Emergency Drugs

Every dentist can expect to be involved in the diagnosis and treatment of medical emergencies during the course of clinical practice. These emergencies may be directly related to dental therapy, or they may simply occur by chance in the dental environment. Although minor medical emergencies occur predictably, a life-threatening emergency may arise as infrequently as once every 10 years. The potential need for acute medical intervention during dental treatment may be increased for those practitioners treating a high percentage of geriatric, special needs, or medically compromised patients, or those using intravenous sedation or general anesthesia. Emergency Drugs Even though many medical emergencies may be properly treated without the use of drugs, every dental office must contain an emergency kit with drugs appropriate to the training of the individual dentist, the patient being treated, and the type of procedures being performed. Obviously, no drug can take the place of a properly trained health professional and support staff in diagnosing and treating emergencies. Nevertheless, the design and/or purchase of an appropriate emergency kit will often play an integral role in dictating the course and outcome of emergency treatment. Besides determining which drugs should be included in an emergency kit, the dentist must understand that it will be necessary to maintain the knowledge base to use them. In the midst of a medical emergency, with the patient by definition in an acutely abnormal or even critical situation, there is no time to begin reading labels, leafing through emergency texts, or administering drugs as suggested by a brochure in the emergency kit. In addition, there is a significant difference between the theoretical knowledge of how to treat an emergency and being able to put such cognitive skills to practical use. Only constant review and training will keep the dental team sharp. Regular continuing education in medical emergencies and review of pharmacology, certification, and recertification in basic life support (BLS), and in some offices advance cardiac life support (ACLS), coupled with emergency drills are the best methods to prepare for emergencies. Without prompt attention to the ABCs (airway, breathing, circulation) of cardiopulmonary resuscitation, drugs are of little value.

a 0. should be attempted by a dentist during a medical emergency is a controversial issue. If any consequence of dental treatment is foreseeable and results in harm. if not the primary. and the purchase of high-quality.The role of drugs and how much intervention. and in what doses to give these specific agents for acutely life-threatening situations. In a review covering the use over a 2-year period of 8500 emergency drug systems purchased by dentists. commercially available emergency drugs kit modified for one's particular needs can provide consistent drug availability (i. Oxygen is a primary. These emergencies include. but are not limited to. In the hypoxemic patient. Mandatory Emergency Drugs There are certain drugs that all dentists must keep readily available in the office in fresh supply for immediate administration (See Table 1 below). The correct approach to the use of drugs in any medical emergency should be essentially supportive and conservative. It is also best to include only one agent for a particular need. Dentists must know reflexively when. Many dentists are not comfortable deciding and purchasing individual drugs for their emergency kits. Emergency drugs are generally powerful. respiratory. rapidly acting compounds. how. especially during an emergency. As a rule. Emergency kits can be either organized by the individual practitioner or purchased commercially. The fewer drugs in an emergency kit. which in turn improves oxygenation of peripheral tissues. the easier it is to know their proper use. a modest increase in oxygen tension can significantly alter hemoglobin saturation in the hypoxemic individual. There is a general tendency to overequip basic dental emergency kits with drugs that are beyond the needs and expertise of many general dentists. breathing enriched oxygen elevates the arterial oxygen tension..75% incidence was reported. periodic drug updating). emergency drug indicated in any medical emergency where hypoxemia may be present. Hypoxemia leads to . Because of the steepness of the oxyhemoglobin dissociation curve. the drugs placed in an office emergency kits should only include those drugs familiar to the dentist. and central nervous systems. liability may be imposed .e. acute disturbances involving the cardiovascular.

