All Emergencies - Basic life support principles:

  1. Maintain an airway
  2. Assess breathing
  3. Monitor circulation
Monitor and record all vital signs.
Chest Pain

Differential Diagnosis:

  • Hyperventilation: highly anxious, light headed, fast respiration
  • Angina - Transient chest pain brought on by exertion, emotional upset; relieved by rest & administration of nitrates (Below)
  • Myocardial Infarction (Below)
  • GERD

Angina Pectoris:
Angina resolves after 3-8 minutes of rest or after administering nitroglycerin. Shortness of breath may also occur.


Other Signs/Symptoms:

  1. Transient chest pain brought on by exertion, emotional upset; relieved by rest & administration of nitrates.
  2. Blood pressure may be normal, elevated or lowered slightly.
  3. Heart rate usually increases with the possible occurrence of dysrhythmias.


Management of Angina:

If the patient has no history of angina:

  1. Notify the EMS immediately.
  2. Terminate dental treatment.
  3. Administer oxygen
  4. Administer nitroglycerin tablets or spray in the usual dose.
    ** Angina pain should be alleviated within 2 minutes with nitroglycerin and should not return.
  5. Monitor vital signs.

If patient does have a history of angina:

  1. Discontinue dental treatment.
  2. Closely monitor circulation.
  3. Administer nitroglycerin. For patient with history of angina - take their normal dose.
    1. Dose is typically 1-3 sublingual tablets or 1-3 translingual sprays from the emergency drug kit.
    2. Nitroglycerin dose may be repeated every 5-15 minutes for a total of 3 doses.
    3. If pt's nitroglycerin tablets don't alleviate the pain, administer a 2nd dose from of spray from emergency kit.
    4. Note: Nitroglycerin tablets lose their potency within 8 weeks after bottle is first opened
  4. If chest pain subsides & does not return, dental treatment may continue.
  5. Activate EMS if chest pain does not subside, or if pain returns, or if patient advises.
  6. Administer fibrinolytic (aspirin) unless contraindicated because of GI history.
  7. Monitor and record vital signs; manage symptomatically until EMS arrives.


After the angina subsides:

  1. Try to determine the cause of the pain; Modify future treatment as indicated
    1. Inadequate pain control?
    2. Severe dental anxiety?
  2. Urge the patient to get a fresh supply of nitroglycerin immediately.
  3. Contact the EMS if a patient with history of angina whose pain subsides after administering nitroglycerin, but then subsequently returns.
    This is likely not angina, but most likely a myocardial infarction.



Signs & Symptoms:

  1. Almost always precipitated by an acute episode that increases the workload of the heart, including fear, pain or exertion.
  2. AMI (acute myocardial infarction) lasts longer than angina, is more severe, and does not respond well to nitroglycerin.
  3. Patient becomes diaphoretic, nauseated and lightheaded. Shortness of breath, generalized weakness, cool moist skin, and cyanosis of mucous membranes. Crushing chest pain.


Management of AMI:

  1. If the patient has no history of chest pain, or if the chest pain subsides but then subsequently returns, contact EMS.
  2. Most patients prefer to sit up or semi-upright. If blood pressure drops or consciousness is lost, place patient in supine position with feet elevated slightly.
  3. AMI patients usually maintain adequate airway & breathe spontaneously.
  4. Loosen constrictive clothing.
  5. Monitor & record heart rate & rhythm, and blood pressure.
  6. Administer oxygen.
  7. Administer 2 doses of either translingual or sublingual nitroglycerin.
    Avoid nitroglycerin if systolic < 90 or if marked bradycardia or marked tachycardia.
  8. If patient is not allergic to aspirin, have patient chew & swallow a 325 mg. aspirin tablet.
  9. Traditionally 2-5mg of morphine is administered every 5-15 minutes to manage the pain or administer nitrous oxide (35-65%).
    (Nitrous Oxide has been shown to be equal to the analgesic ability of morphine to manage the AMI pain.)
  10. Continue monitoring vital signs until EMS arrives.
  11. If patient loses consciousness, place in supine position & reassess and manage the steps of basic life support.




Gastro-esophageal reflux disease can closely mimic the symptoms of a heart attack. Symptoms include severe chest pain & heartburn.


Management of chest pain when GERD is suspected:

  1. Position comfortably - usually upright
  2. Oxygen if needed
  3. Get vital signs: Systolic should be at least 100.
  4. Place patients nitroglycerin 1 tab sublingually (relief in 2-4 minutes if angina is the cause.)
  5. If no relief in 5 minutes, repeat up to a total of 3 times.
  6. If no relief, call EMS unless you can connect the etiology directly to GERD.
  7. Hospital will often be given a GI cocktail of Mylanta, Benadryl 2% and water, which will usually relieve symptoms in 30 minutes.