Pediatric Emergencies

Dental Emergencies in Children

Children are at great risk to suffer trauma of the head and mouth as a result of normal play activities or involvement in sports such bicycling, running, baseball, football and skating. Very commonly, dental personnel have to treat children with intruded, avulsed, or fractured teeth and lacerated lips, tongue, or mucosa on an emergency basis. Dental hygienists must be prepared to manage any medical emergency that might occur in the oral health care field.

Legal Responsibility

A medical emergency is defined as an unforeseen difficulty experienced by the patient. Legal responsibilities of a dental hygienist in a medical emergency include all of the following:

  1. To provide quality care according to the standards of practice established; standards may include training in medical emergency management and cardiopulmonary resuscitation.
  2. Dental hygienist may be held liable if inadequately prepared for a medical emergency within the dental environment according to the standards of care established.
  3. To maintain complete records of the medical emergency in the health care setting
  1. Complete records describe the onset and management of the emergency, the patient’s vital signs, type of and response to treatment performed, type and dose of drugs administered. The records should be made at the time of treatment.
  2. Complete records serve to document the incident and to protect the oral health care team in the event of a legal complication.

Emergencies in Children Rare

Children are especially susceptible to emergencies related to allergy and drug overdose; however, many children outgrow their childhood allergies, including food allergies. Interestingly, over 90% of fatalities from anaphylaxis occur in patients over the age of 19. Children are also at risk for drug overdose reactions, especially with central nervous system (CNS)-depressant drugs such as sedation hypnotics, narcotic agonist analgesics, and local anesthetics. Adult dosages of these agents should not be administered to children.

Unconsciousness is rarely noted in younger children except in the presence of specific disease states such as diabetes mellitus (hypoglycemia), epilepsy, and congenital heart lesions. Psychogenic reactions (vasodepressor syncope) are infrequent in this age group because children are extremely vocal in expressing their feelings toward dentistry, releasing their tensions, and producing muscular movement.

Fractured Teeth

Tooth fracture usually results from a traumatic blow that often affects the crown of the tooth. The anterior segment of the oral cavity is usually affected in tooth fracture accidents. The vitality of an injured tooth must be determined to develop a course of treatment for each situation. Testing involves the sensitivity of the tooth to hot, cold, air, and pressure.

The fracture of the crown may occur in primary or permanent teeth. The Ellis classification system qualifies the extent of tooth structure lost in each situation. A Class I fracture involves the loss of enamel and can be treated by smoothing the fractured surfaces for the patient’s comfort. A Class II fractures is more extensive in that the dentin is also involved in the traumatized area. This type of fracture is treated by placement of a bonding agent and a composite resin layer to restore the tooth to normal. Ellis Class III fractures include not only the enamel and dentin, but the fracture also encroaches on the pulpal tissues. The extent of the pulpal exposure may be minimal– a pinpoint exposure requiring a direct pulp cap–or extensive, necessitating a pulpotomy or pulpectomy.

Partially Developed Teeth

Teeth may not be fully developed at the time they are traumatized, which can result in additional problems. Apexogenesis and apexification are two treatments that involve the status of the root development. When apexogenesis, the development of the root of the tooth as it narrows to the apex, has not been completed before the traumatic injury, further complications occur. If treatment of the vital pulp through direct pulp capping or pulpotomy is not provided, the root and apex will not form properly. Either of these treatments allows maintenance of pulp vitality in the root and the continued formation of the root and apex.

If the tooth is no longer vital and the root and apex are not completely developed, apexification is necessary to close the apex. This procedure involves the complete medication of the pulp, similar to that of endodontic treatment but short of filling the canals with the appropriate material. Instead, calcium hydroxide is placed at the apex of the incompletely formed tooth and a sterile cotton pellet is placed between it and an interim restoration. The calcium hydroxide stimulates the cementum to close the apex, after which endodontic treatment continues and a final restoration is placed. 

Trauma to the oral cavity may result in the need for pediatric oral surgery. An extensively fractured tooth, where only a minor portion of the root is left in the socket, requires removal through a surgical procedure.

Luxation

Injuries to the oral cavity also involve teeth that are luxated. The tooth may be intruded (pushed into the socket or bone) or extruded, with a degree of movement out of the socket. The course of treatment for teeth that are luxated is determined by whether it is a primary or a permanent tooth.

