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Washington State Dental Association’s 2015 Pacific Northwest Dental Conference
Presents
Medical Emergencies in the Dental Office – Medical Emergencies in Life
Dr. J. Mel Hawkins
Friday, June 12, 2015 8:00 a.m. – 11:30 a.m.
Continued 1:00 p.m. – 4:30 p.m.
Official Disclaimer
Neither the content of a program nor the use of the specific products in courses should be construed as indication endorsement or approval by the
Pacific Northwest Dental Conference or Washington State Dental Association
The
Was
hing
ton
Stat
e
Den
tal A
ssoc
iatio
n –
2015
Pac
ific
Nor
thw
est
Den
tal C
onfe
renc
e
June
11-
12, 2
015
Med
ical
Em
erge
ncie
s in
the
D
enta
l Offi
ce,
Med
ical
Em
erge
ncie
s in
Life
!
Mel
Haw
kins
, DD
S B
ScD
AN
D
entis
t/Den
tist A
nest
hesi
olog
ist
Toro
nto,
ON
Can
ada
Alm
ost A
lway
s A
lmos
t Nev
er
Rea
lity
of D
enta
l Em
erge
ncie
s
The
Cha
lleng
e
How
can
we
as h
ealth
pr
ofes
sion
als,
who
are
su
ppos
ed to
hav
e hi
gher
sk
ills,
be
expe
cted
to tr
eat a
n em
erge
ncy
situ
atio
n in
the
offic
e or
in li
fe w
hen
they
N
EVER
occ
ur?
Wha
t tod
ay is
NO
T:
Are
we
faci
ng a
n . .
. .
INC
ON
VE
NIE
NC
E?
UR
GE
NC
Y?
EM
ER
GE
NC
Y?
RA
RIT
Y?
Inco
nven
ienc
es
Syn
cope
15
,407
M
ild A
llerg
y 2,
583
Pos
tura
l Hyp
oten
sion
2,
475
Bro
ncho
spas
m (a
sthm
a)
1,39
2 H
yper
vent
ilatio
n 1,
326
Epi
neph
rine
Rea
ctio
n 91
3
“Em
erge
ncy”
n
=30,6
08
M
artin
& E
llis J
AD
A 11
2:49
9-50
1, M
alam
ed J
AD
A 12
4:4-
53 >
30,0
00 e
vent
s
Urg
enci
es
Syn
cope
15
,407
A
ngin
a 2,
552
Sei
zure
1,
595
Bro
ncho
spas
m (a
sthm
a)
1,39
2 E
pine
phrin
e R
eact
ion
913
Insu
lin S
hock
(con
scio
us)
890
“Em
erge
ncy”
n
=30,6
08
M
artin
& E
llis J
AD
A 11
2:49
9-50
1, M
alam
ed J
AD
A 12
4:4-
53 >
30,0
00 e
vent
s
Syn
cope
15
,407
A
ngin
a 2,
552
Sei
zure
1,
595
Bro
ncho
spas
m (a
sthm
a)
1,39
2
Myo
card
ial I
nfar
ctio
n 28
9
Loca
l Ane
sthe
tic O
verd
ose
204
“Em
erge
ncy”
n
=30,6
08
C.V
.A.
68
Emer
genc
ies
M
artin
& E
llis J
AD
A 11
2:49
9-50
1, M
alam
ed J
AD
A 12
4:4-
53 >
30,0
00 e
vent
s
Rar
ity (“
Non
” Ev
ents
)
Acu
te P
ulm
onar
y E
dem
a 14
1 D
iabe
tic C
oma
105
Adr
enal
Insu
ffici
ency
25
Th
yroi
d S
torm
4
Mar
tin &
Ellis
JA
DA
112:
499-
501,
198
6, M
alam
ed S
JA
DA
124:
4-53
, 199
3
“Em
erge
ncy”
n
=30,6
08
M
artin
& E
llis J
AD
A 11
2:49
9-50
1, M
alam
ed J
AD
A 12
4:4-
53 >
30,0
00 e
vent
s
“Wha
t’s R
eally
Impo
rtan
t?”
Syn
cope
15
,407
Ang
ina
2,55
2
Myo
card
ial I
nfar
ctio
n 28
9 C
ardi
ac A
rres
t ??
?
Ast
hma,
Sev
ere
Alle
rgy �
B
ronc
hosp
asm
1,
392
Ever
ythi
ng E
lse
Has
Tim
e!
