Management of Common Medical Emergencies in the Dental Office: A Comprehensive Review

Medical Emergencies

This course will review the most common medical emergencies that may occur in a dental office, including syncope, anginal attacks, myocardial infarction, hyperventilation, asthma attacks, anaphylaxis and severe hypoglycemia. Understanding these conditions is essential for preparing dental office staff to respond effectively in the event of a medical emergency.

Syncope

Syncope is defined as a sudden, transient loss of consciousness and postural tone, followed by spontaneous recovery, typically resulting from a decrease in cerebral oxygenation and perfusion.1Carlson, M.D. (2021). Syncope. In: Roos, K.L. (eds) Emergency Neurology. Springer, Cham. https://doi.org/10.1007/978-3-030-75778-6_4 This condition, known as cerebral ischemia, is often triggered by stressful situations, such as dental appointments, particularly during the administration of local anesthetics, dental extractions, or endodontic procedures. Syncope is the most common medical emergency in the dental office.2Hutse, I., Coppens, M., Herbelet, S., Seyssens, L., & Marks, L. (2021). Syncope in dental practices: A systematic review on aetiology and management. Journal of Evidence Based Dental Practice, 21(3), 101581.^,3Braimah, R. O., Ali-Alsuliman, D., Taiwo, A. O., Alyami, B., Ibikunle, A. A., Alwalah, A. S., ... & Alalharith, A. S. (2022). Medical emergencies during exodontia in a referral dental center in Saudi Arabia: A cross-sectional study. Scientific Dental Journal, 6(3), 111-117. It can also arise from changes in the quality of blood perfusing the brain, often due to chemical or metabolic disturbances, such as hyperventilation, hyperglycemia, hypoglycemia, drug ingestion, or acute allergic reactions.4Puppala, V. K., Dickinson, O., & Benditt, D. G. (2014). Syncope: classification and risk stratification. Journal of Cardiology, 63(3), 171-177. Additionally, syncope can be caused by alterations within the brain itself, such as those occurring during an epileptic seizure or cerebrovascular accident (CVA).

Syncope can be classified into three primary categories: cardiac syncope, noncardiac syncope, and neurocardiac syncope.4Puppala, V. K., Dickinson, O., & Benditt, D. G. (2014). Syncope: classification and risk stratification. Journal of Cardiology, 63(3), 171-177. Cardiac syncope results from inadequate cardiac output and is often caused by serious underlying heart conditions, such as arrhythmic or obstructive issues within the heart muscle.4Puppala, V. K., Dickinson, O., & Benditt, D. G. (2014). Syncope: classification and risk stratification. Journal of Cardiology, 63(3), 171-177. Noncardiac syncope encompasses a wide range of conditions, including seizures, orthostatic hypotension, hyperventilation, and metabolic diseases.4Puppala, V. K., Dickinson, O., & Benditt, D. G. (2014). Syncope: classification and risk stratification. Journal of Cardiology, 63(3), 171-177. Neurocardiac syncope, the most common form, is also known by various names such as vasodepressor syncope, vasovagal syncope, neurocardiogenic syncope, or neurally mediated syncope.4Puppala, V. K., Dickinson, O., & Benditt, D. G. (2014). Syncope: classification and risk stratification. Journal of Cardiology, 63(3), 171-177. Although its exact pathophysiology is still under investigation, it is generally believed to be triggered by noxious stimuli like pain, fear, exhaustion, or acute illness.4Puppala, V. K., Dickinson, O., & Benditt, D. G. (2014). Syncope: classification and risk stratification. Journal of Cardiology, 63(3), 171-177.

In the dental setting, some patients experience significant anxiety, which can lead to neurocardiac syncope. The initial response to anxiety is activation of the sympathetic division of the autonomic nervous system, triggering the fight-or-flight response.5van Dijk, J. G., van Rossum, I. A., & Thijs, R. D. (2021). The pathophysiology of vasovagal syncope: novel insights. Autonomic Neuroscience, 236, 102899. This results in the release of catecholamines, such as epinephrine and norepinephrine, which increase blood flow to the peripheral muscles in preparation for physical action.5van Dijk, J. G., van Rossum, I. A., & Thijs, R. D. (2021). The pathophysiology of vasovagal syncope: novel insights. Autonomic Neuroscience, 236, 102899. However, since dental patients are typically asked to remain seated during procedures, blood pools in the extremities, leading to a hypotensive response, bradycardia, and reduced cerebral blood flow, which can cause syncope.5van Dijk, J. G., van Rossum, I. A., & Thijs, R. D. (2021). The pathophysiology of vasovagal syncope: novel insights. Autonomic Neuroscience, 236, 102899.

Symptoms of neurocardiac syncope often appear several minutes before the loss of consciousness.6Lippincott Williams & Wilkins. (2015). Handbook of Signs & Symptoms. Wolters Kluwer Health. These pre-syncopal or prodromal signs correlate with sympathetic stimulation and may include pallor, pupil dilation, diaphoresis (cold sweat), goosebumps, weakness, dizziness, vertigo, and nausea.6Lippincott Williams & Wilkins. (2015). Handbook of Signs & Symptoms. Wolters Kluwer Health. A decrease in cerebral perfusion may lead to yawning or sighing.6Lippincott Williams & Wilkins. (2015). Handbook of Signs & Symptoms. Wolters Kluwer Health. Visual changes such as darkening or blurring of vision, seeing spots, shortness of breath, and palpitations or chest pain may also occur.6Lippincott Williams & Wilkins. (2015). Handbook of Signs & Symptoms. Wolters Kluwer Health. Blood pressure and heart rate may be elevated due to sympathetic stimulation. The onset of neurocardiogenic syncope is usually gradual.6Lippincott Williams & Wilkins. (2015). Handbook of Signs & Symptoms. Wolters Kluwer Health.

Once unconsciousness occurs, syncope is diagnosed. The patient will exhibit a weak, slow pulse (typically less than 30 beats per minute), shallow breathing, and a significant decrease in blood pressure.6Lippincott Williams & Wilkins. (2015). Handbook of Signs & Symptoms. Wolters Kluwer Health. In some cases, seizures may occur if the brain is deprived of oxygen for an extended period.6Lippincott Williams & Wilkins. (2015). Handbook of Signs & Symptoms. Wolters Kluwer Health.

If pre-syncopal or syncopal symptoms are recognized, all dental procedures should be immediately suspended, and any objects in the oral cavity should be removed.7Hutse, I., Coppens, M., Herbelet, S., Seyssens, L., & Marks, L. (2021). Syncope in dental practices: a systematic review on aetiology and management. Journal of Evidence Based Dental Practice, 21(3), 101581.^,8Meiller, T. F. (2016). Dental office medical emergencies : a manual of office response protocols / Timothy F. Meiller [and others]. Lexi-Comp. The patient should be placed in a supine position, with the legs slightly elevated to help facilitate blood return.7Hutse, I., Coppens, M., Herbelet, S., Seyssens, L., & Marks, L. (2021). Syncope in dental practices: a systematic review on aetiology and management. Journal of Evidence Based Dental Practice, 21(3), 101581.^,8Meiller, T. F. (2016). Dental office medical emergencies : a manual of office response protocols / Timothy F. Meiller [and others]. Lexi-Comp. The airway should be opened, circulation assessed, and any restrictive clothing, such as ties or belts, should be loosened.7Hutse, I., Coppens, M., Herbelet, S., Seyssens, L., & Marks, L. (2021). Syncope in dental practices: a systematic review on aetiology and management. Journal of Evidence Based Dental Practice, 21(3), 101581.^,8Meiller, T. F. (2016). Dental office medical emergencies : a manual of office response protocols / Timothy F. Meiller [and others]. Lexi-Comp. Oxygen should be administered at a rate of 4-6 liters per minute, and vital signs should be closely monitored.7Hutse, I., Coppens, M., Herbelet, S., Seyssens, L., & Marks, L. (2021). Syncope in dental practices: a systematic review on aetiology and management. Journal of Evidence Based Dental Practice, 21(3), 101581.^,8Meiller, T. F. (2016). Dental office medical emergencies : a manual of office response protocols / Timothy F. Meiller [and others]. Lexi-Comp. Usually, placing the patient in a supine position is sufficient to restore consciousness.7Hutse, I., Coppens, M., Herbelet, S., Seyssens, L., & Marks, L. (2021). Syncope in dental practices: a systematic review on aetiology and management. Journal of Evidence Based Dental Practice, 21(3), 101581.^,8Meiller, T. F. (2016). Dental office medical emergencies : a manual of office response protocols / Timothy F. Meiller [and others]. Lexi-Comp.

