Emergency drugs and equipment must be available in every medical and dental office regardless of whether or not sedation and/or general anesthetic techniques are used. Although successful resolution of most emergency situations does not require drug administration, on occasion drug administration may prove to be lifesaving. In the anaphylactic reaction, for example, prompt administration of epinephrine is critical. In most other emergencies, however, drug administration is consigned to a secondary role in overall management. In situations in which adverse drug reactions (ADRs) develop following administration of drugs for sedation or pain control, it may be possible, in some cases, to significantly improve the clinical picture through the administration of an antidotal drug.

The emergency drug kit is designed in four levels (modules). Module 1, the “bare bones” basic emergency kit, contains drugs and equipment that this author believes should be available in the offices of all practicing dentists and physicians regardless of whether sedative techniques are used. Module 2 consists of drugs that are “nice to have,” but are not as essential as those in level 1. Module 3 drugs are recommended for dentists who have received advanced cardiovascular life support (ACLS) training, and module 4 contains drugs required for the management of ADRs associated with parenteral drug administration.¹

The emergency kit need not and, indeed, should not be overly complex. As Pallasch² has stated, “Complexity in a time of adversity breeds chaos.”

Because the level of training in emergency management of health care providers can vary significantly, it is impossible to recommend any one list of emergency drugs or any one proprietary emergency drug kit that meets the needs and abilities of all dentists. For this reason, dentists should develop their own emergency drug and equipment kits based on their level of expertise in managing medical emergencies.³

The emergency drug kit maintained by the dentist using sedation or general anesthesia will, of necessity, include drugs and equipment not recommended for emergency kits of dentists who are not well trained in anesthesia (used in its broadest sense). The Council on Dental Therapeutics of the American Dental Association, most state dental boards, and specialty organizations have developed and published either recommendations or requirements for the inclusion of specific emergency drugs and equipment for offices in which sedation or general anesthesia is to be administered (Boxes 33-1 and 33-2).^4–6

Box 33-2

From American Association of Oral and Maxillofacial Surgeons, Committee on Anesthesia: Office anesthesia evaluation manual, Rosemont, Ill, 2006, The Association.

Suggested Emergency Equipment and Drugs

Suggested Equipment

A. Source of O₂ and equipment to deliver positive-pressure ventilation

B. Respiratory support equipment

• Oral airways and nasal airways

• Endotracheal tubes with stylets (provision for children’s airway management)

• Laryngoscope and suitable blades (plus extra bulbs and batteries)

• McGill forceps or other suitable instruments

• Cricothyrotomy set with connector

• Laryngeal mask airway

C. Stethoscope or precordial stethoscope

D. Blood pressure cuff or automatic blood pressure monitor

E. ECG, defibrillator, and automated external defibrillator

F. Pulse oximeter and end-tidal carbon dioxide monitor (if intubated anesthesia is used)

G. Equipment to establish IV infusion

• Angiocaths, needles, syringes, IV sets, and connectors

• Tourniquets for venipuncture

• Tape

Suggested Drugs

The following are examples of drugs that will be helpful in the treatment of anesthetic emergencies. The list should not be considered mandatory or all-inclusive.

A. IV fluids

• Sterile water for injection and/or mixing or dilution of drugs

• Appropriate IV fluids

B. Cardiotonic drugs

• O₂

• Epinephrine 1 mg

(10 ml of a 1 : 10,000 solution)

• Atropine 0.4 mg/ml

• Nitroglycerin (0.4 mg: grain)

C. Vasopressors

• Dopamine 200 mg/5 ml

• Epinephrine 1 : 1000 or 1 : 10,000

(1 mg = 1 : 1000)

• Dobutamine 1, 2, or 4 mg/ml

• Ephedrine 50 mg/ml

• Phenylephrine (Neo-Synephrine) 10 mg/ml

D. Antiarrhythmic agents

• Atropine sulfate 0.4 mg/ml

• Lidocaine 2% (Xylocaine) 20 mg/ml

• Propranolol (Inderal) 1 mg/ml

• Procainamide (Procanbid) 100 mg/ml

• Verapamil (Calan) 5 mg/ml

• Amiodarone (Cordarone et al) 50 mg/ml

• Adenosine 3 mg/ml

E. Antihypertensive agents (immediate)

• Diazoxide (Hyperstat) 15 mg/ml

• Hydralazine (Apresoline) 20 mg/ml

• Esmolol (Brevibloc) 10 mg/ml

• Labetalol (Trandate) 5 mg/ml

(20 ml single-dose vial)

