medical facility
d. Diaphoresis
immediately.
2. Slow fall in blood glucose level.
A. Increasing lethargy
B. Slurred speech
C. Lassitude
D. Progressive decreasing mental
status
 Diabetic Coma
Cause:
Hyperglycemia
 Diabetic Coma
Signs/Symptoms: Treatment:
1. Frequent urination. 1. Place patient in supine
2. Loss of appetite. position.
3. Thirst. 2. Assure patient airway.

4. Acetone odor of breath. 3. Administer 100% oxygen.

5. Hyperpnea. 4. Call 911.

6. Nausea and vomiting. 5. Transport to medical

facility.
7. Warm, dry skin.
8. Rapid pulse.
9. Decreased blood pressure.
10. Coma.
 Anaphylaxis
Cause:
Antigen interaction with antibody coated
target cells.
 Anaphylaxis
Signs/Symptoms: Treatment:
1. Sense of impending doom; 1. Place patient in Trendelenberg
2. Bronchial obstruction: wheezing, position.
laryngeal edema.
3. Hypoxia.
2. Airway maintenance.
4. Hypotension. 3. Administer 100% oxygen.
5. Prutitis, urticaria, angioedema. 4. Administer epinephrine 1:1,000
6. Nausea, vomiting, diarrhea, sublingually 0.3 to 0.5 ml over 5
abdominal pain. minutes. May be repeated every
7. Convulsions may occur. 30 minutes up to 3 doses.
Children: epinephrine 1:1,000
sublingually 0.01 mg/kg (0.02
mg/lb). Repeat only once after
one hour.
5. Transport to medical facility.
 Allergic Reaction
Cause:
Delayed hypersensitivity reactions.
 Allergic Reaction
Signs/Symptoms: Treatment:
1. Mild Reaction 1. Place patient in supine

a. Urticaria
position.
2. Assure patient airway.
b. Pruritis
3. Give 100% oxygen.
c. Skin eruptions
4. Mild reaction: 50mg
d. Mild angioneurotic
diphenhydramine HCl
edema
(Benadryl) orally.
2. Severe Reaction
5. Severe reaction: 50mg
a. Bronchial congestion diphenhydramine HCl
b. Respiratory depression (Benadryl) intramuscularly.
c. Edema 6. Transport to medical facility.
 Equipment List
In order to successfully manage a dental emergency in the dental office
you must be properly equipped with the necessary armamentarium which
should include:

1. Sphygmomanometer with 7. Gauze 4x4.

various cuff sizes: a.) children,
b.) average adult, c.) large adult. 8. Alcohol pads.
2. Stethoscope. 10. 1” adhesive tape.
3. 100% oxygen, E size 11. Tourniquet.
compressed cylinder, portable 12. Oropharyngeal airways – various
unit, flow rate indicator. sizes.
4. Clear resuscitation face masks 13. Soft plastic bite protector.
(to allow for recognition of 14. Backboard for CPR in dental
vomiting) of various sizes: a.) chair.
children, b.) average adult, c.) 15. Medical emergency kit (Benadryl,
large adult. Epinephrine, glucose,
5. Self-inflating resuscitation bag Isoproterenol Inhaler,
(amber type bag). Nitroglycerin, and Aspirin).
6. Small paper bags.
 Emergency Drugs and
Equipments
A. ATROPINE SULFATE
1. Actions
 Parasympatholytic agent
2. Indications
 Symptomatic bradycardia
 Sinus bradycardia with hypotension
3. Dosage
 0.5 to 1 mg IV bolus (every 5 minutes)
 Total dose is 2.0 mg for cardiac patients
4. Side effects
 Dry mouth
 Blurred vision
 Aggravates blindness in patients with glaucoma
 Difficulty in urination with older males
5. Contraindications
 Atrial flutter or fibrillation with rapid ventricular response
 Patients with closed angle glaucoma
 Tachycardia