Dia
betic
Com
a/In
sulin
Sho
ck
Sug
ar
Epi
leps
y/S
eizu
re/C
onvu
lsio
ns
Airw
ay
Hyp
erve
ntila
tion
O2
Sat
? 10
0%
Mild
Alle
rgy
Itchi
ness
/Ras
h W
ait
Loca
l Ane
sthe
tic /
Epi
neph
rine
�� B
lock
ers
1
2
3
Prot
ocol
s,
Age
/Ris
k Ph
arm
aco-
dyna
mic
s
Def
ib,
Dru
gs
and
Dia
gnos
is
WH
AT
TOD
AY
IS:
Airw
ay +
a
few
goo
d ad
junc
ts,
Oxy
gen,
Va
soco
n-st
ricto
rs
�
Prot
ocol
s,
Age
/Ris
k Ph
arm
acod
ynam
ics
Emer
genc
y Pr
otoc
ol
IT
DEP
END
S on
: •W
hat,
•W
hen,
and
•W
here
the
prob
lem
is!
Is 9
11 a
fal
se
sens
e of
se
curi
ty?
Emer
genc
y Pr
otoc
ols
911
is a
sol
utio
n.
YES
Wha
t to
do in
the
mea
ntim
e???
Pr
oble
m
Com
mun
icat
ion
•Fro
nt D
esk
•Offi
ce M
anag
er
“Wha
t is
your
Em
erge
ncy?
”
The
3 U
’s
Unc
onsc
ious
U
nres
pons
ive
Una
ble
to fi
nd
a pu
lse
RES
PON
SIB
ILIT
IES
A
ttend
ing
pers
on
91
1“I
HAV
E A
N U
NR
ESPO
NSI
VE C
HIL
D
WIT
HO
UT
A PU
LSE”
.
123
Hom
e S
treet
. H
awki
ns re
side
nce.
Fr
ont d
oor.
“I
will
mee
t you
ther
e”
RES
PON
SIB
ILIT
IES
Fr
ont D
esk
911
“WE
HAV
E A
PATI
ENT
IN C
AR
DIA
C A
RR
EST
WIT
H C
PR IN
PR
OG
RES
S”
91 R
ylan
der B
lvd.
D
r. H
awki
ns o
ffice
. Fr
ont p
arki
ng lo
t.
“I w
ill m
eet y
ou th
ere”
All
the
staf
f mus
t kno
w th
e
loca
tion
of:
•Por
tabl
e ox
ygen
with
mas
ks/c
annu
las
•BVM
Am
bu® b
ag w
ith a
irway
s •A
.E.D
. •E
mer
genc
y dr
ug k
it •P
orta
ble
suct
ion
•Em
erge
ncy
light
ing
sour
ce
Staf
f Tra
inin
g
•Cur
rent
BLS
trai
ning
•T
ask
desi
gnat
ion:
2 g
roup
s,
ac
tion
+ su
ppor
t •M
ock
sim
ulat
ions
: ��
sho
rter
tim
e (1
5 m
in.)
� h
ighe
r fre
quen
cy (2
mo.
)
Staf
f Tra
inin
g
Rec
omm
enda
tion:
C
an y
ou d
isco
ver,
priv
atel
y,
with
out e
mba
rrass
men
t who
is
and
who
may
not
be
prep
ared
fo
r an
assi
gned
dut
y be
fore
an
eve
nt, n
ot d
urin
g.
Ev
ery
2 M
onth
s:
Sync
ope
for 1
5 M
inut
es:
Sync
ope
�
�
�
�
�
�
Moc
k
Sim
ulat
ions
Sync
ope
Alg
orith
m
Pos
itio
n, A
BC
’s
Tim
e, T
ime,
Tim
e A
lway
s!
O2 b
y na
sal
cann
ula
4 lit
res/
min
ute
+
Glu
cose
Med
ical
Con
sulta
tion
MU
ST H
AVE
A G
AM
E PL
AN
!
1. D
enta
l tre
atm
ent r
isk/
bene
fit
2. C
onte
mpl
ated
med
icat
ions
in
mg.
or ��
g.
EMER
GEN
CY
KIT
S
Acm
e�� D
enta
l / M
edic
al K
it
Rea
dy
mad
e?
Sel
f as
sem
bled
?