F. Diuretics

• Furosemide (Lasix) 10 mg/ml

G. Antiemetics

• Prochlorperazine (Compazine) 5 mg/ml

• Ondansetron (Zofran) 2 mg/ml

H. Reversing agents

• Naloxone (Narcan) 0.4 mg/ml

• Flumazenil (Romazicon) 0.1 mg/ml

I. Additional drugs

• Dextrose 50%

• Hydrocortisone sodium succinate or methylprednisolone sodium succinate

(Solu-Medrol) 125 mg

• Dexamethasone (Decadron) 4 mg/ml

• Glycopyrrolate (Robinul) 0.2 mg/ml

• Diazepam (Valium) 5 mg/ml

• Diphenhydramine (Benadryl) 50 mg/ml

• Albuterol (Ventolin) inhaler

• Midazolam (Versed) 5 mg/ml

• Succinylcholine (Anectine) 20 mg/ml

• Morphine sulfate 5 mg/ml

• Dantrolene (Dantrium) 20-mg vials, readily available (36 vials)

• Procaine 10 mg/ml

• Nonenteric aspirin 160-325 mg

A plastic container or fishing tackle box may be used to store drugs. A more inclusive emergency kit might be developed from a mobile tool chest. Labels are applied to each container with both the generic and proprietary name of the drug and its dosage (e.g., diazepam [Valium], 5 mg/ml). The emergency kit must be maintained in an area where it is easily accessible. All emergency drugs and equipment should be checked weekly and replenished before their expiration dates; the oxygen (O₂) cylinder should be checked daily.

The following are guidelines for the development of an office emergency kit. Categories of drugs are listed with a suggestion for specific drug(s) within each grouping. Space precludes lengthy descriptions of the rationale for selecting each drug. Readers desiring more in-depth information are referred to appropriate textbooks.^1,3

Each of the drug categories presented should be considered for inclusion in the emergency kit; however, dentists should select only those drugs with which they are familiar because they are responsible for having the ability to use each and every one of them. The dentist must carefully evaluate everything that goes into the emergency kit. All drugs come with a “drug package insert (DPI).” The DPI should be saved and read, with important information concerning each drug noted, such as usual dose, contraindications, adverse reactions, and its expiration date. Two categories of drugs, injectables and noninjectables, are included in the emergency kit. Items of emergency equipment also have a very definite place in the management of life-threatening situations. As with drugs, however, it is important for a dentist to know his or her limitations when it comes to using this equipment. Improper use of emergency equipment may further complicate an already tenuous situation. There are two categories of emergency equipment: primary, or basic, equipment, which I believe should be available in every medical and dental office, and secondary, or advanced equipment, for those persons who have received training and are experienced in its use.

Merely having items of emergency equipment available does not in and of itself make the office better equipped or the staff more prepared to manage emergency situations. Personnel expected to use emergency equipment must be trained in emergency management and in the proper use of these items. Unfortunately, many emergency devices commonly found in dental and medical offices can prove to be useless or, more significantly, hazardous if used improperly or in the wrong situation. Training in the use of some items, such as the laryngoscope and oropharyngeal airway, may best be obtained only by caring for patients under general anesthesia, a situation usually not readily available. Many items of emergency equipment listed in this section are therefore recommended for use only by trained personnel. All secondary equipment falls into this category; unfortunately, several items listed as primary are also included (e.g., O₂ delivery system). Although all dentists and physicians should be trained in the use of O₂ delivery systems, courses in which these techniques are taught to clinical proficiency are particularly difficult to locate.

In the summer of 2008, the Anesthesia Research Foundation of the American Dental Society of Anesthesiology (ADSA) introduced its advanced airway training course. This program consists of an online didactic training session followed by a live didactic session and a hands-on component using the SimMan high fidelity human simulator (Figure 33-1). SimMan not only allows the user to replicate all of the commonly encountered airway-related medical emergencies seen during sedation and anesthesia, but also permits their treatment without the potential for patient harm. All emergency airway devices and procedures may be demonstrated and placed in this valuable educational environment. It is anticipated that most states will eventually accept completion of this course instead of the less ideal ACLS courses currently mandated for sedation and general anesthesia permits.⁷

Figure 33-1 SimMan.