Medical emergencies do, can and will occur in any dental practice, oral health professionals need to know how to diagnose and manage any such situation when required.

1. Medical Emergencies in the
Dental Practice

2. • A medical emergency could evolve into a life-
threatening emergency without proper
treatment.
• Local anesthesia - backbone of pain control
• Adverse events can occur before, during or
after administration of local anesthesia.

3. “Dental practitioners who employ local
anesthetic agents should be well versed in
diagnosis and management of emergencies
which may arise from their use. Resuscitative
equipment, oxygen and other resuscitative
drugs should be available for immediate use.”

4. How to prep
• Medical History
• Resuscitation training
• Equipment
• Drugs

5. Equipment – age appropriate
1. Oxygen cylinder, regulator and associated
equipment suitable for delivering high flow
oxygen
2. Bag mask device with oxygen reservoir

6. 3. Syringes and needles for administering drugs
4. Spacer device to deliver Salbutamol

8. Oxygen
• Medical use - Almost any type of medical
emergency
• DOSAGE: At least 8-10 liters/minute for
patient
• CAUTION: Do not use with hyperventilation

9. Epinephrine
• Cardiac stimulant/anaphylaxis—activates alpha and beta-
adrenergic receptors increasing heart rate, myocardial
contractility, bronchial dilation and decreases peripheral
vascular resistance
• Medical uses - Anaphylaxis, Superficial bleeding
• Mechanism of action
– Lungs - Increases respiratory rate
– Heart – Increases heart rate
• Routes- IM

10. Nitroglycerin/Glyceryl trinitrate
• Antianginal—stimulates cGMP production which
relaxes vascular smooth muscle specifically in the
coronary arteries in the presence of an anginal attack
• Medical uses – Angina, Acute Myocardial Infarction,
Severe Hypertension, Acute Coronary Artery spasms
• Mechanism of action – Dilates blood vessels
• Routes – oral, sublingual, topical, IV

11. Diphenhydramine
• Antihistamine—antagonizes histamine at the H-1
receptor, causes sedation and has an
anticholinergic effect
• Medical use - Allergic reaction/anaphylaxis
• Routes – IM / IV

12. Albuterol / Salbutamol
• Bronchodilator: stimulates beta-2 adrenergic
receptors causing bronchodilation
• Medical uses – Asthma
• Routes - Inhalation

13. Aspirin
• Antiplatelet—inhibits prostaglandin synthesis
and inhibits platelet aggregation irreversibly
• Medical uses - Suspected myocardial
infarction
• Routes – Oral

14. Oral carbohydrate / Glucose
• Antihypoglycemic—increases glucose level
• Medical use – Hypoglycemia
• Routes- (glucose gel (InstaGlucose) , Oral

15. Medical emergency
situations

16. • Anaphylaxis
• Angina & Myocardial infarction
• Asthma
• Choking & Aspiration
• Epilepsy
• Syncope
• Hypoglycaemia
• Hyperventilation (Anxiety associated)

17. Anaphylaxis
• Severe potentially life threatening
hypersensitivity reaction to AN ANTIGEN.

18. • Presentation: Upper airway (laryngeal)
oedema and bronchospasm and low blood
pressure may develop.
• Symptoms may be severe collapse and
cardiac arrest.

19. • Symptoms:
–General - A sense of impending doom
–Skin / mucosa - Wheals and itching
(urticaria), flushing (erythema), runny nose
(rhinitis), conjunctivitis

20. –Breathing - Difficulty breathing, noisy
breaths (stridor), wheezing and/or hoarse
voice, respiratory arrest
–Cardiovascular - Low blood pressure, rapid
pulse, cardiac arrest
–Gastrointestinal - Abdominal pain, vomiting,
diarrhoea

22. Management
1. Stop
administration of
any IV meds
2. Start Basic Life
Support procedures
(ABCD)
3. Lay the patient
flat, legs elevated
4. Administer oxygen at rate of
8-10L per minute (delivered via
a mask and reservoir bag)
5. If available administer
isotonic saline IV
6. If marked airway,
breathing or circulation
symptoms then administer
1:1000 adrenaline IM
(anteriolateral aspect of
centre of thigh)

23. 1:1000 Adrenaline emergency doses
Age Dose
<6yrs 0.15mL (150 micrograms)
6-12yrs 0.3mL (300 micrograms)
>12yrs 0.5 mL (500 micrograms)

24. • Repeat adrenaline administration if no
improvement in symptoms at 5 minute
intervals depending on respiratory function,
pulse and blood pressure.
• Maintain Basic Life Support procedures (Drs
ABCD) until help arrives.

