W18 66 emergency drugs in dental surgery

Question 1

What are the contents of the red emergency drug boxes in the dental hospital?

Answer 1

Epinephrine 1:1000
Hydrocortisone
Chlorphenamine
Salbutamol
Atropine
GTN spray
Aspirin
Midazolam
Dextrose
Glucagon

Question 2

What else might dental practices stock for mild allergic reactions?

Answer 2

Antihistamines - cetirizine, chlorphenamine, loratidine

Question 3

Pg368 - Emergency drugs in dental practice summary table

Answer 3

Read the summary table/print on wall

Question 4

What routes might be quicker than intravenous in an emergency?

Answer 4

Intramuscular, sublingual, buccal and intra nasal routes

Question 5

When is oxygen indicated?

Answer 5

Any medical emergency with hypoxaemia - eg acute cardiac, respiratory, CNS disorders

Question 6

How much oxygen should be delivered?

Answer 6

High flow - 15L per minutes

Question 7

How is oxygen delivered?

Answer 7

Via a full face mask

Question 8

What is the target saturation of oxygen using pulse oximetry?

Answer 8

94-98%, above 10kPa

Question 9

What is adrenaline?

Answer 9

An endogenous catecholamine

Question 10

When is adrenaline indicated?

Answer 10

Anaphylaxis, cardiac arrest

Question 11

What are the actions of adrenaline?

Answer 11

Bronchdilatation
Peripheral vasoconstriction
Increased myocardial contractility

Question 12

How much adrenaline should be administered in anaphylaxis and what is the typical presentation of adrenaline?

Answer 12

1:1000, meaning 1mg in 1ml IM. Only want to administered 500mg though so half, 0.5mls.
May be repeated at 5 min intervals if no improvement.

Question 13

What is the presentation of adrenaline for cardiac arrest?

Answer 13

1mg in 10mls (1:10,000) IV

Question 14

What type of reaction is anaphylaxis?

Answer 14

Severe type 1 hypersensitivity reaction.

Question 15

What happens in anaphylaxis?

Answer 15

Leads to the release of vasoactive mediators like histamine, leading to vasodilatation, swelling of the upper airways, low blood pressure so anaphylactic shock.

Question 16

What are the signs and symptoms of anaphylaxis?

Answer 16

Flushing and swelling of face
Generalised itching
Bronchospasm and laryngospasm
Rapid weak pulse; hypotension, pallor; finally cardiac arrest

Question 17

Why is adrenaline the treatment for anaphylaxis?

Answer 17

Reverses vasodilatation, bronchoconstriction and angioedema
Since stimulates alpha and beta adrenergic receptor stimulating activity

Question 18

When is aspirin indicated?

Answer 18

For suspected acute myocardial infarction

Question 19

What is the emergency treatment for suspected acute myocardial infarction?

Answer 19

MONAR
Morphine, Oyxgen, Nitrates (GTN), Aspirin, Reperfusion therapy

Question 20

How much aspirin is delivered for acute MI?

Answer 20

300mg dispersible or chewable, stat

Question 21

When would you suspect an acute MI?

Answer 21

After severe chest pain (angina) that isn’t going away, sweating, nausea etc, that doesn’t go away after a puff of GTN

Question 22

How do you treat hypoglycaemia in a conscious patient?

Answer 22

Initially 10-20g go glucose given by mouth either as liquid form or granulate sugar.
Approx 10g of glucose is available from: non diet lucozade, Coca Cola 100ml, Ribena blackcurrant 19mL (diluted), 2 teaspoons of sugar
If necessary repeat in 10-15 minutes

Question 23

When might you use glucagon?

Answer 23

If glucose cannot be given by mouth, is infective or if hypoglycaemia leads to unconsciousness.

Question 24

What is glucagon?

Answer 24

An endogenous peptide hormone produced from alpha cells in the pancreas. Presented as hydrochloride powder for reconstitution.

Question 25

What is the action of glucagon and why might it not work?

Answer 25

Mobilises glycogen from the liver. Converts our body stores into glucose. Takes about 5-10mins to work. Needs sufficient glycogen storage for this - eg sometimes won’t work in starved or malnourished patients.

Question 26

What is the dose of glucagon given?

Answer 26

1mg intramuscular (or subcutaneous) injection

Question 27

What is GTN?

Answer 27

Glyceryl trinitrate. It’s converted into nitric oxide in the body = a potent vasodilator.

Question 28

What are the actions of GTN?

Answer 28

Coronary artery vasodilatation - to reduce coronary workload, relieving pain from angina Reduction in myocardial oxygen consumption

Question 29

What is the dose and route of GTN?

Answer 29

Sublingually 2 sprays (300mg / spray) (can come in tablet form too)

Question 30

What should you take caution with when giving GTN?

Answer 30

Given in cases of angina - sit them down Caution with getting up after, as will lower blood pressure greatly.

Question 31

What is midazolam?

Answer 31

Benzodiazepine agent (fast-acting) GABA agonist (inhibitory neurotransmitter), so damps down the brain quickly. Water-soluble, rapid onset of action

Question 32

What are the indications for midazolam?

Answer 32

Anti-epileptic, sedation

Question 33

What is the presentation of midazolam?

Answer 33

Oromucosal solution. Different syringes (dosing) for different ages. Adult dose usually 10mg. In the form of Bucolam usually (midazolam is a schedule 3 controlled drug so needs to be ordered on the special FP10CDF form, but doesn’t require storage in custody in the form of Bucolam).

Question 34

How is midazolam delivered?

Answer 34

Full amount of solution is inserted slowly into the space between the gum and the cheek. Rapidly absorbed by buccal mucosa into bloodstream and readily crosses the BBB to hopefully stop the fit within a minute or two.

Question 35

What are the 2 phases of a generalised seizure and their signs/symptoms?

Answer 35

Tonic phase: aura, sudden loss of consciousness, rigid, falls, may give out a cry, cyanosis Clonic phase: jerking limb movements, tongue may be bitten May be frothing of mouth, urinary incontinence

Question 36

What is the treatment for seizures?

Answer 36

Safety position, oxygen, recovery position, blood glucose check? (as can have hypoglycaemia fits). Medication after 5 mins (but get it ASAP as every minute the brain is getting less oxygen).

Question 37

When should you ring 999 because of a seizure (according to NICE)?

Answer 37

Status epilepticus (when 1 seizure turns to another to another etc) High risk of recurrence 1st seizure Difficulty monitoring the patient

Question 38

When should medication for a seizure be administered?

Answer 38

Medication should only be administered if fits are prolonged (convulsive movements lasting 5 minutes or more) or recur in quick succession.

Question 39

What if you cannot give buccal liquid midazolam 10mg?

Answer 39

Rectal diazepam

Question 40

What is salbutamol?

Answer 40

Short-acting b2 adrenoceptor agonist

Question 41

How is salbutamol presented?

Answer 41

In an inhaler (blue)

Question 42

What is the action of salbutamol?

Answer 42

Bronchodilator

Question 43

How much salbutamol should you deliver in an asthma attack?

Answer 43

Most attacks response to 2 puffs (200mg) of a patients inhaler (with spacer device!) Further puffs if the patient doesn’t respond rapidly - upto 10 puffs - saves someone from needing further treatment like nebulisers etc