Table 1

Essential Emergency Drugs

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Additional Emergency Drugs

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Management of Medical Emergencies in the Dental Office: Conditions in Each

Country, the Extent of Treatment by the Dentist
Daniel A Haas
Professor and Associate Dean, Head of Dental Anaesthesia, Faculty of Dentistry,
University of Toronto
Reprinted with permission from Journal of Japanese Dental Society of
Anesthesiology (2005;33:153–157). Copyright 2005, Japanese Dental Society of
Anesthesiology.
Address correspondence to Dr Daniel A. Haas, Faculty of Dentistry, University of
Toronto, 124 Edward St, Toronto, Ontario, M5G 1G6, Canada; Email:
[email protected] .

• Other Sections▼
o I. ESSENTIAL EMERGENCY DRUGS
o II. ADDITIONAL DRUGS
o REFERENCES

Dentists must be prepared to manage medical emergencies which may arise in

practice. In Japan, a study was conducted between 1980 and 1984 by the Committee
for the Prevention of Systematic Complications During Dental Treatment of the Japan
Dental Society of Anesthesiology, under the auspices of the Japanese Dental Society.1
The results from this study showed that anywhere from 19% to 44% of dentists had a
patient with a medical emergency in any one year. Most of these complications,
approximately 90%, were mild, but 8% were considered to be serious. It was found
that 35% of the patients were known to have some underlying disease. Cardiovascular
disease was found in 33% of those patients.
Medical emergencies were most likely to occur during and after local anesthesia,
primarily during tooth extraction and endodontics. Over 60% of the emergencies were
syncope, with hyperventilation the next most frequent at 7%.
In the United States and Canada, studies have also shown that syncope is the most
common medical emergency seen by dentists.2,3 Syncope represented approximately
50% of all emergencies reported in one particular study, with the next most common
event, mild allergy, represented only 8% of all emergencies. In addition to syncope,
other emergencies reported to have occurred include allergic reactions, angina
pectoris/myocardial infarction, cardiac arrest, postural hypotension, seizures,
bronchospasm and diabetic emergencies.
The extent of treatment by the dentist requires preparation, prevention and then
management, as necessary. Prevention is accomplished by conducting a thorough
medical history with appropriate alterations to dental treatment as required. The most
important aspect of nearly all medical emergencies in the dental office is to prevent,
or correct, insufficient oxygenation of the brain and heart. Therefore, the management
of all medical emergencies should include ensuring that oxygenated blood is being
delivered to these critical organs. This is consistent with basic cardiopulmonary
resuscitation, with which the dentist must be competent. This provides the skills to
manage most medical emergencies, which begin with the assessment, and if necessary
the treatment of airway, breathing and circulation (the ABCs of CPR). Usually, only
after these ABCs are addressed should the dentist consider the use of emergency
drugs.
Drugs that should be promptly available to the dentist can be divided into two
categories.4 The first category represents those which may be considered essential.
These drugs are summarized in Table 1. The second category contains drugs which
are also very helpful and should be considered as part of the emergency kit. These
supplementary drugs are summarized in Table 2. The precise composition of the drug
kit can vary as the presence of the drugs in this latter group may depend on the nature
of the dental practice.
Table 1
Essential Emergency Drugs

Table 2
Additional Emergency Drugs

• Other Sections▼
o I. ESSENTIAL EMERGENCY DRUGS
o II. ADDITIONAL DRUGS
o REFERENCES