however. 0. such as oropharyngeal and nasopharyngeal airways. or mouth-to-mask techniques. The C. . E emergencies where tanks. 690 L hypoxemia may be present Acute allergic reactions Acute asthma (not responding to adrenergic inhaler) Angina pectoris Acute myocardial infarction Ampules: 1 mg Vials: 1 and 30 mg Syringes: 0. Wynn RL. mouth-tonose. self-inflating bag. nasal cannulae.3 and 1 mg Tablets (sublingual): 0.anaerobic metabolism and metabolic acidosis. laryngeal masks. V. Controlled ventilation may be accomplished with the use of a bag-valve-mask device (consisting of a mask. Table 1: Mandatory Emergency Drugs Drugs Oxygen Indications Preparations For use in all medical Steel cylinders (green). endotracheal equipment. and 0. and nonrebreathing valve) or with a manually triggered oxygen-powered breathing device (consisting of a mask connected via a valve activated by a lever and high-pressure tubing to the oxygen supply). 1988. however. St. which often adversely affects the efficacy of emergency pharmacologic interventions. Louis. The oxygen-powered device is easier to use but care must be taken not to inflate the stomach. 0. Each method of providing positive-pressure ventilation requires some practice for effective use. Requa-Clark.4 mg/actuation Epinephrine Nitroglycerin Adapted from: Holroyd SV.15. ed 4. Dental offices should also have the capacity to deliver oxygen via positive-pressure ventilation. Airway adjuncts. Without appropriate training. B: Clinical pharmacology in dental practice.4.3. their use may prove deleterious in an acute emergency.6 mg Spray: 0. Mosby Company Oxygen can be delivered to the spontaneously breathing patient via full face mask. Both techniques. or nasal hood. are preferred over mouth-to-mouth. It is difficult with the bag-valve mask device to provide a seal around the nose and mouth while simultaneously ventilating the patient. and the means of establishing an emergency airway via cricothyrotomy and transtracheal ventilation can be useful or even life-saving in the hands of a trained and experienced health professional.

First. there is little gain in promoting peripheral vasoconstrictions. This statement holds true even for the rare patient whose respiratory drive is dependent on hypoxemia because of chronically elevated carbon dioxide concentrations. Second. Third. Undesirable actions include its tendency to predispose the heart to dysrhythmias and its relatively short duration of action. oxygen should never be withheld during any medical emergency. There are a few clinicians who maintain the mistaken belief that epinephrine is the drug of choice in shock or shocklike states. and increased coronary blood flow. Perpetuation of this condition could be undesirable. decreased diastolic blood pressure (14%).There are absolutely no contraindications to the administration of oxygen in emergency situations. as in peripheral vessels. This could be especially disastrous in the dental office where defibrillation equipment is usually not available. which is already present because of the massive release of endogenous catecholamines (epinephrine and norepinephrine). increased systolic blood pressure (5%). If clinically indicated. Epinephrine The inclusion of epinephrine in a dental office emergency kit is mandatory for the treatment of cardiac arrest and overwhelming anaphylaxis. and its actions on the heart. it is not an issue during clinical resuscitation. Desirable properties of this agent include a rapid onset of action. . Because the peripheral action of epinephrine is primarily on the arterial side. Here. Although oxygen toxicity may occur after prolonged therapy with high concentrations of oxygen. potent action as a bronchial smooth muscle dilator (beta2 properties). vasopressor actions. In early treatment of shock states the patient will benefit more from measures aimed at correction of the primary cause such as hypovolemia rather than misdirected attempts at pharmacologic correction. increased cardiac output (51%). the possible precipitation of ventricular fibrillation in the ischemic and irritable myocardium is an important factor. in shock from almost any cause there is decreased venous return to the heart because of peripheral venous pooling. antihistaminic actions. There are three principal reasons for disputing this belief. However. which include an increased heart rate (21%). At this point administration of epinephrine may further decrease venous return and tissue perfusion. it must be emphasized that these extreme conditions are the only situations that would require its use in the dental office emergency. the blood supply is constricted in a compensatory effort to increase blood flow to the more vital brain and heart tissues. a possible deleterious effect is an increase in selective ischemia that takes place in certain viscera such as the kidney.