SEN
IOR
CIT
IZEN
“A
VER
-AG
E” P
ATI
ENT
PED
IATR
IC
CO
NSI
DER
ATI
ON
S
Pha
rmac
odyn
amic
s: A
ge/R
isk
Phys
ical
Cla
ssifi
catio
ns -
ASA
ASA
I –
norm
al, h
ealth
y A
SA II
– m
ild s
yste
mic
dis
ease
A
SA II
I – s
ever
e m
ultip
le s
yste
ms,
med
icat
ion
ASA
IV –
sev
ere
dise
ase,
thre
at to
life
A
SA V
– w
on’t
surv
ive
with
out o
pera
tion
ASA
VI –
bra
in d
ead,
aliv
e fo
r org
an
tran
spla
nt
E –
ope
ratio
n m
odifi
catio
n e.
g. A
SA II
I-E
The
Seni
or C
itize
n
Alth
ough
inac
cura
te, a
“s
enio
r” in
our
soc
iety
is
usua
lly d
efin
ed a
s 65
ye
ars
old,
unl
ess
you’
re
in s
ome
drug
sto
res
on a
Tu
esda
y.
A “b
ad d
ay”
will
usu
ally
ha
ppen
bec
ause
of a
n at
tack
of a
pre
-exi
stin
g co
nditi
on...
Seni
or C
itize
n C
onsi
dera
tions
Fear
Fac
tors
: •
Loss
of f
unct
ion
and
inde
pend
ence
•
Long
term
inst
itut
iona
l-
izat
ion
• D
isab
ility
•
Dea
th
Seni
or C
itize
n C
onsi
dera
tions
C.N
.S:
• Lo
ss o
f Neu
rons
C
.V.S
: •
Syst
olic
B.P
. �� w
ith a
ge
• R
ate �
due
to
par
asym
path
etic
act
ivity
Seni
or C
itize
n C
onsi
dera
tions
Pulm
onar
y:
• Lo
ss o
f alv
eola
r sep
ta
• ��
ela
stic
ity o
f lun
gs
• C
hron
ic s
mok
ing
a fa
ctor
Seni
or C
itize
n C
onsi
dera
tions
CO
MM
UN
ICA
TIO
N
DIF
FIC
ULT
IES
The
“Ave
r-ag
e” P
atie
nts
ASA
I or
II a
re g
ener
ally
sa
fe p
atie
nts
med
ical
ly.
ASA
III i
s a
judg
men
t cal
l.
A “h
eart
” pa
tient
is s
afer
w
ith s
edat
ion.
A “b
ad d
ay”
will
usu
ally
hap
pen
beca
use
of la
ck o
f at
tent
ion
to th
e ru
les
- dos
es, l
ack
of g
ood
L.A
. or “
poin
t of
no
retu
rn”
feel
ings
.
Why
doe
s M
orbi
dity
–
Mor
talit
y “target”
C
HIL
DR
EN?
Alth
ough
inac
cura
te, a
“c
hild
” in
our
soc
iety
is
usu
ally
def
ined
as
up to
12
year
s ol
d.
A “b
ad d
ay”
will
us
ually
hap
pen
beca
use
of la
ck o
f re
spec
t of t
heir
airw
ay...
Chi
ldre
n
Pedi
atric
Con
side
ratio
ns
Hig
h M
YOC
AR
DIA
L
O2 C
onsu
mpt
ion
Hig
h B
RA
IN
O2 C
onsu
mpt
ion
THE
2 M
OST
IM
POR
TAN
T P
hysi
olog
ical
C
onsi
dera
tions
IN
PED
IATR
IC
RES
CU
E ar
e:
C.V
.S /
C.N
.S:
Pedi
atric
Con
side
ratio
ns
C.N
.S:
The
CPR
/ B
LS g
uide
line
of:
“3 –
6 m
inut
es u
ntil
perm
anen
t bra
in
dam
age
begi
ns”
is fo
r the
adu
lt w
ithou
t an
O2 d
ebt a
nd d
oes
NO
T ap
ply
in
pedi
atric
life
.”
Pedi
atric
Con
side
ratio
ns
Dru
g (lo
cal a
nest
hetic
) im
pact
: •U
npre
dict
able
•B
lood
Bra
in B
arrie
r is
imm
atur
e
•�� M
etab
olis
m d
ue to
imm
atur
e liv
er
Pedi
atric
Con
side
ratio
ns
CO
MM
UN
ICA
TIO
N
DIF
FIC
ULT
IES
·
Airw
ay,
A F
ew G
ood
Adj
unct
s,
Oxy
gen
and
Vaso
cons
tric
tors
MA
NA
GEM
ENT
O
F A
IRW
AY
Act
ions
& A
rmam
enta
rium
• Airw
ay
Obs
truc
tions
: Th
e
Con
scio
us
Vict
im
Airw
ay C
onsi
dera
tions
• Kno
w E
ach
Patie
nt’s
Airw
ay
• Alw
ays
Mai
ntai
n Pa
tenc
y • H
ead
Posi
tion
• Cle
ar D
ebris
• U
se T
hroa
t Par
titio
ns
• Use
Rub
ber D
am W
hen
Poss
ible
It w
ould
be
idea
l to
be a
ble
to u
se th
e em
erge
ncy
arm
amen
taria
in d
ay-to
-day
de
ntis
try,
for c
ost e
ffici
ency
, fa
mili
arity
and
for p
ract
ice!
