Emergencies in pediatric dental practice

Made by

Fatima Gilani

Under the guidance of

M.K.Jindal

Contents

•Duties and responsibilities of a dentist during dental emergency•Critical steps in preparation of emergency•Fundamental steps in emergency management•Treatment protocols in pediatric emergency•Emergency drugs and equipment•Basic life support•Emergency situations in pediatric dental practice•Management of unconsciousness/fainting/syncope•Management of respiratory difficulty•Management of altered consciousness/hyper and hypoglycemic states•Management of seizures•Management of drug related emergencies/ allergy/ anaphylaxis / drug

toxicity

•Management of bleeding

•Management of chest pain

•Management of cardiac arrest

Duties and responsibilities of a dental professional during medical emergencies in pediatric dental practiceA medical emergency is defined as an unforeseen difficulty experienced by the patient.It can occur anywhere even in a dental office.Emergencies may due to a variety of causes, including a child’s pre-existing medical condition, an airway obstruction caused by dental material or problems related to a sedation procedure.Prompt and organized therapy can usually save a life.It is the responsibility of the pediatric dental surgeon to be prepared to recognize a medical emergency & render appropriate care.Many medical emergencies that occur in a dental office are fear-related. therefore, if fear and apprehension are reduced, the chances of having a medical emergency are also reduced.

Medical risk determination

The best treatment for medical emergencies is prevention

By consulting the physician of the patient, emergency complications can be minimized or the severity of the complication can be reduced.

Hospitalization may be required sometimes due to seriousness of the illness for the dental procedure to be carried out.

Emergencies may be related directly to dental therapy or they may occur by chance in the dental office environment.

A best practice dictates that dental personnel must be prepared to provide effective basic life support and seek emergency medical services in a timely manner

Rationale in Emergency

Management Recognize that a problem exists .

Diagnose the problem correctly .

Activate the emergency medical service (EMS)

system immediately.

Keep the patient alive until better trained personnel

arrives .

Remain calm and act swiftly and definitely.

Never administer drugs without definite indication

Medico legal aspects

For medico legal aspects, a written record of the

following should be kept:

Time of onset

Vital signs elicited during the emergency

Time, Name, Dose and Route of drugs

administered

Effects of drugs and therapy provided

Time of initiation of Cardiopulmonary

Resuscitation

Status of the patient at the time of transfer to

Emergency Medical Services system

Steps in the preparation of the emergency in dental office

The ability to perform Basic Life Support

A functioning dental office emergency team

Ready access to emergency assistance

The availability of emergency drugs and

other equipments

Emergency plan

All staff members should have specific assigned duties

Contingency plans should be in place in case a staff member is absent

All staff members should receive appropriated training in the management of

medical emergencies.

All clinical staff members should be trained in Basic Life Support system for

health care providers.

The dental office should be Equipped with emergency equipment and the

supplies should be appropriate for that practice

Emergency drills should be conducted at least quarterly.

Emergency telephone numbers should be placed prominently near each

telephone.

Oxygen tanks and oxygen delivery system should be checked regularly;

other emergency respiratory support equipment should be present; in a good

working order and located according to the emergency plan.

All medical emergency medications should be checked and replacements

should be ordered for specific drugs before their expiratory dates.

One staff member should be assigned the task of ensuring that the above

procedures are completed or not.

Dental Office Emergency System

Team member 1

• Remain with the victim

• Activate office emergency system

• Basic life support system necessary

Team member 2

• Bring emergency equipment to the scene

Team member 3

• Activate emergency medical support system

• Meet and escort Emergency medical support system to office

• Assist with BLS

• Prepare emergency drugs for administration

• Monitor and record vital signs

TREATMENT PROTOCOLS IN PEDIATRIC EMERGENCY

POSITION

(P)

AIRWAY MAINTENANCE

(A)

BREATHING (B)

CIRCULATION ( C )

DEFINITIVE CARE

(D ) EMERGENCY GUIDELINES

EMERGENCY GUIDELINES

POSITION (P)

For a conscious patient: Whatever

position is comfortable for the patient.

For an unconscious patient: All

unconscious patients are placed in a

position to increase cerebral flow with

minimal interference with ventilation.– Place the patient in a supine position

– Head at the same level as the body

– Feet slightly elevated (10-15 angle)

Airway maintenance (A)

The anatomical factors that increases the risk

of airway obstruction in infants are:

Smaller infant mouth, nose and air passages

Larger infant tongues relative to oral cavity

Narrow trachea, glottis opening

Narrowest cricoid cartilage ring

Non palpable cricothyroid membrane.