Once the patient regains consciousness, they should remain supine until they feel well enough to sit up and their pulse returns to baseline.8Meiller, T. F. (2016). Dental office medical emergencies : a manual of office response protocols / Timothy F. Meiller [and others]. Lexi-Comp. A cool, damp towel on the forehead can help with recovery, and providing reassurance and empathy is essential.8Meiller, T. F. (2016). Dental office medical emergencies : a manual of office response protocols / Timothy F. Meiller [and others]. Lexi-Comp. Patients should be repositioned slowly to avoid recurrence of syncope.8Meiller, T. F. (2016). Dental office medical emergencies : a manual of office response protocols / Timothy F. Meiller [and others]. Lexi-Comp. The cause of the episode should be investigated to prevent future occurrences.7Hutse, I., Coppens, M., Herbelet, S., Seyssens, L., & Marks, L. (2021). Syncope in dental practices: a systematic review on aetiology and management. Journal of Evidence Based Dental Practice, 21(3), 101581. All dental treatment should be suspended for the day, and an emergency contact should be arranged to escort the patient home, as syncope may recur.8Meiller, T. F. (2016). Dental office medical emergencies : a manual of office response protocols / Timothy F. Meiller [and others]. Lexi-Comp. The risk of recurrence is highest in the first 24 hours following the event.9Chang, A. M., Hollander, J. E., Su, E., Weiss, R. E., Yagapen, A. N., Malveau, S. E., Adler, D. H., Bastani, A., Baugh, C. W., Caterino, J. M., Clark, C. L., Diercks, D. B., Nicks, B. A., Nishijima, D. K., Shah, M. N., Stiffler, K. A., Storrow, A. B., Wilber, S. T., & Sun, B. C. (2019). Recurrent syncope is not an independent risk predictor for future syncopal events or adverse outcomes. The American journal of emergency medicine, 37(5), 869–872. https://doi.org/10.1016/j.ajem.2018.08.004 Anti-anxiety medications may be recommended for future appointments.10Husack, E., & Ouanounou, A. (2023). Pharmacological Management of the Dentally Anxious Patient. Compendium of Continuing Education in Dentistry (15488578), 44(3).

Angina Pectoris and Myocardial Infarction

Angina is a form of ischemic heart disease (IHD), a pathological condition of the myocardium (heart muscle) caused by insufficient oxygen supply to the heart tissue.11Ye, S. (2020). Angina Pectoris. In Encyclopedia of Behavioral Medicine (pp. 113-113). Cham: Springer International Publishing. IHD and its complications, including angina pectoris and myocardial infarction (MI or heart attack), contribute to a significant number of deaths each year.12Nowbar, A. N., Gitto, M., Howard, J. P., Francis, D. P., & Al-Lamee, R. (2019). Mortality from ischemic heart disease: Analysis of data from the World Health Organization and coronary artery disease risk factors From NCD Risk Factor Collaboration. Circulation: cardiovascular quality and outcomes, 12(6), e005375. The most common cause of myocardial ischemia and subsequent angina is atherosclerosis of the coronary arteries.11Ye, S. (2020). Angina Pectoris. In Encyclopedia of Behavioral Medicine (pp. 113-113). Cham: Springer International Publishing. Atherosclerosis is an arterial disorder characterized by the accumulation of yellowish plaques made up of cholesterol, lipids, and cellular debris on the inner walls of large and medium-sized blood vessels.11Ye, S. (2020). Angina Pectoris. In Encyclopedia of Behavioral Medicine (pp. 113-113). Cham: Springer International Publishing.

Several predisposing factors contribute to the development of ischemic heart disease, including poor diet, hypertension, smoking, diabetes, obesity, lack of physical activity, increased stress, and heredity.13Varghese, T. P., & Kumar, A. V. (2019). Predisposing risk factors of acute coronary syndrome (ACS): A mini review. Journal of Pharmaceutical Sciences and Research, 11(5), 1999-2002. If a patient presents with any of these risk factors, dental professionals should inform them of their increased likelihood of developing atherosclerosis and coronary artery disease. Given that dental professionals are likely to treat patients with either diagnosed or undiagnosed IHD, a thorough evaluation of each patient's medical history is essential prior to the commencement of any dental treatment.14Gupta, K., Kumar, S., Kukkamalla, M. A., Taneja, V., Syed, G. A., Pullishery, F., ... & Chaturvedi, S. (2022). Dental management considerations for patients with cardiovascular disease—a narrative review. Reviews in Cardiovascular Medicine, 23(8), 261.

Angina pectoris is one of the more common emergencies encountered in the dental office.15Haas D. A. (2006). Management of medical emergencies in the dental office: conditions in each country, the extent of treatment by the dentist. Anesthesia progress, 53(1), 20–24. https://doi.org/10.2344/0003-3006(2006)53[20:MOMEIT]2.0.CO;2 The major symptom of angina is discomfort (burning or tightness) in chest from transient and reversible myocardial oxygen deficiency.16MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US); [updated Jun 24; cited 2020 Jul 1]. Available from: https://medlineplus.gov/. The key words here are transient meaning the symptoms come and go and reversible meaning the myocardial oxygen deficiency can be reversed by medication or reduction in the workload of the heart.

There are different types of angina: stable, unstable,Prinzmetal's (variant or vasospastic), microvascular or refractory angina.17Angina (Chest Pain). (2023, July 10). National Heart, Blood and Lung Institute. https://www.nhlbi.nih.gov/health/angina/types. Stable angina is characterized by predictable and reproducible discomfort, typically in the left side of the chest, lasting from 1 to 15 minutes.17Angina (Chest Pain). (2023, July 10). National Heart, Blood and Lung Institute. https://www.nhlbi.nih.gov/health/angina/types. It usually responds positively to rest and/or the administration of nitroglycerin, typically within 10 to 15 minutes.17Angina (Chest Pain). (2023, July 10). National Heart, Blood and Lung Institute. https://www.nhlbi.nih.gov/health/angina/types. Angina is classified as stable if the frequency, duration, or precipitating causes of the symptoms have remained unchanged for the past 60 days.17Angina (Chest Pain). (2023, July 10). National Heart, Blood and Lung Institute. https://www.nhlbi.nih.gov/health/angina/types.

Unstable angina, also known as preinfarctory angina, coronary insufficiency, crescendo angina, intermediate coronary syndrome, or impending myocardial infarction, represents a clinical syndrome that occurs between stable angina and acute myocardial infarction.17Angina (Chest Pain). (2023, July 10). National Heart, Blood and Lung Institute. https://www.nhlbi.nih.gov/health/angina/types. It indicates an imbalance between myocardial oxygen supply and demand. Patients with unstable angina should receive only minimal or emergency dental care after consultation with a physician.17Angina (Chest Pain). (2023, July 10). National Heart, Blood and Lung Institute. https://www.nhlbi.nih.gov/health/angina/types.

Prinzmetal's (variant) angina, also referred to as atypical or vasospastic angina, typically occurs spontaneously.17Angina (Chest Pain). (2023, July 10). National Heart, Blood and Lung Institute. https://www.nhlbi.nih.gov/health/angina/types. The symptoms resemble those of other forms of angina; however, these episodes most often occur at rest, typically at night or during unusual hours of the day.17Angina (Chest Pain). (2023, July 10). National Heart, Blood and Lung Institute. https://www.nhlbi.nih.gov/health/angina/types. Emotional stress or physical exertion do not typically trigger these attacks.17Angina (Chest Pain). (2023, July 10). National Heart, Blood and Lung Institute. https://www.nhlbi.nih.gov/health/angina/types. Variant angina is more common in women under 50, particularly those considered to be at low risk for coronary artery disease (CAD).17Angina (Chest Pain). (2023, July 10). National Heart, Blood and Lung Institute. https://www.nhlbi.nih.gov/health/angina/types. It is believed to be precipitated by a transient spasm of a coronary artery, causing a temporary occlusion of the vessel.17Angina (Chest Pain). (2023, July 10). National Heart, Blood and Lung Institute. https://www.nhlbi.nih.gov/health/angina/types.