Equi
pmen
t Adj
unct
M
anag
emen
t
“Mou
th R
este
r”…
not
a p
rop
Dis
posa
ble
Lary
ngos
cope
“A to
ngue
dep
ress
or
with
a li
ght o
n it”
Mag
ill
Forc
eps
Sera
ted,
circ
ular
tips
, do
uble
lum
en
��
Dis
posa
ble
“lon
g sa
liva
ejec
tor”
…w
ith a
scr
een
tip
that
doe
sn’t
co
me
off
• Airw
ay
Obs
truc
tions
: Th
e
Unc
onsc
ious
Vi
ctim
Ora
l Pha
ryng
eal A
irway
Size
? A
ngle
of M
andi
ble
to C
orne
r of M
outh
CR
ICO
THYR
OTO
MY
Old
and
New
Idea
s
Cric
othy
roid
M
embr
ane
Punc
ture
fo
r Tr
ache
al
Acc
ess C
ricot
hyro
tom
y W
hat y
ou re
ally
nee
d to
kn
ow a
bout
old
and
new
id
eas
of c
ricot
hyro
tom
y
is…
MA
NA
GEM
ENT
O
F B
REA
THIN
G
Act
ions
& A
rmam
enta
rium
Oxy
gen
Sour
ces
•Por
tabl
e ta
nks
(Ste
m &
Wre
nche
s)
•Cen
tral
tank
s •R
egul
ator
s an
d C
ompo
nent
s •F
low
met
ers
Flow
m
eter
: 0-
15
liter
s/m
in
Full:
20
00
PSI
Nas
al C
annu
la -
Dis
posa
ble
O2
��
4 l/
min
Non
-reb
reat
hing
Mas
k (N
RB
)
O2
��
6-10
l/m
in
Bag
-val
ve-m
ask
Syst
ems
(B.V
.M.)
Bag
Val
ve M
ask
(BVM
) In
flata
ble
Mas
k
(use
10
cc. s
yrin
ge –
air)
�
O
ne w
ay v
alve
- onc
e se
aled
no
need
to li
ft ed
ge o
f mas
k fo
r ex
hala
tion
�
Supp
lem
enta
l O2
with
re
serv
oir a
t 10-
15
liter
s/m
inut
e
2-3
l. b
ag
Can
be
used
IF
brea
thin
g
Tran
spar
ent m
ask
–
can
see
regu
rgita
tion
Thes
e 3
finge
rs p
ull u
p
� �
�
Thes
e 2
digi
ts
pres
s
Dem
and
Valv
e
MA
NA
GEM
ENT
O
F C
IRC
ULA
TIO
N
Act
ions
& A
rmam
enta
rium
VASO
CO
NST
RIC
TOR
“I
SSU
ES”
Vaso
cons
tric
tor
Con
side
ratio
ns
A.U
se is
bas
ed o
n va
soco
nstr
ictiv
e al
pha
rece
ptor
ago
nist
s 1.
Del
ays
abso
rptio
n, re
duci
ng to
xici
ty a
nd
prol
ongi
ng d
urat
ion
N
o A
dvan
tage
With
C
once
ntra
tions
> 1
:200
,000
2.
Red
uces
hem
orrh
age
at s
urgi
cal s
ite
(C
ON
CEN
TRA
TIO
N IS
AD
VAN
TAG
EOU
S IN
TH
IS C
ASE
)
Vaso
cons
tric
tor
Con
side
ratio
ns
Dee
p
Arte
ries
Adr
ener
gic
alph
a re
cept
or fu
nctio
ns
and
vasc
ular
dis
trib
utio
n
��
Vaso
cons
tric
tion
� 2
Vaso
dila
tion
+ B
ronc
hial
dila
tion
� 1
Car
dio-
trop
ic
Vein
s an
d Su
bmuc
osal
Ar
terie
s
�
�
� 2
Rel
ativ
e R
ecep
tor A
ffini
ties:
•Epi
neph
rine
50:5
0 al
pha:
beta
1=2
re
cept
or a
ffini
ty
•Lev
onor
defr
in 7
5:25
alp
ha:b
eta
1 re
cept
or a
ffini
ty
•The
se ra
tios
are
mis
lead
ing
- ref
lect
le
vono
rdef
rin’s
lim
ited
actio
n at
bet
a 2
rece
ptor
s.
