Presented by : Dr.

jigar thakkar

CONTENTS
y Introduction y Emergency drug kit y Requirement of drug kit y Emergency drug modules

or levels

y Conclusion y References

INTRODUCTION
y All staffs in dental practice must be trained y All dental offices and the hospitals should maintain at least the basic recommended emergency equipment and drugs

y Course of medicine that include all possible condition like .seizures, chest pain and respiratorty difficulty etc . y BLS [P-positioning, A-airway, B-breathing, C-circulation, D-definitive care]

EMERGENCY KITS
y Commercially available or designed personally y As simple as possible y 3 things to be remembered
y Primary management of all emergency

situation involves BLS y drug administration- not necessary for the immediate M/o medical emergencies except anaphylaxis y When in doubt, never medicate

Requirements of drug kits

y Dental office emergency kit should not be

complicated. y Should be as simple as possible to use. y It is always best to use a drug with which clinician is most familiar and comfortable. y Should not have too many drugs of similar types, because this leads to confusion and indecision. y All drug package inserts should be kept in it.

y Home made kits are always better as clinician will be

aware of drug and equipment that should be included in the kit. y Select the kit which best fits the individual needs of his office or augment the kit with separately purchased items. y Drugs and equipments should be included as per the individual s training.

EMERGENCY DRUGS
Emergency drugs
Module 1 Module 2 Module 3 Module 4

critical drugs & equipment

non critical drugs ACLS & equipment

antidotal drugs

Injectable drugs and Non-injectable drugs

Injectable drugs and Non-injectable drugs

Most injectable emergency drugs: 1ml glass ampule or vial. c/d as therapeutic dose- except epinephrine infant one-quarter, Pediatric pt one-half than adult dose Non injectable drugs: one tablet or spray is adult therapeutic dose. Other items of emergency equipment should be available in both pediatric and adult forms. E.g. face masks, airways etc

ADMINISTRATION OF INJECTABLE DRUGS

y Enough of the inj drugs

must enter the blood stream and be transported to the part of the body where it is needed
y Ideal route for emergency-

IV- onset of action approximately 20 sec

y IM route- 10 min y Various sites: y Mid-deltoid region y Vastus lateralis y Gluteal region y The tongue - Onset of action - 5-10 min y Endotracheal route(when available)

MODULE ONE
Critical emergency drugs and equipment
y

Injectable drugs
1) 2)

Epinephrine Histamine blockers Oxygen Vasodilators Bronchodilator Antihypoglycemics Aspirin

Noninjectable drugs
1) 2) 3) 4) 5)

Emergency equipment
1) 2) 3) 4) 5)

Oxygen delivery system Suction and suction tips Tourniquets Syringes Magill intubation forceps

MODULE TWO
y
y y y y y y y

Injectable drugs
Anticonvulsants Analgesics Vasopressors Antihypoglycemics Corticosteroids Antihypertensives Anticholinergics

y
y y

Noninjectable drugs
Respiratory stimulant Antihypertensives

y
y y y

Emergency equipment
Scalpel or cricothyrotomy needle Artificial airways Laryngoscope and endotracheal tubes

MODULE THREE
y

Advance cardiovascular life support(ACLS) essential drugs

y y y y y y y

Epinephrine Oxygen Lidocaine Atropine Dopamine Morphine sulphate Verapamil

MODULE FOUR
y
y y y y

Anti dotal drugs

Opioid antagonist Benzodiazepine antagonist Antiemergence delirium drug Vasodilator / local anesthetic

MODULE ONE
Critical emergency drugs and equipment

Primary injectable: drug for acute allergic reaction

Drug Of Choice : Drug class:
EPINEPHRINE

catecholamine

BValuable in management of both

respiratory and cardiovascular manifestation of acute allergic reaction. B and agonist BProperties

BRapid onset action, bronchodilator,

vasopressor action, histamine- blocking properties Baction on heart: HR, SBP, CO, coronary blood flow, DBP

y Therapeutic indication:
y To treat cases of acute allergic reaction y Acute asthmatic attack y Mangement of cardiac arrest
1:1000

1:10,000

y precautions pregnant women y availibility: in 2 concentration y Suggested for emergency kit:

y 1 preloaded syringe [1ml of 1:1000 (1mg

epinephrine)] and y 3 to 4 ampules of 1:1000 epinephrine

Primary injectable: for allergic reaction (antihistamine)

