Emergency Drugs in Pediatric Dentistry

CATEGORY 1 - Essential Drugs (Every Dental Office)

1. Oxygen (O₂)

• Indication: First-line for almost every emergency
• Dose: 100% inhalation via mask
• Supply: "E" cylinder with adjustable regulator (0-15 L/min)
• Notes: The single most important emergency drug. Never omit.

2. Epinephrine (Adrenaline)

• Indication: Anaphylaxis; severe asthma unresponsive to albuterol
• Concentration/Dose:
  • 1:1000 (1 mg/mL) ampule - draw and inject
  • EpiPen (≥30 kg): 0.3 mg auto-injector IM
  • EpiPen Jr (<30 kg): 0.15 mg auto-injector IM
  • Weight-based: 0.01 mg/kg IM (max 0.3 mg), repeat every 15 min x2 if needed
• Route: IM (anterolateral thigh preferred)
• Notes: Most critical drug for anaphylaxis. Always stock both adult and junior auto-injectors in a pediatric office.

3. Albuterol / Salbutamol (Bronchodilator)

• Indication: Acute asthmatic bronchospasm
• Dose: 2 puffs via metered-dose inhaler (MDI); repeat as needed
• Also available: 2.5 mg/3 mL nebulized solution
• Notes: First-line for bronchospasm before escalating to epinephrine.

4. Nitroglycerin

• Indication: Angina pectoris (chest pain)
• Dose: 0.4 mg sublingually every 3-5 minutes (up to 3 doses)
• Supply: Metered-dose spray (0.4 mg/spray)
• Notes: Rarely needed in children, but relevant for adolescents with cardiac conditions.

5. Diphenhydramine (Benadryl)

• Indication: Mild-to-moderate allergic reactions (urticaria, angioedema)
• Dose: 1 mg/kg IM or IV; maximum 50 mg
• Dosing by age (approximate):

  Age	Dose
  2-5 years	6.25 mg
  6-11 years	12.5-25 mg
  ≥12 years	25-50 mg

• Supply: 50 mg/mL vials + oral 25 mg tablets
• Notes: Adjunct to epinephrine, NOT a replacement.

6. Aspirin (for MI)

• Indication: Suspected myocardial infarction
• Dose: 81 mg chewable tablet
• Notes: More relevant for adult patients; still worth stocking.

7. Glucose (Oral Glucose Gel)

• Indication: Hypoglycemia (conscious or semi-conscious patient)
• Dose: 37.5 mg (1 tube), repeat as needed
• Notes: For unconscious patients, IV dextrose (D50W) or glucagon injection is required.

CATEGORY 2 - Optional / Advanced Drugs (Sedation Practices)

8. Atropine

• Indication: Clinically significant bradycardia (HR <60 bpm)
• Dose: 0.02 mg/kg IV or IM (minimum 0.1 mg, max single dose 0.5 mg)
• Supply: 1 ampule (1 mg/10 mL)
• Notes: Also used as pre-medication to reduce secretions. Minimum dose of 0.1 mg must be observed to avoid paradoxical bradycardia.

9. Hydrocortisone

• Indication: Adrenal insufficiency / corticosteroid-dependent patient; recurrent anaphylaxis
• Dose: 100 mg IV or IM (mixed with 3-5 mL sterile water)
• Supply: 1 vial (100 mg)
• Notes: Not for acute anaphylaxis first-line - epinephrine takes priority.

10. Flumazenil (Romazicon)

• Indication: Reversal of benzodiazepine (midazolam, diazepam) overdose
• Dose: 0.01 mg/kg IV at 1-minute intervals; max cumulative dose = lower of 0.05 mg/kg or 1 mg
• Supply: 0.5 mg/5 mL multidose vial
• Notes: Monitor for at least 2 hours after last dose. Re-sedation can occur as flumazenil wears off faster than the benzodiazepine.

11. Naloxone (Narcan)

• Indication: Reversal of opioid (narcotic) overdose - e.g., meperidine overdose in pediatric sedation
• Dose: 0.1 mg/kg IV or IM; max 2 mg
• Supply: 4 mg/10 mL multidose vial
• Notes: Repeat dosing may be needed. Meperidine (Demerol) is the most common oral opioid sedative in pediatric dentistry.

12. Lorazepam or Midazolam (for Seizures)

• Indication: Status epilepticus / prolonged seizure
• Dose:
  • Lorazepam (Ativan): 0.05-0.1 mg/kg IV (max 4 mg)
  • Midazolam (Versed): 0.2 mg/kg IM or intranasal (max 5-10 mg)
• Notes: Midazolam preferred in pediatrics due to intranasal route availability. Diazepam 0.05-0.3 mg/kg IV is an alternative.

13. Morphine or Nitrous Oxide

• Indication: Angina pain unresponsive to nitroglycerin
• Dose: Morphine: titrate 2 mg IV / 5 mg IM; Nitrous oxide: ~35% inhalation

Quick-Reference Summary Table

Key Points for Pediatric Dentistry

1. EpiPen Jr (0.15 mg) should always accompany EpiPen (0.3 mg) since most pediatric patients weigh under 30 kg.
2. Midazolam is the most commonly used sedative in pediatric dentistry - given orally (0.25-1.0 mg/kg) or intranasally (0.25 mg/kg).
3. Flumazenil has a shorter half-life than midazolam - re-sedation monitoring for 2 hours is mandatory.
4. Meperidine (Demerol) is the most common oral opioid used for pediatric dental sedation (1-2 mg/kg) - naloxone must be on hand.
5. Minimum atropine dose is 0.1 mg - lower doses can paradoxically worsen bradycardia.
6. Drug selection depends on the practitioner's training level and whether sedation is used in the practice.