It’s
activ
ity a
t car
diac
bet
a 1
rece
ptor
s is
co
mpa
rabl
e to
epi
neph
rine’
s at
equ
ipot
ent
dose
s.
With
mos
t hea
rt c
ondi
tions
, the
mos
t se
rious
med
ical
-den
tal r
isk
for d
enta
l
trea
tmen
t is
the
vaso
cons
tric
tor.
True
Fa
lse
or
Vaso
cons
tric
tor
Con
side
ratio
ns
B.P
osol
ogy
C.C
once
ntra
tion
repr
esen
t gra
ms
/ ml
1:1
00,0
00 =
0.0
1 m
g or
10
µg p
er m
l
1:50
,000
= tw
ice
the
amou
nt o
r 20
µg
1:
200,
000
= ha
lf th
is a
mou
nt o
r 5 µ
g
Vaso
cons
tric
tor
Con
side
ratio
ns
D. S
yste
mic
influ
ence
s fo
llow
ing
abso
rptio
n ar
e U
NEQ
UIV
OC
AL.
1.
Syst
emic
abs
orpt
ion
WIL
L oc
cur!
2.
Rat
e/Pr
essu
re P
rodu
ct W
ILL
incr
ease
! 3.
Issu
e is
whe
ther
this
effe
ct is
de
trim
enta
l to
patie
nt.
Vaso
cons
tric
tor
Con
side
ratio
ns
E. P
oten
tial f
or e
nhan
ced
pres
sor r
espo
nse
in th
ose
patie
nts
med
icat
ed w
ith
nons
elec
tive
beta
blo
cker
s.
1. L
ow d
oses
of e
pine
phrin
e ex
hibi
t bet
a 2
pref
eren
ces
on la
rge
syst
emic
art
erie
s.
2. If
bet
a bl
ocka
de is
pre
sent
, epi
neph
rine
will
bin
d w
ith a
lpha
rece
ptor
s +
incr
ease
pe
riphe
ral r
esis
tanc
e.
EPI
LEVO
�
�
Nor
mal
Bot
h ��1
, �2
bloc
ked
“alri
ght”
�� 1
blo
cked
onl
y
“bew
are”
� 1
,2 b
oth
bloc
ked
“coo
l” a
ll b
lock
ed
Cas
e R
epor
t #1
43 y
ear o
ld fe
mal
e, C
anda
ce, 1
hou
r hyg
iene
app
t. In
dera
l�� 4
0 m
g. b
.i.d.
for m
igra
ine
head
ache
s, b
ut n
o C
VD,
BP
128/
86 H
R 8
8 IV
sed
atio
n - 4
mg.
mid
azol
am w
ith R
N N
ancy
Lo
cal a
nest
hesi
a: 4
% a
rtic
aine
1:
100K
epi
6.8
ml.
– 4
cart
ridge
s Q
2 m
inut
es:
152/
94
92
Q3
168/
98
78
Q4
190/
104
64
Q5
min
utes
: 1
58/9
8
78
Cas
e R
epor
t #1
1.IF
SYM
PTO
MS
�� A
ctiv
ate
EM
S
2.Po
sitio
n, A
BC
’s, O
2, 3.
Low
er B
lood
Pre
ssur
e –
Nitr
ogly
cerin
e sp
ray
+ su
ppor
t 4.
ASA
???
NO
W W
HA
T?
Man
agin
g B
eta
Blo
cked
Pa
tient
s
No
issu
e w
ith c
ardi
osel
ectiv
e ag
ents
, (a
) cat
egor
y B
UT
Inde
ral��
and
Cor
gard�
, non
-sel
ectiv
e,
(b) c
ateg
ory
WH
AT
TO D
EFIN
ITEL
Y D
O!
1. L
ook
it up
in th
e PD
R (C
PS C
anad
a)
2. W
ait 5
min
utes
afte
r eac
h ca
rtrid
ge a
nd
reas
sess
vita
ls
Man
agin
g B
eta
Blo
cked
Pa
tient
s
WH
AT
TO P
OSS
IBLY
DO
?
3. A
void
usi
ng a
vas
opre
ssor
if (b
) ca
tego
ry
4. C
onsu
lt ph
ysic
ian
rega
rdin
g di
scon
tinui
ng (b
) bet
a bl
ocke
r or
chan
ging
it to
a c
ardi
osel
ectiv
e (a
) be
ta b
lock
er
Hyp
erte
nsio
n A
lgor
ithm
Syn
cope
Pro
toco
l
Rea
sses
s B
P / P
erfu
sion
Nitr
ogly
cerin
N
ifedi
pine
EM
S tr
ansp
ort i
f sym
ptom
atic
�
Def
ibril
latio
n,
Dru
gs a
nd
Dia
gnos
is
Vict
im
Mus
t Be
On
“Firm
” Su
rfac
e ??
