10: Medical and Dental Emergencies

CHAPTER 10 Medical and Dental Emergencies

EMERGENCY PREVENTION

The combination of pain, stress, infection, and anesthesia use in the dental setting may contribute to medical emergencies. Evaluation includes completion of a comprehensive health history, in-depth history of present illness, assessment of vital signs, physical assessment, and thorough emergency preparation in the dental setting. Instances of when to request a medical consult regarding a patient and/or when to consider a situation an emergency and activate the Emergency Medical Service (EMS) system are discussed in this chapter.

• See CD-ROM for Chapter Terms and WebLinks.

• See Chapters 6, General and Oral Pathology: pathological disorders risk for emergencies; 8, Microbiology and Immunology: allergic reactions in a dental setting; 9, Pharmacology, drugs in emergency kit in a dental setting; 14, Pain Management: local anesthesia and nitrous oxide administration emergencies in a dental setting.

HEALTH HISTORY

Patient’s health history includes BOTH medical and dental history, as well as in-depth history of present illness. Crucial to BOTH the diagnosis and treatment of and prognosis for conditions experienced by dental patients. Modifying dental treatment as indicated by the health history creates less risk of emergencies in the dental setting.

• See Chapters 9, Pharmacology: antibiotic premedication and Physician’s Desk Reference; 11, Clinical Treatment: health history; 18, Ethics and Jurisprudence: related ethical concerns.

A. Identifies changes in drugs and/or conditions that may require antibiotic premedication (e.g., valvular replacement and/or congenital heart disease or transplant).

B. Identifies precautions, allergies, or conditions that may contraindicate or modify treatment.

C. Includes record of vital signs.

D. May assist in identification of oral manifestations associated with some drugs or systemic diseases.

E. Assists in planning treatment according to physiological and psychological status.

F. Serves as medicolegal document.

Vital Signs

Vital signs include blood pressure reading, pulse rate, respiration rate, temperature reading (if needed), pupil size. Obtained as a baseline for patient. Specific vital signs are retaken as needed. Information in the following is taken from the “7th Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure” (2003).

• See Chapter 3, Anatomy, Biochemistry, and Physiology: physiology of blood pressure; Chapter 6, General and Oral Pathology: high blood pressure.

A. Blood pressure: force exerted by circulating blood on the walls of blood vessels.

2. Prehypertension (“high normal”):

a. 120 to 139/80 to 89 mm Hg.

b. Treat as usual, but recommend that patient schedule a consult with physician.

c. Usually involves changes in lifestyle to reduce risk of further complications.

3. Hypertension (high blood pressure [HBP]):

a. Indicated by sustained readings that are ≥140/90 mm Hg.

b. Can occur for either systolic or diastolic or both.

4. Blood pressure affected by:

a. Heart rate (HR), stroke volume, total peripheral resistance.

b. Exercise, eating, stimulants, pain, stress, anxiety, patient positioning.

c. Drugs being taken, such as antihypertensives or others (e.g., monoamine oxidase inhibitors [MAOIs]).

d. Recordings taken from right and left arm may differ.

5. Technique for taking blood pressure reading: instruments used to measure blood pressure include stethoscope and sphygmomanometer (cuff size is determined by arm size, cuff too small or large will give false HBP reading); SIMILAR for digital devices; need to wait 2 to 3 minutes between readings for all types.

a. Cuff placed snugly 1 inch above antecubital fossa, NO clothing between cuff and arm.

b. Cuff pumped until radial pulse is NO longer felt; note this point (estimated systolic number) and release the pressure.

c. Cuff then repumped to 10 to 30 mm Hg above previously recorded point (maximum inflation level).

d. Pressure released slowly until systole (FIRST pulse sound) is heard.

e. Continues to release pressure slowly until diastole (last pulse sound) is heard (must listen ALL the way down because at times there is a gap in the sounds).

f. Patient is informed of reading, which is recorded in patient record.

B. Pulse rate frequency of the heart beat or rate, measured in beats per minute (BPM):

1. Taken from radial artery if patient is conscious (easy access) and from common carotid artery in unconscious patient (more accurate) for adults and brachial artery on infants but ONLY by EMS system personnel; fingers used for palpation, since thumb has own pulse.

2. Taken for 30 seconds if within range (number is multiplied by 2 if the rate is regular); if increased or irregular, taken again for 1 minute.

