Emergency Drug Kit Strategies For The Dental Office

INTRODUCTION
Every dentist should realize that medical emergencies can, do and will happen during the course of practice. These emergencies could be related to dental treatment, patient risk factors or they could occur unexpectedly in the dental environment. A medical emergency could evolve into a life-threatening emergency without proper treatment. It is for these reasons emergency medications should be present in dental offices.

The majority of states require certain emergency medications if the dentist is performing any type of advanced anesthesia, such as minimal and moderate sedation (either oral or intravenous) as well as deep sedation/general anesthesia.

The ADA Council on Scientific Affairs in their 2002 report in the Journal of the American Dental Association, Volume 133, No 3, 364-365 titled “Office Emergencies and Emergency Kits” stated the following:

In designing an emergency drug kit, the Council suggests that the following drugs be included as a minimum: epinephrine 1:1,000 (injectable), histamine-blocker (injectable), oxygen with positive-pressure administration capability, nitroglycerin (sublingual tablet or aerosol spray), bronchodilator (asthma inhaler), sugar and aspirin. Other drugs may be included as the doctor’s training and needs mandate. It is particularly important that the dentist be knowledgeable about the indications, contraindications, dosages and methods of delivery for all items included in the emergency kit. Dentists are also urged to perform continual emergency kit maintenance by replacing soon-to-be-outdated drugs before their expiration. 1

Local anesthesia is the backbone of pain control in dentistry. Dentists realize and know that adverse events can occur before, during or after administration of local anesthesia. Package insert of all local anesthetics clearly illustrates the importance of the dental practitioner having the proper equipment and resuscitative drugs prior to administering any local anesthetic. Here is what the warnings section state:

“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.” 3

Emergency Drug Kit Key Facts

1. An emergency drug kit is critical in the dental setting. The ADA states that all dentists should have an emergency drug kit, equipment and knowledge to properly use all items.
2. Emergency drugs, along with their actions and dosages, should be known by the dentist and his or her team.
3. Know how to use your emergency drug kit BEFORE the emergency in your office.
4. Know the location of your emergency drug kit.
5. Develop an emergency drug logbook and review your drugs each month.
6. Never give an expired drug.
7. Know how to administer each emergency drug in your kit.

CANAL Acronym
Medical emergencies happen in dental offices and we must be ready to react and respond. Here is an acronym that could assist you in trying to remember the many emergencies along with the emergency drugs that could potentially be used to treat them.

C = Cardiac

• Chest pain: oxygen, nitroglycerin
• Myocardial infarction: oxygen, aspirin
• Dysrhythmias: ACLS drugs
• Sudden Cardiac Arrest: AED
• Ventricular Fibrillation: ACLS drugs

A = Airway

• Foreign body obstruction: airway techniques
• Bronchospasm; albuterol, oxygen, epinephrine
• Larygnospasm: oxygen, succinylcholine
• Hyperventilation
• Aspiration/Emesis: airway techniques

N = Neurological

• Seizures: anticonvulsant
• Transient ischemic attack
• Stroke
• Panic attack: antianxiety agent
• Anxiety: antianxiety agent

A = Allergic and drug reaction

• Latex allergy: diphenhydramine
• Anaphylaxis: epinephrine, diphenhydramine, albuterol, dexamethasone
• Allergic reaction: diphenhydramine
• Epinephrine Overdose:
• Benzodiazepine Overdose: flumazenil
• Local anesthetic overdose: oxygen
• Narcotic Overdose: narcan

L = Loss of consciousness

• Syncope: ammonia
• Sudden Cardiac Arrest: AED
• Hypoglycemia: glucose
• Stroke

Understanding the Actions of the Sympathetic and Parasympathetic Receptor Sites

Here is a suggested list of the core 8 emergency drugs needed for each dental office along with suggested other emergency medications for those doing advanced anesthesia. Check with your state dental board for the mandatory emergency medications you must have in your office.