?
A.E
.Ds
One
-Tou
ch
$124
5.00
C
PR S
aver
s an
d Fi
rst
Aid
Sup
ply®
AED
Phi
loso
phy
•If y
ou a
re S
tate
Boa
rd re
gula
ted
to
have
one
, the
n ge
t one
!
AED
+ E
CG
Sim
ple
but
Soph
istic
ated
$199
9.00
C
PR S
aver
s an
d
Firs
t Aid
Su
pply®
Dru
gs
Wha
t do
you
need
?
Gui
delin
es
Emer
genc
y M
edic
atio
ns
Res
pons
ible
Aux
iliar
y:
•Che
ck k
it ev
ery
two
mon
ths
(on
moc
k si
mul
atio
n da
y) to
ass
ure
drug
s ar
e no
t exp
ired
or b
roke
n.
Rep
lace
as
need
ed.
•Rev
iew
cor
rect
met
hod
for
prep
arat
ion
in e
mer
genc
y pe
riodi
cally
.
OXY
GEN
Epin
ephr
ine
EPIP
EN®
* for
ana
phyl
axis
(sev
ere
alle
rgy;
be
e st
ings
, pea
nuts
) and
bro
ncho
spas
m
CH
ILD
/ A
DU
LT: E
piPe
n 2-
Pak®
:
child
: 0.1
5 m
g…..
$279
.06
ad
ult:
0.3
mg…
. $ 2
79.0
6 *u
ntil
you
can
draw
up
from
an
amp.
Epin
ephr
ine
Equi
-pot
ent d
oses
: (1m
l 1:1
000
amps
) by
rout
e of
adm
inis
trat
ion:
•SC
- 0.
5 m
g
•IM
- 0.
3 m
g.
•IL
- 0.
2 m
g.
•IV
- 0.
1 m
g. -
mus
t dilu
te 1
:10,
000
If pa
tient
has
air
exch
ange
: ß
-2 in
hale
r: a
lbut
erol
(Ven
tolin
®)
Nitr
ogly
cerin
A
ctio
n is
unc
lear
: SL
adm
inis
trat
ion ��
va
sodi
latio
n re
sult
in a
redu
ced
veno
us re
turn
, or
pre
load
redu
ctio
n, lo
wer
ing
myo
card
ial O
2 co
nsum
ptio
n.
In
dica
tions
: Isc
hem
ic c
hest
pai
n - 1
tab
Q5M
x 3
S
ympt
omat
ic h
yper
tens
ive
epis
odes
•D
ose:
0.3
-0.6
SL
mg.
tabs
/ 0.
4-0.
8 SL
spr
ay
W
arni
ng: d
o no
t giv
e an
othe
r “ni
tro”
if S
BP
< 90
$9.0
0 / 1
00
Ex
pira
tion
date
m
ust b
e “S
harp
ied”
to
8-10
wee
ks fr
om
“tod
ay’s
se
al b
reak
ing”
$32.
00
N
itrol
ingu
al®
Pu
mps
pray
bu
t . .
.
. . .
expi
ry d
ate
IS th
e ex
piry
da
te
ASA
Giv
ing
the
max
imum
as
a 3
25 m
g. ta
blet
is
OK
but
…
325
mg.
= p
eak
effe
ct
It
’s b
est
via
4X b
aby
A
SA
(81
mg.
) ch
ewed
, as
ide
from
, and
ove
r an
d ab
ove
prop
hyla
ctic
us
e
AS
A (
for
MI)
325
mg.
= p
eak
effe
ct
Act
ion:
Kee
ps #
of
plat
elet
s fr
om in
crea
sing
, whi
ch c
ould
le
ad t
o fu
rthe
r co
rona
ry
arte
ry b
lock
age
or if
cer
ebra
l blo
ckag
e,
ST
RO
KE
!
AS
A (
for
MI)
Vent
olin
®
Alb
uter
ol /
Bro
ncho
dila
tor
Inha
ler:
Inha
le 1
to 2
puf
fs o
f al
bute
rol u
p to
4 ti
mes
dai
ly.