3. Measurements for healthy patients: adults 60 to 90 BPM; children 80 to 110 BPM.

4. Affected by age, exercise, stress, drugs, stimulants, fasting, long-term illness, emotional state.

5. Unusual pulse rates:

a. Tachycardia: faster than normal; >100 BPM for adult.

b. Bradycardia: slower than normal; <60 BPM for adult.

c. Pulsus alternans: beats are alternately weak and strong.

d. Premature ventricular contractions (PVCs): longer than normal pause or a skip noted between beats; if MORE than 5 per minute, cause for concern as this may represent a heart block.

6. AVOID palpating carotid pulse unless EMS personnel (lack indicates death), since stimulating its baroreceptors with vigorous palpation can provoke severe bradycardia or even stop the heart in some sensitive persons; BOTH should not be palpated at the same time to AVOID risk of fainting or brain ischemia.

C. Respiration rate: obtained by counting number of breaths for 30 seconds (number is multiplied by 2 if rate is regular), one exhalation and one inhalation together count as one breath; if increased or irregular, taken again for 1 minute.

1. Measurement for healthy patient: adults 14 to 20 breaths/min; children 18 to 30 breaths/min.

2. Normal rates can be altered if patient knows that breathing is being observed; overall rates can be affected by anxiety, pain, excitement, infection, presence of fever.

3. Rate, rhythm, quality (if strong, labored, shallow, deep) should be noted MAINLY for those who present with medical history of respiratory symptoms, e.g., asthma, emphysema, congestive heart failure, or allergic reactions.

4. Unusual respiration rates:

a. Dyspnea: difficult or labored breathing.

b. Hyperventilation: increased rate and depth of respirations that result in decreased level of carbon dioxide.

c. Kussmaul breathing: heavy, labored breathing, either rapid or slow; occurs during hyperglycemic incident.

D. Temperature reading: taken with covered thermometer when needed because of signs of clinical infection or inflammation:

1. Measurement in healthy patient: 97.0° to 99.6° F (36.1° to 37.6° C).

2. Fever: elevated temperature by at least a full degree; occurs with infection, acute inflammation, shock, or changes in temperature exposure.

a. Hyperthermia: >105.8° F; with infection or overexposure to heat.

b. Hypothermia: <96.0° F; with shock or overexposure to cold.

E. Pupil size: evaluate for signs of constriction, dilation, evenness during extraoral examination.

1. Dilated pupils (mydriasis): indication of shock, heart failure, hallucinogens, or amphetamine use.

2. Constricted or pinpoint pupils (miosis): with morphine, heroin, or barbiturate use.

3. Loss of evenness (two pupils with different sizes): with concussion.

ASA Physical Classification

Emergencies may be minimized or prevented by the pretreatment evaluation of physical classification status. The ASA (American Society of Anesthesiologists) physical status classification is used to determine risks and necessary modifications before treatment.

A. ASA I: healthy.

1. Able to walk up one flight of stairs or two level city blocks without distress.

2. Little or no anxiety; little or no risk.

B. ASA II: mild systemic disease or healthy ASA I who demonstrates a MORE extreme anxiety and fear toward dentistry.

1. Able to walk up one flight of stairs or two level city blocks but will have to stop after completion because of distress.

2. History of well-controlled disease, which includes non-insulin-dependent diabetes mellitus (DM), HBP, epilepsy, asthma, or thyroid conditions; ASA I with a respiratory condition, pregnancy, active allergies.

3. Minimal risk during treatment.

C. ASA III: severe systemic disease that limits activity but is NOT incapacitating.

1. Able to walk up one flight of stairs or two level city blocks, but MUST stop enroute because of distress.

2. History of controlled chronic disease, which includes angina pectoris, myocardial infarction (MI), cerebrovascular accident (CVA), congestive heart failure (CHF) or cardiac surgery more than 4 to 6 weeks in the past, slight chronic obstructive pulmonary disease (COPD), controlled insulin-dependent DM/HBP (with drugs).

3. May need medical consult before elective treatment.

4. If dental care is indicated or allowed, stress reduction protocol and other treatment modifications are indicated.

D. ASA IV: severe systemic disease that limits activity and is a constant threat to life.

1. NOT able to walk up one flight of stairs or two level city blocks; distress is present even at rest.

2. History of uncontrolled acute or chronic disease, which includes unstable angina pectoris, MI/CVA within the last 4 to 6 weeks, severe CHF, moderate to severe COPD, and uncontrolled HBP, epilepsy, DM, or thyroid condition.