Emergency drugs should be available in all dental offices ready to address the medical emergency that they would be used for. These 8 emergency drugs should be the minimum in dental offices. They are:

• Epinephrine for anaphylaxis, bronchospasm
• Benadryl for allergic reactions, anaphylaxis
• Albuterol for asthmatic attack, bronchospasm
• Nitroglycerin for angina
• Aspirin for suspected myocardial infarction
• Glucose source for diabetic emergency (hypoglycemia)
• Ammonia inhalants for syncope
• Oxygen as supplemental adjunct

The Core 8 Emergency Drugs

1. ALBUTEROL
DEFINITION—Bronchodilator: stimulates beta-2 adrenergic receptors causing bronchodilation
USE: Bronchospasm (acute asthmatic attack)
DOSAGE: one to 2 puffs per dose
CAUTION: No contraindications to using albuterol in acute episodes of bronchospasm
SUGGESTED STOCK: One albuterol Metered-dose inhaler

2. AMMONIA INHALANTS
DEFINITION: a respiratory stimulant
USE: Syncope/fainting/loss of consciousness
DOSAGE: one to 2 vaporules
SUGGESTED STOCK: One box of ammonia vaporules

3. ASPIRIN
DEFINITION: Antiplatelet—inhibits prostaglandin synthesis and inhibits platelet aggregation irreversibly
USE: Suspected myocardial infarction
DOSAGE: One 325 mg nonenteric, coated aspirin tablet, chewed and swallowed or four-81 mg chewable tablets, chewed and swallowed
CAUTION: Aspirin should not be given to persons who are allergic to it or have active gastrointestinal bleeding
SUGGESTED STOCK: One or 2 packets of chewable 325 mg nonenteric, coated aspirin or four 81-mg chewable tablets

4. DIPHENHYDRAMINE
DEFINITION: Antihistamine—antagonizes histamine at the H-1 receptor, causes sedation and has an anticholinergic effect
USE Allergic reaction/anaphylaxis
DOSE: 50 mg intramuscular or intravenous
CAUTION: No contraindications to giving diphenhydramine during an allergic reaction unless noted allergy or hypersensitivity to diphenhydramine
SUGGESTED STOCK: 1. Two 1-mL ampules or vials of diphenhydramine 50 mg/mL and/or
2. Diphenhydramine hydrochloride capsules 25 mg

5. EPINEPHRINE 1:1,000
DEFINITION: Cardiac stimulant/anaphylaxis—activates alpha and beta-adrenergic receptors increasing heart rate, myocardial contractility, bronchial dilation and decreases peripheral vascular resistance
USE: Anaphylaxis/bronchospasm
DOSAGE: 0.3 mg intramuscular every 5 minutes.
CATUION: No contraindications to giving epinephrine during anaphylaxis
SUGGESTED STOCK: 1. Two autoinjectors of epinephrine in adult form and pediatric form (EpiPen and EpiPen Jr)
2. Two 1-mL ampules or vials of epinephrine 1:1,000

6. GLUCOSE SOURCE
DEFINITION: Antihypoglycemic—increases glucose level for treatment of hypoglycemia
USE: Hypoglycemia
DOSAGE: One tube of glucose gel.
CAUTION: Unconsciousness. Never place anything orally into an unconscious person.
SUGGESTED STOCK: 1. Three tubes of glucose gel (InstaGlucose)
2. Three tubes of glucose tablets

7. NITROGLYCERIN
DEFINITION: Antianginal—stimulates cGMP production which relaxes vascular smooth muscle specifically in the coronary arteries in the presence of an anginal attack
USE: Chest pain (angina)
DOSAGE: The usual dose of nitroglycerin is one sublingual (0.4 mg) tablet or one spray (0.4 mg) from nitroglycerin spray atomizer administered every 5 minutes
CAUTION: Patients with low blood pressure

8. OXYGEN
USE: Almost any type of medical emergency
DOSAGE: At least 2 liters/minute for patient
CAUTION: Do not use with hyperventilation
SUGGESTED STOCK: One portable “E” cylinder of oxygen with regulator and the equipment necessary to deliver O2 to the victim (nasal cannula and ambu-bag)

Additional Medications
Reversal Agent—Benzodiazepine

Flumazenil (Romazicon)—Benzodiazepine Antagonist: Reverses effect of benzodiazepines by inhibiting the gamma amino butyric acid (GABA) receptors

Reversal Agent—Narcotics
Naloxone (Narcan)—Narcotic Antagonist: Reverses the effect of narcotics by competively inhibiting narcotic receptor sites

Injectable AntiConvulsant
Midazolam or diazepam: A benzodiazepine that acts on the inhibitory neurotransmitter GABA, limbic system, hypothalamus and thalamus to produce sedation, anti-anxiety effect and skeletal muscle relaxation

Injectable Antihypoglycemics
Dextrose (50% Dextrose)—Antihypoglycemic: a source of calories and fluid for patients that are not able to take oral fluids in the event of a hypoglycemic reaction
Glucagon (GlucoGen)—Antihypoglycemic: causes a rise in blood glucose levels by promoting hepatic glycogenolysis and gluconeogenesis.