Mor
e th
an 8
inha
latio
ns p
er d
ay is
no
t rec
omm
ende
d. Alb
uter
ol -
Vent
olin
® -
β2
ago
nist
Dip
henh
ydra
min
e (B
enad
ryl®
)
•Act
ion
and
effe
ct b
ased
on
bloc
king
hi
stam
ine
rele
ase
•Ind
icat
ions
/ D
ose:
(50m
g/m
l am
p or
SD
V)
•pr
uritu
s / u
rtic
aria
/ na
usea
•
50m
g IM
follo
wed
by
50m
g TI
D P
.O.
•m
edic
al fo
llow
up
to a
naph
ylax
is
• TH
INK
FIR
ST!
GGlu
cose
Sou
rce
A
LL d
enta
l offi
ces
have
su
gar
Seda
tion
Res
ourc
e, In
c
texa
sros
e@se
datio
nres
ourc
e.co
m
w
ww
.sed
atio
nres
ourc
e.co
m
80
0-75
3-63
76
Hal
s M
ed D
ent S
uppl
y &
Pha
rmac
y, In
c
ww
w.h
alsm
edde
nt.c
om
Sout
hern
Ane
sthe
sia
& S
urgi
cal
w
ww
.sou
ther
nane
sthe
sia.
com
Res
ourc
es fo
r Em
erge
ncy
Dru
gs a
nd E
quip
men
t
AC
E Su
rgic
al S
uppl
y C
ompa
ny
10
34 P
earl
St. B
rock
ton,
MA
A
AM
OS
Supp
lier M
arke
tpla
ce
aa
oms@
mul
tivie
w.c
om
w
ww
.mul
tivie
w.c
om 8
00-8
16-6
710
Salv
in D
enta
l Spe
cial
ties,
Inc.
C
ritic
are
mon
itors
, AED
’s,
3450
Lat
robe
Dr.
NC
282
11
w
ww
.sal
vin.
com
Res
ourc
es fo
r Em
erge
ncy
Dru
gs a
nd E
quip
men
t
Dia
gnos
is
Dep
ende
nt
Trea
tmen
ts
Sync
ope
•Sud
den,
tran
sien
t los
s of
co
nsci
ousn
ess
•Com
mon
imm
edia
tely
pre
- or p
ost
in
ject
ion
•Mos
t com
mon
pro
cedu
re –
ext
ract
ion
•Ofte
n re
cove
ry b
efor
e ad
vanc
ed
trea
tmen
t can
be
impl
emen
ted
Sync
ope
Prof
ile o
f Pre
vale
nce
• Mal
e »
Fem
ale
• Nev
er in
chi
ldre
n • A
vera
ge a
ge?
35 y
ears
old
• S
cena
rio:
Mal
e, 3
5 y.
o., a
nxio
us,
“m
acho
” gu
y,
“nee
dlep
hobi
c”
Sync
ope
– Si
gns
/ Sym
ptom
s
•Pa
llor
•N
ause
a •
Dis
orie
ntat
ion
•Lo
ss o
f Con
scio
usne
ss
•B
lood
pre
ssur
e •
Puls
e th
read
y, m
ay a
rres
t 30-
45 s
ec.
•Lo
w b
lood
sug
ar
Sync
ope
Cau
ses
•Anx
iety
, Pai
n •S
it up
too
fast
•I
njec
t too
fast
•I
ntra
osse
ous
inje
ctio
ns
•Hyp
ogly
cem
ia (p
rolo
nged
NPO
)
Sync
ope
Alg
orith
m
Pos
itio
n, A
BC
’s
Tim
e, T
ime,
Tim
e A
lway
s!
O2 b
y na
sal
cann
ula
4 lit
res/
min
ute
+
Glu
cose
Hyp
erve
ntila
tion
Sign
s / S
ympt
oms:
•
Rap
id, s
hallo
w b
reat
hs, “
air h
unge
r”
•Im
paire
d in
spira
tion
/ exp
iratio
n •
Sens
e of
pan
ic
•D
isor
ient
atio
n •
O2 s
atur
atio
n =
100%
Ang
ina
•Pal
lor,
ches
t pai
n in
“w
aves
” •“
Indi
gest
ion?
” •D
enia
l •M
idst
erna
l pai
n, le
ft ar
m, l
eft m
andi
ble
•Nau
sea,
dia
phor
esis
•R
apid
, sha
llow
bre
athi
ng, t
reat
men
t -
adm
inis
ter 1
nitr
ogly
cerin
e
Myo
card
ial I
nfar
ctio
n
•Fem
ale:
“w
eigh
t on
ches
t” /
indi
gest
ion?
