A patient reports using amphetamines. He presents with facial swelling and pain, heart rate 120 bpm and blood pressure 160/110 mmHg. What is the most appropriate next step?

Correct answer: D. Defer treatment and refer for urgent medical evaluation

• A. A benzodiazepine may form part of medical management of stimulant toxicity, but it is not the dentist's role to sedate and proceed in an unstable patient.
• B. Telling a patient to stop a drug of dependence and return is neither safe nor realistic, and it leaves the acute cardiovascular problem unaddressed.
• C. This is the dangerous option. Epinephrine in an amphetamine-intoxicated patient can precipitate a hypertensive crisis or dysrhythmia — the interaction is potentially fatal and is an absolute contraindication to vasoconstrictor use while the drug is active.
• D. CORRECT. Tachycardia at 120 with a blood pressure of 160/110 in a patient with circulating sympathomimetic drug represents an unstable cardiovascular state. Elective and semi-elective dental treatment must be DEFERRED and the patient referred for urgent medical assessment. Amphetamine intoxication risks hypertensive crisis, arrhythmia, myocardial ischaemia and stroke.

Note: If treatment for the acute infection genuinely cannot wait, use a PLAIN anesthetic (3% mepivacaine), limit the intervention to what relieves the acute problem, and coordinate with medicine. General guidance is to avoid vasoconstrictors for at least 24 hours after last stimulant use.