medical emergencies in pediatric dental office by s. shifaya nasrin

1. DR.SHIFAYA NASRIN
Medical emergencies

2. BE PREPARED……..
The meaning 0f the motto is
that a Scout must prepare himself by Previous
thinking out and practicing how to act on any
Accident or emergency so that he never taken by
surprise
- Robert Baden Powell

3. INTRODUCTION
A medical emergency is an injury or illness
that is acute and possess an immediate risk
to a person’s life or long term health

4. The dental office’s successful management
of medical emergencies requires preparation,
prevention and response not just by the
dentist but by all dental staff.
Adequate preparation for emergencies
reduces the possibility of an emergency
occurring and further complications if it does
occur. .

5. PREPARATION STEPS INCLUDE:
 Taking and reviewing a comprehensive medical and dental history.
 Providing minimum basic life support (BLS) training for providers
and staff.
 Advanced Cardiac Life Support (ACLS) or Pediatric Advanced Life
Support (PALS) training especially for those administering
sedation and general anesthesia.
 Initiation and coordination of an office emergency team.
 Organizing an emergency drug kit and equipment.
 Retraining on a regular bas

6. INTERACTING WITH CHILD PATIENT
 Smile
 Touch or hold child’s
hand or foot
 Do not use equipment
without first explaining
what you will do with it
 Let child see your face
 Stop occasionally to find
out if child understands
 Never lie to child

7. PEDIATRIC AGE CATEGORIES
 Newborns and infants: birth to 1 year
 Toddlers: 1–3 years
 Preschool: 3–6 years
 School age: 6–12 years
 Adolescent: 12–18 years

9. PREPARATION
Four steps critical in preparing the office
and staff to recognize and effectively manage
medical emergencies
 The ability to properly perform BLS
 functioning dental office emergency team
 Ready access to emergency assistance
 The availability of emergency drugs and
equipment

10. PEDIATRIC BASIC LIFE SUPPORT
Defined as
 position -Head tilt
chin lift
 Airway
 Breathing
 Circulation
 defibrillation

11. AIRWAY AND BREATHING
ASSESSMENT OF VENTILATION
 Look-chest moving
 listen and feel –exchange of air against rescuer
cheek
IN ABSENCE OF SPONTANEOUS BREATHING
 Rescue breath are delivered
 infant and child :12 – 20 breath per minute(1
breath every 3-5 seconds)
 Pubescent patient :10 – 12 breath per minute
(one breath every 3-5 seconds)

12. AIRWAY, BREATHING AND CIRCULATION

13. CIRCULATION
 Palpation of carotid artery(>1 year)
 Brachial pulse in infants(<1 year)
 Radial pulse in child
In absence of palpable pulse:
 Chest compression should be performed with
EMS

14. DEFINITIVE CARE
 Determine the cause of the problem
 Implement the appropriate treatment

15. PEDIATRIC ADVANCED LIFE SUPPORT

16. EMERGENCY TEAM
Team member responsibilities
Member 1 (first person on scene of
emergency)
Remain with victim
Activate office emergency team
BLS as necessary
Member 2 Bring emergency equipment to scene
Member 3(and other members of dental
offices staff)
Assist as necessary
Activate EMS
Meet and escort EMS to office
Assist with BLS
Prepare emergency drugs for
administration
Monitor and record vital signs

17. EMERGENCY DRUGS AND EQUIPMENT

18. EMERGENCY DRUGS AND EQUIPMENT
Drug Indication Availability Recommended
for kit
Epinephrine Anaphylaxis 1:2000(0.15
mgdose)
1 pre loaded
syringe +3x1 ml
ampoules of
1:1000
Diphenhydramine
hcl
Mild allergy 50 mgml 2-3 x1 ml ampules
of 50 mgml
Oxygen All emergencies “E” cylinder
+delivery devices
Minimum 1
;preferably 2
Albuterol Bronchospasm Metered aerosol
inhaler
1 aerosol inhaler
Sugar Hypoglycemia Orange juice;
instant glucose
12 ounce bottles of
orange juice or 1
tube of insta
glucose
Aspirin Suspected
myocardial
infarction
325 mg tablets 1-2 sealed tablets

