Emergency Drugs for the Dental Clinic
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Direct answer
Syncope is the emergency you will actually meet first; anaphylaxis is the one that kills fastest — and the dental emergency tray must serve both with a short, dated list: oxygen, adrenaline 1 mg/mL injection, sublingual glyceryl trinitrin, dispersible aspirin 300 mg, a salbutamol inhaler, oral and injectable glucose with glucagon, an antihistamine, hydrocortisone 100 mg, a benzodiazepine, and a bag-valve-mask. Adrenaline for anaphylaxis is 0.5 mg intramuscularly into the anterolateral thigh, repeated every five minutes. Position is a drug in itself: supine with legs raised for syncope and anaphylaxis, upright for angina and asthma, and nothing oral for the unconscious patient.
What you must remember
- Anaphylaxis: adrenaline 0.5 mg IM (0.5 mL of 1:1000) into the mid-anterolateral thigh, repeated at 5-minute intervals; children 0.01 mg/kg. Adrenaline comes before antihistamines and steroids, which are adjuncts.
- Vasovagal syncope — the commonest dental emergency — is treated with position, not pharmacy: supine, legs elevated, oxygen, a calm voice, a loosened collar.
- Angina: glyceryl trinitrin 0.3–0.5 mg sublingually, repeated at 5-minute intervals up to three doses; pain unrelieved after 10–15 minutes is myocardial infarction — aspirin 300 mg chewed, oxygen if hypoxic, ambulance.
- Never give GTN within 24 hours of sildenafil (48 hours for tadalafil): catastrophic hypotension.
- Asthma: salbutamol by inhaler, repeated puffs via spacer, oxygen, upright posture; failure to respond or inability to speak in sentences is status — call an ambulance.
- Hypoglycaemia: conscious patient, 15–20 g oral glucose (the rule of 15); unconscious patient, glucagon 1 mg IM or intravenous glucose — never anything by mouth.
- Prolonged seizure: protect and time it; beyond five minutes give midazolam 10 mg buccally or IM (adult), call an ambulance, and check glucose.
- Adrenal crisis in a steroid-dependent patient: hydrocortisone 100 mg IM or IV with fluids and urgent transfer; and kit discipline — monthly expiry checks, annual team drills, oxygen cylinder pressure logged, and every staff member able to fetch the tray.
Running the first five minutes
Two contrasting calls show the method. In the first, a patient develops an itchy rash, widespread urticaria and a tight wheeze within minutes of the first amoxicillin capsule. Stop the trigger, call for help and an ambulance together, lay the patient flat with legs raised, give high-flow oxygen — and give adrenaline 0.5 mg IM into the thigh now, not after observations. Only after adrenaline do antihistamine and hydrocortisone follow, because they act over hours while the airway closes over minutes; repeat the adrenaline at five minutes if wheeze or hypotension persists, and observe in hospital for a biphasic reaction. In the second, a patient mid-extraction turns pale, sweats, yawns and slides into the headrest — vasovagal syncope: stop, lower the chair, raise the legs, loosen clothing and speak reassuringly while oxygen flows; the pulse is slow, the skin cold and clammy, and recovery is visible within a minute. The pivot between the look-alikes is distribution: urticaria, wheeze and a rapid pulse point to anaphylaxis; pallor, yawning and bradycardia point to syncope. Both begin the same way — recognise, call, position, oxygen — so the first five minutes are a drill, not a debate.
Where students slip
The examination errors are route and site for adrenaline (intramuscular into the thigh, not subcutaneous or undiluted intravenous), giving hydrocortisone pride of place in anaphylaxis (too slow to save the airway), and forgetting the aspirin in suspected infarction because "the paramedics will give it". Practical slips: an unconscious diabetic given oral glucose aspirates; an asthmatic laid flat worsens; GTN given without asking about sildenafil drops the blood pressure through the floor. Indian exam convention asks each emergency as a named station — drug, dose, route, first action — so practise reciting each as a single sentence in the order recognise, call, position, oxygen, drug.
Frequently asked questions
What is the dose and route of adrenaline in adult anaphylaxis?
0.5 mg intramuscularly — 0.5 mL of 1:1000 (1 mg/mL) — into the mid-anterolateral thigh, repeated every five minutes if features persist.
What is the first-line management of vasovagal syncope?
Position: supine with legs elevated, plus oxygen and reassurance — recovery is usually evident within a minute; drugs have no role in a simple faint.
Why must GTN be withheld after sildenafil?
Phosphodiesterase-5 inhibitors potentiate nitrate vasodilatation, producing profound hypotension — defer nitrates 24 hours after sildenafil and 48 after tadalafil.
How is suspected myocardial infarction managed in the chair?
Call an ambulance, give dispersible aspirin 300 mg chewed, glyceryl trinitrin if blood pressure allows and no PDE-5 inhibitor was taken, oxygen only if hypoxic, and stay with the patient.
Which drug is given for an unconscious hypoglycaemic patient?
Glucagon 1 mg intramuscularly (or intravenous glucose in trained hands) — never oral glucose in an unconscious patient because of aspiration.
What is the drug management of a seizure lasting beyond five minutes?
A benzodiazepine — buccal or intramuscular midazolam 10 mg in adults — with ambulance activation, airway protection and a glucose check, since hypoglycaemia can masquerade as epilepsy.