Anginal attacks typically occur when additional stress is placed on the heart, causing it to require more oxygen than can be supplied due to compromised blood flow.18Chen, M.A. (2023, January 1). Stable Angina: Causes. National Library of Medicine. https://medlineplus.gov/ency/article/000198.htm Common triggers for anginal attacks include increased physical exertion, stressful situations, eating a large meal, or exposure to high altitudes.18Chen, M.A. (2023, January 1). Stable Angina: Causes. National Library of Medicine. https://medlineplus.gov/ency/article/000198.htm As mentioned, angina is generally characterized by chest discomfort, which patients often describe as pressure, burning, heaviness, squeezing, or a choking sensation.18Chen, M.A. (2023, January 1). Stable Angina: Causes. National Library of Medicine. https://medlineplus.gov/ency/article/000198.htm^,19Nakas, G., Bechlioulis, A., Marini, A., Vakalis, K., Bougiakli, M., Giannitsi, S., Nikolaou, K., Antoniadou, E. I., Kotsia, A., Gartzonika, K., Chasiotis, G., Bairaktari, E., Katsouras, C. S., Triantis, G., Sionis, D., Michalis, L. K., & Naka, K. K. (2019). The importance of characteristics of angina symptoms for the prediction of coronary artery disease in a cohort of stable patients in the modern era. Hellenic journal of cardiology : HJC = Hellenike kardiologike epitheorese, 60(4), 241–246. https://doi.org/10.1016/j.hjc.2018.06.003 This discomfort frequently radiates from the chest to the left shoulder, down the arm, and to the neck, lower jaw, or tongue.18Chen, M.A. (2023, January 1). Stable Angina: Causes. National Library of Medicine. https://medlineplus.gov/ency/article/000198.htm Symptoms may also include diaphoresis, nausea, pallor, and dyspnea.18Chen, M.A. (2023, January 1). Stable Angina: Causes. National Library of Medicine. https://medlineplus.gov/ency/article/000198.htm During an acute episode, the patient may appear anxious, pressing their fist against their sternum, and show signs of elevated heart rate and blood pressure.18Chen, M.A. (2023, January 1). Stable Angina: Causes. National Library of Medicine. https://medlineplus.gov/ency/article/000198.htm The anxiety and fear caused by the chest pain can further exacerbate these symptoms.18Chen, M.A. (2023, January 1). Stable Angina: Causes. National Library of Medicine. https://medlineplus.gov/ency/article/000198.htm

The primary goal in treating an anginal episode is to reduce the myocardium's oxygen demand.20Kloner, R. A., & Chaitman, B. (2017). Angina and its management. Journal of cardiovascular pharmacology and therapeutics, 22(3), 199-209. If an anginal episode occurs during dental treatment, the procedure should be immediately halted, and the patient should be positioned in a semi-supine or upright posture, depending on their comfort level.21Syed, M. (2021). Dental Management of Cardiovascular Compromised Patient: A Review. Journal of Advanced Medical and Dental Sciences Research, 9(6), 60-63. An assessment of the patient's airway, breathing, and circulation should be performed.21Syed, M. (2021). Dental Management of Cardiovascular Compromised Patient: A Review. Journal of Advanced Medical and Dental Sciences Research, 9(6), 60-63. Vital signs should be monitored throughout the episode.21Syed, M. (2021). Dental Management of Cardiovascular Compromised Patient: A Review. Journal of Advanced Medical and Dental Sciences Research, 9(6), 60-63.

After addressing these initial steps, inquire about the patient's symptoms. If the symptoms match those of their usual anginal attack, the episode can be managed accordingly. If the patient is conscious, a sublingual nitroglycerin tablet or transmucosal nitroglycerin spray should be administered, provided the blood pressure is not hypotensive as nitroglycerin should not be given to hypotensive patients.21Syed, M. (2021). Dental Management of Cardiovascular Compromised Patient: A Review. Journal of Advanced Medical and Dental Sciences Research, 9(6), 60-63.^,22MA Healthcare. (2017). How to handle a heart attack. Dental Nursing. Nitroglycerin should not be given to hypotensive patients.22MA Healthcare. (2017). How to handle a heart attack. Dental Nursing. Ideally, the patient’s own nitroglycerin should be used, as the dosage would have been prescribed by their physician or cardiologist.22MA Healthcare. (2017). How to handle a heart attack. Dental Nursing. The typical dosage is 0.3 to 0.6 mg.22MA Healthcare. (2017). How to handle a heart attack. Dental Nursing. If the patient’s nitroglycerin is outdated or improperly stored, use the fresh supply from the emergency kit.22MA Healthcare. (2017). How to handle a heart attack. Dental Nursing.

If sublingual tablets are used, administer one tablet every five minutes, with a maximum of three tablets in 15 minutes.22MA Healthcare. (2017). How to handle a heart attack. Dental Nursing. If using the nitroglycerin spray, one or two metered sprays are recommended initially, with no more than three doses in a 15-minute period.22MA Healthcare. (2017). How to handle a heart attack. Dental Nursing. Nitroglycerin works by dilating the coronary blood vessels, reducing cardiac workload and oxygen demand.24Tarkin, J. M., & Kaski, J. C. (2016). Vasodilator therapy: nitrates and nicorandil. Cardiovascular drugs and therapy, 30, 367-378. Typically, nitroglycerin will alleviate anginal pain within two to four minutes.24Tarkin, J. M., & Kaski, J. C. (2016). Vasodilator therapy: nitrates and nicorandil. Cardiovascular drugs and therapy, 30, 367-378. If the patient feels stable, dental treatment may be resumed; however, it may be more prudent to reschedule the patient and complete the treatment at a later appointment.22MA Healthcare. (2017). How to handle a heart attack. Dental Nursing.

If chest pain persists despite the administration of two doses of nitroglycerin (either spray or tablet) within a 10-minute interval, or if the patient reports that the pain is more intense than previously experienced, emergency medical services (EMS) should be contacted without delay.21Syed, M. (2021). Dental Management of Cardiovascular Compromised Patient: A Review. Journal of Advanced Medical and Dental Sciences Research, 9(6), 60-63. In cases where the patient has no prior history of angina pectoris and the chest pain continues for two minutes or longer, it is imperative to activate emergency services by dialing 911, and the patient should be managed as a potential myocardial infarction.21Syed, M. (2021). Dental Management of Cardiovascular Compromised Patient: A Review. Journal of Advanced Medical and Dental Sciences Research, 9(6), 60-63.