Drug Of Choice : Drug class: Alternative drug:
MOA:

Chlorpheniramine Histamine Blocker Diphenhydramine

Competitive antagonists of histamine, Chlorpheniramine is less sedative than diphenhydramine Therapeutic indication: M/o delayed-onset allergic reactions Definitive m/o acute allergic reaction As Local anesthetics when the patient has h/o allergy to LA

y Side effects : CNS depression , BP, thickening

of bronchial secretion resulting from drug drying action y Contraindication: acute asthma y Availability:
y Chlorpheniramine

10mg/ml (1ml& 2ml ampules) 1ml preloaded syringes y Diphenhydramine- 10 mg/ml (10 & 30ml multidose vial) 50 mg/ml(1ml & 10ml multidose vial

y Suggested for emegency kit

1 ml of 3 to 4 ampules

Primary noninjectable : oxygen(O2)

y Most useful y Supplied variety of sizes y Recommended E cylinder

provide 02 for approx 30 minutes y Therapeutic indication

y In any emergency situation n which

Respiratory distress is evident, like .

y Contraindicated:
y Rx of hyperventilation

y Suggested for emergency kit

Primary Noninjectable Drug Drug of choice : Alternative drug : Nitrogylcerine Amyl nitrite

Vasodilator

y Drug Action: y Coronary and systemic vasodilator - decreases peripheral vascular resistance and preload
y Decreases cardiac workload and oxygen demand

on the heart

y y y y y

2 varieties of available: tab and spray Amyl nitrite-inhalant form-act in 10 sec Applied subligually Onset of action: 1 to 2 mins Shelf life: once exposed to air , is short (abt 12 weeks), stored in pill box

y Therapeutic indication
y y y y

Chest pain Definitive m/o angina pectoris Early m/o actue myocardial infarction m/o acute hypertesive episodes hypotensive patient

y Contraindication:
y

y Sildenafil(viagra) create drug-drug

interaction y Availability
y y

Nitroglycerin tablets , 0.15, 0.3,0.4, 0.6 mg sublingual tablet & 0.4 , 0.8 mg/ dose nitroglycerin spray.

y 1 bottle of metered translingual

nitrogylcerin spray (0.4 mg

Primary noninjectable: bronchodilator

Drug of choice : Alternative drug : Albuterol(salbutamol) Metaproterenol

adrenergic agonist
y

Brochial muscle-relaxing properties with little/no stimulatory action on the CVS & GIT

y Onset of action within 5 min and last

for 2-4 hrs y Therapeutic indication:

y y

To treat brochospasm (acute asthmatic episodes) Allergic reactions with brochospasm

Contraindicatied : in patients with preexisting tachydysrhythmias from prior use of the drug Dose: 2-4mg oral, 100-200 mue g by inhalation Availability: Albuterol inhalers Metaproterenol inhalers Suggested for emergency kit: 1 metered albuterol inahaler

Primary noninjectable drugAntihypoglycemics

Drug of choice : Alternative drug : orange juice soft drink (non diet)

y Therapeutic indications:
y

Hypoglycemic states secondary to DM or fasting hypoglycemia in conscious pt Emergency m/o unconscious pt: in absence parenteral medication

y No side effect y Availability:

y

Glucola, insta-gulcose, fruit juices

Primary noninjectable drug antiplatelet

Drug of choice : aspirin
 Action: inhibits TxA2 production &has

antithrombotic effects lasting > 3 days  Therapeutic indication Patient with suspected myocardial infarction or unstable angina  Contraindicated



in recent bleeding ulcer and h/o aspirin allergy

 Availability: 65, 81, 162, & 325mg tablets  Suggested for emergency kit : 3 or 4 chewable

aspirin ( 162mg)

Oral surgery in patients on anticoagulant therapy(aspirin)

(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:57-64)

y Precaution
y

For uncomplicated forceps extraction of 1 to 3 teeth, there is usually no need to interfere with aspirin treatment In patients receiving up to 100mg daily, bleeding during oral surgical procedures is controllable with suturing and direct packaging. with gauze, resorbable gelatin sponge, oxidized cellulose, or microfibrillar collagen. In patients receiving higher doses of Aspirin, - bleeding time > 20 minutes - surgery should be postponed if emergency surgical treatment is needed :medical advice should be sought to discontinue the use of aspirin intake 7 days before oral surgery procedures