I. ESSENTIAL EMERGENCY DRUGS

The following will summarize the drugs which should be part of a dentist's emergency
kit.4 There are 6 drugs which should be considered essential for all dentists.
1. Oxygen
Oxygen is indicated for every emergency except hyper-ventilation. This should be
done with a clear full face mask for the spontaneously breathing patient and a bag-
valve-mask device for the apneic patient. Therefore whenever possible, with the
exception of the patient who is hyperventilating, oxygen should be administered. For
the management of a medical emergency it should not be withheld for the patient with
chronic obstructive lung disease, even though they may be dependent on low oxygen
levels to breathe if they are chronic carbon dioxide retainers. Short term
administration of oxygen to get them through the emergency should not depress their
drive to breathe.
Oxygen should be available in a portable source, ideally in an “E”-size cylinder which
holds over 600 liters. This should allow for more than enough oxygen to be available
for the patient until resolution of the event or transfer to a hospital. If the typical adult
has a minute volume of 6 liters per minute, then this flow rate should be given as a
minimum. If the patient is conscious, or unconscious yet spontaneously breathing,
oxygen should be delivered by a full face mask, where a flow rate of 6 to 10 liters per
minute is appropriate for most adults. If the patient is unconscious and apneic, it
should be delivered by a bag-valve-mask device where a flow rate of 10 to 15 liters
per minute is appropriate. A positive pressure device may be used in adults, provided
that the flow rate does not exceed 35 liters per minute.
2. Epinephrine
Epinephrine is the drug of choice for the emergency treatment of anaphylaxis and
asthma which does not respond to its drug of first choice, albuterol or salbutamol.
Epinephrine is also indicated for the management of cardiac arrest, but in the dental
office setting, it may not be as likely to be given, since intravenous access may not be
available. Its administration intramuscularly is not as likely to be very effective in this
latter emergency, where adequate oxygenation and early defibrillation is most
important for the cardiac arrest dysrhythmias with the relatively best prognoses,
namely ventricular fibrillation or pulseless ventricular tachycardia.
As a drug, epinephrine has a very rapid onset and short duration of action, usually 5 to
10 minutes when given intravenously. For emergency purposes, epinephrine is
available in two formulations. It is prepared as 1 : 1,000, which equals 1 mg per ml,
for intramuscular, including intralingual, injections. More than one ampule or pre-
filled syringe should be present as multiple administrations may be necessary. It is
also available as 1 : 10,000, which equals 1 mg per 10 mL for intravenous injection.
Autoinjector systems are also present for intramuscular use (such as the EpiPen)
which provides one dose of 0.3 mg as 0.3 mL of 1 : 1,000, or the pediatric
formulation which is 1 dose of 0.15 mg as 0.3 mL of 1 : 2,000.
Initial doses for the management of anaphylaxis are 0.3 to 0.5 mg intramuscularly or
0.1 mg intravenously. These doses should be repeated as necessary until resolution of
the event. Similar doses should be considered in asthmatic bronchospasm which is
unresponsive to a beta-2 agonist, such as albuterol or salbutamol. The dose in cardiac
arrest is 1 mg intravenously. Intramuscular administration during cardiac arrest has
not been studied, but would appear to be unlikely to render significant effect.
Epiniphrine is clearly a highly beneficial drug in these emergencies. Concurrently,
however, it can be a drug with a high risk if given to a patient with ischemic heart
disease. Nevertheless, it is the primary drug needed to reverse the life-threatening
signs and symptoms of anaphylaxis or persistent asthmatic bronchospasm.
3. Nitroglycerin
This drug is indicated for acute angina or myocardial infarction. It is characterized by
a rapid onset of action. For emergency purposes it is available as sublingual tablets or
a sublingual spray. One important point to be aware of is that the tablets have a short
shelf-life of approximately 3 months once the bottle has been opened and the tablets
exposed to air or light. The spray has the advantage of having a shelf-life which
corresponds to that listed on the bottle. Therefore, if a patient uses his/her own
nitroglycerin, there is a possibility of the drug being inactive. This supports the need
for the dentist to always having a fresh supply available. With signs of angina
pectoris, one tablet or spray (0.3 or 0.4 mg) should be administered sublingually.
Relief of pain should occur within minutes. If necessary, this dose can be repeated
twice more in 5-minute intervals. Systolic blood pressures below 90 mmHg
contraindicate the use of this drug.
4. Injectable Antihistamine
An antihistamine is indicated for the management of allergic reactions. Whereas mild
non-life threatening allergic reactions may be managed by oral administration, life-
threatening reactions necessitate parenteral administration.
Two injectable agents may be considered, either diphenhydramine or
chlorpheniramine. They may be administered as part of the management of
anaphylaxis or as the sole management of less severe allergic reactions, particularly
those with primarily dermatologic signs and symptoms such as urticaria.
Recommended doses for adults are 25 to 50 mg of diphenhydramine or 10 to 20 mg of
chlorpheniramine.
5. Albuterol (Salbutamol)
A selective beta-2 agonist such as albuterol (salbutamol) is the first choice for
management of bronchospasm. When administered by means of an inhaler, it
provides selective bronchodilation with minimal systemic cardiovascular effects. It
has a peak effect in 30 to 60 minutes, with a duration of effect of 4 to 6 hours. Adult
dose is 2 sprays, to be repeated as necessary. Pediatric dose is 1 spray, repeated as
necessary.
6. Aspirin
Aspirin (acetylsalicylic acid) is one of the more newly recognized life-saving drugs,
as it has been shown to reduce overall mortality from acute myocardial infarction.
The purpose of its administration during an acute myocardial infarction is to prevent
the progression from cardiac ischemia to injury to infarction. There is a brief period of
time early on during a myocardial infarction where aspirin can show this benefit. For
emergency use there are relatively few contraindications. These would include known
hypersensitivity to aspirin, severe asthma or history of significant gastric bleeding.
The lowest effective dose is not known with certainty, but a minimum of 162 mg
should be given immediately to any patient with pain suggestive of acute myocardial
infarction.
7. Oral Carbohydrate
An oral carbohydrate source, such as fruit juice or non-diet soft-drink, should be
readily available. Whereas this is not a drug, and perhaps should not be included in
this list, it should be considered essential. If this sugar source is kept in a refrigerator
it may not be appreciated that it is a key part of the emergency equipment. Therefore,
consideration should be given to making this part of the emergency kit. Its use is
indicated in the management of hypoglycemia in conscious patients.