3. Pose significant risk, since patients in this category have a severe medical problem of GREATER importance to the patient than the planned dental treatment.

4. Whenever possible, NO elective dental care should be performed; should be postponed until medical condition has improved to at least ASA III; will need medical consult before emergency treatment.

E. ASA V: moribund; NOT expected to live longer than 24 hours, hospitalized, terminally ill; elective dental treatment is definitely contraindicated; however, emergency care or palliative treatment may be necessary.

F. ASA VI: died, and organs are to be harvested.

G. Emergency operation of any variety modifies classifications (e.g., ASA III-E).

H. Those who demonstrate a MORE extreme anxiety and fear toward dentistry have a baseline of ASA II even before their medical history is considered; situation raises ASA one level each time.

PREPARATION FOR MEDICAL EMERGENCIES IN DENTAL SETTING

When emergency situations occur, mandatory that ALL personnel in the dental setting know procedures to be followed, location and use of the emergency kit and oxygen, possibly a portable defibrillator and pulse oximeter, and are able to provide basic life support (BLS). MAIN management of emergency involves BLS; drugs delivered are of secondary importance. Kit can be assembled by personnel or purchased as a unit and must not contain expired drugs. Personnel are MORE likely to be familiar with one they have organized, which is MORE likely to contain articles that meet needs of particular dental setting. Kit MUST be readily available during treatment time.

ALL staff must be trained to use emergency kit’s contents. Periodic emergency drills and posting the telephone numbers of EMS or other appropriately trained healthcare providers is also recommended at the dental setting. Many states require all dental settings to have portable automated external defibrillator (AED).

A. Basic emergency kit: MUST include:

1. Noninjectable drugs:

a. Nitroglycerin (sublingual tablets or nitrolingual aerosol spray) for angina attacks.

b. Bronchodilator (asthma inhaler).

c. Glucose source (e.g., orange juice, oral glucose gel or tablets).

d. Aspirin, prevents additional platelet activation and interferes with platelet adhesion and cohesion with cardiac events.

e. Secondary (additional): aromatic ammonia (amyl nitrate), can be used to stimulate breathing.

2. Injectable (IV) drugs:

a. Epinephrine (1:1000; EpiPens are also recommended) for allergic responses.

b. Diphenhydramine (Benadryl), histamine blocker.

c. Secondary (additional): glucagon, hormone that converts stored glycogen into glucose and releases it into the bloodstream.

3. Oxygen with positive pressure administration capability:

a. Oxygen cylinder (size E) SHOULD be available to deliver 100% oxygen for 30 minutes (5 liters/min with a nasal cannula).

b. For patient who is NOT breathing, delivery requires pocket mask and demand-valve resuscitator (alternative is Ambu bag); full masks of clear material that provide tight seal are necessary.

B. AED: portable electronic device that automatically diagnoses potentially life-threatening cardiac arrhythmias of ventricular fibrillation and ventricular tachycardia.

1. Arrhythmia can be treated by application of electrical therapy, which stops arrhythmia, allowing heart to reestablish effective rhythm.

2. When turned on or opened, unit will instruct user to connect the electrodes (pads) to patient:

a. Once pads are properly attached, everyone should AVOID touching victim to prevent false readings by unit.

b. Pads allow unit to examine electrical output from heart and determine if patient is in viable, shockable rhythm (either ventricular fibrillation or ventricular tachycardia); if device determines that a shock is viable, will use battery to charge internal capacitor in preparation to deliver shock.

C. Pulse oximeter: indirectly measures oxygen saturation and changes in blood volume in skin, producing a photoplethysmograph; useful for monitoring patients during surgical procedures.

1. BEST for simplicity and speed for patients with respiratory and cardiac problems.

2. Monitor displays percentage of arterial hemoglobin in the oxyhemoglobin configuration (possibly heart rate); acceptable normal ranges are from 95% to 100%; for a patient breathing room air at not far above sea level, estimate of arterial po₂ can be made from blood-oxygen monitor SpO₂ reading.

3. NOT a complete measure of respiratory sufficiency; example: patient with hypoventilation (poor gas exchange in the lungs) given 100% oxygen can have excellent blood oxygen levels while still suffering from respiratory acidosis caused by excessive carbon dioxide.

4. NOT a complete measure of circulatory sufficiency; example: if insufficient blood flow or insufficient hemoglobin in the blood (anemia), tissues can suffer hypoxia despite high oxygen saturation in the blood that does arrive.