Injectable Anticholinergic
Atropine—Anticholinergic: antagonizes acetylcholine at the muscarinic receptors, increasing the heart rate as well as having an antisialagogue effect.

Injectable Corticosteriod
Hydrocortisone (Solu-Cortef)—Anti-inflammatory: a corticosteroid secreted by the adrenal cortex which has anti-inflammatory, anti-allergic, mineralocorticord activity and stimulates gluconeogenesis.
Dexamethasone – Anti-inflammatory: a corticosteroid secreted by the adrenal cortex which has anti-inflammatory, anti-allergic, glucocorticord activity, and stimulates gluconeogenesis.

Injectable Antihypertensive
Esmolol—Beta-antagonist: is a cardioselective beta1 receptor blocker with rapid onset and a very short duration of action, with no significant intrinsic sympathomimetic or membrane stabilizing activity at therapeutic dosages. It decreases the force and rate of heart contractions by blocking beta-adrenergic receptors of the sympathetic nervous system
Labetolol—Beta-antagonist: is a mixed alpha/beta adrenergic antagonist, which is used to treat high blood pressure.
Hydralazine—is a direct-acting smooth muscle relaxant used to treat hypertension by acting as a vasodilator primarily in arteries and arterioles

Advanced Cardiovascular Life Support and Pediatric Advanced Life Support Emergency Medications:
NOTE: Practitioners may vary on what they carry in their office with these medications as well as the dosing dependent upon the training they received related to advanced cardiovascular life support (ACLS) and pediatric advanced life support (PALS).

Drugs for ventricular fibrillation/pulseless ventricular tachycardia

• Epinephrine
• Vasopressin
• Amiodarone
• Lidocaine
• Magnesium

Drugs for asystole and pulseless electrical activity

• Epinephrine
• Vasopressin

Drugs for bradycardia

• Atropine
• Epinephrine
• Dopamine

Drugs for tachycardia

• Adenosine
• Diltiazem
• Beta-blockers
• Amiodarone
• Digoxin
• Verapamil
• Magnesium

Drugs for acute coronary syndrome

• Oxygen
• Nitroglycerin
• Morphine
• Fibrinolytic therapy
• Heparin
• Beta-blockers

Adenosine (Adenocard)—Antiarrhythmic: used for treatment of paroxysmal supraventricular tachycardia by slowing conduction time through the atrioventricular (AV) node as well as interrupting the re-entry pathways through the AV node.

Amiodarone (Cordarone)—Antiarrhythmic: a Class III agent that inhibits adrenergic stimulation which prolongs the action potential, decreases AV conduction and sinus node function which is used for life-threatening recurrent ventricular fibrillation or hemdynamically-unstable ventricular tachycardia.

Atropine (Atropine)—Anticholinergic: antagonizes acetylcholine at the muscarinic receptors, increasing the heart rate as well as having an anti-sialagogue effect.

Lidocaine—Antiarrhythmic: is a Class IB antiarrhythmic drug which is used intravenously for the treatment of ventricular arrhythmias.

Vasopressin (Pitressin)—Antidiuretic hormone: adjunctive treatment used in pulseless ventricular tachycardia/ventricular fibrillation.

Verapamil (Isoptin/Calan)—Antiarrhythmic: used for the treatment of paroxysmal supraventricular tachycardia, atrial flutter and atrial fibrillation.

Development of an Emergency Drug Kit for your Office

Dentists can make their own emergency drug kit.

• First, know which drugs you will need in your office. Do you need the Core 8 drugs? Do you need more advanced medications such as used in ACLS or PALS protocols? Dentists should be thoroughly knowledgeable on the emergency drugs they have in their office.
• Second, purchase those drugs and then maintain them in some type of container whether it is a plastic container/box or a metal crash cart.
• Third, place these emergency medications in ziploc bags or smaller plastic containers with color coded labels for easy identification.
• Fourth, know the medical emergencies for which these emergency drugs are used for.
• Finally, develop an emergency drug logbook and keep up with your drugs and their expiration dates.