In the absence of drug therapy. cerebral blood flow during CPR is minimal. Epinephrine also preserves blood flow to the brain. Following administration of a drug with a-adrenergic properties. Antihistamines act as competitive antagonists of histamine. cardiac arrest). all vital signs must be monitored frequently. They do not prevent the release of histamine from cells in response to injury. most blood enters the common carotid artery and flows into the external carotid branch. 0. Side effects. In the setting of the dental practice. Epinephrine should be used with caution in pregnant women because it decreases placental blood flow and may induce premature labor. The drug can be injected subcutaneously 0. Because of its profound bronchodilating effects. not the internal carotid artery. especially in patient receiving digitalis. both supraventricular and ventricular.6 mL of the same solution. such as epinephrine. Thus. or intramuscularly (for a more serious emergency). but it may induce or exacerbate ventricular ectopy. . Antihistamines will be of value in the treatment of the delayed allergic response and in the definitive management of the acute allergic reaction (administered after epinephrine has terminated the acute life-threatening phase of the reaction). but do prevent access of histamine to its receptor site in the cell and thereby block the response of the effector cell to histamine. and precautions: Tachydysrhythmias. drugs. In effect there are no contraindications to the administration of epinephrine under these conditions. antihistamines are more potent in preventing the actions of histamine than in reversing these actions once they develop. When used. cerebral blood flow is significantly increased. epinephrine will usually be considered for administration in situations that are considered to be life threatening (anaphylaxis.5 mL of a 1:1000 solution.3 to 0.Epinephrine is an important drug during cardiac arrest because no other drug is capable of maintaining coronary artery blood flow while CPR is in progress. Under such situations the advantages of administering this agent clearly outweigh any risk. The intravenous route is also possible.4 to 0. or antigens. may develop. epinephrine must be administered as soon as the condition is diagnosed. which is essential for preserving the chances of survival from cardiac arrest. contraindications. epinephrine is also indicated for the treatment of acute asthmatic attacks unrelieved by b2-adrenergic sprays or aerosols. For the effective treatment of acute allergic reactions. Epinephrine may also be instilled directly into the tracheobronchial tree via an endotracheal tube with good results.

the 0. Tablets remain the most popular form of TNG. Nitroglycerin tablets placed sublingually usually taste bitter and sting. Suspect that the drug has become ineffective if the bitter taste is absent. another vasodilator. Two varieties of vasodilator are available: nitroglycerin (TNG) as a tablet and a spray. and a degree of hypotension (noted especially if the patient is in an upright position). nitroglycerin acts in 1 to 2 minutes. Inactivation of the TNG is more likely to occur in the dental office supply where its use is extremely sporadic. but may be used with some degree of effectiveness in the management of acute hypertensive episodes. Side effects. The shelf life of TNG tablets once exposed to air is quite short (about 6 weeks). During dental care a patient's nitroglycerin source should be readily accessible. which when crushed between one's finger and held under the victim's nose will act in about 10 seconds to produce a profound vasodilation. dizziness. Placed sublingually or sprayed onto the lingual soft tissues.Nitroglycerin Vasodilators are used in the immediate management of chest pain (such as may occur with angina pectoris or acute myocardial infarction). This is not normally a problem with patients most of whom will use a bottle of tablets in 4 to 6 weeks. pounding pulse. although most patients prefer the translingual spray once they have used it. contraindications. This is especially true when the container is not adequately sealed or the tablets are stored in a pill box. Primary Support Drugs . facial flushing. intense headache. The duration of action of amyl nitrite is shorter than that of TNG. and an inhalant. however. nitroglycerin is contraindicated in patients who are hypotensive.3 mL. amyl nitrite. In these cases the active nitroglycerin vaporizes. These include facial flushing. A patient with a history of angina pectoris will usually carry a supply of nitroglycerin. is available for use as an inhalant. but if it is not available or is ineffective. A patient's drug should be used if at all possible. It is supplied in a yellow vaporole or a gray cardboard vaporole with yellow printing in a dose of 0. leaving behind an inert filler. Side effects occur with all vasodilators but they are more significant with amyl nitrite. the shelf life of the vaporole is considerably longer. and hypotension. Amyl nitrite should not be administered to patients who are in an upright position because the patient may feel dizzy and suffer a fall. and precautions: Side effects of nitroglycerin include a transient pulsating headache.4-mg dosage form should be available in the emergency kit. Because of its mild hypotensive actions. Amyl nitrite. Side effects of amyl nitrite are similar to but more intense than those of nitroglycerin.

Vasopressor 4. Antihypertensive 7. particularly in situations where the dentist is familiar with their use and where emergency medical services may not be immediately available. Although it is not mandatory that every dentist include these drugs in the emergency kit. Corticosteroid 6. Secondary Injectable Drugs: Seven drug categories are included in this level: 1. Anticholinergic Noninjectable drugs: There are three noninjectable drugs that are considered at this level: 1. Analgesic 3. they are all useful. Antihypoglycemic 5. Bronchodilator Table 2: Emergency Support Drugs Category Generic Proprietary Alternative Injectables Anticonvulsant Analgesic Vasopressor Antihypoglycemic Midazolam Morphine Methoxamine 50% Dextrose sol. Vasoxyl Versed Diazepam Meperidine Phenylephrine Glucagon . Antihypoglycemic 3. Anticonvulsant 2. Respiratory stimulant 2.Primary support drugs are helpful for treating medical emergencies that are usually not acutely life-threatening.

