Chapter 41: Drugs for Medical Emergencies

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1

In studies surveying the incidence and type of medical emergencies in dental practice, many of the report medical emergencies. When do most medical emergencies in dental practice occur?

Many medical emergencies occur during the administration of local anesthesia and during painful procedures.

2

It has been postulated that the incidence of medical emergencies in dentistry is increasing. What are five possible reasons for this increase?

  1. increasing age of the general population
  2. effect of medical and dental advances
  3. pharmacologic therapies
  4. drug abuse
3

How might increasing age contribute to medical emergencies?

Elderly patients take more prescription and over-the-counter drugs than young patients.

4

How might medical and dental advances contribute to medical emergencies?

There is a growing number of medically stabilized yet chronically ill patients seeking dental treatment.

5

How might pharmacologic therapies contribute to medical emergencies?

Each new drug has its own inherent indications, contraindications, and possible side effects.

6

What must all dental personnel be prepared to provide in emergency situations?

basic life support for health care providers (BLS-HCP)

7

Every dental office must have a medical emergency management kit. What is the appropriate approach to administration of drugs in emergency settings?

The correct approach to the use of drugs in any dental office should be conservative and supportive.

8

What is the fundamental emergency drug indicated in any emergency where hypoxemia may be present?

oxygen

9

What is the the most important injectable drug in the dental emergency kit?

epinephrine

10

What is the mechanism of action of epinephrine?

It is an endogenous catecholamine with α-receptor and β-receptor stimulating activity.

11

Epinephrine is an endogenous catecholamine with α-receptor and β-receptor stimulating activity. What are six therapeutic effects of epinephrine?

  1. bronchodilation
  2. increased vascular resistance
  3. increased arterial blood pressure
  4. increased heart rate
  5. increased myocardial contractility
  6. increased myocardial and cerebral blood flow
12

What is the dose of epinephrine for treatment of acute anaphylactic reactions?

0.3 to 0.5 mg can be injected intramuscularly as 0.3 to 0.5 mL of a 1:1000 solution.

13

What is the drug treatment of choice for acute angina pectoris?

nitroglycerin

14

What are the appropriate forms of nitroglycerin for the dental office?

sublingual tablet or translingual spray

15

What is the mechanism of action of nitroglycerin?

It acts as a vasodilator by relaxing vascular smooth muscle, reducing systemic vascular resistance.

16

What is the dose of nitroglycerin for treatment of acute angina pectoris?

One tablet or spray (0.4 mg), repeated every 5 minutes to a total dose of three administrations.

17

What should be suspected if discomfort is not relieved by nitroglycerin?

myocardial infarction

18

What are two contraindications to the administration of nitroglycerin?

  1. patients who are hypotensive
  2. patients who are taking sildenafil (Viagra) or another phosphodiesterase type 5 inhibitor
19

What is used in the treatment of acute bronchospasm encountered during asthma and anaphylaxis?

β2-adrenergic receptor agonist

20

What is the mechanism of action of metaproterenol, terbutaline, and albuterol?

These are β2-adrenergic receptor agonists which result in bronchial smooth muscle relaxation.

21

What is used to treat hypoglycemia?

glucose

22

What is the drug of choice for patients experiencing an evolving myocardial infarction?

aspirin

23

What are two contraindications to the administration of aspirin?

  1. patients with aspirin intolerance
  2. patients with severe bleeding disorders
24

What drugs are useful in the treatment of minor or delayed allergic reactions?

antihistamines (e.g. diphenhydramine)

25

What drug is used as a general arousal agent during syncope where the patient is still breathing?

aromatic ammonia

26

What is the mechanism of action of aromatic ammonia?

It is a pungent irritant that stimulates the respiratory and vasomotor centers of the medulla.