• Other Sections▼
 o I. ESSENTIAL EMERGENCY DRUGS
o II. ADDITIONAL DRUGS
o REFERENCES

II. ADDITIONAL DRUGS

In addition to the 6 drugs discussed above, a number of other drugs should be
considered as part of an emergency kit, as shown in Table 2.4
1. Glucagon
The presence of this drug allows intramuscular management of hypoglycemia in an
unconscious patient. The ideal management of severe hypoglycemia in a diabetic
emergency is the intravenous administration of 50% dextrose. Glucagon is indicated if
an intravenous line is not in place and venipuncture is not expected to be
accomplished, as may often be the case in a dental office. The dose for an adult is 1
mg. If the patient is less than 20 kg, the recommended dose is 0.5 mg. Glucagon is
available as 1 mg formulation, which requires reconstitution with its diluent
immediately prior to use.
2. Atropine
This anti-muscarinic, anti-cholinergic drug is indicated for the management of
hypotension, which is accompanied by bradycardia. The dose recommended is 0.5 mg
initially, followed by increments as necessary until one reaches a maximum of 3 mg.
Paradoxically, doses of less than 0.4 mg have been associated with induction of a
bradycardia, likely due to atropine's central nervous system's actions.
3. Ephedrine
This drug is a vassopressor which may be used to manage significant hypotension. It
has similar cardiovascular actions compared with epinephrine, except that ephedrine
is less potent and has a prolonged duration of action, lasting from 60 to 90 minutes.
Similar precautions as noted with epinephrine administration should be considered
when given to a patient with ischemic heart disease. For the treatment of severe
hypotenson, it is ideally administered in 5 mg increments intravenously.
Intramuscularly it should be given in a dose of 10 to 25 mg.
4. Corticosteroid
Administration of a corticosteroid such as hydrocortisone may be indicated for the
prevention of recurrent anaphylaxis. Hydrocortisone may also play a role in the
management of an adrenal crisis. The notable drawback in their use in emergencies is
their relatively slow onset of action, which approaches one hour even when
administered intravenously. This is the reason why these drugs are not considered
essential, as they are of minimal benefit in the acute phase of the emergency. There is
low likelihood of an adverse response with one dose. The prototype for this group is
hydrocortisone, which may be administered in a dose of 100 mg as part of the
management of these emergencies.
5. Morphine
Morphine is indicated for the management of severe pain which occurs with a
myocardial infarction. Advanced Cardiac Life support recommendations list
morphine as the analgesic of choice for this purpose.5 The dose involves titration in
one to three mg increments intravenously until pain relief is accomplished. This
should be guided by a decrease in blood pressure and respiratory depression. Extreme
caution should be used in the elderly. If an intravenous is not in place, consideration
can be given to administering morphine in a dose of approximately 5 mg
intramuscularly. Again, lower doses need to be considered for the older patient.
6. Naloxone
If either morphine is included in the emergency kit, or opioids are used as part of a
sedation regimen, then naloxene should also be present for the emergency
management of inadvertent overdose. Doses should ideally be titrated slowly in 0.1
mg increments to effect.
7. Nitrous Oxide
Nitrous oxide is a reasonable second choice if morphine is not available to manage
pain from a myocardial infarction. For management of pain associated with a
myocardial infarction, it should be administered with oxygen, in a concentration
approximating 35%, or titrated to effect.
8. Injectable Benzodiazepine
The management of seizures which are prolonged or recurrent, also known as status
epilepticus, may require administration of a benzodiazepine. In most dental practices,
it would not be realistic to assume that the dentist could achieve venipuncture in a
patient having an active seizure. This leads to the need for a water-soluble agent such
as midazolam or lorazepam. Lorazepam has been reported as the drug of choice for
status epilepticus and can be administered intramuscularly. Midazolam, however, is
another alternative which is water soluble and could be considered. Sedation would be
an expected side effect and patients should be appropriately monitored. Adult doses to
consider for lorazepam are 4 mg intramuscularly, or midazolam 5 mg intramuscularly.
If an intravenous is in place, these drugs should be slowly titrated to effect.
9. Flumazenil
The benzodiazepine antagonist flumazenil should be part of the emergency kit when
oral or parenteral sedation is used, as these techniques are usually based on effective
use of benzodiazepines. Dosage is 0.1 to 0.2 mg intravenously, incrementally.
In addition to having drugs available, a small amount of basic equipment should be
readily available. This includes a stethoscope, blood pressure cuff, an oxygen delivery
system, syringes and needles. Dentists should also consider having an automated
external defibrillator (AED), as a means to treat cardiac arrest. Usage of this latter
piece of equipment is easily learned and only requires strong knowledge of basic CPR
with a small amount of additional training.
In summary, medical emergencies do occur in dental offices with similar frequencies
in both Japan and North America. Dentists must be prepared to manage these patients
until they recover or help arrives.
This manuscript is based on the presentation to the joint ASDA/KDSA/JDSA
International Symposium held in Tokyo on October 1, 2004. The description of
emergency drugs is largely based on reference number 4 in this manuscript (Haas DA:
Emergency drugs, Dent Clin North America, 2002, 46, 815–830)