1991. the degree of postseizure depression is accentuated and its duration prolonged because of the pharmcologic action of the barbiturate. Proventil Procardia Metaproterenol Adapted from: Malamed SF: Sedation: a guide to patient management. hypoglycemic reactions.Corticosteroid Antihypertensive Anticholinergic Hydrocortisone SoluCortef sodium succinate Labetalol HCl Atropine Dexamethasone Normodyne Noninjectables Respiratory stimulant Aromatic Ammonia Antihypoglycemic Bronchodilator Antihypertensive Carbohydrate Decorative icing Albuterol Nifedipine Many Ventolin. When barbiturates are administered to terminate seizure activity. St. Because seizure disorders are characterized by a stimulation of the central nervous and cardiorespiratory and cardiovascular systems. With its introduction. If the doctor is not adapt at recognizing and managing this situation. diazepam became the preferred anticonvulsant. followed by a period of depression of these same systems. Louis. drugs that depress the systems at therapeutic does are more likely to produce postseizure complications. Mosby-Year Book. ed 2. Local anesthetic overdoses or accidental intravascular injection may also require the administration of an anticonvulsant. unlike barbiturates. the patient may be worse off after the seizure than during it. The benzodiazepines. . cerebrovascular accidents. Anticonvulsant Seizures that may require acute medical intervention may be associated with epilepsy. will usually terminate seizure activity without the pronounced depression of the respiratory and cardiovascular systems. Current management of a seizure that interferes with ventilation or persists for longer than 5 minutes includes the use of an intravenous benzodiazepine such as diazepam or midazolam. hyperventilation episodes. or vasodepressor syncope.

contraindications. an agent such as epinephrine will not be the drug of choice. Two such circumstances are acute myocardial infarction and congestive heart failure. In addition to an increase in blood pressure.Analgesic medications will be useful during emergency situations in which acute pain or anxiety is present. A compensatory bradycardia accompanies the rise in blood pressure produced by methoxamine. they should be used with care in persons with compromised respiratory function. Vigilant monitoring of vital signs is mandatory whenever these agents are used. Its vasopressor action is associated with a marked increase in peripheral resistance and no increase in cardiac output. One reason for this is that epinephrine elicits an extreme antihypotensive response. and precautions: Narcotic agonists are potent CNS and respiratory depressants. The onset of the pressor action is almost immediate following IV administration and may persist for up to 60 minutes. Vasopressor In most emergency situations in which a vasopressor is indicated in the dental office. Phenylephrine acts in a similar fashion. it also increases the irritability of the myocardium by sensitizing it to dysrhythmias. As with methoxamine. . Vasopressors such as methoxamine (Vasoxyl) and phenylephrine (NeoSynephrine) are drugs that produce moderate blood pressure elevations through peripheral vasoconstriction. epinephrine causes an increase in the workload of the heart through its effect on heart rate and cardiac contraction. Side effects. Epinephrine will be used primarily in the management of acute allergic reactions and is rarely employed in cases of clinically mild to moderate hypotension. with a 5-mg IM dose causing a 30-mm Hg elevation of systolic blood pressure and a 20-mm Hg elevation of diastolic blood pressure. The choice of analgesic drugs includes the narcotic agonists morphine sulfate and meperidine (Demerol). a pronounced and persistent bradycardia will be noted (average decline in heart rate from 70 to 44 beats per minute). In most instances the presence of pain or anxiety will cause an increase in the workload of the heart (and an increased myocardial oxygen requirement) that may prove detrimental to the well-being of the patient. Use of narcotic agonists is contraindicated in victims of head injury and multiple trauma. Methoxamine is a clinically useful vasopressor with sustained action and little effect on the myocardium or central nervous system. After IM injection the response occurs within 15 minutes and persists for 90 minutes. with the response persisting for 50 minutes.