03/10/24 39
 Emergency Drugs and
B. Diazepam
Equipments
1. Actions
 Minor tranquilizer
 CNS Depressant
 Anticonvulsant
 Muscle relaxant
2. Indications
 Status epilepticus
 Hysteria/anxiety
3. Dosage
 2 to 15 mg slowly IV(5mg/min maximum in larger veins)
 Given in small doses initially
 May give more if patient’s condition requires
4. Side effects
 Respiratory depression
 Sleepiness
 Hypotension
 CNS depression
 Dysrhythmias
5. Contraindications
 Hypotension
 Ventilatory insufficiency
 Pregnancy
 Alcohol intoxication
 Narrow angle glaucoma

03/10/24 40
 Emergency Drugs and Equipments
C. Diphenhydramine HCI
1. Actions
 Antihistamine – binds to histamine receptor sites to prevent further action
 Antiemetic
 Mild central nervous system depressant
 Reverses actions of phenothiazines
2. Indications
 Anaphylaxis
i. Preferred before encountering allergen to keep reaction from occurring
ii. Will not reverse effects of histamine once histamine is active in system, but will keep from further histamine effects
 Delayed hypersensitivity reactions
3. Dosage
 25 to 50 mg IM or IV
4. Side effects
 Drowsiness
 Blurring of vision
 Respiratory depression
 Dry mouth
 Wheezing
 Urinary retention
 Hypotension
5. Contraindications
 Hypotension
 Alcohol intoxication
 Closed angle glaucoma
 Ulcer disease with GI obstruction
 Pregnancy

03/10/24 41
 Emergency Drugs and Equipments
D. Epinephrine
1. Action – alpha and beta sympathomimetic drug
 Increases heart rate
 Increases contractile state of heart
 Bronchodilates
 Vasoconstricts
 Increases blood pressure
2. Indications
 Cardiac arrest
i. Ventricular fibrillation
ii. Asystole
 Asthma
 Anaphylaxis
3. Dosage
 Cardiac arrest
i. 0.5 to 1.0 mg of a 1:10,000 concentration IV
ii. May be repeated every 5 to 10 minutes
 Asthma
i. 0.3 to 0.5 mg of a 1:1,000 concentration SQ
ii. May be repeated every 10 minutes as necessary
 Anaphylaxis
i. 0.5 mg of a 1:1,000 concentration SQ
ii. May be repeated as required
4. Side effects
 Ventricular dysrhythmias
 Angina
 Hypertension
 Ectopic beats
 Nausea
 Dilated pupils
D. Contraindications
1. Angina
2. Hypertension
3. Hyperthyroidism
4. No contraindications for patients in cardiac arrest or anaphylaxis

03/10/24 42
 Emergency Drugs and Equipments
E. Morphine Sulfate
1. Actions
 Analgesic
 Vasodilator
i. Reduces preload
ii. Reduces afterload
 Stimulates parasympathetic nervous system
2. Indications
 To reduce pain and anxiety associated with acute myocardial infraction
 Pulmonary edema from congestive heart failure
3. Dosage
 2.0 to 5.0 mg IV bolus
4. Side effects
 Respiratory depression or arrest
 Hypotension
 Sleepiness
 Bradycardia
 Increased intracranial pressure
5. Contraindications
 Respiratory depression
 Head injuries
 Trauma to chest or abdomen
 Uncontrolled bleeding
 Alcohol intoxication
 Use with caution when giving to patients with inferior or posterior wall myocardial infarction as morphine may cause
bradycardia

03/10/24 43
 Emergency Drugs and Equipments
F. Naloxone
1. Actions
 Narcotic antagonist; blocks the effects of narcotics on the central nervous system
2. Indications
 Overdose of opiate and opioid drugs
Common opiates and opioids:
Morphine
Heroine
Codeine
Darvon
Lomotil
Percodan
Methadone

3. Dosage
 0.4 to 2.0 mg initially given only to point of stimulating patient’s respiratory rate
4. Side effects
 May precipitate withdrawal in patients who are addicted to narcotics
 When it wears off, patient may lapse back into coma
5. Contraindications
 None