Myocardial Infarction

Acute myocardial infarction (AMI) refers to the necrosis of a segment of the myocardium resulting from the complete or partial occlusion of a coronary artery.25Frangogiannis N. G. (2015). Pathophysiology of myocardial infarction. Comprehensive Physiology, 5(4), 1841–1875. https://doi.org/10.1002/cphy.c150006 This occlusion may be caused by atherosclerosis, the formation of a thrombus, or a coronary spasm, and can develop either acutely or over an extended period.25Frangogiannis N. G. (2015). Pathophysiology of myocardial infarction. Comprehensive Physiology, 5(4), 1841–1875. https://doi.org/10.1002/cphy.c150006^,26Yasue, H., Mizuno, Y., & Harada, E. (2019). Coronary artery spasm - Clinical features, pathogenesis and treatment. Proceedings of the Japan Academy. Series B, Physical and biological sciences, 95(2), 53–66. https://doi.org/10.2183/pjab.95.005 Individuals experiencing an AMI are at significant risk for complete cardiac arrest, a condition in which the heart ceases to beat.27Chrispin, J. (n.d.) Cardiac Arrest. John Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/cardiac-arrest#:~:text=Cardiac%20arrest%2C%20also%20known%20as,die%20if%20not%20treated%20immediately. Annually, approximately one million Americans and three million individuals worldwide suffer from an AMI, making it the leading cause of death in the United States.28Vos, T., Lim S.S., Abbafati, C., Abbas, K.M., Abbasi, M., Abbasifard, M., Abbasi‐Kangevari,,M., Abbastabar, H., Abd‐Allah, F, Abdelali,m A, et al. (2020).Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: A systematic analysis for the Global Burden of Disease Study 2019. The Lancet, 396:1204–1222. https://doi.org/10.1016/S0140-6736(20)30925-9^,29Virani, S.S., Alonso, A., Benjamin, E. J., Bittencourt, M. S., Callaway, C.W., Carson, A.P., Chamberlain, A. M., Chang, A. R., Cheng, S., Delling, F. N., et al. (2020). Heart disease and stroke statistics—2020 update: a report from the American heart association. Circulation, 141:e139–e596. https://doi.org/10.1161/CIR.0000000000000757

Survival following an acute myocardial infarction (AMI) is heavily reliant on prompt and appropriate medical intervention, making the early recognition of its signs and symptoms crucial. The hallmark symptom of AMI is chest pain or discomfort that persists for 20 minutes or more.21Syed, M. (2021). Dental Management of Cardiovascular Compromised Patient: A Review. Journal of Advanced Medical and Dental Sciences Research, 9(6), 60-63. Typically, individuals describe the sensation as pressure, tightness, heaviness, burning, squeezing, or a crushing feeling located in the middle of the chest and/or the lower third of the epigastrium.21Syed, M. (2021). Dental Management of Cardiovascular Compromised Patient: A Review. Journal of Advanced Medical and Dental Sciences Research, 9(6), 60-63. This pain may radiate to the arms, shoulders, neck, jaw, or back.21Syed, M. (2021). Dental Management of Cardiovascular Compromised Patient: A Review. Journal of Advanced Medical and Dental Sciences Research, 9(6), 60-63. Additionally, patients may experience weakness, dyspnea, diaphoresis, and an irregular pulse.21Syed, M. (2021). Dental Management of Cardiovascular Compromised Patient: A Review. Journal of Advanced Medical and Dental Sciences Research, 9(6), 60-63. The skin often appears ashen gray, and nausea and vomiting may occur, particularly if the pain is severe.21Syed, M. (2021). Dental Management of Cardiovascular Compromised Patient: A Review. Journal of Advanced Medical and Dental Sciences Research, 9(6), 60-63. Those suffering from an AMI may exhibit signs of significant anxiety, expressing a profound sense of "impending doom" and often clutching their chest with their fist.21Syed, M. (2021). Dental Management of Cardiovascular Compromised Patient: A Review. Journal of Advanced Medical and Dental Sciences Research, 9(6), 60-63. If left untreated, AMI can progress to cardiac arrest, resulting in the absence of pulse, respiration, and blood pressure.25Frangogiannis N. G. (2015). Pathophysiology of myocardial infarction. Comprehensive Physiology, 5(4), 1841–1875. https://doi.org/10.1002/cphy.c150006

In the dental setting, treatment should be immediately halted upon the onset of chest pain. If the patient has a history of angina, the appropriate steps for managing an anginal episode should be initiated.30Reed, K. (2010). Basic management of medical emergencies. Journal of the American Dental Association, 141, S20- S24. In the absence of a known history of angina, the situation should be treated as an acute myocardial infarction (AMI). This includes positioning the patient in a comfortable position, typically upright, assessing the airway, breathing, and circulation, and promptly activating the emergency medical services (EMS) system.30Reed, K. (2010). Basic management of medical emergencies. Journal of the American Dental Association, 141, S20- S24.

If the patient is experiencing dyspnea or if the pulse oximeter reading is below 94%, oxygen should be administered via nasal cannula at a flow rate of 2-5 L/min, or via a non-rebreather mask at a flow rate of 4-6 L/min.31Cabello, J.B., Burls, A., Emparanza, J.I,. Bayliss, S.E., & Quinn, T. (2016). Oxygen therapy for acute myocardial infarction. Cochrane Database Syst Rev,12:CD007160-CD007160 Recent research highlights the importance of administering oxygen under these circumstances, emphasizing the need for a pulse oximeter in the emergency kit.31Cabello, J.B., Burls, A., Emparanza, J.I,. Bayliss, S.E., & Quinn, T. (2016). Oxygen therapy for acute myocardial infarction. Cochrane Database Syst Rev,12:CD007160-CD007160 Vital signs should be recorded, and if the patient is not hypotensive, nitroglycerin should be administered.22MA Healthcare. (2017). How to handle a heart attack. Dental Nursing. Fibrinolysis should be initiated as soon as possible.30Reed, K. (2010). Basic management of medical emergencies. Journal of the American Dental Association, 141, S20- S24.

Aspirin has a well-documented antithrombotic effect, aiding in the revascularization of the myocardium during an ischemic event. It is recommended that individuals suspected of having an AMI receive a single chewed dose of 325 mg of aspirin immediately upon recognition of the condition.32Dai, Y., & Ge, J. (2012). Clinical use of aspirin in treatment and prevention of cardiovascular disease. Thrombosis, 2012, 245037. https://doi.org/10.1155/2012/245037 Chewing the tablets allows acetylsalicylic acid to be absorbed through the oral mucosa, entering the bloodstream more rapidly. Four low-dose aspirin tablets are preferred due to their more tolerable flavor compared to regular aspirin. When chewed, the clinical effects of aspirin are typically realized within 20 minutes, whereas swallowing the tablets results in a considerably delayed onset of action.32Dai, Y., & Ge, J. (2012). Clinical use of aspirin in treatment and prevention of cardiovascular disease. Thrombosis, 2012, 245037. https://doi.org/10.1155/2012/245037

Vital signs should be monitored and recorded every five minutes.30Reed, K. (2010). Basic management of medical emergencies. Journal of the American Dental Association, 141, S20- S24. Pain management is critical to prevent the development of cardiogenic shock while awaiting the arrival of emergency medical technicians (EMTs). Nitroglycerin alone is generally insufficient for relieving pain associated with AMI. Opioid analgesics, such as morphine or meperidine, are recommended, although they are not typically available in the dental setting. An alternative approach includes the use of nitrous oxide and oxygen, which can effectively manage or significantly reduce pain.33Ferreira, J. C., & Mochly-Rosen, D. (2012). Nitroglycerin use in myocardial infarction patients. Circulation Journal, 76(1), 15–21. https://doi.org/10.1253/circj.cj-11-1133 If available, a flow of 3.5 to 4.0 L/min of nitrous oxide (N2O) and 6.5 to 6.9 L/min of oxygen (O2) can be administered, providing sufficient pain relief.33Ferreira, J. C., & Mochly-Rosen, D. (2012). Nitroglycerin use in myocardial infarction patients. Circulation Journal, 76(1), 15–21. https://doi.org/10.1253/circj.cj-11-1133

In the event that a patient experiences a full cardiac arrest during the management of an acute myocardial infarction (AMI), it is imperative that emergency medical services (EMS) be contacted immediately.34What is CPR? (n.d.). American Heart Association. https://cpr.heart.org/en/resources/what-is-cpr The patient should be positioned in the supine position, and cardiopulmonary resuscitation (CPR) should be initiated promptly.34What is CPR? (n.d.). American Heart Association. https://cpr.heart.org/en/resources/what-is-cpr Forced oxygen via a bag-mask device should be administered at a rate of 15 liters per minute until the arrival of EMS.34What is CPR? (n.d.). American Heart Association. https://cpr.heart.org/en/resources/what-is-cpr Given that ventricular fibrillation (VF) often occurs in cardiac arrest cases, defibrillation may be necessary.35Rymer, J.A., Wegermann, Z.K., Wang, T.Y., et al. (2024), Ventricular arrhythmias after primary percutaneous coronary intervention for STEMI. JAMA Netw Open,7(5):e2410288. doi:10.1001/jamanetworkopen.2024.10288 Health care providers should be proficient in the use of an automatic external defibrillator (AED) and prepared to utilize one if available.34What is CPR? (n.d.). American Heart Association. https://cpr.heart.org/en/resources/what-is-cpr According to the American Heart Association, in cases of witnessed cardiac arrest associated with VF, the immediate initiation of CPR, coupled with the use of an AED within the first 3 to 5 minutes, offers the greatest likelihood of survival for the patient.34What is CPR? (n.d.). American Heart Association. https://cpr.heart.org/en/resources/what-is-cpr