27

What are drugs used to treat medical emergencies that are not acutely life-threatening called?

primary support drugs

28

What drugs are used manage seizures that interfere with ventilation or persist for longer than 5 minutes?

benzodiazepines (e.g. diazepam)

29

What drugs are used in the definitive management of acute allergic reactions and acute adrenal insufficiency?

corticosteroids

30

What is the first drug to consider for the treatment of bradycardia?

atropine

31

What is the mechanism of action of atropine?

It is an anticholinergic drug, which blocks the action of the vagus nerve, increasing firing of the SA node.

32

What is the dose of atropine for the treatment of bradycardia?

0.5 mg every 3 to 5 minutes as needed, with a maximal total dosage of 3 mg (6 dosages)

33

What is the standard of care for patient resuscitation by health care providers with advanced skills and training?

card image

advanced cardiac life support (ACLS)

34

What are the two types of pulseless arrest rhythms?

  1. shockable
  2. non-shockable
35

What are the two types of shockable pulseless arrest rhythms?

  1. ventricular fibrillation (VF)
  2. ventricular tachycardia (VT)
36

What is the definitive therapy for shockable pulseless arrest rhythms (VF/VT)?

BLS CPR with defibrillation

37

What are the two types of nonshockable pulseless arrest rhythms?

  1. asystole
  2. pulseless electrical activity
38

What is the definitive therapy for nonshockable pulseless arrest rhythms?

drug therapy (i.e. epinephrine and vasopressin)

39

What is a heart rate less than 60 beats/min combined with symptoms called?

symptomatic bradycardia

40

What is a heart rate greater than 100 beats/min combined with symptoms called?

symptomatic tachycardia

41

What are regular QRS complexes greater than 0.12 seconds on an ECG called?

wide-complex tachycardias

42

What is is recommended for the treatment of VF or pulseless VT unresponsive to other measures?

amiodarone

43

What is the mechanism of action of amiodarone?

It acts on ion channels and has α-adrenergic–blocking and β-adrenergic–blocking properties.

44

What is the dose of amiodarone administered for treatment of VF or pulseless VT?

150 mg intravenous bolus over 10 minutes followed by an initial maintenance infusion of 1 mg/min.

45

What drug may be used as an alternative to amiodarone when amiodarone is unavailable?

lidocaine

46

What is the mechanism of action of lidocaine?

It is a a class IB antiarrhythmic that acts by inhibiting the ion flux via Na+ channels.

47

What drugs are used to terminate reentrant tachyarrhythmias and control atrial fibrillation?

Ca2+ channel blockers (CCBs)

48

What is the mechanism of action of verapamil and diltiazem?

They inhibit extracellular Ca2+ influx through slow Ca2+ channels, inhibiting automaticity in the SA node and conduction via the AV node.

49

What is the difference in the effect of diltiazem compared to verapamil?

Both drugs are used for the same indications, but diltiazem seems to produce less myocardial depression than verapamil.

50

What drug is used for controlling AV nodal reentrant tachycardia and junctional tachycardias?

adenosine

51

What is the mechanism of action of adenosine?

It is is an endogenous purine nucleoside that acts by temporarily depressing AV and sinus node activity.

52

What drug is used to increase heart rate during periods of symptomatic sinus bradycardia?

atropine

53

What heart condition can be precipitated by hypomagnesemia?

torsades de pointes

54

What drugs are used to control the ventricular rate in the presence of atrial tachyarrhythmias?

β-adrenergic blockers (e.g. atenolol)

55

What drugs increase arterial and aortic pressures, resulting in increased cerebral and coronary perfusion, and reduced blood flow to visceral and muscle tissues?

vasoconstrictors (e.g. catecholamines, vasopressin)

56

What is the initial catecholamine recommended in ACLS for pulseless VT/VF, asystole, and pulseless electrical activity arrest?

epinephrine

57

What is the mechanism of action of vasopressin?

It causes peripheral vasoconstriction by stimulation of vasopressin receptors located in skin and skeletal muscle, shunting blood to vital organs.

