1

Medical
emergencies
Contents 2

 Introduction
 Emergency situations encountered in a pediatric dental practice
 Critical steps in preparation of emergency
 Fundamental steps in emergency management
 Treatment protocols in pediatric emergency
 Emergency drugs and equipment
 Basic life support
 INTRODUCTION 3

Medical emergencies in a dental office are of common occurrence. A simple protocol will help the dentist
to be in control of the situation. So, dentist should have following objectives in mind while dealing with
any child patient:

•Be able to recognize a medical emergency

•Be able to manage various life threatening medical emergencies
•Know what equipments and medications should be in an emergency kit and know when and how to use
them
•Be competent in Basic Life Support
•Work effectively in a team to achieve optimal patient outcome
•Be able to make an appropriate record of the emergency and know what follow-up is necessary
 4

Emergency situations encountered in a

pediatric dental practice
Unconsciousness/Fainting/Syncope 5

Causes of fainting are :

Vasovagal syncope

Orthostatic hypotension

 Adrenal insufficiency
Vasovagal syncope 6

 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.
 Fall in BP
 Gasp for breath
 Cold clammy skin
 Eyes dilate
 Some muscle rigidity
7
Management of syncope 8

 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
Acute adrenal insufficiency 9

 Deficiency of glucocorticosteroid hormone can cause unconsciousness

 MANAGEMENT

 OXYGEN AND SUPPORTIVE THERAPY

 DECADRON (IV OR IM) 1-4mg (child ) 4-6mg (adult)

Hypoglycemia 10

 Hypoglycemia is a condition of low blood glucose levels.

 It represents the most common acute complication of diabetes but can also
develop in patients who do not have diabetes.
 Symptoms:
 tremor
 hunger
 palpitations
 anxiety
 sweating, headache, fatigue, disturbances of consciousness, convulsions and
pallor
Treatment: 11

 Stop all procedures, place the patient in a comfortable position (usually this means
to sit up straight)

 pay attention to breathing and circulation, give oral carbohydrates (sugar

dissolved in water, orange juice, chocolate), with one dose containing 40 g of
glucose.

 Repeat the dose every 10 min until symptoms disappear; if not effective, give 1
mg glucagon intramuscularly or 50 ml of 50% dextrose intravenously over 2–3
minutes .
Respiratory Difficulty 12

 Causes :
 Airway obstruction
 Hyperventilation
 Asthma
FOREIGN BODY : UPPER AIRWAY 13

OBSTRUCTION
 Upper and lower airways can be obstructed, and depending upon where the cause of the obstruction
occurs, different symptoms will appear.

 Symptoms:

 obstruction of the upper airways is clinically manifested by coughing, cyanosis and inspirational stridor,

 while in the lower respiratory tract obstruction, cough is present along with shortness of breath,
inspiratory - expiratory wheezing, and cyanosis.

 If obstruction persists it can cause loss of consciousness.

Treatment: 14

 If the child is coughing, encourage the child to do so,

because a spontaneous cough is more effective in the
treatment of obstruction than any other external process.

 when coughing becomes ineffective, child cannot talk,

cry or breathe between coughs, do the following: first
proceed with 5 strokes on the back with an open palm
.
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 if the obstruction is not resolved, apply the

Heimlich maneuver five times

 The Heimlich maneuver is performed with the

rescuer standing behind the victim and clasping his
hands; one hand is made into a fist and placed on the
child’s abdomen above the navel while the palm of
the other hand holds the fist as they strongly press
against the child’s belly and move upwards.
 16

 if the child becomes unconscious and is not breathing, the child needs to be ventilated.

 If there are no signs of circulation, then chest compression is required . If the object causing
the obstruction is not ejected with the above treatment procedures, it is necessary to perform
a tracheotomy
Hyperventilation 17

 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 respiratory alkalosis
MANAGEMENT 18

 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 19

 Bronchial asthma is a type of pulmonary incompetency manifested by

characteristic wheezing and caused by narrowing of smaller bronchi and
bronchioles.
 Asthma manifests as wheezing, with rapid and full pulse, prolonged expirations.
 Symptoms:
 Dyspnea, chest tightness, audible wheezing or problematic breathing.
 For physical status, the most significant findings are extended and difficult-
expiration, with a marked expiratory whistle
DRUGS TO BE AVOIDED IN 20

ASTHMATIC PATIENTS
 Drugs containing aspirin (10-28% of all asthmatics may not tolerate the latter).
 Nonsteroidal antiinflammatory drugs (patients with intrinsic asthma).
 Macrolide antibiotics in patients treated with theophylline. The serum
methylxanthines levels (theophylline) may be increased.
 Opiates: these can cause respiratory depression and histamine release.
 Local anesthetics: use solutions without adrenalin or levonordefrin, due to the
sulfite preservative contents.
 If the patient is receiving prolonged systemic corticosteroid treatment,
supplements may be needed (prior to dental procedures that might cause stress).
Treatment: 21

 Immediate treatment begins with the inhalation of beta-agonists (salbutamol),

which will be sufficient if the problem is a mild attack;

 In severe attacks, administration of epinephrine is indicated at a dose of 0.01 to

0.03 ml/kg of a 1:1000 solution, administered intramuscularly or subcutaneously

22
Epileptic Seizures 23

Epileptic sezieur is an intermittent disorder of nervous system caused by a sudden

discharge of cerebral neurons resulting in instantaneous disturbance of sensation ,
loss of consciousness and convulsive movements.
Stages of epilepsy
 Aura prodrome
 Ictal phase
loss of consciousness,
Tonic contraction of muscles, which takes 10 to 20 sec .
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Clonic Phase

 which is characterized by contraction of the whole

musculature .