MEDICAL EMERGENCIES IN DENTAL SETTING

COMMON medical emergencies that may occur in the dental setting include syncope, hyperventilation, airway obstruction. After emergency, patient should be called at home or at hospital later in the day to ensure well-being. Cardiovascular and other less common emergencies in the dental setting are discussed later.

Syncope and Orthostatic Hypotension

A. Syncope (fainting): MOST common dental setting emergency; MOST common cause of loss of consciousness.

1. MOST often associated with a form of stress.

2. Caused by decreased oxygen flow to the brain, which in turn is caused by:

a. Psychogenic factors: stress, unwelcome news, noxious smell or sight of a needle or blood (MOST common cause in dental setting).

b. Nonpsychogenic factors: poor health or exhaustion.

3. Presyncope stage:

a. Pallor, dizziness, and nausea.

b. Lowered blood pressure (hypotension) and increased pulse rate (tachycardia).

4. Syncope symptoms:

a. Loss of consciousness, shallow breathing, dilated pupils.

b. Lowered blood pressure (hypotension) and thready pulse.

5. As with ALL emergencies that involve unconscious patient, may lead to airway obstruction and death if improperly recognized and treated.

a. Place in Trendelenburg position (subsupine with feet elevated higher than head), EXCEPT for pregnant patient (on side before feet are elevated); usually ensures recovery (Figure 10-1).

b. Maintain open airway to prevent airway obstruction by tongue; imperative for unconscious patient.

c. Use of aromatic ammonia inhalant (amyl nitrate), as needed, to provide stimulus for breathing; caution is necessary during use to prevent burning of tissue.

d. Administration of oxygen.

e. Carefully monitor until vital signs return to baseline; mandatory because syncope is LIKELY to recur soon after recovery; vomiting MOST commonly occurs after unconsciousness.

f. NO further dental treatment should take place for 24 hours.

7. Prevention: place supine during treatment; use of relaxation techniques and pharmacological means such as use of antianxiety premedication such as diazepam (Valium) and/or nitrous oxide sedation to relieve stress (see Chapter 14, Pain Management).

B. Orthostatic (postural) hypotension:

1. May occur when patient sits up quickly from being in a supine position and may result in loss of consciousness (second MOST common cause of unconsciousness).

a. Sitting upright or standing can lead to a drop in blood pressure; with standing, systolic drops at <25 mm Hg, diastolic drops at <10 mm Hg.

b. Highest risk: antihypertensives predispose patient (see discussion on angina and nitroglycerin).

c. Also at risk: patients who are elderly, pregnant, have Addison’s disease, or are under nitrous oxide or diazepam (Valium) IV sedation.

2. Patient usually asymptomatic just before incident and returns to consciousness after lying down.

a. Check vital signs and administer oxygen at 5 liters/min through nasal cannula, if needed.

b. Reposition slowly from supine position when patient feels recovered.

4. Prevention: bring ALL patients slowly up after being supine; especially if at risk.

C. Hyperventilation: in dental setting usually related to anxiety.

1. Increased rate and depth of respirations, which results in decreased level of carbon dioxide.

a. Other symptoms: tightness of chest, sensation of suffocating, dizziness, tingling in fingers.

b. Does NOT usually occur in children, since anxiety is released by other means (e.g., crying, refusing to cooperate).

c. May lead to syncope and then vomiting; vicious cycle.

a. Calm and place in upright position; respiratory emergencies SHOULD be managed with patient upright, if conscious.

b. Restore carbon dioxide:

(1) Have patient try to regulate breathing: inhale, hold breath, then exhale.

(2) Have patient breathe (called rebreathing) into a paper bag or headrest cover (NOT plastic); patient should hold bag and breathe 6 to 10 times/min.

(3) ONLY emergency situation in which oxygen does NOT benefit patient; further decreases carbon dioxide levels, which then slows return to normal.

c. Administration of tranquilizer drug such as diazepam (Valium) by supervising dentist in severe cases, if available.

3. Prevention: same as syncope.

D. Airway obstruction or foreign body airway obstruction (FBAO):

1. Occurs MORE easily in dental setting because of supine position; includes cotton rolls, extracted teeth or fragments, restorative materials, vomit.

2. Types of FBAO:

a. Partial FBAO with adequate air exchange:

(1) Occurs when airway is NOT completely blocked, allows patient to cough forcibly and talk.

