USEFUL EMERGENCY KIT

1. DRUGS
1.Glyceryl Trinitrate Spray
(400 micrograms/ spray)

-1 -1 -5 Ampules

2.Salbutamol Aerosol inhaler

( 100 micrograms /spray)

3.Adrenaline injection
( 1:1000, 1mg/ml)

*** Please note this drug should never be given in this concentration through IV,if you do You would kill the patient instantly. 4.Aspirin 300 mg ( Dispirin) 5.Chlorpheniramine maleate
(10mg/ ml)

10 tablets - 5 ampules

6.Glucagon Inj 1mg -5 Ampules ***Should be given only once , even if you give more than once it doesnt work 7.Glucose 20 or 50% in 50 ml 8.Glucose powder 9.Diazepam 10 mg in 2ml -1 bag -1 -10 ampules

10.Midazolam ( Hypnovel )
(5mg/ml or 10mg/l buccal or intranasal)

-10 ampules

11.Flumazenil
200 micrograms IV over 15 sec Followed by 100 micrograms at 1 minute interval. (Can be given in respiratory depression due to excessive use diazepam or midazolam.)

13.Fluids- Dextrose and Normal saline

2. EMERGENCY EQUIPMENT
Following is the minimum equipment recommended: 1. Portable oxygen cylinder ( D-size) with pressure reduction valve and flow meter. 2. oxygen face mask with tubing 3. Basic set of oropharyngeal airways ( sizes 00, 1, 2, 3,and 4) 4. Laerdal pocket mask. 5. Self inflating bag and mask apparatus with oxygen 6. Portable suction with appropriate suction catheters and tubing Yankauer sucker 7. Disposable syringes 2, 5, 10 ml, needles 19 and 21 gauge, tourniquet, butterfly needles, IV cannulae, tape, scissors, gloves and alcohol wipes. 8. Automated blood glucose measurement device. 9. Automated external defibrillator
(*** if you have money, you should buy, cost 3-4 lakhs)

MANAGEMENT OF VARIOUS MEDICAL EMERGENCIES IN DENTAL CLINIC

1.
Clinical recognition :

SYNCOPE

Premonitory dizziness, feels faint and light headed Pale, cold and clammy extremities Pulse initially slow and thready becoming rapid and full Management:

1.

Lay the patient flat legs raised 2. Loosen the clothing around the neck in presence of witness 3. Feel the pulse 4. Patient usually recover immediately if it is syncope.

2. HYPOGLYCEMIA
Cliinical Recognition :

Clumsy or inappropriate behaviour aggressive and irritable tremor, pallor, sweating Loss of consciousness Management:

1.

Place the patient in supine position

2. If the patient is conscious able to swallow, give glucose powder in glass of water, or sugar, fruit juice, coke etc.

3. Drowsy, sublingual glucose gel if available in india, if not available treat same as unconscious patient as below. If patient is unconscious Glucagon 1mg IM lateral aspect of the thigh through clothing followed by when conscious a drink containing sugar.
4.

**please remember you can give Glucagon only once if you repeat, no effect.. if you know IV skills 50 ml of 20 -50% glucose followed by normal saline or dextro saline.
5.

3. ASTHMATIC ATTACK IN THE DENTAL CLINIC

Clinical Recognition: Features of severe asthma attack: Inability to complete sentences in one breath Pulse greater than 110 beats/ inute Respiratory rate greater than 25 minutes Features of life threatening asthma;

Silent chest, feeble respiratory effort Cyanosis Slow heart rate < beats /minute Hypotension Exhaustion, confusion Management: 1. Remain calm and confident 2. Sit the patient up 3. Ask the patient to use his or her own inhaler 4.If resolves , stabilise dental treatment, discharge and inhaler prior to next dental treatment. 5. If no response repeat salbutamol 400 micrograms every 2 minutes

6. o2 high flow 10 litres/ minute if you have 7. Call ambulance

4. MYOCARDIAL PAIN
Clinical Recognition: Central retrosternal pain described as heavy or crushing, band like described as elephant sitting on the chest.

Patient tend to grip his hand over the central chest and may sit forward.