•m
ild s
hort
ness
of b
reat
h (S
OB
), na
usea
•M
ale:
che
st p
ain,
sha
rp, s
ever
e, le
ft ar
m
•�� S
OB
, � B
P (p
ain)
•P
anic
, fea
r, bu
t den
ial
•Rap
id, s
hallo
w b
reat
hing
A
ngin
a / M
I Alg
orith
m
Sy
ncop
e Pr
otoc
ol
��
Nitr
ogly
cerin
q. 5
min
x 3
�
A
ssum
e M
I / C
all E
MS
Car
diac
Arr
est
•M
arke
d hy
pote
nsio
n •
Rap
id, s
hallo
w b
reat
hing
�� L
OC
•
Apn
ea �
cya
nosi
s =
resp
irato
ry
arre
st
•Fi
brill
atio
n =
no p
ulse
•
AED
giv
es d
iagn
osis
and
act
ion
C
ardi
ac A
rres
t Alg
orith
m
Sy
ncop
e Pr
otoc
ol
��
CPR
100%
Oxy
gen
� 1
- 2
mg
epin
ephr
ine
Ast
hma
and
Seve
re A
llerg
y Si
gns/
Sym
ptom
s C
ombi
natio
n
AC
UTE
AST
HM
A A
ND
B
RO
NC
HO
SPA
STIC
EVE
NTS
AC
UTE
AST
HM
A
Bro
ncho
spas
m A
lgor
ithm
AB
C’s
& P
ositi
on
��
Oxy
gen
�
B
-2 in
hale
r B
UT
if no
t exc
hang
ing
air:
ep
inep
hrin
e 0.
3 m
g
•Prim
ary
asse
ssm
ent
is in
fron
t of y
ou o
r in
the
hist
ory
•Act
ivat
e EM
S, 9
11
•Ass
ign,
Des
igna
te
In T
he D
enta
l Offi
ce o
r
Witn
esse
d at
hom
e
It is
stil
l A
, B, C
•Prim
ary
asse
ssm
ent
•Cal
l for
HEL
P, g
et to
a
phon
e ev
en if
it’s
yo
u th
at h
as to
leav
e •N
o m
edic
al h
isto
ry,
no re
lativ
es, n
o kn
owle
dgea
ble
frie
nds
Une
xpla
ined
, Unw
itnes
sed,
U
ncon
scio
us
Car
diac
arr
est
NO
W
C, A
, B
IN L
IFE…
trip
le “
U”
•Loo
k fo
r MED
IC A
LER
T br
acel
et o
r ne
ckla
ce
•Rea
d al
lerg
ies,
med
ical
con
ditio
ns
•Pho
ne e
mer
genc
y ho
t lin
e #
on
MED
ICA
L A
LER
T ta
g, q
uote
vic
tim’s
ID
# •Med
ical
his
tory
will
be
give
n 24
/ 7
by
phon
e
The
Was
hing
ton
Stat
e
Den
tal A
ssoc
iatio
n –
2015
Pac
ific
Nor
thw
est
Den
tal C
onfe
renc
e
June
11-
12, 2
015
Med
ical
Em
erge
ncie
s in
the
D
enta
l Offi
ce,
Med
ical
Em
erge
ncie
s in
Life
!
Mel
Haw
kins
, DD
S B
ScD
AN
D
entis
t/Den
tist A
nest
hesi
olog
ist
Toro
nto,
ON
Can
ada
1
2
3
Prod
uct
Issu
es
Den
tist
Issu
es
CO
NS
ULT
ING
DIL
EM
MA
S
Patie
nt
Issu
es
CA
SE
RE
PO
RT
PR
OD
UC
T
CO
MP
LAIN
T:
CCO
MP
LAIN
T:
7 pa
tient
s 's
trok
e-lik
e' re
actio
ns to
3
% m
epiv
acai
ne (p
lain
)
33% M
EP
IVA
CA
INE
(P
LAIN
) C
omm
on lo
cal a
nest
heti
c ad
min
iste
red
DDO
CT
OR
’S I
NT
ER
VIE
W
INFO
RM
AT
ION
WH
AT’
S YO
UR
D
IAG
NO
SIS,
D
OC
TOR
?
The
Was
hing
ton
Stat
e
Den
tal A
ssoc
iatio
n –
2015
Pac
ific
Nor
thw
est
Den
tal C
onfe
renc
e
June
11-
12, 2
015
Med
ical
Em
erge
ncie
s in
the
D
enta
l Offi
ce,
Med
ical
Em
erge
ncie
s in
Life
!
Mel
Haw
kins
, DD
S B
ScD
AN
D
entis
t/Den
tist A
nest
hesi
olog
ist
Toro
nto,
ON
Can
ada
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