too). There is also the potential for encountering what appears initially to be a syncopal episode but is in reality the more serious problem of acute adrenal insufficiency in a patient chronically taking systemic corticosteroids to treat a medical condition. but only after the acute phase has been brought under control through the use of basic life support. For this life-threatening emergency. only the prompt diagnosis and infusion of corticosteroids will be curative. or cola drink will act rapidly to restore circulating blood sugar. The primary value of the corticosteroids is in the prevention of recurrent episodes of anaphylaxis. cake icing. On the other hand. the incidence of extreme acute blood pressure elevation is quite rare and. a parasympathetic blocking agent. epinephrine. First. Antihypertensive The need to administer drugs to decrease excessive elevations in blood pressure is extremely uncommon. oral carbohydrates such as chocolate bar. may be administered in most situations to provide a minor depression of blood pressure. intravenous administration of 50% dextrose solution is the treatment of choice.Antihypoglycemic Glucose preparations are used to treat hypoglycemia that results either from fasting or insulin use in a patient with diabetes mellitus. Anticholinergic Atropine. is delayed. If the patient is conscious. By enhancing discharge from the sinoatrial (SA) . Corticosteroids are considered second-line drugs primarily because of their slow onset of action. if the patient is unconscious and acute hypoglycemia is suspected. second. but the drugs can be useful in halting the progression of a major allergic or anaphylactoid reaction. Corticosteroids are also important in the management of acute adrenal insufficiency. Emergency Drugs Oral drugs. such as hydrocortisone sodium succinate. Corticosteroids will be administered in the management of an acute allergic reaction. such as nifedipine or nitroglycerin. The inclusion of a drug in this category is in response to state requirements for general anesthesia permits (and in a few states for parenteral sedation. The onset of intravenous corticosteroids. and antihistamines. is recommended for the management of symptomatic bradycardia (adult heart rate of <60 beats per minute). Hydrocortisone sodium succinate is considered the drug of choice for the dental emergency kit. there are other means of decreasing blood pressure without resorting to parenteral antihypertensive drugs.

which is crushed and placed under the victim's nose until respiratory stimulation is effected. Aromatic ammonia has a noxious odor and acts by irritating the mucous membrane of the upper respiratory tract. Atropine will be of benefit in situations in which the patient has an overload of parasympathetic activity on the heart. disorientation.node. Side effects. and precautions: Large doses of atropine (>2. Administration of atropine is contraindicated in patients with glaucoma or prostatic hypertrophy. Movement of the arms and legs often occurs in response to inhalation of ammonia. and precautions: Ammonia should be employed with caution in persons with chronic obstructive pulmonary disease (COPD) or asthma because its irritating effects on the mucous membranes of the upper respiratory tract may precipitate bronchospasm. this in turn increases respiration and blood pressure.0 mg) may produce clinical signs of overdosage. headache. Side effects. contraindications. in life-threatening situations the benefits of atropine administration usually outweigh the possible risks. Atropine is also considered an essential drug in advanced cardiac life support (ACLS). Antihypoglycemic agents will be useful in the management of hypoglycemic reactions occurring in patients with diabetes mellitus or in the nondiabetic patient with hypoglycemia (low blood sugar). contraindications. Extremely fearful patients are likely candidates for this response. blurred near vision. The diabetic patient will usually carry a ready source of carbohydrate such as a candy bar or hard candy. aromatic ammonia is the most commonly used drug in the emergency situation. thereby stimulating the respiratory and vasomotor centers of the medulla. and hallucination. Although epinephrine remains the drug of choice in the . It is available in a silver-gray vaporole. atropine may provoke tachycardia (adult heart rate>100 beats per minute). Such items should also be available in the dental office for use in the conscious patient with hypoglycemia. Respiratory stimulant After oxygen. including: hot. dryness of the mouth and throat. This too acts to increase the return of blood from the periphery and aids in raising blood pressure. dry skin. However. Bronchodilator Asthmatic patients and patients with allergic reactions manifested primarily by respiratory difficulty will require the use of bronchodilator drugs. in which it is employed in the management of bradydysrhythmias (hemodynamically significant heart block and asystole). especially if the patient has been positioned properly.