Hyperventilation

Hyperventilation is a physiological condition in which an individual breathes more rapidly and/or deeply than is required by the body's metabolic demands, leading to the excessive expulsion of carbon dioxide (CO₂) relative to its production.36Ogle, O. E., Dym, H., & Weinstock, R. J. (2016). Medical Emergencies in Dental Practice. International Quintessence Publishing Group. The normal adult respiratory rate typically ranges from 10 to 16 breaths per minute, rarely exceeding 22 breaths per minute.37Robson A. (2017). Dyspnoea, hyperventilation and functional cough: a guide to which tests help sort them out. Breathe (Sheffield, England), 13(1), 45–50. https://doi.org/10.1183/20734735.019716 In contrast, individuals experiencing hyperventilation may exhibit a respiratory rate greater than 22 breaths per minute. This condition is commonly observed in situations such as high-altitude exposure, pregnancy, the use of central nervous system stimulants, aspirin toxicity, and acute anxiety states.38MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US); [updated 2022Jul 25]. Hyperventilation. Particularly in clinical settings, fear and anxiety are frequent precipitating factors that can induce hyperventilation.36Ogle, O. E., Dym, H., & Weinstock, R. J. (2016). Medical Emergencies in Dental Practice. International Quintessence Publishing Group.

From a physiological perspective, hyperventilation results in a reduction of carbon dioxide in the bloodstream, leading to hypocapnia, which is characterized by respiratory alkalosis—an elevation in blood pH.39Palmer, B. F., & Clegg, D. J. (2023). Respiratory acidosis and respiratory alkalosis: Core curriculum 2023. American Journal of Kidney Diseases, 82(3), 347-359 The ideal pH for human blood is approximately 7.35 – 7.45, which is slightly alkaline.40Shaw, I., & Gregory, K. (2022). Acid-base balance: a review of normal physiology. BJA education, 22(10), 396–401. https://doi.org/10.1016/j.bjae.2022.06.003 Through hyperventilation, pH levels can rise to 7.5 or higher, even a modest shift in pH can have substantial physiological consequences.41Gill, R.S. (2024, Oct. 1) Respiratory Alkalosis Treatment & Management, Medscape, https://emedicine.medscape.com/article/301680-treatment?&icd=login_success_email_match_fpf Symptoms of hyperventilation may include prolonged rapid and deep respirations, heart palpitations, and potential chest pain.42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16. Additionally, hyperventilation can adversely affect cognitive and motor functions, impairing problem-solving abilities, motor coordination, balance, and perceptual tasks.42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16. These disturbances are often attributed to inadequate cerebral oxygenation, as vasoconstriction of the cerebral blood vessels can lead to dizziness, lightheadedness, and impaired vision. Furthermore, this vascular constriction may heighten the risk of seizures.42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16.

Other clinical manifestations associated with hyperventilation include feelings of apprehension, diaphoresis (excessive sweating), trembling, fatigue, and circumoral paresthesia (tingling or numbness around the mouth).36Ogle, O. E., Dym, H., & Weinstock, R. J. (2016). Medical Emergencies in Dental Practice. International Quintessence Publishing Group. As hyperventilation progresses, it can precipitate hypocalcemia, a reduction in serum calcium levels, which may in turn lead to tetany.43Gryglas A, Dudkowiak R, & Smigiel R. (2015). Tetany as a frequent cause of an emergency consultations--etiology, symptoms and cure. 72(1):20-24. PMID: 26076573. Clinically, tetany presents as muscle twitching or spasms, often accompanied by carpopedal spasms (sharp flexion of the wrist and ankle joints) and parasthesia in the extremities.43Gryglas A, Dudkowiak R, & Smigiel R. (2015). Tetany as a frequent cause of an emergency consultations--etiology, symptoms and cure. 72(1):20-24. PMID: 26076573.

Once a diagnosis of hyperventilation has been determined, therapy is directed at alleviating symptoms.42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16. The basic premise for treatment is to increase carbon dioxide levels in the bloodstream while addressing the psychological factors the patient is experiencing.42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16. Breathing into a paper bag was once the well-known cure for hyperventilation. This treatment modality is no longer recommended.44Callaham M. (1989). Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients. Annals of emergency medicine, 18(6), 622–628. https://doi.org/10.1016/s0196-0644(89)80515-3 Several studies noted by Callahan have indicated that breathing into a bag caused suffocation or even cardiac arrest.44Callaham M. (1989). Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients. Annals of emergency medicine, 18(6), 622–628. https://doi.org/10.1016/s0196-0644(89)80515-3 The recommended treatment is to place the patient in the position of their choice, usually upright.36Ogle, O. E., Dym, H., & Weinstock, R. J. (2016). Medical Emergencies in Dental Practice. International Quintessence Publishing Group. In addition, loosen tight clothing around the neck region.36Ogle, O. E., Dym, H., & Weinstock, R. J. (2016). Medical Emergencies in Dental Practice. International Quintessence Publishing Group. The next and most important step is to work with the patient to control the rate of respirations.36Ogle, O. E., Dym, H., & Weinstock, R. J. (2016). Medical Emergencies in Dental Practice. International Quintessence Publishing Group. Breathing through pursed lips or the nose will help slow breathing.36Ogle, O. E., Dym, H., & Weinstock, R. J. (2016). Medical Emergencies in Dental Practice. International Quintessence Publishing Group. You can also have the patient breathe into their cupped hands over their mouth and nose. While attempting to control breathing, vital signs should be monitored.45Evans, S. (2014, July 18). Dealing with hyperventiliation in practice. Dentistry. https://dentistry.co.uk/2014/07/18/dealing-hyperventilation-practice/#:~:text=The%20simplest%20re%2Dbreathing%20method,air%20holes%20with%20your%20fingers. If the condition does not improve, the patient should be transported by EMS to an emergency department for additional pharmacotherapy and to determine if the patient may be suffering from a more serious condition.38MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US); [updated 2022Jul 25]. Hyperventilation. Anti-anxiety medications may need to be considered for future appointments.45Evans, S. (2014, July 18). Dealing with hyperventiliation in practice. Dentistry. https://dentistry.co.uk/2014/07/18/dealing-hyperventilation-practice/#:~:text=The%20simplest%20re%2Dbreathing%20method,air%20holes%20with%20your%20fingers.