58

What drug is indicated in patients with low peripheral resistance and severe hypotension?

norepinephrine

59

What drug is indicated in the treatment of shock, such as that associated with heart failure?

dopamine

60

What drug is indicated in the treatment of heart failure when signs and symptoms of shock are absent?

dobutamine

61

What two nonadrenergic cardiotonic agents cause vasodilation with hemodynamic effects similar to dobutamine?

  1. inamrinone
  2. milrinone
62

What specific opioid antagonist reverses opioid-induced respiratory depression?

naloxone

63

What specific benzodiazepine antagonist reverses sedation and respiratory depression resulting from benzodiazepine administration?

flumazenil

64

What drug is used to overcome laryngospasm during deep sedation or general anesthesia by relaxing skeletal muscle controlling the vocal cords?

succinylcholine

65

What genetically transmitted disorder causes excessive Ca2+ release in skeletal muscle during general anesthesia?

malignant hyperthermia syndrome

66

What drug is used to arrest the development of malignant hyperthermia syndrome?

dantrolene

67

What antiarrhythmic drug is indicated for the following?

  1. ventricular tachycardia
  2. pulseless ventricular tachycardia
  3. ventricular fibrillation

lidocaine

68

What antiarrhythmic drug is indicated for the following?

  1. pulseless ventricular tachycardia
  2. ventricular fibrillation
  3. supraventricular tachycardia

amiodarone

69

What antiarrhythmic drug is indicated for intermittent or recurrent ventricular tachycardia?

procainamide

70

What antiarrhythmic drugs are indicated for the following?

  1. atrial flutter
  2. atrial fibrillation
  3. supraventricular tachycardia

Ca2+ channel blockers (e.g. verapamil, diltiazem)

71

What antiarrhythmic drug is indicated for supraventricular tachycardia?

adenosine

72

What antiarrhythmic drug is indicated for the following?

  1. bradycardia
  2. asystole
  3. atrioventricular block

atropine

73

What antiarrhythmic drug is indicated for the following?

  1. torsades de pointes
  2. ventricular fibrillation

magnesium sulfate

74

What antiarrhythmic drugs are indicated for the following?

  1. atrial flutter
  2. atrial fibrillation
  3. supraventricular tachycardia
  4. refractory ventricular tachycardia

β blockers (e.g. propranolol)

75

What ionotropic drug is indicated for the following?

  1. anaphylactic shock
  2. asystole
  3. pulseless electrical activity
  4. pulseless ventricular tachycardia
  5. ventricular fibrillation
  6. bradycardia

epinephrine

76

What ionotropic drug is indicated for the following?

  1. pulseless ventricular tachycardia
  2. pulseless ventricular fibrillation

vasopressin

77

What ionotropic drug is indicated for refractory hypotension?

norepinephrine

78

What ionotropic drug is indicated for the following?

  1. bradycardia
  2. hypotension

dopamine

79

What ionotropic drug is indicated for congestive heart failure?

dobutamine

80

What ionotropic drug is indicated for the following?

  1. refractory symptomatic bradycardia
  2. long QT syndrome

isoproterenol

81

What ionotropic drug is indicated for the following?

  1. atrial flutter
  2. fibrillation
  3. heart failure

digoxin

82

What two ionotropic drugs are indicated for the refractory congestive heart failure?

  1. inamrinone
  2. milrinone
83

What vasodialator is indicated for the following?

  1. hypertension
  2. acute heart failure

nitroprusside

84

What vasodialator is indicated for the following?

  1. hypertension
  2. acute heart failure
  3. angina

nitroglycerin

85

What drug is indicated for the following?

  1. hyperkalemia
  2. metabolic acidosis
  3. hypoxic lactic acidosis

sodium bicarbonate

86

What drug is indicated for the following?

  1. acute pulmonary edema
  2. pain
  3. anxiety

morphine

87

What drug is indicated for acute pulmonary edema?

furosemide

88

What drugs are indicated for acute thrombosis?

thrombolytics (e.g. alteplase, streptokinase)