Advanced Education In General Dentistry

Module 01: Advanced Pain Control and Sedation

Medical Emergencies and Complications

Respiratory and Cardiac Complications

Emesis in an Unprotected Airway

A patient who is deeply sedated and has emesis may not have complete control of his/her reflexes, and is at risk for aspiration, broncho-spasm and pneumonia. Procedure:

  1. Put the patient in the Trendelenburg Position on the right.
  2. Turn the patient onto the right side.
  3. Suction.
  4. Call 9-1-1.
  5. If you are technically able to, intubate the patient.
  6. Administer oxygen.
  7. Perform tracheal lavage through the endotracheal tube.

Administration of I.V. steroids is recommended.

Laryngeal Spasm

Laryngeal spasm is closure of the glottis by the intrinsic muscles of the larynx; it can be prevented with throat partionment, by placing throat partitions when we work. In the event that laryngeal spasm occurs, patients may be treated with oxygen and suction. It may also be necessary to ventilate the patient with positive pressure; in rare cases it is necessary to administer succinylcholine in a low dose to break the spasm.


Patients may also hyperventilate in the chair due to anxiety. Calm the patient, have the patient breathe into cupped hands so they are re-breathing their CO2 and administer I.V. medazalam or diazepam to decrease the anxiety, and generally hyperventilation will stop by calming the patient and having them re-breathe, and call 9-1-1 if seizures develop.


In the event of a seizure, do not place anything into the patient's mouth, especially your fingers.

  1. Protect the patient.
  2. Call 9-1-1.
  3. Maintain the airway, and
  4. Administer oxygen.

If the seizures persist, administer midazolam, 1 mg per minute, or diazepam, 5 mg per minute, and watch for post-seizure apnea.

Duration of seizures are related to the cause. Generally, epileptic, generalized tonoclonic seizures last anywhere up to five minutes. If the seizures are due to local anesthesia overdose, which is a toxic reaction, the seizures will stop when the cerebral blood flow of the anesthetic falls below the seizure threshold. If it is due to hyperventilation, seizures will cease when the CO2 level rises to normal. If due to severe airway obstruction or anoxia, unfortunately, it is often associated with extreme morbidity and patient death; fortunately these conditions are extremely rare.


Hypoglycemia is common in patients with Type I diabetes (non-insulin dependent), and leads to diminished CNS functioning. If the patient is alert, you can administer sugar by mouth in the form of a juice. If the patient is abtunded, then sugar has to be given intravenously, usually 50 ccÕs of 50% dextrose is sufficient. The insulin dose may be adjusted when the patient is NPO using D5W as the I.V. infusate. Remember, it is better to keep the patient a little sweet than to drop the sugar. These patients should not be home alone after sedation. For diabetic patients, it is also important to keep in mind that NPH insulin is long-acting; if the patient takes NPH insulin in the morning, it is important to ensure that the patient can take PO fluids later in the day after the sedation and procedure are over.

Cardiac Emergencies

Patients with cardiac emergencies such as chest pain may present with a chest pain or disrythmias in your office For chest pain:

  1. Sit the patient up.
  2. Loosen the patientÕs clothing.
  3. Administer oxygen, and
  4. Administer nitroglycerin sublingually.

If anginal, the pain will disappear. If the pain doesn't disappear, the patient may be having a myocardial infarction.

  1. Take his/her vital signs.
  2. Call 9-1-1, and
  3. Administer aspirin.
  4. Be ready to perform BLS and ACLS.
  5. If available, administer 2-5 mg morphine I.V

Morphine will cause peripheral vasodilation, decreasing the workload of the heart, and it will also provide some anxiolysis for the patient. Nitrous oxide oxygen can also be used for that purpose as well.


Hypotension is usually the result of chest pain, myocardial infarction, or congestive heart failure, and is characterized by disorientation, restlessness, anxiety, and cold, clammy skin. Hypotension can also be seen in patients with adrenal insufficiency, who have often been on chronic steroids and should have a steroid boost prior to the procedure.

Blood pressure varies according to the site at which the reading is taken: radial pulse - systolic pressure > 80 carotid artery pulse - systolic pressure = 60

To manage hypotension:

  1. Elevate the legs.
  2. If nitrous oxide is being administered, discontinue.
  3. If narcotics or benzodiazapines have been given, use an antagonist
  4. Turn up the I.V. fluids.
  5. Administer basic life support as needed.
  6. Administer an alpha- and beta-agonist such as methanteramine either intravenously or intramuscularly to manage the hypotension.

The most common cause of hypertension during a procedure is light anesthesia and pain, so it is important to provide an adequate level of sedation and analgesia with the local anesthetic. Patients may become hypercarbic and hypoxic due to excess catecholamine release, which is also seen in hypertensive patients. Again, managing the airway and pain are critical.

With patients who are in crisis, the goal of therapy is to lower the blood pressure to the patient's baseline and get them to the emergency room.

If there is an I.V. present and the patient is in hypertensive crisis, administer either nipride or nitroglycerin I.V., if there's a cardiac cause. If there's a non-cardiac cause, administer diazoxide or hyperstat, 1-3 mg per kilo I.V. every 5 or 10 minutes. Also, a nitroglycerin tablet sublingually will also help drop the blood pressure.

Remember, a good history and physical and a careful technique will prevent most emergencies, but it is important to always be prepared.