Breathing (B)During the immediate assessment of breathing, it is vital to diagnose and treat life

threatening breathing problems immediately, i. Clinical signs include Sweating, Central Cyanosis, use of the accessory muscles of

respiratory and abdominal breathing.ii. Seeing the victim’s chest moving does not always mean that the victim is

breathing, but means that an attempt to breathe is made. “LOOK-LISTEN-and-FEEL” technique is used.

iii. Count the respiratory rate, normal rate is 12-20breath/min and a child’s resp. rate is 20-30 breath/min. increase in the breathing rate denotes illness, a warning that a patient may deteriorate and may need medical help

iv. Listen to the patients breath sounds a short distance from their face.v. If the patient’s depth or rate of breathing is inadequate,use bag and mask or

pocket mask ventilation with sufficient oxygen.vi. The rescue breathe is delivered at the rate of 10-12 breaths/min (1breath/5-

6seconds) vii. Acc. To Melamed, hearing and feeling the exchange of air against the rescuer’s

cheek is the only option of a successful spontaneous ventilation.viii. Hyperventilation and panic attacks are relatively common in general dental

practice that will be resolved with simple reassurance.

Circulation (C)

Simple faints or vasovegal episodes are the most likely cause of

circulation problems in general dental practice.

i. Look at the color of the hands and fingers: Are they blue, pink,

pale or mottled?

ii. Assess the limb temp. by feeling the patient’s hand: Are they cool

or warm?

iii. Measure the capillary refill time, apply cutaneous pressure for 5

seconds on a fingertip held at heart level with enough pressure to

cause blanching, check the time how long it takes for the skin to

return to the color of the surrounding skin after releasing the

pressure

iv. The normal refill time is less than 2 sec, increase in

refill time indicates poor peripheral perfusion.

v. Counter the patient’s pulse rate

vi. Palpation of carotid artery preferred in children and

adults, brachial pulse preferred in infants

vii. Weak pulses in a patient with a decreased

conscious level and slow capillary refill time

suggest a low blood pressure

viii. In absence of palpable pulse, chest compression

should be started immediately.

DEFINITIVE CARE

Definitive care involves treating the

specific emergency situation, which is

usually carried out in a hospital.

Emergency drugs and equipment

General principles in using Emergency DrugsTo manage a medical emergency in a dental practice following

drugs should be available :- Glyceryl trinitrate(GTN) spray ( 400 micro gram/dose) Salbutamol aerosol inhaler (100 micro gram/actuation) Adrenaline inj. (1:1000; 1mg/ mL) Aspirin injection (300mg) Glucagon injection 1 mg Oral glucose sol/tab/gel/powder Midazolam 10mg (buccal) Oxygen

Whenever possible, drugs in solution

should be in a prefilled syringe.

The use of intravenous (I V) drugs in dental

practice should be discouraged.

Inhalational, sublingual buccal and

intranasal routes should be preferred.

All drugs should be kept in an “emergency

drug” container.

Oxygen cylinders should be of sufficient

sizes to be easily portable, but also allow

adequate flow

Specific drugs

I. OXYGEN: It is of primary importance in any medical emergencies in

which hypoxemia might be present. These emergencies include CVS ,Respiratory System ,CNS In the hypoxemic patients, breathing enriched with oxygen

elevates the arterial oxygen which increases the oxygen tension and alters the Hb saturation in these patients

Hypoxemia leads to anaerobic metabolism and metabolic acidosis, that diminishes the efficacy of these emergency drugs

2) Epinephrine Single most important injectable drug. Drug of choice for CVS & respiratory systems of acute allergic

reactions. Pharmacological actions include bronchodilation, and increased

systemic vascular resistance, myocardial contractility and cerebral flow.

For better response in case of acute allergic reaction epinephrine should be administered immediately after recognizing the condition.

Epinephrine should be available in preloaded syringes or auto injector to use immediately.

Because of its bronchodilating effects, used in case of acute asthmatic attacks that are not relieved by sprays or aerosols.

3) Diphenhydramine

Histamine blockers reverse the actions of histamine by occupying H1 receptor sites on the effector cell and are effective in patients with mild or delayed onset of allergic reactions.

4) Glucose

Glucose preparations are used by the clinicians to treat hypoglycemia resulting from fasting in a diabetic patient or in a non-diabetic patient with hypoglycemia.

In a conscious patient oral carbohydrates such as orange juice, choc bar act rapidly in circulating blood sugar.

In an unconscious patient if the dentist suspects acute hypoglycemia, oral drugs should not be administered to avoid airway obstruction.