Emergency equipment
y O2 delivery system
y y y

Positive pressure Bag- valve-mask device Pocket mask

Oxygen delivery systems y Types

y Positive pressure mask y Bag

valve mask device y Full face mask y Pocket mask

y Suggested for kit

y One portable cylinder with positive pressure mask y One portable self

inflating bag-valve-mask device y Minimum of one child, one small adult and one large adult full face mask y One pocket mask

y Syringes:

y Suction and aspirating apparatus

Magill intubation forceps

y Blunt ended scissors with

right-angle bend y Aids in placement of endotracheal tube during nasal intubation y Suggested for emergency kit
y 1 pediatric size

Tourniquet
y Types
y Rubber or Velcro tourniquet y Rubber tubing y Sphygmomanometer

y Suggested for emergency kit

y 3 tourniquet y 1 Sphygmomanometer

Automated external defibrilator

MODULE TWO: Secondary (Noncritical) Emegency Drugs And Equipment

Secondary injectable drug ANTICONVULSANTS

Drug of choice : Drug class: Alternative drug : Midazolam Benzodiazepine Diazepam

y Seizure disorder may occur in the

dental office under several circumstances. y Including epileptic seizures, overdose reaction to LA, obstructive airway in an unconscious patient, and febrile convulsion, y Midazolam preferred over diazepam because its lack of water solubilitylimited iv use

y Therapeutic indication:
y y y y

To treat prolonged seizures Local anasthetic- induced seizures Hyperventilation Thyroid storm

y Side effects Respiratory depression

or arrest y Availbility
y y

Midazolam : 5mg/ml in (1,2,5, and 10 ml vial) and 2ml preloaded syringes 1mg/ml in (2ml ampules and 10ml vials) and in 2ml preloaded syringes Diazepam : 5mg/ml (2ml ampules and 10ml vials) and 2ml preloaded syringes one 5ml vial of midazolam(5mg/ml)

y Suggested for emergecy kit:

y

Secondary injectable drug analgesic

Drug of choice : Drug class: Alternative drug : Morphine sulphet Opioid agonist Meperidine

y Action of opioid agonist y Therapeutic indication

y y y

Intense, prolonged pain or anxiety, acute myocardial infarction and congestive heart failure

y Side effects: CNS and RS depressants y (recent year n2o -o2 are used)

y Precaution:
y y

Infant and elderly are more susceptible to respiratory depressant action of morphine Dangerous in pt with respiratory insufficiency, sudden death have occurred

y Conraindicated in head injury y Availability:

y y

Morphine sulfate 8,10,and 15mg/ml (in 2 ml ampules and 20 ml vials Meperidine : 50 100 mg/ml (in 1ml ampules and 20 and 30 ml vials

y Suggested for emergecy kit:

y y

10mg/ml of morphine sulfate two 2ml ampules 50mg/ml of meperidine 2ml ampules

Secondary injectable drug vasopressor

Drug of choice : phenylephrine

y MOA :

receptor agonist y Onset of action:

y methaxone y Imdiate after IV administration and persist for 1 hr y After IM : 15 min, persist for 90 min y Phenylephrine: y 5mg IM dose : SBP to elevate 30mmHg, where DBP 20mmHg and response for last 50min

y Therapeutic indication:
y

y y y y y

To manage hypotension, in which the status of the pt s heart is unknown and the intent is to raise the BP without undue cardiac stimulation Syncopal reactions Drug overdose reactions Postseizure states Acute adrenal insufficiency Allergy

y Contraindicate in pt with high BP/ventricular tachycardia y Precaution: hyperthyrodism, bardycardia, partial heart block, myocardial disease, or severe atherosclerosis y Availability:
y

Phenylephrine 10mg/ml (1 ml ampules)

Secondary injectable drug antihypoglycemic

Drug of choice : Dextrose, 50% Solution Alternative drug : Glucagon
y Helps in management of low blood

sugar (hypoglycemia)

y Therapeutic indication:
y y

Antihypoglycemics hypogylcemia Diagnostic aid in unconsciousness or seizures of unknown origin.