03/10/24 44
 Emergency Drugs and Equipments
G. Nitroglycerin
1. Actions
 Vasodilator – dilates both arteries and veins
 Reduces cardiac workload
i. Reduces preload
ii. Reduces afterload
 Reduces oxygen demand by myocardium
2. Indication
 Angina
 Acute myocardial infarction
 Congestive heart failure with pulmonary edema

3. Dosage
 0.3 mg given SL, and may be repeated at 5 minute intervals three times
4. Side effects
 Headache
 Burning under the tongue
 Hypotension
 Weakness
 Dizziness
5. Contraindications
 Myocardial infarction with hypotension
 Hypotension
 Increased intracranial pressure
 Glaucoma

03/10/24 45
 Emergency Drugs and Equipments
H. Nitrous Oxide
1. Actions
 Analgesic
2. Indications
 Pain related to acute myocardial infarction
3. Dosage
 Mixture of 50% nitrous oxide and 50% oxygen
 Patient self-administers to prevent overdose
4. Side effects
 Light-headedness
 Drowsiness
 Nausea and vomiting
5. Contraindications
 Head injuries
 COPD
 Pulmonary edema
 Abdominal distention
 Shock

03/10/24 46
 Emergency Drugs and Equipments
I. Oxygen
1. Actions
 Increased arterial oxygen tension
 Increased hemoglobin saturation
 Increased oxygen delivery to tissues
2. Indications
 Hypoxemia of any cause
 Acute myocardial infarction
 Trauma
 Shock
 Cardiopulmonary arrest
3. Dosage
 Nasal cannula – 2 to 6 liters per minute
 Simple mask – not less than 6 liters per minute
 Reservoir mask – 10-15 liters per minute
4. Side effects
 Decreased rate and depth of ventilations if patient has COPD
 No side effects when given in high concentrations over short periods of time
 Drying of mucous membranes if not humidified
5. Contraindications
 None

03/10/24 47
 REFERENCES

1. Medical Emergencies: Prepare Your Team for A Quick Response. Fast, T.B. Dental
Management. Jan. 1987, 32-6.
2. Managing Emergencies in the Dental Office. Terezhlamy, G.T.
3. When the Patient’s Life in Your Hands. Dental Management. Aug. 1976.
4. Medical Emergencies: The Team Approach. Malamed, S.F. Alpha Omega. Fall 1984,
29-36.
5. Medical Emergencies in Dental Practice Part I – Preparation. Gobetti, J.P., et al.
Journal of Michigan Dental Assoc. Vol. 61, Feb. 1979.
6. Emergency Preparedness: A Survey of Dental Practitioners. Fast, T.B., et al. JADA.
Vol. 112, Apr. 1986, 499-501.
7. Emergency Kits for the Dental Practitioner. Jastak, J.T. J. Oreg. Dentl. Assoc. Winter
1983/84.
8. Medical Emergencies in Dental Practice Part III – Cardiovascular Emergencies.
Dworin, A.M. and Gobetti, J.P. J. of Michigan Dental Assoc. Vol. 61, July-Aug. 1979.
9. Medical Emergencies in Dental Practice Part V: Miscellaneous Medical Emergencies.
Dworin, A.M. and Gobetti, J.P. J. of Michigan Dental Assoc. Vol. 61, July-Aug. 1979.
10. Office Emergencies: An Outline of Causes, Symptoms, and Treatment. Freeman, N.S.
et al. JADA. Vol. 94, Jan. 1977, 91-96.
11. Emergency Medical Therapy. Eisenberg and Copass. W.B. Saunders 2nd Ed. 1982.
12. Medical Emergencies in Dental Practice Part IV: The Dyspenic Patient. Dworin, A.M.
and Gobetti, J.P. J. of Michigan Dental Assoc. Vol. 61, July-Aug. 1979.