5) Aspirin

The antiplatelet properties of aspirin decreases myocardial mortality by preventing further clot formation when administered while evolving myocardial infarction.

Contraindications to its use include allergy to aspirin and severe bleeding disorders.

6) Bronchodilator

Inhalation of a Beta2 adrenergic receptor agonist such as metaproterenol or albuterol are used to treat bronchospasm that is experienced during an asthmatic attack or anaphylaxis.

Albuterol is an excellent choice because it is associated with fewer cardiovascular adverse effects than other bronchodilator.

Emergency Equipments for dental office

Portable oxygen cylinder with regulator. Oxygen source with flowmeter Nasal cannula Non-rebreathing mask with oxygen reservoir Nasal blood Bag-valve-mask device with oxygen reservoir Oropharyngeal airways Magill forceps Automated external defibrillator Suction devices- powered and manual backup Suction tips and catheters- yankauer 8,10,14 F Intubation equipment-laryngoscope handle with batteries, extra

bulb

Stylets (small and large )-which should never extend beyond the distal end of the endotracheal tube

Adhesive tape to secure the endotracheal tube Needle cricothyrotomy kit Intraosseous needles- 15 or 18 gauge Catheters,short,over the needle 18,20,22,24 gauge Butterfly needles-23gauge Pediatric drip chambers and tubing Isotonic fluids (normal saline or lactated ringer’s solution ) Automatic blood pressure cuff- infant , child , adult Nasogastric tubes -8,10,14 F Sphygmomanometer with adult small, medium and large

cuffs Wall clock with second hand.

Basic life support for a child

Assess consciousness and position the patient Assess and open the airway: Head tilt-chin lift (unless there

has been trauma) Assess and ensure breathing :– Initial rescue breathing-provide two breaths at 1

second/breath– Create a mouth-to-mouth seal and pinch the nose closed– Subsequent 20 breath/min for rescue breathing only– Activate EMS only

Assess and ensure circulation :– Pulse check –palpate the carotid artery/brachial artery, the pulse is

checked for not less than 5 sec. and no more than 10 sec.– Compress if the pulse is less than 60 and the are signs of poor

systemic perfusion– Depth of compressions-one third deep of thoracic cavity– Rate compressions-100per min.– Compressions to ventilations ratio for children – 30:2 for single

rescuer and 15:2 if two rescuers are present– Location-lower one third of sternum– Technique- use the heel of one hand Activate the EMS after 20 cycles (1 min.) of compressions +

ventilations Administer oxygen at 15 L/min and monitor /record vital signs

Emergency situations encountered in a pediatric dental practice

They are classified as follows :1. Unconsciousness Syncope Orthostatic hypotension Adrenal insufficiency2. Respiratory difficulty Airway obstruction Hyperventilation Asthma Chf 3. Seizures 4. Cardiac arrest

5. Drug related emergencies Allergy Toxic overdose.6. Bleeding problems Bleeding disorders Clotting disorders Liver disorders Drug induced7. Altered consciousness Diabetes mellitus Cerebrovascular disorders8. Chest pains Angina pectoris Myocardial infarction

Management of unconsciousness/fainting/syncope

Unconsciousness is rarely noticed in younger children except in the presence of disease

Psychogenic reactions are infrequent in this age group, because children are unable to express their feelings towards dentist.

Causes of fainting are : Vasovegal syncope Orthostatic hypotension Adrenal insufficiency

Vasovegal syncope

It is a loss of consciousness secondary to stress and anxiety. Defined as transient loss of consciousness due to cerebral

ischemia caused by less blood supply to brain.Sign and symptoms

Warm feeling, pale, feeling faint or sick, nausea, bradycardia,hypotension,tachycardia

Fall in BP Gasp for breath Cold clammy skin Eyes dilate Some muscle rigidity Most common in males who try to be macho

Management of syncope

Lie the patient flat in trendelenburg position Relieve any compression on the neck and maintain an airway Raise patient’s leg Use ammonia stimulant Cold towel on forehead and back of the neck Give supplemental oxygen When consciousness is regained, patient should be kept flat and

reassured Once pulse and blood pressure recover, slowly raise patient to

seated position

ORTHOSTATIC HYPOTENSION

Drugs that can trigger orthostatic hypotension are: Anti hypertensive's Antidepressants Narcotics Antiparkinson drugsSigns and symptoms Poor physical condition Obesity Medications Prolonged supine position Not precipitated by stress

Management

Place the patient in supine position Airway maintenance Slowly elevate the patient monitor

Acute adrenal insufficiency

More dangerous than orthostatic hypotension or vasovegal syncope.