y Side effects: may produce tissue necrosis

if extravascular infiltration occurs

y Glucagon administeretd

either via IV or IM routes y Availability

y y

50% dextrose in 50ml glass ampules Glucagon : 1mg of dry powder with 1 ml of diluent and 10mg of dry powder with 10ml of diluent.

y Suggested for emergency

kit: 50% dextrose (12vial),1mg/ml of glucagone

Secondary injectable drug corticosteroid

Drug of choice : Hydrocortisone sodium succinate drug class : adrenal glucocorticosteroid

y Onset of action: slow y Therapeutic indications

y y

Definitive m/o acute allergy Rx of acute adrenal insufficiency

y Availability:
y hydrocortisone sodium succinate

50

mg/ml (2ml vial)

y One 2ml vial

Secondary injectable drug antihypertensive

Drug of choice : Drug class: Alternative drug :
y MOA:
y

Esmolol
1 adrenergic blocker

propranolol

(cardio selective) receptor blocking agent with a very short duration of axn. Acute hypertensive episodes For m/o intra and postoperative tachycardia and hypertension bradycardia, Heart block, cardiogenic shock 10mg/ml in 10ml vial

1selective adrenergic

y Therapeutic indications
y y

y contraindication:
y

y Availability
y

Secondary injectable drug

parasympathetic blocking agent
Drug of choice : Drug class:
y

Atropine
anticholinergic

y Therapeutic indications
To treat bradycardia & haemodynamically significant bradydysrhythmias over dose can produce hot , dry skin, headache, blurred vision, dry mouth & throat, hallucination

y Side effects:
y

y Contra indicated in narrow angle glaucoma: y Availability

y 0.5mg/ml vials- IM y 1mg/ml in 10ml preloaded syringe-IV

Secondary non-injectable drug

respiratory stimulant
Drug of choice : Drug class:
y MOA:
y

Aromatic ammonia
respiratory stimulant

which irritates MM of URT Stimulates respiratory and vasomotor centre of medulla Resp Bp Movement of hand and leg Rx respiratory depression

y y

y Therapeutic indications
y

y Precaution : in COPD/ Asthma- precipitate

brochospasm y Availability: silver-gray vaporoles containing 0.3ml of aromatic ammonia. y 1 or 2 boxes of vaporoles,

Secondary non-injectable drug

antihypertensive
Drug of choice : Drug class: Alternative drug :
y y

Nifedipine
ca channel blocker

nitrogylcerine

y Therapeutic indication:
Hypertension, Acute anginal pain 10mg and 20mg capsules

y Availability:
y

y Sug for emer: One bottle of 10mg

capsules

Secondary emergency equipments

y Scalpel and cricothyrotomoy needle

y Suggested for emergency kit

y One scalpel with a disposable blade and one

cricothyrotomy device

Artificial airways
y Suggested for emergency kit
y One set each of adult and

pediatric airway

Nasopharangel airway

Laryngeal mask airway (LMA

Advanced airway devices

y Suggested for emergency kit
y One laryngoscope and adult and pediatric size

endotracheal tubes

ACLS essential drugs(advanced cardiovascular life support)

y Epinephrin y Oxygen y Lidocain y Atropin y Dopamin y Morphin sulfate y verapamil

ACLS essential: Antidysrhythmic

Drug of choice : Drug class: Alternative drug : lidocaine(xylocaine)
LA, antidysrhythmic

procainamide

y Therapeutic indication:
y

y y

Premature ventricular contraction occur >6 times/min sustained ventricular tachycardia with pulse Ventricular fibrillation increase dose - Myocardial, circulatory, and CNS depression More sever overdose- tonic clonic seizure

y S/E:
y

y Avaibility:
y y

50 or 100 mg (5ml prefilled syringes) 100mg- 5ml ampule One 100mg preloaded syringe, 5ml ampules

y Suggest for emergency kit:

y y

ACLS essential: symptomatic hypotension

Drug of choice : Drug class: Alternative drug : dopamine
sympathomimetic amine

dobutamine

y Chemical precursor of epinephrine y MOA:

y in large (stimulates both

& receptors y small dose (dilates renal , mesenteric and cerebral arteries,)

y Therapeutic indication:
y

To treat haemodynamically significant hypotension in the absence of hypovolemia

y S/E:
y y y

it increase HR induce supraventicuar or ventcular dysrhytnmias Myocardial ishcmieaNausea, vomiting

y Avaibility:
y

200, 400, and 800mg in 5-ml ampules

y One or two ampules of 400mg

dopamine (80mg/ml)