(2) Requires NO treatment but must be monitored closely.

b. Partial FBAO with poor air exchange:

(1) Patient is NOT able to cough forcibly, and wheezing occurs during inhalation.

(2) May lead to complete FBAO and SHOULD be treated the same (see next).

c. Complete FBAO:

(1) Patient is NOT able to talk; may exhibit universal distress signal of hands clasped at throat.

(2) Symptoms include cyanosis (blue face from lack of oxygen) and loss of consciousness when the object is NOT removed.

d. Treatment for conscious adult or child with complete or partial FBAO with poor air exchange is the SAME:

(1) Ask “Are you choking?” and “Can you speak?”

(2) Perform Heimlich maneuver: stand behind patient, wrap both arms around the patient and deliver abdominal thrusts (position flat portion of one fist between navel and bottom of rib cage; wrap other hand around fist), push inward and upward until object is expelled or patient becomes unconscious.

(3) For pregnant or obese patient: chest thrusts in SAME manner on lower portion of the sternum.

(4) Activate EMS system if patient becomes unconscious:

(a) Help patient to the floor or perform abdominal thrusts in the chair, straddling patient’s hips or standing close to hips at one side (if in dental unit).

(b) Place heel of one hand between navel and bottom of rib cage; position other hand above first, interlacing fingers; push inward and upward five times; then move to head and open airway.

(c) After abdominal thrusts, repeat process of lifting chin, moving tongue, feeling for and possibly removing the object.

(d) If airway is still NOT clear, repeat abdominal thrusts as often as necessary; if object has been removed but patient is still NOT breathing, provide BLS and start CPR as needed (see Table 10-1).

(5) In ALL cases, referral to hospital emergency unit because of risk of laryngeal edema.

e. Prevention: use rubber dam and suction; exercise care when working with small objects in the mouth; do NOT use instruments that can break off easily.

Figure 10-1 Trendelenburg position with patient in a subsupine position and feet elevated higher than head.

Table 10-1 Basic life support (by lay rescuer), ABCDs (see notes below)

CLINICAL STUDY

Age	33 YRS	SCENARIO
Sex	 Male ⌧ Female	The patient dreads dental appointments but currently experiences less anxiety because she has been following 6-month oral prophylaxis schedule and her appointments take less time. Her dental health is good. After her medical history is updated and her vital signs are obtained, bitewing radiographs are taken. While the dental hygienist leaves to process the radiographs, the patient remains seated in an upright position. Upon returning to the patient, the dental hygienist notes that she is breathing rapidly, and she complains of tightness in her chest and tingling in her fingers.
B/P	122/82
Chief Complaint	“I just hate being here and I hate all that happens here!”
Medical History	Varicose veins removed 6 months ago Knee surgery 5 years ago Achilles’ tendon rupture and repair 2 years ago

Current Medications

Social History

Physician at free clinic

Husband recently died in a freak accident

1. What is the patient most likely experiencing?

2. How should this emergency be handled?

3. Is oxygen indicated? Why or why not?

4. What can further emergency complications can result from this type of breathing?

1. Probably experiencing hyperventilation, indicated by increased rate of respiration, dizziness, chest tightness, tingling in fingers. Most often occurs in the dental setting because of anxiety. Anxiety about dental appointments was a problem, although the patient believed it had lessened. Her recent personal loss and stressful career must also be taken into consideration.

2. Treatment includes calming her and keeping her positioned upright. Rapid rate of breathing results in decreased level of carbon dioxide. To restore carbon dioxide, patient should inhale, hold her breath, and then exhale. If this is ineffective, should breathe into paper bag 6 to 10 times/min (known as rebreathing); important to allow her to hold bag in position.

3. Hyperventilation is one emergency in which administration of oxygen is not indicated; although oxygen would not harm her, it would not benefit her.

4. May lead to syncope and then vomiting, which can become a vicious cycle.

Allergic Reactions

Allergic reactions, including asthmatic attacks, are common in a dental setting. MOST are due to increased sensitivity to allergen (antigen, foreign) that has entered the body (type I [immediate] hypersensitivity). A.Allergic reactions:

1. Immune system then releases chemicals, such as histamine from mast cells, resulting in varying degrees of reaction.

2. Skin reactions generally are NOT considered true emergencies; however, MUST be monitored for potential advancement; reactions may be localized or generalized, severity and type of reaction are related to type and amount of allergen to which patient is exposed.