Bronchial Asthma Attack

Asthma is a chronic respiratory disorder in which there is increased responsiveness of the trachea, bronchi and bronchioles to various triggers resulting in the narrowing of the airways.46Chhabra, K., Sood, S., Sharma, N., Singh, A., & Nigam, S. (2021). Dental Management of Pediatric Patients with Bronchial Asthma. International Journal of Clinical Pediatric Dentistry, 14(5), 715–718. https://doi.org/10.5005/jp-journals-10005-2024 It is characterized by recurring episodes of dyspnea, wheezing, coughing and chest tightness.46Chhabra, K., Sood, S., Sharma, N., Singh, A., & Nigam, S. (2021). Dental Management of Pediatric Patients with Bronchial Asthma. International Journal of Clinical Pediatric Dentistry, 14(5), 715–718. https://doi.org/10.5005/jp-journals-10005-2024 In the dental office stress-induced asthma or an allergic response to a dental material may result in an asthmatic attack.46Chhabra, K., Sood, S., Sharma, N., Singh, A., & Nigam, S. (2021). Dental Management of Pediatric Patients with Bronchial Asthma. International Journal of Clinical Pediatric Dentistry, 14(5), 715–718. https://doi.org/10.5005/jp-journals-10005-2024 Although the symptoms of asthma can range from mild to life threatening, they are usually controlled with a combination of medications and lifestyle changes.46Chhabra, K., Sood, S., Sharma, N., Singh, A., & Nigam, S. (2021). Dental Management of Pediatric Patients with Bronchial Asthma. International Journal of Clinical Pediatric Dentistry, 14(5), 715–718. https://doi.org/10.5005/jp-journals-10005-2024 More specifically, asthma is the result of an abnormal immune response in the bronchial airways.46Chhabra, K., Sood, S., Sharma, N., Singh, A., & Nigam, S. (2021). Dental Management of Pediatric Patients with Bronchial Asthma. International Journal of Clinical Pediatric Dentistry, 14(5), 715–718. https://doi.org/10.5005/jp-journals-10005-2024 The airways of asthmatics become hypersensitive to certain triggers stimuli.46Chhabra, K., Sood, S., Sharma, N., Singh, A., & Nigam, S. (2021). Dental Management of Pediatric Patients with Bronchial Asthma. International Journal of Clinical Pediatric Dentistry, 14(5), 715–718. https://doi.org/10.5005/jp-journals-10005-2024 In response to these stimuli the bronchi contract into spasm resulting in difficulty breathing.46Chhabra, K., Sood, S., Sharma, N., Singh, A., & Nigam, S. (2021). Dental Management of Pediatric Patients with Bronchial Asthma. International Journal of Clinical Pediatric Dentistry, 14(5), 715–718. https://doi.org/10.5005/jp-journals-10005-2024 Inflammation leads to a further narrowing of the airways and excessive mucus production which results in coughing and wheezing on expiration and inspiration.46Chhabra, K., Sood, S., Sharma, N., Singh, A., & Nigam, S. (2021). Dental Management of Pediatric Patients with Bronchial Asthma. International Journal of Clinical Pediatric Dentistry, 14(5), 715–718. https://doi.org/10.5005/jp-journals-10005-2024

Patients undergoing an asthma exacerbation typically exhibit respiratory distress, characterized by a mildly increased respiratory rate, chest tightness, and shortness of breath.47Jevon P. Basic guide to medical emergencies in the dental practice. 3rd ed. Oxford: Wiley Blackwell; 2021 Some individuals may also present with coughing and wheezing.47Jevon P. Basic guide to medical emergencies in the dental practice. 3rd ed. Oxford: Wiley Blackwell; 2021 Additionally, the patient's skin may appear pale or exhibit a subtle bluish discoloration, indicative of impaired oxygenation.47Jevon P. Basic guide to medical emergencies in the dental practice. 3rd ed. Oxford: Wiley Blackwell; 2021

The management of an asthma exacerbation begins by positioning the patient upright with their arms forward to promote optimal airflow.42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16. Patients should be administered their prescribed bronchodilator for self-administration, with instructions to inhale slowly and exhale through pursed lips to enhance medication delivery and reduce airway resistance.42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16. In the absence of the patient's personal inhaler, the administration of a standard emergency inhaler containing albuterol is recommended, as it acts rapidly and has a duration of 4-6 hours. Supplemental oxygen, delivered at a rate of 4-6 liters per minute via a non-rebreather mask, should be provided, and continuous monitoring of vital signs is essential.46Chhabra, K., Sood, S., Sharma, N., Singh, A., & Nigam, S. (2021). Dental Management of Pediatric Patients with Bronchial Asthma. International Journal of Clinical Pediatric Dentistry, 14(5), 715–718. https://doi.org/10.5005/jp-journals-10005-2024

If the symptoms persist, a second dose of albuterol should be administered.42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16. A spacer device is particularly beneficial in pediatric patients, as it allows for more efficient medication delivery, reducing the need for rapid inhalation and increasing the amount of medication absorbed.48Keeley, D., & Partridge, M. R. (2019). Emergency MDI and spacer packs for asthma and COPD. The Lancet. Respiratory medicine, 7(5), 380–382. https://doi.org/10.1016/S2213-2600(19)30046-3 If the symptoms remain unrelieved, consideration should be given to the administration of a subcutaneous injection of epinephrine, using the standard dosage typically employed for allergic reactions.46Chhabra, K., Sood, S., Sharma, N., Singh, A., & Nigam, S. (2021). Dental Management of Pediatric Patients with Bronchial Asthma. International Journal of Clinical Pediatric Dentistry, 14(5), 715–718. https://doi.org/10.5005/jp-journals-10005-2024 At this point, emergency medical services (EMS) should be contacted for further intervention.48Keeley, D., & Partridge, M. R. (2019). Emergency MDI and spacer packs for asthma and COPD. The Lancet. Respiratory medicine, 7(5), 380–382. https://doi.org/10.1016/S2213-2600(19)30046-3

Anaphylaxis

An allergy is defined as an exaggerated immune response to a typically innocuous substance, the majority of which are environmental in origin.42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16. The most prevalent triggers of allergic reactions include exposure to allergens, such as dust, pollen, latex, certain foods (notably peanuts, tree nuts, shellfish, milk, eggs, and wheat), insect stings, and medications, with particular emphasis on aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), penicillin, and radiographic contrast meda.49Lei, D. K., & Grammer, L. C. (2019). An overview of allergens. Allergy and Asthma Proceedings, 40(6), 362–365. https://doi.org/10.2500/aap.2019.40.4247 The clinical manifestations of allergic reactions can vary significantly in severity, ranging from mild symptoms, such as erythema, sneezing, conjunctival irritation, rhinorrhea, and/or cutaneous discomfort to potentially life-threatening conditions, including profound hypotension and respiratory distress.42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16.^,50Muraro, A., Roberts, G., Worm, M., Bilò, M. B., Brockow, K., Fernández Rivas, M., ... & EAACI Food Allergy and Anaphylaxis Guidelines Group. (2014). Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology. Allergy, 69(8), 1026-1045. The most severe form of allergic reaction is classified as anaphylaxis.42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16.

Allergic reactions generally follow a consistent physiological process. Upon initial exposure to a specific antigen, known as the sensitizing dose or sensitization, the body mounts its primary immune response.51Shamji, M. H., Valenta, R., Jardetzky, T., Verhasselt, V., Durham, S. R., Würtzen, P. A., & van Neerven, R. J. J. (2021). The role of allergen-specific IgE, IgG and IgA in allergic disease. Allergy, 76(12), 3627–3641. https://doi.org/10.1111/all.14908^,42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16. In the case of allergies, this response involves the production of antibodies, specifically immunoglobulin E (IgE), which is activated to combat the antigen.51Shamji, M. H., Valenta, R., Jardetzky, T., Verhasselt, V., Durham, S. R., Würtzen, P. A., & van Neerven, R. J. J. (2021). The role of allergen-specific IgE, IgG and IgA in allergic disease. Allergy, 76(12), 3627–3641. https://doi.org/10.1111/all.14908 The IgE binds to mast cells and basophils, which are primarily located in the lungs, small intestine, blood vessels, and connective tissues, with mast cells residing interstitially.51Shamji, M. H., Valenta, R., Jardetzky, T., Verhasselt, V., Durham, S. R., Würtzen, P. A., & van Neerven, R. J. J. (2021). The role of allergen-specific IgE, IgG and IgA in allergic disease. Allergy, 76(12), 3627–3641. https://doi.org/10.1111/all.14908 Following this initial exposure, these cells remain dormant until the body encounters the same antigen again, referred to as the challenge dose.51Shamji, M. H., Valenta, R., Jardetzky, T., Verhasselt, V., Durham, S. R., Würtzen, P. A., & van Neerven, R. J. J. (2021). The role of allergen-specific IgE, IgG and IgA in allergic disease. Allergy, 76(12), 3627–3641. https://doi.org/10.1111/all.14908 Upon subsequent exposure, the antigen becomes classified as an allergen.51Shamji, M. H., Valenta, R., Jardetzky, T., Verhasselt, V., Durham, S. R., Würtzen, P. A., & van Neerven, R. J. J. (2021). The role of allergen-specific IgE, IgG and IgA in allergic disease. Allergy, 76(12), 3627–3641. https://doi.org/10.1111/all.14908

