Dental Emergency Drugs and Dosages

• Most common medical emergencies occur in the dental setting.

Emergency Drugs Kit

• Emergency kits should be present with drugs and dosages that are known.
• Emergency drugs in the kit: GTN, Adrenaline, Midazolam, Oxygen, Aspirin, Glucagon, Glucose and Salbutamol

Emergency Drugs in the Dental Practice

• Adrenaline: For anaphylaxis, administer 500 micrograms (0.5ml of 1:1000) IM for adults, may repeat every 5 minutes until adequate response.
• Adrenaline: For children under 6 years is 150 micrograms (0.15ml of 1:1000) IM, for 6-12 years use 300 micrograms (0.3ml of 1:1000) IM and over 12 years give the adult dose.
• B2 bronchodilator (Salbutamol inhaler): Use if asthma attack, administer 2 actuations, using a spacer. Doses can be repeated for adults and children.
• Glyceryl Trinitrate Spray: For angina or suspected heart attack, give 2 actuations sublingually, may be repeated.
• Dispersible Aspirin: For suspected heart attack, administer 300mg (chewed).
• Glucose: Patient must be cooperative and able to swallow safely, administer 15-20g quick acting glucose e.g. 1.5 - 2 tubes of Glucogel or 4-5 Glucotabs®.
• Glucagon: When patient unable to swallow safely administer 1mg IM.
• Midazolam: For prolonged convulsive seizures, give a single dose of 10mg via buccal route.
• Midazolam: For children 1-5 years use 5mg, 5-10 years use 7.5mg, and 10-18 years use 10mg.

Key Features of Dealing With Medical Emergencies

• Keep calm.
• Reassure the patient.
• Lead and/or support.
• Monitor and record.

Choking/Foreign Body Airway Obstruction

• Signs: Coughing, struggling to breathe, grasping for the throat, cyanosis.
• Symptoms: Patient unlikely to be able to explain.
• Triggers: Eating/drinking, tablets, neurological or cerebral impairment, reduced ability to swallow (cancer treatment, Parkinson's), lunchtime.
• Management: Assess severity and manage. Assess if mild airway obstruction (effective cough) or severe airway obstruction (ineffective cough).
• Prevention: Risk assessment, taking a history, and use of rubber dam.

Anaphylaxis

• Signs: Sudden onset, angioedema (swelling), flushing, urticaria (rash), respiratory distress, stridor/wheezing, hypotension, tachycardia (increased heart rate).
• Symptoms: May complain of itchiness, difficulty breathing, feels tongue or face swelling up.
• Triggers: Known allergy (food, drugs, latex) or unknown.
• Management: ABCDE, remove trigger, call for help, lie flat/elevate legs, give O2 15L/min, intramuscular injection of 500mg/0.5ml for adults, repeat after 5 mins until an adequate response.
• Prevention: Risk assessment, taking a history, preparation, communicate with team.

Issues with Adrenaline Auto-Injectors (AAI) and Anaphylaxis

• The recommended needle length for IM injections is 25 mm (a blue 23G 25 mm needle) for all ages.
• In anaphylaxis, healthcare professionals should be administering the recommended dose of adrenaline for a patient over 12 years of age, which is 500 mcg.
• An AAI should only be used if it is the only available adrenaline preparation when treating anaphylaxis in a healthcare setting.

Asthma

• Signs: Difficulty breathing, expiratory wheezing, breathlessness, fast pulse, RR > 25/min, Pulse >110/min or life threatening emergency 999: cyanosis, exhaustion, reduced level of consciousness, RR<8/min , Pulse <50/min.
• Symptoms: May start saying cannot breathe, may look for inhaler, exhaustion.
• Triggers: Allergy, fear, stress, extreme weather, pollutants.
• Management: ABCDE, assess situation if life threatening, if able, sit upright and support patient in having 2 puffs of Salbutamol (continue to maximum of 10 puffs over 2 mins), provide O2 15L/min and if no improvement call 999 SBAR.
• Prevention: Risk assessment, taking a history, preparation, communicate with team.

Epilepsy

• Signs: May lose consciousness, cry out as if in pain, body becomes rigid, noisy breathing, jerking movements, frothing at mouth, incontinence.
• Symptoms: May say they can smell flowers and may feel an aura.
• Triggers: Fear/stress, brain injury, alcohol, alcohol withdrawal, raised body temperature, meningitis, brain tumours.
• Management: ABCD, clear instruments away and if in dental chair place in supine or ease patient to floor so that they are laying down and place a cushion under head, do not restrain or put anything in their mouth, call for help and time the seizure, call 999 if mores than 5 mins and give O2 15L/min.
• Prevention: Risk assessment; taking a history, preparation, and communicate with team.
• Once the Seizure has finished: Do not undertake further dental treatment that day, Allow time for the level of consciousness to return, Do not attempt to restrain the patient, as he or she might be confused, Do not allow the patient to leave the practice until you are sure they have made a full recovery, Contact the patient's family, if he or she is alone, Do a brief oral examination for sustained injuries. And, depending on post-ictal state, discharge the patient home with a responsible person, to his or her family physician or call the emergency services.
• Remember: Never put your fingers or anything in their mouth to try and prevent them biting their toungue - as this will cause serious injury; Do not try and move them unless they are in immediate danger; Do not restrain their movements whilst fitting; Do not give them anything at all to eat and drink until fully recovered; And, Never 'bring them round.'

Faint/Syncope/Vasovagal Attack

• Signs: Pale, sweating, slow pulse and low BP
• Symptoms: Complains about feeling dizzy, light headed and feeling sick/nausea.
• Triggers: Fear, stress and hunger
• Management: ABCDE, Lie flat, elevate legs, offer glucose drink once consciousness regained. If slow recovery reconsider diagnosis, Unresponsive check for signs of life.
• Prevention: Risk assessment, taking a history, preparation, communicate with team.