One to two inhalations every 4 to 6 hours is the recommended dosage for albuterol.g. more specific agents known as b2-adrenergic agonists. may have a clinically significant cardiac effect in some patients. Bronchodilators must be administered precisely as directed. Table 3: Advanced Cardiac Life Support Drugs Drug Indication Antiarrhythmics . Drugs For Advanced Cardiac Life Support ACLS is the standard of care for comprehensive resuscitation by health care providers with advanced skills and training.management of bronchospasm. In situations in which these nebulized agents fail to terminate the attack.. State regulations should be consulted to determine which of the drugs described here must be available when sedation or anesthesia is administered. of which albuterol is an example. b2agonists appear more attractive for management of the acute asthmatic episode than agents that have both b1 and b2 agonist properties. like other b2 agonists. Metaproterenol. Side effects. have specific bronchial smooth muscle-relaxing properties (b2) with little or no stimulatory effect on the cardiovascular and gastrointestinal systems (b1) . Primatene-Mist â ) should be administered one to two inhalations per hour. other bronchodilators (e.g. isoproterenol) must be administered parenterally (intramuscularly or subcutaneously). epinephrine. Training in ACLS is necessary for those dentists administering deep sedation or general anesthesia and is sometimes required by state law for providers of parenteral conscious sedation. epinephrine. aminophylline. and isoproterenol mistometers are more likely to produce cardiovascular side effects. contraindications. and precautions: Albuterol. In the dental situation in which the patient's true cardiovascular status may be unknown. including tachycardia and ventricular dysrhythmias.. This response is less likely to develop with albuterol than with other bronchodilators. its wide ranging actions on systems other than the respiratory tract has resulted in the introduction of newer. thus its selection for the emergency kit. These agents. such as epinephrine and isoproterenol. Nebulized epinephrine (e.

ventricular fibrillation Atrial flutter or atrial fibrillation. anginal pain Others . first-degree and Mobitz type I atrioventricular block. pulseless ventricular tachycardia or ventricular fibrillation Atrial flutter or atrial fibrillation. diltiazem Adenosine Atropine Magnesium ß blockers (e. pulseless. fibrillation Refractory congestive heart failure Vasodilators/Antihypertensives Nitroprusside Nitroglycerin Hypertension. acute heart failure Hypertension. asystole. ventricular tachycardia. acte heart failure. or ventricular fibrillation Ventricular tachycardia. pulseless.g. paroxysmal supraventricular tachycardia Paroxysmal supraventricular tachycardia Bradycardia.. Mobitz type II and third-degree block Torsades de pointes. asystole. propranolol) Inotropes Epinephrine Norepinephrine Dopamine Dobutamine Isoproterenol Digitalis Amrinone Ventricular fibrillation.Lidocaine Ventricular tachycardia. electrical activity. pulseless ventricular tachycardia or ventricular fibrillation Ventricular tachycardia. refractory ventricular tachycardia or ventricular fibrillation Procainamide Bretylium Verapamil. hypotension Congestive heart failure Refractory bradycardia Atrial flutter. bradycardia Refractory hypotension Bradycardia.

Requa-Clark. B: Clinical pharmacology in dental practice. Louis. The C.Sodium bicarbonate Furosemide Morphine Thrombolytic agents (e. Benzodiazepine antagonist 3. anistreplase) Hyperkalemia. Mosby Company Supplementary Drugs Supplementary drugs are additional emergency drugs that must be available when certain sedative or anesthetic drugs are administered. Louis. St. Wynn RL. They include drugs that are used to reverse untoward effects of anesthetics and others that are used to treat specific medical conditions that may occur during anesthesia. Narcotic antagonist 2. 1988. metabolic acidosis with bicarbonate loss. Categories of antidotal drugs include: 1.. Mosby-Year Book. . Vasodilator Table 4: Antidotal Drugs Category Narcotic antagonist Benzodiazepine antagonist Antiemergence delirium Vasodilator Generic Naloxone Flumazenil Physostigmine Procaine Proprietary Narcan Mazicon Antilirium Novocain Alternative Nalbuphine Adapted From: Malamed SF: Sedation: a guide to patient management. St. ed 2. ed 4. pain and anxiety Acute myocardial thrombosis Adapted From: Holroyd SV. Antiemergence delirium drug 4. hypoxic lactic acidosis Acute pulmonary edema Acute pulmonary edema.g. 1991. V.