At this stage, the IgE identifies the allergen, prompting degranulation of mast cells and basophils.52Galli, S. J., & Tsai, M. (2012). IgE and mast cells in allergic disease. Nature medicine, 18(5), 693–704. https://doi.org/10.10\ Degranulation occurs when the cell membrane ruptures, releasing the cell’s contents, including various chemical mediators aimed at neutralizing the antigen.52Galli, S. J., & Tsai, M. (2012). IgE and mast cells in allergic disease. Nature medicine, 18(5), 693–704. https://doi.org/10.10\ The release of these mediators triggers the allergic reaction, with histamine being the principal chemical mediator involved.52Galli, S. J., & Tsai, M. (2012). IgE and mast cells in allergic disease. Nature medicine, 18(5), 693–704. https://doi.org/10.10\

In more severe allergic reactions, symptoms include pallor or flushed skin, and angioedema, characterized by swelling of the lips, eyes, hands, neck, or throat due to increased tissue fluid.53Spickett, G. P., & Stroud, C. (2011). Does this patient with urticaria/angioedema have anaphylaxis?. Clinical medicine (London, England), 11(4), 390–396. https://doi.org/10.7861/clinmedicine.11-4-390 If angioedema affects the larynx, it can result in airway obstruction, potentially causing asphyxia and respiratory arrest.53Spickett, G. P., & Stroud, C. (2011). Does this patient with urticaria/angioedema have anaphylaxis?. Clinical medicine (London, England), 11(4), 390–396. https://doi.org/10.7861/clinmedicine.11-4-390 Additionally, bronchospasm and dyspnea can manifest as wheezing and chest tightness.53Spickett, G. P., & Stroud, C. (2011). Does this patient with urticaria/angioedema have anaphylaxis?. Clinical medicine (London, England), 11(4), 390–396. https://doi.org/10.7861/clinmedicine.11-4-390 Severe allergic reactions also lead to profound hypotension and a rapid, weak, which can precipitate cardiovascular collapse in cases of extreme hypotension.53Spickett, G. P., & Stroud, C. (2011). Does this patient with urticaria/angioedema have anaphylaxis?. Clinical medicine (London, England), 11(4), 390–396. https://doi.org/10.7861/clinmedicine.11-4-390 Tachycardia, arrhythmias, and diminished cardiac contractility are further indications of a severe response.53Spickett, G. P., & Stroud, C. (2011). Does this patient with urticaria/angioedema have anaphylaxis?. Clinical medicine (London, England), 11(4), 390–396. https://doi.org/10.7861/clinmedicine.11-4-390 Without intervention, fatality may occur within minutes of exposure to the allergen.54Sheikh, A., Shehata, Y. A., Brown, S. G., & Simons, F. E. (2008). Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock. The Cochrane database of systematic reviews, 2008(4), CD006312. https://doi.org/10.1002/14651858.CD006312.pub2

In cases where anaphylaxis is suspected, immediate contact with emergency medical services (EMS) is essential, followed by the administration of epinephrine.55Karunarathna, I., Gunasena, P., De Alvis, K., & Jayawardana, A. (2024). Clinical management of anaphylaxis: Best practices and pitfalls. Researchgate.net The clinical indications for this critical intervention include severe hypotension, dyspnea, or laryngeal edema.55Karunarathna, I., Gunasena, P., De Alvis, K., & Jayawardana, A. (2024). Clinical management of anaphylaxis: Best practices and pitfalls. Researchgate.net Epinephrine should be administered intramuscularly, with the preferred injection sites being the deltoid or quadriceps muscle.55Karunarathna, I., Gunasena, P., De Alvis, K., & Jayawardana, A. (2024). Clinical management of anaphylaxis: Best practices and pitfalls. Researchgate.net The recommended adult dosage is between 0.2 and 0.5 ml of a 1:1000 epinephrine solution.55Karunarathna, I., Gunasena, P., De Alvis, K., & Jayawardana, A. (2024). Clinical management of anaphylaxis: Best practices and pitfalls. Researchgate.net Epinephrine is available in an autoinjector format with a single 0.3 mg dose of 1:1000 concentration.55Karunarathna, I., Gunasena, P., De Alvis, K., & Jayawardana, A. (2024). Clinical management of anaphylaxis: Best practices and pitfalls. Researchgate.net If an epinephrine autoinjector (e.g., Epipen) is used, it is important to maintain the injection in the arm or leg for a minimum of 10 seconds to ensure full delivery of the medication.

Epinephrine counteracts the immediate symptoms of anaphylaxis by binding to alpha and beta adrenergic receptors.56Ring, J., Klimek, L., & Worm, M. (2018). Adrenaline in the Acute Treatment of Anaphylaxis. Deutsches Arzteblatt international, 115(31-32), 528–534. https://doi.org/10.3238/arztebl.2018.0528 It reverses peripheral vasodilation, reduces edema, induces bronchodilation, exerts a positive inotropic and chronotropic effect on the myocardium, and inhibits the release of chemical mediators, such as histamine, from mast cells.56Ring, J., Klimek, L., & Worm, M. (2018). Adrenaline in the Acute Treatment of Anaphylaxis. Deutsches Arzteblatt international, 115(31-32), 528–534. https://doi.org/10.3238/arztebl.2018.0528 Research indicates that fatalities are more likely when epinephrine is administered too late.57Song, T. T. & Lieberman, P. (2015). Epinephrine in anaphylaxis: doubt no more. Current Opinion in Allergy and Clinical Immunology 15(4):p 323-328. https://DOI: 10.1097/ACI.0000000000000185

If administered to an adult, a second dose may be required after five minutes if symptoms persist.56Ring, J., Klimek, L., & Worm, M. (2018). Adrenaline in the Acute Treatment of Anaphylaxis. Deutsches Arzteblatt international, 115(31-32), 528–534. https://doi.org/10.3238/arztebl.2018.0528 Therefore, a second Epipen or an additional vial of epinephrine (1:1000 concentration) with a syringe should be included in the emergency medical kit.57Song, T. T. & Lieberman, P. (2015). Epinephrine in anaphylaxis: doubt no more. Current Opinion in Allergy and Clinical Immunology 15(4):p 323-328. https://DOI: 10.1097/ACI.0000000000000185 For children, the appropriate doses are 0.25 ml of 1:1000 epinephrine for those aged 6-12 years, and 0.01 ml of 1:1000 epinephrine for children aged 6 months to 6 years with a severe allergic reaction.58Sicherer, S.H. & Simons, E.R. (2017) Epinephrine for first-aid management of anaphylaxis. Pediatrics,139 (3), e1 – e9.

In addition to epinephrine administration, patients experiencing an allergic reaction should be placed in a supine position with their legs slightly elevated to facilitate venous return.59Resuscitation Council UK. Emergency treatment of anaphylactic reactions: Guidelines for healthcare providers. 2021. https://www.resus.org.uk/sites/default/files/2021-05/Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf However, if the patient is experiencing significant respiratory distress, an upright position may aid breathing. It is important to note that certain positional changes, such as shifting from supine to sitting or standing, can exacerbate allergic symptoms and may be potentially fatal due to altered blood flow.59Resuscitation Council UK. Emergency treatment of anaphylactic reactions: Guidelines for healthcare providers. 2021. https://www.resus.org.uk/sites/default/files/2021-05/Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf If the patient is exhibiting signs of dyspnea or has a pulse oximetry reading below 94%, supplemental oxygen should be administered at 4-6 liters per minute.48Keeley, D., & Partridge, M. R. (2019). Emergency MDI and spacer packs for asthma and COPD. The Lancet. Respiratory medicine, 7(5), 380–382. https://doi.org/10.1016/S2213-2600(19)30046-3