ACLS essential:
paroxymal supraventicular tachycardia
Drug of choice : Drug class: Verapamil
Ca channel blocker

y Therapeutic indication:
y

Used primarily to treat

paroxysmal supraventicular tachycardia,

MAO-slows conduction through the atrioventricular node

y S/E: y transient decrease arterial pressure y Contraindicated in ventricular tachycardia y 2.5mg/ml in 2ml and 4ml ampules y One or two 4ml ampules

Anti dotal drugs

Anti dotal drugsOpioid antagonist

Drug of choice : Drug class: Alternative drug :
y MOA:
y

Naloxone
Thebaine derivative

Nalbufine

It reverses other properties of opioids, like analgesia and sedation

y Therapeutic indication:
y Use in opioid induced depression, including

respiratory depression

y S/E: y Recurrance rs depression may be observed if the opioid previously administerd in longer duration so give second dose IM after IV y Adult: 0.4mg/ml in 1-ml ampules and 10ml vials y Pediatric: 0.02mg/ml in 2ml ampules

Anti dotal drugsbenzodiazepine antagonist

Drug of choice : Drug class: flumazenil
benzodiazepine antagonist

y Uses: y Its reduce the duration of anterograde amnesia associated with midazolam (frm 121 min to 91 min) y Use to reverse the clinical actions of parenterally administered benzodizepines

y 0.1mg/ml in 5ml and 10ml multidose

vials y One 10ml multidose vial of flumazenil

Anti dotal drugsantiemergence delirium

Drug of choice : Drug class: physostigmine
Reversible Anticholinesterase

y Emergence delirium:
y

Pt appear lose contact with reality, increase muscular movement and may seem to speak but make only unintelligible sound. Scopolamine and benzodiazepines most likely produce this phenomenon reversible anticholinesterase that can cross BBB

y MOA:
y

y Therapeutic indication: y To reverse the emergence delirium

y S/E: bradycardia and hyper

salivation y Contra Indication:

y Asthma , DM, CVS Ds,

mechanical obstruction of GIT

y 1mg/ml in 2ml ampules y 2 or 3 ampules

Anti dotal drugsVasodilator

Drug of choice : Drug class: procaine
local anesthetic

y uses: y To manage vasospasm and compromised circulation following intra-arterial drug injection y To manage pain and vascular compromise following extra vascular administration of irritating drugs

y 1%(10mg/ml) solution in 2ml and

6ml ampules y 2 ml ampules

Other important drugs y Injection Lasix (Frusemide)

y Indications
y Renal failure y Pulmonary edema y Forced diuresisi in the treatment of barbiturate

poisioning

y Available
y 10 mg / ml in 2ml ampule

y Dose
y 20mg IV / IM

y Sodium bicarbonate y Indications

y Following cardiac arrest y Correction of metabolic acidosis

y Dose
y 1mEq / kg as IV bolus

y Available as 10ml ampule containing 7.5% solution

y Aminophylline y Indications
y Bronchial asthma

y Dosage
y 12.5 mg / min IV (250 mg diluted in 250cc of sterile

water)

y Availability
y 250mg / 2 ml in 10ml vial

y Calcium gluconate y Indications

y After massive blood transfusion y Cardiac arrest y As a coagulant

y Availability
y 10 ml ampule with 10% w/v (1gm)

y Dosage
y 100-200mg /kg

Other equipments
Defibrillators ECG

Other essentials
y Alcohol sponges y IV infusion sets y IV catheters y Disposable gloves y Crystalloids
y NS y DNS y RL

Conclusion

References:y Essentials of Medical Pharmacology - KD Tripathi y Pharmacology and Pharmacokinetics - Satoskar y Medical Emergencies in the dental office- Stanley f.

Malamed y Principles and practice of medicine- Davidson s y Principle of contemporary Peterson y The pharmacological basis of therapeutics y Goodman and Gillman s