25. Angina and myocardial infarction
• Symptoms
– Pallor
– ‘cold sweat’
– chest pain
– shortness of breath
– changes in heart rate
– increased respiratory
rate
– low blood pressure
– Confusion
– loss of consciousness
Severe - (indicative of a
MI):
• severe, crushing pain in
the centre and across
the front of the chest
• pain may radiate into
shoulders, arms, neck
and jaw
• Shortness of breath
• weak pulse
• falling blood pressure
• nausea
• vomiting

26. • For mild symptoms in patients previously
diagnosed with angina
– Administer glyceryl trinitrate, 400 micrograms
(spray or tablet).
– If there is no (or only partial) resolution of
symptoms repeat glyceryl trinitrate, 400
micrograms (spray or tablet) after 5 minutes.
– If symptoms persist treat as for ‘severe symptoms’.

27. • Severe symptoms
– Call for medical help immediately.
– Position the patient for their comfort and reassure
– Administer glyceryl trinitrate, 400 micrograms
(spray or tablet)
– Administer aspirin 300 mg orally.
– Administer oxygen (8-10L per minute delivered via
a mask and reservoir bag) if the patient is
cyanosed or if level of consciousness deteriorates.
– If loss of consciousness start BLS procedures
– When medical assistance arrives tell them what
drugs you have administered

28. Asthma
• Asthma is a chronic inflammatory disease of
the airways with spasm and narrowing leading
to obstruction to air flow.
• Patient administered bronchodilator
medication

29. • If no response to medications or symptoms worsen
(breathing rate slowed, heart rate slowed, cyanosis
developed etc)
– Call for help
– Administer salbutamol (10 activations) through
the large volume spacer device, repeat at 10
minute intervals as necessary
– Give oxygen (8-10 litres per minute delivered via a
mask and reservoir bag).
– The salbutamol should be repeated at 10 minutes
until assistance arrives.
– If the patient becomes unresponsive start BLS

30. Choking and aspiration
• Remove any visible obstruction.
• Encourage patient to cough
• Back-blows / chest thrust
• Hospital referral if the object remains and/or
the symptoms persist.
• Unconscious - CPR and call for help.

34. Epilepsy
• Protect patient
• Do not attempt to restrain them or attempt to
place anything between their teeth.
• Administer oxygen at 8-10 litres per minute
delivered via a mask and reservoir bag per
minute.
• Post-seizure place in the recovery position and
monitor
• If unconscious commence Basic Life Support
• During recovery active supervision and support.

36. Fainting (Syncope)
• Transient loss of consciousness due to
inadequate blood flow to the brain.

37. Presentation
• Feeling of light headedness or dizziness
• Pallor
• ‘cold sweat’
• slowing of pulse
• low blood pressure
• nausea and vomiting
• loss of consciousness

38. • Management:
– Lay the patient down flat and elevate the legs
– Loosen tight clothing around the neck.
– Administer oxygen (8-10 litres per minute
delivered via a mask and reservoir bag.).
– Reassure patient when they regain consciousness.
– If the patient does not regain consciousness
promptly commence Basic Life Support
procedures (Drs ABCD).

39. Hypoglycaemia
• Blood glucose levels below 3.0mmol/L
• Acute hypoglycaemia may clinically occur in
patients who have diabetes and who fail to
eat after taking insulin.

40. • Presentation:
–Symptoms can be non-specific and include
• Hunger
• Trembling
• Sweating
• slurring of speech
• difficulty concentrating
• agitation and confusion
• Headache with progressive drowsiness
• seizures and unconsciousness

41. • Management:
–Hypoglycaemia in conscious patients can
usually be reversed with rapid acting oral
glucose (eg. glucose powder dissolved in
water, sugar – sucrose) which can be
repeated after 10 minutes.

42. • The oral glucose should be followed by food
high in carbohydrate as the patient recovers.
• The patient should be actively supervised until
fully recovered, they should not drive and
they should be accompanied home.

43. • If the patient is unconscious or uncooperative,
glucagon if available can be given via the IM
route – 1mg for adults and children over 8
years of age of who weigh more than 25kg

44. • 0.5mg for children under 8 years or weighing
less than 25kg.
• If glucose cannot be administered or if the
administration of glucose is ineffective then
Basic Life Support procedures (Drs ABCD)
should commence immediately.

45. Hyperventilation (anxiety associated)
Prolonged rapid breathing
Fall in arterial carbon dioxide
Acute respiratory alkalosis
Cerebral vasoconstriction
Loss of consciousness

46. Hyperventilation
• Reassure and calm
the patient.
• If the patient loses
consciousness
commence Basic Life
Support procedures
(DRS ABCD).

47. References
1. Resuscitation Council (UK) Emergency
treatment of anaphylactic reactions.
Guidelines for healthcare providers January
2008.
2. http://www.dentistrytoday.com/emergency-
medicine/6767-emergency-drug-kit-
strategies-for-the-dental-office