Def. of glucocorticosteroid hormone can cause unconsciousness

MANAGEMENT OXYGEN AND SUPPORTIVE THERAPY DECADRON (IV OR IM) 1-4mg (child ) 4-6mg (adult)

Management of respiratory difficulty

Causes : Airway obstruction Hyperventilation Asthma CHF FOREIGN BODY : UPPER AIRWAY OBSTRUCTIONSevere or complete upper airway obstruction due to a foreign body rapidly progresses to unconsciousness

MANAGEMENT 1. Partial obstruction2. Complete obstruction3. Unconscious obstruction

Hyperventilation

Prolonged rapid deep breathing often seen in anxious patients, that leads to metabolic changes and result in unconsciousness.

Fall in arterial co2 that causes cerebral vasoconstriction and resp. alkalosis

MANAGEMENT Reassure patient If conscious patient, rebreath into paper bag to increase inspired

co2 If unconscious patient, maintain airway until patient regains

consciousness. Place in stable side position and reassure patient, while

rebreathing into paper bag

Asthma Asthma manifests as wheezing, with rapid and full pulse,

prolonged expirations.MANAGEMENT Acute severity-patient unable to speak incomplete sentences,

pulse rate more than 110/min, resp. rate more than 45/min. Life-threatening asthma- ‘silent chest’ ,cyanosis, sweating,

hypercarbic flush, bradycardia/hypertension, confusion, Agitation.

Congestive heart failureIn this condition, blood is pooled in the venous system and cause

difficulty in breathing.SIGNS AND SYMPTOMS Pallor Sweating Narrow BP Sleeps semi-sitting Dyspnoea Cyanosis Frothly pink sputum

Treatment

Place in an upright position Administer oxygen Record vitals Call for professional help Bloodless phlebotomy: rotating tourniquets from arm-

to-leg-to-leg altering blood flow back to heart.

Management of seizures

Epilepsy Stages of epilepsy Aura prodrome Ictal phase– Rigidity– Cyanosis– Cheek or tongue biting – Urinary/fecal incontinence– Loss off consciousness Postictal – Disorientation, confusion, amnesia– Somnolence– guilt

Sign and symtoms

Management

Remove dangerous objectives from the mouth and around the patient, e.g. dental cart

Loosen tight clothing Avoid restraining the patient Mouth should not be forced open, nor attempts should be

made to insert anything into the mouth Turn the victim into a stable side-position as soon seizure

stops, open and maintain a clear airway and avoid aspiration, check for breathing.

Most tonic clonic seizures stops within a minute and almost always within 2 min.

Allow the victim to sleep under supervision. On recovery, give reassurance.

Diazepam IV 0.03 mg/kg slow infusion can be administered – Child up to 5 yrs: 0.2-0.5mg slowly every 2-5 min – Child 5 yrs and up: 1 mg every 2-5 min Midazolam nasal spray or buccal placements in case of recurrent

attacks Transfer to hospital if:– First fit– Tonic phase lasts longer than 5 min.– Repeated seizure– Any post seizure respiratory difficulty– Patient has suffered an injury– Post seizure confusion greater than 5 min.

Management of drug-related emergencies/ allergy/anaphylaxis/drug toxicity

Drug allergy/anaphylaxisPotential for drug allergy in dentistry Local anaesthetic -amide solution-overdose/toxicity vs allergy,

vasoconstrictor-cardiac effects Antibiotic-penicillin like drugs Analgesic-ASA, NSAIDs allergy Latex allergy Stressing a medically compromised patientSIGNS OF ALLERGIESMODERATE Hives and itching Skin rash Pallor, light headed Pilomotor erection Palpitation, tachycardia

Severe Asthmatic breathing due to bronchial constriction Large drop in BP These two things indicate allergy is developing into anaphylactic shockAnaphylaxis Develops after re-exposure to a sensitizing antigen within min It is a potentially life-threatening immune reaction to a foreign body Hypersensitivity reactions mediated by immunoglobulin E and IgG4 subclass of

antibodiesSIGNS AND SYMPTOMS Chemical release of mediators from mast cellss causes:– Vasodilation– Increased capillary permeability – Airway constriction– Hypotension– Bronchospasm– Angioedema– Urticaria,rhinitis,conjunctivitis,abdominal pain,vomitting,diarrhoea

Management

Assess the degree of cardiovascular collapse (pulse and BP) Assess the degree of air way obstruction Stop administration of drug Patient supine Check pulse, BP Assess breathing difficulty ( stridor, wheeze, cannot speak) Give O2 Monitor consciousness, airway, breathing, circulation, pulse, BP