Chest pain may radiate to one or both arms or shoulders, the neck mandible. Precipitated by exercise, anxiety emotion , cold air, or pain. If it is relieved by rest and Glyceryl tri nitrate angina If not relieved by rest and GTN and associated with : Coexisting breathlessness, sweating ,nausea and vomiting leading to unconsciousness = Myocardial infarction. Absence of pulse and breathing suggests Cardiac arrest requires Basic Life support. Management: 1. 2. 3. 4. 5. 6. Stop treatment and sit the patient up Remain calm and confident Reaassure the patient. GTN sublingual 0.5 mg If it resolves Rest, stabilize dental treatment, ask the patient to see the specialist or physician. After 10 minutes still there is pain repeat GTN,

( you can repeat as much as you can, it relieves or reduces pain.)

If no response ,it is Myocardial infarction: 7. 8. 9. 10. 11. Give o2 10- 15 litre /minute by mask Aspirin 300 mg orally, patient has to crush it and swallow. Call the ambulance ( 108) Monitor conscious level and pulse If patient collapses, and no pulse and no breathing suggests cardiac arrest, do BLS and if you have defibrillator give shocks

5. FOREIGN BODY ASPIRATION

Clinical recognition: Stridor high pitch inspiratory sound

May be complete absence of air flow with violent respiratory effort, Normal breathing depending upon degree of obstruction

Complete obstruction occurs, hypoxia, cyanosis, loss of consciousness and eventually cardiac arrest Management: 1. 2. 3. 4. 5. 6. If the patient is reclined maintain this position Reassure the patient Visually search the oropharynx Finger sweep to locate the foreign body in the mouth Ask the patient to cough this may help in dislodging the aspirated object If the lost foreign body is not found and above mentioned procedures not successful call the ambulance 108.

7. 8. 9. 10. 11.

5 back slaps between the shoulders , stiil not recovered 5 abdominal thrusts , not recovered Alternate back slaps and abdominal thrusts If patient become unconscious commence Basic life support. If the object is lodged in the lower part of the respiratory system, patient is fully conscious , call the ambulance, take the patient to hospital , take the chest x-ray, refer to chest physician for the removal of object through bronchoscopy.

6. ANAPHYLAXIS
Clinical recognition:

Erythema Angioedema Itching Abdominal pain Urticaria Conjuctivitis Hypotension Facial flushing Tongue or upper airway swelling Features of acute severe asthma Loss of consciousness

Management: 1. 2. 3. Call ambulance 108 Epinephrine 1: 1000 0.5 ml IM lateral aspect of thigh, can be repeated Followed by: chlorpheniramine 10-20 mg , IM lateral aspect of thigh Hydrocortisone 200mg IM lateral aspect of thigh Salbutamol 400 micrograms if any features of asthma.

6.

7.

Always give o2 10- 15 litres/ minute to any sick patient if you have o2 cylinder and other equipment.

7. EPILEPTIC ATTACK
Clinical recognition: 1. Aura 2. Sudden loss of consciousness 3. Patient becomes rigid, falls, may give a cry, and becomes cyanosed ( Tonic phase). 4. Jerking movements of the limbs, the tongue may be bitten ( clonic phase) 5. Frothing from the mouth and urinary incontinence 6. Lasts for few minutes, the patient may then become floppy but remain unconscious. 7. Patient confused. 8 If seizures are prolonged and recur in quick succession is called status epilepticus Management: 1. Stop treatment and remove all surrounding equipment. 2. Lay the patient flat in the chair. Do not try to move while actively fitting 3. If fit terminates leave the patient chair sat at 30 -40 degree position. 4. Fit continues longer than normal or fit continues > 10 mts ask accompanying person to administer usual medication or midazolam 10mg IM. 5. Fit continues for further 5 minutes despite treatment give High flow o2 6. Call ambulance 108 .

8. ADRENAL INSUFFICIENCY:
Clinical Recognition: Tachycardia Pallor Sweating Rapidly falling blood pressure Weakness Confusion Eventual loss of consciousness Hypoglycemia Management: 1. Call ambulance 108 2. Hydrocortisone 200 mg IM 3. Oxygen 10 l/minute 4. If you know how to put IV cannula then give 1 litre dextrose saline. 5. Wait for ambulance, monitor the patient with pulse and observing breathing. Dr.Srinivas Gadipelly, MDS, FDSRCS (London) Professor &HOD