3. If reaction occurs immediately after exposure, is MORE severe; when reaction occurs MORE than 60 minutes after exposure, LESS severe.

4. Types of hypersensitivity and allergic reactions:

a. Contact dermatitis: occurs when skin is exposed to an allergen.

(1) Results in erythema, edema, vesicle formation; usually acute and localized but can spread.

(2) Treatment includes removing cause; referral to dermatologist or allergist; supervising dentist may administer an antihistamine (histamine blocker) such as diphenhydramine (Benadryl) or chlorpheniramine (Chlor-Trimeton) to reduce reaction in an emergency situation.

b. Urticaria (hives): appears as raised areas of edema, accompanied by pruritus (itching).

(1) Caused by ingestion of food or drug or by direct skin contact with allergen.

(2) Treated by removing cause; referral to dermatologist or allergist; supervising dentist may administer antihistamine (histamine blocker), such as diphenhydramine (Benadryl) or chlorpheniramine (Chlor-Trimeton), to reduce reaction.

c. Angioedema: initially may be mistaken for hives.

(1) Localized, unilateral, colorless and painless swellings of face or neck without well-defined borders of hives; allergic reaction to food or drug; affects tissues of the hands, face, genitals; rarely results in pain or itching.

(2) Treated by removing cause; referral to dermatologist or allergist, supervising dentist may administer antihistamine, such as diphenhydramine (Benadryl) or chlorpheniramine (Chlor-Trimeton), to reduce reaction; localized, mild allergic reactions should be treated with oral histamine blocker for minimum of 3 days because of risk of recurrence.

d. Anaphylaxis (anaphylactic reaction): MOST severe allergic reaction.

(1) Level depends on amount of allergen to which patient is exposed, acquired sensitivity, route of entry; occurs almost immediately after exposure; may be fatal despite treatment.

(2) Can be caused by foods, drugs (MOSTLY penicillin and related antibiotics), rubber latex, or other environmental factors.

(3) With allergy to local anesthetic agent (rare), MUST be determined if true allergic reaction or some other adverse reaction occurred.

(a) Allergic reaction occurs MORE often in response to ester injectable local anesthetic agents (e.g., procaine was removed from American market for this reason); allergic reactions to amide agents are rare; NO longer using injected ester agents, so has become rare with injectables.

(b) Allergy to preservative sodium metabisulfite (antioxidant for the vasoconstrictor) must also be considered; using plain local anesthetic, such as 2% lidocaine (Xylocaine), 3% carbocaine (Mepivacaine), or 4% prilocaine (Citanest), without any vasoconstrictor will prevent almost ALL local anesthetic-related allergic reactions.

(c) Increased sensitivity to articaine (Septocaine) from sulfites in agent for some patients with history must be considered, MORE in asthmatic population; may want to AVOID use in sensitive or asthmatic patients.

(d) Localized reaction to topical benzocaine is also possible, since this is an ester; will need to use amide (lidocaine or prilocaine) for topical use instead (see earlier discussion).

(4) Symptoms affect different body systems and may occur separately or simultaneously:

(a) Begins rapidly as a skin response (pruritus, urticaria, angioedema); angioedema in mouth may result in airway obstruction.

(b) Gastrointestinal system may respond with spasms, cramps, nausea, diarrhea; respiratory system exhibits varying degrees of laryngeal edema, which is MOST common cause of death from anaphylaxis.

(c) Circulatory system involvement includes hypotension, shock, cardiac arrest.

(5) Treatment for anaphylaxis:

(a) Place in supine position, administer oxygen at 5 liters/min through nasal cannula; provide BLS as needed.

(b) Activate EMS system; epinephrine administration (0.3 mg every 5 minutes for adults, 0.15 mg for children; in some cases of systemic allergic reactions, clinical signs of bronchospasm and hypotension persist after FIRST dose of epinephrine) by supervising dentist when diagnosis is definite.

(c) Because of urgent nature of epinephrine administration in anaphylactic shock, prefilled syringes provide quicker, MORE foolproof method for administering; autoinjectors (EpiPen) are available to inject single adult or pediatric dose when pressed against the thigh (even through clothing) by patient or supervising dentist.

(d) Since MORE than one dose may be needed, must have MORE than one dose of epinephrine available in the kit (see earlier discussion); referral to emergency unit via ambulance is essential.

B. Asthma attack: respiratory emergency that affects individuals of A/>

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