Note: many dental software programs may already have a “task manager” or you may have Outlook on your computer. You can enter each of your emergency drugs along with their expiration dates so a reminder is sent to you before the actual expired date.

At monthly staff meetings, encourage emergency medications as a regular topic so that area is covered each month and you can prevent your drugs from being expired.

The next several pages of downloadable documents illustrate a suggested source for dentists to use to develop a checklist of emergency drugs they need in their office depending on if they use local anesthesia or a specific type of advanced anesthesia. These can be modified by the individual dentist to the needs of their practice.

DOWNLOADABLE DOCUMENT #1: EMERGENCY DRUGS LIST FOR PRACTITIONERS WHO USED LOCAL ANESTHESIA, MILD SEDATION, MODERATE SEDATION, DEEP SEDATION AND/OR GENERAL ANESTHESIA

DOWNLOADABLE DOCUMENT #2: THE ADULT EMERGENCY CRASH CART. A SUGGESTED LIST OF EMERGENCY EQUIPMENT AND EMERGENCY DRUGS FOR THE DENTIST TREATING ADULTS.  6, 8

DOWNLOADABLE DOCUMENT #3: THE PEDIATRIC EMERGENCY CRASH CART. A SUGGESTED LIST OF EMERGENCY EQUIPMENT AND EMERGENCY DRUGS FOR THE DENTIST 7, 8

DOWNLOADABLE DOCUMENT #4: PREPARATION CHECKLISTS ON EACH MEDICAL EMERGENCY THAT COULD ARISE IN A DENTAL OFFICE. THE PRACTITIONER SHOULD DEVELOP THEIR OWN MEDICAL EMERGENCY ALGORITHMS TO GO ALONG WITH THESE CHECKLISTS OR THEY PURCHASE THEM FROM A VENDOR

DOWNLOADABLE DOCUMENT #5: THE EMERGENCY DRUG TRACKER COMPLIMENTS OF EMERGENCY DRUG RESOURCE; buildyourowndrugkit.com

DOWNLOADABLE DOCUMENT #6: EMERGENCY DRUG LABELS

Conclusion

In conclusion, the emergency drug kit is essential for the practice of dentistry. No practitioner is able to determine when he or she will be faced with a medical emergency that will require the use of emergency drugs. It is for that reason alone, dental healthcare practitioners should stay up-to-date on medical emergencies as well as the drugs used to treat them. Develop a regular protocol to where you and your staff are able to rehearse various emergencies using your emergency drugs. Know their actions along with the route of administration. You and your staff should always know the location of your emergency drugs. Assign a staff member the role of reviewing your emergency drugs each month to prevent expiration of these drugs.

None of us know when our patient’s life may depend on our readiness as well as having the proper emergency drugs.

References

1. Journal of the American Dental Association, Volume 133, No 3, 364-365 titled “Office Emergencies and Emergency Kits”
2. Journal of the American Dental Association, May 2010, Supplement on Medical Emergencies
3. Package Insert on Local Anesthesia, “WARNINGS” section
4. Wikipedia: Central Nervous System
5. American Heart Association
6. Advanced Cardiovascular Life Support (ACLS)
7. Pediatric Advanced Life Support (PALS)
8. CRASH CART, SAJITH KUMAR. RN, RM, MScN / Emergency Medicine; www.emergencymedicinemims.com
9. http://acls-algorithms.com
10. Emergency Drug Tracker, compliments of Emergency Drug Resource. buildyourowndrugkit.com

Dr. Roberson is a full-time practicing Oral & Maxillofacial Surgeon. He performed his residency in Oral & Maxillofacial Surgery at University Hospital at the University of Cincinnati. Dr. Roberson has dual Board Certifications by the American Board of Oral & Maxillofacial Surgery and the National Dental Board of Anesthesiology. He is a member of the American Association of Oral & Maxillofacial Surgeons, Southeastern Society of Oral & Maxillofacial Surgeons, American Dental Association, American Dental Society of Anesthesiology, Mississippi Dental Association, South Mississippi Dental Association, and the Mississippi Society of Oral & Maxillofacial Surgeons.