19. ANTIDOTAL DRUGS
Drug Indication Availability Recommended
for kit
Flumazenil Benzodiazipine
antagonist
0.1mgml 1x10 ml multidose
vial
Naloxone Opioid antagonist 0.4 mg/ml 2x1 ml ampule of
0.4 mg/ml

20. EMERGENCY EQUIPMENT
 Automated external
defibrillator
 Face masks
 Disposable syringes
and needles
 Spacer for
bronchodilator inhaler

21. SPECIFIC EMERGENCIES

22. COMMON MEDICAL EMERGENCIES
 Foreign body induced airway obstruction
 Allergic reaction or anaphylaxis
 Drug over dosage
 acute asthmatic attack
 Seizures
 Hypoglycemic attack
 syncope

23. INCIDENCE OF SPECIFIC EMERGENCY SITUATION
Situation # Incidents
Syncope (fainting) 75 (mostly parents)
Hysteria 23 (mostly children)
Allergy, mild 22
Seizures 13
Hypoglycemia 9
Hyperventilation 7
Aspiration 5
Respiratory distress 4
Bronchospasm 3
Airway obstruction 3
Allergy, anaphylaxis 1
Drug overdose 1
Local anesthesia overdose 1
Cardiac arrest 1
Source: 2004 AAPD, “Pediatric Emergencies in the Dental Office”

24. BRONCHOSPASM(ACUTE ASTHMATIC ATTACK)
CONSCIOUS PATIENT DEMONSTRATE:
 WHEEZING
 SUPRACLAVICULAR AND INTERCOSTAL
RETRACTION
 PRIOR HISTORY OF ASTHMA

26. MANAGEMENT
 PABCD
 Sit patient upright or in a comfortable position
 Administer 02 via face mask or Nasal cannula at a
flow rate of 3-5 l/min
 Administer bronchodilator
 If bronchodilator is ineffective, administer
epinephrine
 Call for emergency medical services with
transportation for advanced care if indicated

27. GENERALIZED TONIC CLONIC SEIZURE
 Period of muscle rigidity followed by muscle
contraction and relaxation lasting for 1 -2
minutes
 Positive medical history
 Typical pre seizure appearance –aura
 Loss of consciousness

28. MANAGEMENT
 P position supine
 A,B,C (respiratory and cardiovascular
stimulation noted during seizure)
 D(definitive care)
 Protect victim from injury gently hold arms and
legs preventing uncontrolled movements do not
hold so tightly
 If convulsion last for >5 minutes or reappear at
short interval dial EMC
 Administer Diazepam 0.3 mg/kg IV

29. ANAPHYLACTIC SHOCK
Sudden and generalized manifestation of symptoms:
 Skin : urticaria
Erythema
pruitis
 Respiratory system : dyspnoea
stridor
 GI System : nausea
vomiting
GI pain
 Urinary incontinence
 Tachycardia
 cyanosis of nail beds
 Unconsciousness
 Cardiac arrest

31. MANAGEMENT
 D
 PABC
 Administer 0.15ml 1:1000 adrenaline sc or
IM
 Dial EMC to shift child to the hospital
 Maintain PABC
 Monitor vital signs
 Repeat adrenaline in five minutes

32. LOCAL ANAESTHESIA OVERDOSAGE
 Manifestation appearing suddenly or during
L.A administration
 Inarticulate and confuse state of mind
 Dizziness
 Generalized seizures
 unconsciousness

33. MANAGEMENT
 Reassure patient
 Assess and support airway, breathing, and
circulation (CPR if warranted)
 Administer oxygen
 Monitor vital signs
 Call for emergency medical services with
transportation for advanced care if indicated