 Foaming at the mouth can occur because of mixing of air

and saliva

 the patient may bite themselves during the clonic

contractions and injure soft tissue intraorally, and blood
may be visible; this phase lasts for 2–5 min
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In the last stage,

breathing becomes normal and the patient gradually returns to consciousness.

Urinary or fecal incontinence may occur because of relaxation of the sphincter

Precautions to be taken while performing a 27

dental procedure
 Treatment procedures should be carried out only after patient has consumed their
medicine
 Appointments are scheduled during a time of day when seizure activity is less
likely to occur.
 Seizure triggering factors like operating light on the eyes can be prevented by
using dark glasses.
 Neurologist and paediatrician consent should be taken during entire treatment
protocol.
Management 28

 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.
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 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

 31

 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.
Drug Toxicity 32

 Toxic reactions occur because of rapid absorption of the drug into the blood
stream, overdosing
 Symptoms:
confusion, slurred speech, tremors of the face and limbs, high blood pressure, rapid
heartbeat and breathing, dizziness, nystagmus, headache, tinnitus, disorientation, loss
of consciousness, tonicclonic seizures.
Following the first phase of excitation, the patient subsequently passes through a
depression of the nervous system and experiences a reduction in blood pressure, heart
rate and respiratory rate and intravascular injection
Treatment: 33

 Place the patient in a supine position, check circulation, breathing and air flow
 If the patient exhibits tonic-clonic convulsions, it is necessary to ensure the supply
of oxygen; then the clonic phase lasts less than one minute.
 If the supply of oxygen is not secured, the patient enters acidosis because of CO2
retention; be sure to secure the airway and allow for normal breathing;
 if any phase lasts longer than two minutes and the patient is not breathing, call an
ambulance
Anaphylactic reaction 34

 Anaphylactic reactions occur because of antigen - antibody interaction.

 For the development of acute anaphylactic reactions, antigen is required to
stimulate the immune system and form IgE antibodies.
 Then, a latent period occurs after exposure to the antigen, during which the mast
cells and basophils are sensitized and exposure to the antigen takes place.
 When the mast cells react with antigen during re-exposure, a release of histamine
and vasoactive amines occurs.
 Such a reaction can develop between a few seconds and several hours (or if it is a
delayed reaction, at a few hours to several days) after exposure to an allergen.
 35

SIGNS AND SYMPTOMS

 Chemical release of mediators from mast cells causes:
– Vasodilation
– Increased capillary permeability
– Airway constriction
– Hypotension
– Bronchospasm
– Angioedema
– Urticaria, rhinitis, abdominal pain, vomitting, diarrhoea
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Management 38

 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
 39

 If shocked, angioedema or bronchospasm: Raise legs if low BP

 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
Bleeding 40

 Duration off bleeding is more important than frequency

 Causes of bleeding in oral cavity includes bleeding/platelet disorders, clotting

disorders, drugs and toxins and liver disorders

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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
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 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.
Myocardial infarction 44

 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.
45
Sign and symptoms : 46

 Persisting central chest pain,with possible radiation to the left or right arms, jawor
neck
 Nausea, vomiting
 A sense of impending doom
 Restlessness
 Shortness of breath
 Pallor, cold sweaty skin
 47

 Pump failure:
hypotension raised venous pressure, tachycardia and possibly pulmonary edema.
Management 48

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
 49

 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

CARDIAC ARREST 50

 Heart does not pump blood in cardiac arrest namely cardiac standstill and
ventricular fibrillation
Cardiac arrest in children may be a consequence of respiratory or circulatory failure
SIGN
 Gasping for air
 Pupils dilate
 Syncope
 No pulse, BP breathing
51
Principle Of Cardio Pulmonary 52

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%
 53

 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

54
AUTOMATED EXTERNAL 55

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
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Use of AED
Medical risk determination 58

 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 59

 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 60

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 61

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

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Emergency plan
63
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TREATMENT PROTOCOLS IN 67

PEDIATRIC EMERGENCY
 68

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)
 69

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.
 70
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
 71

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/56seconds)
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.
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 73

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
 74

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.
 75

 DEFINITIVE CARE

Definitive care involves treating the specific emergency situation, which is usually
carried
Emergency drugs and equipment 76

 General principlesin using Emergency Drugs

To 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
Specific drugs 77

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
 78

 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
2) Epinephrine 79

 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.

 80

 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 81

 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.
 82

4) Glucose
 Glucose preparations are used by the clinicians to treat hypoglycaemia 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 notbe administeredto avoid airway obstruction.
 83

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.
 84

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
Basic life support for a child 85

 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
 86

 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-onethird deep of thoracic cavity
– Rate compressions-100per min.
 87

– 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
Precautions: 88

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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THANKYO
U!