Emergency Drugs and Equipment

By Stanley F. Malamed, DDS

Office preparation is essential for the prompt recognition, and successful management, of medical emergencies that do arise in dental offices. Though most medical emergency situations can be successfully managed without the need for drug administration, for example, syncope and seizures, others do require their administration. Examples include bronchospasm, angina, hypoglycemia, and myocardial infarction.

Almost all states and provinces have lists of mandatory emergency drugs and equipment for dentists who have received permits to administer general anesthesia, parenteral moderate sedation and, increasingly, enteral (oral) moderate sedation for either children and/or adults. Some states are considering and implementing emergency drug and equipment lists for those dentists using local anesthesia.

Following are this author’s suggestions for the basic emergency drugs and items of equipment needed in the well-equipped dental office. Following this will be items of secondary importance and drugs indicated for specific situations (eg, sedation).

Basic Emergency Kit

Epinephrine 1:1,000

Epinephrine represents the most important drug in the emergency kit. Though (hopefully) rarely used, it must be available for administration as soon as possible in the event of an anaphylactic reaction (see Dr. Reed’s article on page 126). Epinephrine (adrenaline) administered rapidly in anaphylaxis has a number of properties that act to save lives in this situation: (1) epinephrine is a potent bronchodilator, reversing bronchospasm (frequently seen in anaphylaxis); (2) it elevates blood pressure and stimulates the myocardium, increasing heart rate, both of which counteract the vasodilation common in anaphylaxis; (3) additionally, in the event of edema formation, epinephrine prevents any further edema from developing that, if intraoral, could lead to airway obstruction or occlusion.

Indication: Anaphylaxis

Dose: 0.3 mg IM q5 minutes until patient recovers or help arrives on scene to take over management.

Contraindication: There are no contraindications to epinephrine administration in anaphylaxis.

Recommendation: Minimally one (preferably two) preloaded, self-injecting syringe, plus two 1-mL ampules of epinephrine 1:1,000.

Injectable Histamine-Blocker/Diphenhydramine HCl

A histamine-blocker is also administered in the allergic reaction. Its primary indication is the very common non-life-threatening allergy (itching, hives, rash). A histamine-blocker is also administered in anaphylaxis following epinephrine administration.

Indication: Allergy

Dose: 50 mg IM or IV

Contraindication: There are no contraindications to diphenhydramine administration in an allergic reaction.

Recommendation: Two 1-mL ampules or vials of diphenhydramine HCl (Benadryl™) 50 mg/mL.

Oxygen

Oxygen (O₂) is the second most important drug “in” the emergency kit. The “E” cylinder of O₂ will not physically be located in the emergency drug kit, being of considerable size, but it must be readily available for administration in any emergency situation. It is recommended that, if possible, the emergency drug kit be attached to the O₂ cylinder.

Indication: Almost any emergency situation. Oxygen may not make the victim better, but it will not make their condition worse (see contraindication below for one exception).

Dose: As needed by victim.

Contraindication: Oxygen administration is contraindicated in hyperventilation.

Recommendation: One “E” cylinder of oxygen with regulator and the equipment necessary to deliver O₂ to the victim (see Equipment later in this presentation).

Nitroglycerin

Nitroglycerin sublingual (SL) tablets or MDI (metered dose inhaler) are used in management of acute episodes of angina pectoris (see Dr. Becker’s article on page 124). The author prefers the MDI for its extended shelf-life (years) as compared to the bottle of SL tablets (weeks). The cost of the MDI, however, is considerably greater than a bottle of SL tablets. Patients with angina will commonly have their own nitroglycerin on their person. This dose should be administered initially, with the emergency-kit nitroglycerin being used secondarily in case the patient’s nitroglycerin is ineffective or they do not have it with them.

Indication: Chest pain of anginal origin (patient has a history of angina) or a first-ever episode of chest pain.

Dose: The usual dose of nitroglycerin is one to two sublingual tablets or one to two puffs from the MDI administered q5m.

Contraindication: Signs and symptoms of low blood pressure—for example, lightheadedness, dizziness, or a systolic BP of less than 100 mm Hg.

Recommendation: One MDI of nitroglycerin (Nitrolingual Spray™) or one bottle of sublingual tablets (Nitrostat™). The usual dosage form is 0.4 mg per tablet or puff.

Bronchodilator/Albuterol

A bronchodilator is necessary in management of the acute asthmatic attack (bronchospasm). Though epinephrine is an excellent bronchodilator (see above), its administration in asthma is relegated to that of a back up to albuterol in the event that drug is ineffective in terminating the bronchospasm (eg, status asthmaticus). Albuterol is an effective bronchodilator (as is epinephrine) that does not normally produce any significant undesirable stimulation of the cardiovascular system (eg, increased BP and heart rate) as occurs when epinephrine is used. Patients with asthma usually have their own (MDI) bronchodilator with them at all times. The patient’s should be used first, with the emergency-kit bronchodilator being used in case the patient failed to bring theirs.