34. OVERDOSAGE OF BENZODIAZEPINES
 Somnolescence
 Confusion
 Diminished reflexes
 Respiratory depression
 Apnoea
 Respiratory arrest
 Cardiac arrest

35. MANAGEMENT
 Assess and support airway breathing and
circulation
 Administer oxygen
 Monitor vital signs
 Establish iv access and reverse with
Flumazenil 0.01 mg/IV at a rate not to exceed
0.2 mg/min
 Monitor recovery (for at least 2 hours after the
last dose of flumazenil) and call for emergency
medical services with transportation for
advanced care if indicated

36. OVER DOSAGE OF NARCOTIC
 Decreased responsiveness
 Respiratory depression
 Respiratory arrest
 Cardiac arrest

37. DEFINITIVE TREATMENT
 ABC
 Monitor vital signs
 Reverse with naloxone 0.01 mg/kg IV ,IM
subq
 Monitor recovery
 Administer oxygen

38. ACUTE AIRWAY OBSTRUCTION
 Child grasps his throat
–universal sign of
choking
 Unable to breathe
cough speak
 Cyanosis
 Unconsciousness
 Cardiac arrest if not
managed

40. DEFINITIVE TREATMENT
 Clearing the airway
 If child is able to cough
then child is turned to a
left lateral position on
the dental chair with face
down
 Cough encouraged in
this position by back
blow between the
scapulae
 This expel the foreign
body

41. PEDIATRIC CHOKING TREATMENT ALGORITHM

42.  If child is conscious
but choking an
attempt is made to
expel the foreign
body with upward
thrust using Heimlich
maneuver

44.  If unconscious –dial
EMC ,place the child
n supine position
give inward and
upward thrust 5
times
 Finger sweep in oral
cavity
 If unsuccessful -
cricothyrotomy

45. ACUTE HYPOGLYCEMIC ATTACK
 Positive medical history
 type 1 diabetes mellitus
 Bizarre and confused behaviour
 Loss of consciousness
 convulsions

46. DEFINITIVE TREATMENT
 If conscious-oral carbohydrate
 If unconscious-dial EMC
 Administer glucagon 1mg IM
 50% dextrose IV

47. SYNCOPE
 Extremely tense and rigid
 Cold extremities
 Nausea and dizziness
 Loss of consciousness

48. DEFINITIVE TREATMENT
 No drugs usually indicated
 Proper supine position with feet elevated
slightly
 Loosen clothing
 Cold towel at the back of neck
 Respiratory stimulant –ammonia
 Maintain ABC

49. FOR ALL EMERGENCIES….
 Discontinue dental treatment
 Call for assistance/someone to bring oxygen
and emergency kit
 Position patient: ensure open and unobstructed
airway
 Monitor vital signs
 Be prepared to support respiration, support
circulation, provide cardio pulmonary
resuscitation (CPR), and call for emergency
medical services

50. CONCLUSION
 The dentist and the staff must be trained to
handle any emergency which can arise in a
dental set up . Having medical personnel on
call is very useful under such circumstances .
However ,one should always remember that
the best form of managing a medical
emergency is by prevention.

51. REFERENCES
 Malamad.S.F . Medical Emergencies In The Dental
Office ,6th Edition, 2007, Mosby Elsevier
 Pediatric Advanced Life Support: 2010 American
Heart Association Guidelines For Cardiopulmonary
Resuscitation And Emergency Cardio-vascular Care
 Jimmy R.Pinkham ,Pediatric Dentistry Infancy
Through Adolescence 4th Edition,2005
 Emergency Medicine in Pediatric Dentistry:
Preparation and Management ,Stanley F. Malamed,
DDS,October 2O10,VOL:31,NO:10 CDA journal
 M.S. Muthu,pediatric Dentistry Principles And
Practice,2nd Edition,2011