Continuous monitoring of vital signs is crucial.56Ring, J., Klimek, L., & Worm, M. (2018). Adrenaline in the Acute Treatment of Anaphylaxis. Deutsches Arzteblatt international, 115(31-32), 528–534. https://doi.org/10.3238/arztebl.2018.0528 If a histamine antagonist has not been administered intramuscularly, it should be given to alleviate symptoms such as pruritus.56Ring, J., Klimek, L., & Worm, M. (2018). Adrenaline in the Acute Treatment of Anaphylaxis. Deutsches Arzteblatt international, 115(31-32), 528–534. https://doi.org/10.3238/arztebl.2018.0528 Finally, referral to an appropriate medical facility is required for further evaluation and management.56Ring, J., Klimek, L., & Worm, M. (2018). Adrenaline in the Acute Treatment of Anaphylaxis. Deutsches Arzteblatt international, 115(31-32), 528–534. https://doi.org/10.3238/arztebl.2018.0528

Severe Hypoglycemia

Diabetes mellitus (DM) is a metabolic disorder characterized by chronic hyperglycemia, resulting from either a reduction or absence of insulin production by the pancreatic beta cells, or defects in the insulin receptors.42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16. Although diabetes is associated with a range of complications, the most effective strategy for preventing these issues is the maintenance of optimal blood glucose levels.60American Diabetes Association Professional Practice Committee (2022). 6. Glycemic Targets: Standards of Medical Care in Diabetes-2022. Diabetes care, 45(Suppl 1), S83–S96. https://doi.org/10.2337/dc22-S006

Diabetic patients should monitor their blood glucose levels multiple times throughout the day to ensure their medication regimen is appropriate.60American Diabetes Association Professional Practice Committee (2022). 6. Glycemic Targets: Standards of Medical Care in Diabetes-2022. Diabetes care, 45(Suppl 1), S83–S96. https://doi.org/10.2337/dc22-S006 Normal blood glucose levels typically range from 50 to 150 mg/dL. Readings below 50 mg/dL indicate hypoglycemia, while values above 150 mg/dL signal hyperglycemia—both of which may require medical intervention.60American Diabetes Association Professional Practice Committee (2022). 6. Glycemic Targets: Standards of Medical Care in Diabetes-2022. Diabetes care, 45(Suppl 1), S83–S96. https://doi.org/10.2337/dc22-S006

In addition to routine blood glucose monitoring, the glycated hemoglobin test (HbA1c) is crucial.60American Diabetes Association Professional Practice Committee (2022). 6. Glycemic Targets: Standards of Medical Care in Diabetes-2022. Diabetes care, 45(Suppl 1), S83–S96. https://doi.org/10.2337/dc22-S006 This test provides an average of the patient's blood glucose levels over the past two to three months, offering a broader picture of glucose management.60American Diabetes Association Professional Practice Committee (2022). 6. Glycemic Targets: Standards of Medical Care in Diabetes-2022. Diabetes care, 45(Suppl 1), S83–S96. https://doi.org/10.2337/dc22-S006 An HbA1c level of less than 7.0% is considered ideal.60American Diabetes Association Professional Practice Committee (2022). 6. Glycemic Targets: Standards of Medical Care in Diabetes-2022. Diabetes care, 45(Suppl 1), S83–S96. https://doi.org/10.2337/dc22-S006 Maintaining optimal HbA1c levels significantly reduces the risk of diabetes-related complications, including retinopathy, nephropathy, neuropathy, stroke, and heart failure.60American Diabetes Association Professional Practice Committee (2022). 6. Glycemic Targets: Standards of Medical Care in Diabetes-2022. Diabetes care, 45(Suppl 1), S83–S96. https://doi.org/10.2337/dc22-S006

Dental professionals play a pivotal role in supporting diabetic patients. Prior to dental treatment, several key questions should be asked to ensure safe and effective care:

• Do you monitor your blood sugar levels? If so, how often?
• What were your most recent blood glucose readings?
• How are you feeling today?
• Do you take medication for diabetes? If so, did you take it today?
• Have you eaten today? If so, when?
• Are you experiencing any issues with your eyes, feet, or legs?
• Do you have regular check-ups with your physician?
• Do you see an eye specialist annually?
• Are you aware of your average hemoglobin A1c value?61Wilkins EM. Clinical practice of the dental hygienist. 10th ed. Philadelphia, Pa: Lippincott,Williams & Wilkins; 2009.

The most common emergency among diabetic patients is severe hypoglycemia, which occurs when blood glucose levels fall below 40-50 mg/dL.62Price, T. (2013). How to care for patients with diabetes, Dimensionsof Dental Hygiene, 11(1): 62–65. https://dimensionsofdentalhygiene.com/article/how-to-care-for-patients-with-diabetes/#:~:text=The%20most%20common%20medical%20emergency,before%20the%20patient%20is%20diagnosed. This condition typically results from missed meals, irregular eating patterns, alcohol consumption, or increased physical activity without appropriate insulin adjustments.

Since the brain depends on a continuous supply of glucose, significant drops in blood sugar lead to a range of symptoms, including confusion, seizures, and ultimately, coma.42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16. Additional signs of hypoglycemia may include dizziness or fainting, weakness, headache, intense hunger, cold and clammy skin, profuse perspiration, irritability, or aggressive behavior.42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16.

For a conscious patient experiencing hypoglycemia, the recommended treatment is the administration of 15 – 40 grams of a rapidly absorbed sugar source.42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16. Suitable options include table sugar, soda, honey, candy, orange juice, or glucose tablets/paste.42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16. It is essential to ensure the patient's airway is secure, and vital signs are continuously monitored during treatment.42Zingade, J., Kumar, G., & Gujjar, P. K. (2021). Medical Emergencies in Dentistry: A Review. Journal of Health Sciences & Research, 12(1), 11-16. A positive response to glucose should typically occur within 10-15 minutes.

In cases where the patient is unconscious and unable to ingest oral carbohydrates, the treatment of choice is the administration of 1 mg of glucagon, either subcutaneously, intramuscularly, or intravenously.24Tarkin, J. M., & Kaski, J. C. (2016). Vasodilator therapy: nitrates and nicorandil. Cardiovascular drugs and therapy, 30, 367-378. Glucagon stimulates hepatic glycogenolysis, facilitating the release of glucose into the bloodstream.63Ramnanan, C. J., Edgerton, D. S., Kraft, G., & Cherrington, A. D. (2011). Physiologic action of glucagon on liver glucose metabolism. Diabetes, obesity & metabolism, 13 Suppl 1(Suppl 1), 118–125. https://doi.org/10.1111/j.1463-1326.2011.01454.x If glucagon is unavailable, glucose paste can be applied transmucosally to the gingival tissues or buccal mucosa to facilitate absorption. However, it is crucial to exercise caution and ensure that the patient's airway remains unobstructed during this process.64Cohen, E. A., Porter, L., Crews, C. D., Mott, J., Tardo, A. M., & Gilor, C. (2024). Transmucosal glucagon rapidly increases blood glucose concentration in healthy cats. Journal of feline medicine and surgery, 26(11), 1098612X241280516. https://doi.org/10.1177/1098612X241280516 A recent advance in glucagon administration that has is intranasally for patients 4 years of age or older.65BaqsimiTM (glucagon nasal powder) [package insert]. Indianapolis, IN: Eli Lilly and Company; October 2020. https://uspl.lilly.com/baqsimi/baqsimi.html#pi. Accessed January 4, 2025. These two approaches offer an alternative means of increasing blood glucose levels in critical situations when immediate access to injectable glucagon is not possible.65BaqsimiTM (glucagon nasal powder) [package insert]. Indianapolis, IN: Eli Lilly and Company; October 2020. https://uspl.lilly.com/baqsimi/baqsimi.html#pi. Accessed January 4, 2025.

Conclusion

This course provided a comprehensive review of the most frequently encountered medical emergencies in a dental office setting. A thorough understanding of the symptoms and appropriate management of these emergencies is crucial for ensuring that dental professionals are prepared to respond effectively in critical situations. Possessing the requisite knowledge and skills to address such emergencies is not only vital for patient care but may also prove lifesaving.

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• 64.Cohen, E. A., Porter, L., Crews, C. D., Mott, J., Tardo, A. M., & Gilor, C. (2024). Transmucosal glucagon rapidly increases blood glucose concentration in healthy cats. Journal of feline medicine and surgery, 26(11), 1098612X241280516. https://doi.org/10.1177/1098612X241280516
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