Indication: Bronchospasm (acute asthmatic attack).

Dose: As needed by victim. Usually one to two puffs per dose

Contraindication: There are no contraindications to albuterol MDI in acute episodes of bronchospasm.

Recommendation: One albuterol MDI (ProAir™, Proventil™, Ventolin™). A spacer should be available to aid in administration from the albuterol MDI in children and some adults (see Equipment below).

Aspirin

Aspirin is a thrombolytic drug used to limit enlargement of the blood clot occurring in a coronary artery during a myocardial infarction and has been associated with decreased mortality rates in a number of clinical trials. One adult, non-enteric, coated aspirin tablet is chewed and swallowed.

Indication: Suspected myocardial infarction (see Dr. Becker’s article on page 124).

Dose: One 325-mg non-enteric, coated aspirin tablet, chewed and swallowed along with 8 ounces of water.

Contraindication: Aspirin should not be administered to persons who are known to be allergic to it or have active gastrointestinal hemorrhage.

Recommendation: One or two packets of chewable 325-mg non-enteric, coated aspirin.

Antihypoglycemic Aids

Several forms of “sugar” should be available in the dental office for prevention or management of hypoglycemia (low blood sugar). A 12-ounce bottle of orange juice or a non-diet cola beverage may be kept in the office refrigerator; however, it is strongly recommended that a “medical” form also be available as all too often the juice or soft drink is missing when needed.

Indication: The administration of “sugar” represents definitive management of hypoglycemia. Though most apt to be noted in type-1 diabetics, low blood sugar can happen to anyone, not uncommonly to healthy but dental-phobic men.

Dose: One 12-ounce bottle of orange juice or non-diet soft drink, or one tube of glucose gel.

Contraindication: Depressed consciousness or unconsciousness.

Never place any liquid or gel into the mouth of an unconscious person.

Recommendation: One tube of glucose gel (InstaGlucose™) and one 12-ounce bottle of either orange juice or non-diet soft drink.

Tailoring the Emergency Kit for Pediatric Patients

For dentists treating children less than 30 kg weight, injectable epinephrine in a preloaded, self-injecting syringe must be available in a 1:2,000 dosage form in addition to the 1:1,000 form for larger patients. Additionally, a “spacer” should be available to aid younger patients receiving the bronchodilator albuterol.

Emergency Equipment

Automated External Defibrillator (AED)

The AED should be a mandatory item of dental office equipment. Implementation of basic life support (P-C-A-B) in sudden cardiac arrest will be ineffective without early defibrillation. AEDs are discussed more fully in Dr. Phero’s article on page 122.

Oxygen Delivery Devices

These should include a nasal cannula, a nasal hood (inhalation sedation “nose piece”), and a full-face mask.

Additional Devices and Drugs

Every dental practice should also have the following items in a convenient place; all team members should know where they are located and be able to collect them quickly in case of an emergency.

Bag-valve-mask (BVM) device (eg, “Ambu-Bag”)
Magill intubation forceps
Syringes for injectable drug administration (eg, two 3-mL plastic disposable syringes with 18- or 20-gauge needle)
Stethoscope and sphygmomanometer with child-size, adult-medium, and adult-large size cuffs.
Wall clock with a second hand

Other “emergency” drugs, considered as secondary (for use by doctors specifically trained in their administration [eg, ACLS]) include:

Aromatic ammonia vaporoles (smelling salts)
Analgesics (injectable), eg, morphine
Anticholinergics (injectable), eg, atropine
Anticonvulsants (injectable), eg, midazolam
Antihypertensives (injectable), eg, metoprolol
Antihypoglycemics (injectable), eg, dextrose 50%
Corticosteroids (injectable), eg, hydrocortisone Na succinate

And lastly, for doctors using either benzodiazepines for sedation or opioids (eg, narcotics) for analgesia, the reversal agents flumazenil (Romazicon) and naloxone (Narcan) are required.

Preparation of the Emergency Drug Kit

Dentists can prepare their own individualized emergency drug kit or purchase a proprietary kit. Both have advantages and disadvantages. Making one’s own emergency drug kit is likely to be less expensive than a proprietary kit, however one must go to the “trouble” of procuring the drugs. Names of companies that can be contacted to purchase drugs and equipment can be found in the “Emergency Kit Supply Resources” sidebar, which can be downloaded by clicking here or viewed by clicking here. Companies selling premade emergency drug kits have programs enabling them to replace emergency drugs that are approaching, but not yet at, their expiration date. Companies presently marketing emergency drug kits to the dental profession are also listed in the sidebar mentioned above.

The emergency drug kit, AED, and “E” cylinder of oxygen should be maintained in an area of the office in which they are readily accessible at all times.

Disclosure

Dr. Malamed is a consultant to the following companies involved in emergency drug kits and devices: Healthfirst Corporation.