If shocked, angioedema or bronchospasm: Raise legs if low BP– Twinject is the new device, for administration of epinephrine Repeat IM adrenaline every 5 min while waiting for

ambulance.There are no contraindications to epinephrine when given for

anaphylactic shock (death can occur with anaphylactic shock)

Up to 3 injections of epinephrine may be needed before arrival of emergency medical technician team

Oxygen If you have doubt, give the epinephrine Call for emergency medical service

Management of bleeding

If bleeding occurs, search for bleeding or bruises, nose bleeds, spontaneous bruising and menstrual bleeding in females

Duration off bleeding is more important than frequency Reasons of bleeding could be manifold- bleeding disorders,

clotting disorders, disorders of liver and effects of drugs. Causes of bleeding in oral cavity includes bleeding/platelet

disorders, clotting disorders, drugs and toxins and liver disorders

MANAGEMENT Pressure application for min 5 min. If bleeds from sockets and compression is ineffective, pack the

socket with gel foam for 7 days Suturing

Hemophilic patients form loose, friable clots that may be readily dislodged or quickly dissolved, antifibrinolytics prevent lysis of clots within oral cavity

They are used as an adjunct to factor concentrate replacement to prevent or control oral bleeding with or without factor replacement.

Epsilon aminocaproic acid (EACA) administration :– 100mg/kg every 6hrs for 7 days to prevent secondary

hemolysis for children– 5g every 6hrs for 5-7 days for children greater than 30

kg.

Management of chest pain

Myocardial infarction Myocardial infarction usually begins with varying degree of

atheromatous coronary occlusion M.I is usually initiated by rupture or erosion of a thin cap,

that over lies the atheromatous plaques. Platelet adhesion and aggregation then occurs over the

ruptured surface. The hemodynamic effects of this thrombus formation may

lead to prolonged ischemic symptoms and pain at rest. If the clot occludes the coronary artery, a myocardial

infarction occurs.

Sign and symptoms :

Persisting central chest pain, with possible radiation to the left or right arms, jaw or neck

Pain is no longer improved with Glyceryl trinitrate Nausea, vomiting A sense of impending doom Restlessness Shortness of breath Pallor, cold sweaty skin Pump failure: hypotension raised venous pressure, tachycardia

and possibly pulmonary edema.

Sign and symtoms

Management

If myocardial infarction is suspected Reassure the victim, keep them warm Sit them up, if breathless Lay them flat, if they are faint Give GTN tablets or sprays, one tablet chewed or one spray

under the tongue Repeat in 5 min, if pain unrelieved activate EMS Give high flow oxygen by face mask Give 300mg aspirin, chewed or sucked, if patient not

allergic Continue monitoring level of consciousness and be

prepared to initiate adult collapse guidelines, if patient becomes unconscious

ANGINA PECTORIS Symptoms of myocardial infarction are similar to that of angina

pectoris, but pain is usually relieved by nitroglycerine. BP is usually raised in Angina while in Myocardial infarction it is

lowMANAGEMENT OF CARDIAC ARREST

Heart does not pump blood in cardiac arrest namely cardiac standstill and ventricular fibrillationSIGN

Gasping for air Pupils dilate Syncope No pulse, BP breathing

Principle Of Cardio Pulmonary Resuscitation When the heart stops, there is still blood (oxygen) in the

tissues This is what gives us the few min. before permanent tissue

damage begins to occur The survival rate for an individual after cardiac arrest,

receiving CPR is 2%-5% If an automated external fibrillator (AED) is utilized, that

survival rate jumps to 86% Most cardiac arrests on children are due to lack of adequate

respiration, therefore open the airway first, before you attempt CPR or attempt to call emergency

Most cardiac arrests on adults are due to a diseased heart, so call emergency first, and then do CPR

AUTOMATED EXTERNAL DEFIBRILLATOR Easy to use If used within min of cardiac arrest, survival rate is

86 % Survival rate decreases with each passed minute by

10% AEDs cause the heart to go to flat-line and then the

body will adjust to the normal heart rhythm The AED is 90% accurate in reading and diagnosing

the patient’s correct cardiac condition AEDs cost is high

Use of AED

Precautions: Do not touch the patient, while AED is reading the heartbeat/rhythm- can confuse the machine

After shocking the patient, do CPR for 2min. If you witness the cardiac arrest(CA), Shock the

patient right away If you do not witness the CA, do 2 min of CPR

and then shock

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