intramuscular sedation. and sedation. Physostigmine (Antilirium). The availability of a specific antagonistic agent for benzodiazepines adds another degree of safety to intravenous and. and precautions: When administered intravenously or endotracheally. Benzodiazepine antagonist Although the benzodiazepines have been described as the most nearly ideal agents for anxiety control and sedation. This regimen will minimize the possibility of a recurrence of respiratory depression. It is mandatory in practices where parenteral opioids are administered. morphine). excessive duration of sedation. This action is not entirely innocuous because if narcotics have been employed for postsurgical analgesia naloxone administration will antagonize this effect and leave the patient with unmanaged postsurgical pain. there are still a number of adverse reactions associated with their administration. Emergence delirium. Naloxone will also reverse other properties of narcotics. a reversible cholinesterase with the ability to cross the blood-brain barrier. Antiemergence delirium Several drugs that are commonly employed parenterally to induce sedation have the ability to produce what is known as emergence delirium. Flumazenil is recommended whenever benzodiazepines such as diazepam. Side effects. and possible (though unlikely in most instances) respiratory depression are but a few side effects. Flumazenil has been demonstrated to produce a rapid reversal of sedation and improve a patient's ability to comprehend and obey commands. contraindications. A recurrence of respiratory depression may be observed if the narcotic employed is of longer duration (e. midazolam. Indications for the use of this drug are extravascular . has become the drug of choice in the management of emergence delirium. the duration of naloxone is but 30 minutes..g. Vasodilator A local anesthetic that also possesses significant vasodilating properties is recommended for inclusion in the emergency kit whenever IM or IV drugs are employed. diazepam and midazolam.Narcotic antagonist Naloxone is a specific opioid antagonist that reverses opioid-induced respirator depression. the duration of therapeutic action of IM naloxone is considerably longer than IV administration. are most likely to produce this phenomenon in which the patient appears to lose contact with reality. Scopolamine and the benzodiazepines. It is common for a second dose of naloxone to be administered intramuscularly following the intravenous dose. namely analgesia. to a lesser extent. or lorazepam are administered parenterally. Though slower in onset.

V. Louis. given succinate (Solu-Medrol)-125 acute adrenocortical slowly mg Monovile insufficiency Sodium bicarbonate–7. anaphylaxis. cardiac arrest Adult Dosage and Route of Administration 0. 1988.5 ml intravenously Methylprednisolone sodium cardiac arrest. both of which make this drug ideal for administration in the aforementioned situations. The C. St. then half this every 10 minutes 5 ml intravenously one ampule. ed 2.injection of an irritating chemical and accidental intraarterial administration of a drug. B: Clinical pharmacology in dental practice. Mosby-Year Book. by inhalation one tablet sublingually 1 ml subcutaneously or intravenously 1 to 2 ml intravenously . 1991. Procaine possesses excellent vasodilating properties along with its painrelieving actions. Mosby Company Malamed SF: Sedation: a guide to patient management. St. Table 5: Emergency Drug Kit Drug Epinephrine (Adrenalin)1:1000 Indications anaphylaxis.6 mg tablet Morphine sulfate–15mg/ml Phenylephrine cardiac arrest acute allergic reaction. Wynn RL. extrapyramidal reaction to phenothiazine syncope angina pectoris myocardial infarction toxic reaction to local 1 mEq/kg intravenously initially. ed 4. Sources: Holroyd SV. In both instances the problem is that of compromised circulation in either a localized area (extravascular administration) or a limb (intraarterial administration).5% Diphenhydramine (Benadryl) 10 mg/ml Aromatic spirits of ammoniacrush ampules Glyceryl trinitrate–0. Requa-Clark. Louis. 125 mg intravenously.

25% Physostigmine salicylate – 1mg/ml Atropine sulphate–0.5 to 2 ml intravenously (slow titration) 0.4 mg/ml anesthetic hypovolemia.1.0 mg IV Isoproterenol hydrochloride bronchospasm aerosol–0. IV route for drug administration severe or prolonged convulsion as in toxic reaction to local anesthetic – narcotic depression 1000 ml IV drip 1 to 8 ml intravenously (titrated) 1 ml intravenously or intramuscularly one or two inhalations 0.5 .1 mg/ml CNS depression following diazepam administration bradycardia with hypotension .hydrochloride (NeoSynephrine Hydrochloride) – 1:500 Dextrose in water–5% Diazepam– 5 mg/ml Naloxone hydrochloride(Narcan) 0.

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