A primary tooth that is luxated is usually extracted to protect the developing permanent tooth. A radiograph may be taken to predict the eruption time of the permanent tooth that is still unerupted. If it is determined that eruption will not be soon, a space maintainer can be positioned in the space that is vacated by the lost primary tooth, thereby allowing the permanent tooth to erupt in the proper position. The caregiver may not realize the importance of the maintenance of this space and question the need for this treatment. It may be the responsibility of the dental assistant to instruct the caregiver on the importance of this appliance and on the necessity of maintaining the abutment teeth in their positions so that the permanent tooth can erupt correctly. 

A repositioned primary tooth is susceptible to periodontal infection, which could damage a developing permanent tooth. A permanent tooth that is luxated is usually returned to the normal position in the arch and stabilized for approximately 7 to 10 days. The stabilization may be done with the use of orthodontic wire that is bonded in place on the facial surfaces of the luxated tooth and the surrounding teeth, which acts as the anchor for the injured tooth. A more extensive technique may be required through the use of a temporary splint to maintain the position of the tooth in the dental arch.

Avulsed Tooth

A tooth that is avulsed has been completely removed from the mouth as a result of a traumatic injury. An avulsed primary tooth normally is not replaced within the alveolus because of the possibility of periodontal infection. A permanent tooth that is avulsed must be replanted immediately, followed by stabilization until the tooth is secure in approximately 7 to 10 days.

Educating a patient and the caregiver to the potential problems involving avulsed teeth has resulted in the successful replantation of teeth. The factor that is of most importance in replantation is time. A tooth that is outside of the socket for an excess of 30 minutes is less likely to survive this procedure. The avulsed tooth should be immediately rinsed off with water and replaced in the socket if possible. If the tooth cannot be replanted, it should be kept in oral fluids inside the cheek, only if the patient is conscious and aware of this action. If the patient is not conscious or willing to have the tooth immediately replanted, it should be stored in milk or cold water until the dental visit. Successful reimplantation may require subsequent dental care: endodontic treatment to maintain the tooth in the mouth or splinting. 

Urgent care may also come in the form of a child who has a loosened primary tooth. Caregivers may find themselves in circumstances where the child has a loosened primary tooth that needs to be removed. The child may not want to remove it alone or will not allow the caregiver to remove the tooth. This may necessitate a trip to the dental office. Primary teeth with resorb roots may be attached only through soft tissue. The tissue attachments can be extremely sensitive and painful, and any movement of the tooth may cause discomfort. 

Another factor to be considered is that the child may not have experienced dental pain in the past and may be frightened with the impending treatment. It will probably be necessary to comfort the child and to explain the procedure to reduce fear and anxiety. The dental assistant must explain that this is a common procedure and that sometimes the primary teeth need additional assistance in exfoliation. 

 

Source: Finkbeiner BL, Johnson CS: Comprehensive Dental Assisting, 1995, Mosby-Year Book, Inc.

Infant Resuscitation

For the purpose of basic life support technique, the infant is a person under 1 year of age. 

Lack of responsiveness is determined by the “shake and shout" technique. Once unresponsiveness is determined, the rescuer will immediately call for help and place the infant in the supine (horizontal) position. 

The airway is opened and assessed for patency (look, listen, and feel) and the presence or absence of spontaneous ventilation. Three to five seconds are allowed for assessment. Two ventilations are delivered (1 to 1.5 seconds per ventilation) forcefully enough to produce chest inflation and permit complete deflation between breaths. Over inflation is dangerous because it produces gastric distention, which reduces the effectiveness of subsequent ventilation and increases the risk of regurgitation. The adult rescuer’s mouth or mask can usually cover both the mouth and nose of the infant victim. If this is not possible, mouth-to-mouth or mouth-to-nose ventilation is recommended. 

The pulse is next assessed. The brachial artery in the upper portion of the arm is palpated for 5 to 10 seconds and, if absent, the EMS system is activated and external chest compression is begun. The proper site for finger placement is midsternum, one finger’s width below the intermammary line. The chest is compressed at a rate of 100 per minute (5 in 3 seconds or less) with one ventilation interspersed after every fifth compression (ratio of 5:1). The depth of compression of the infant’s chest is 1/2 to 1 inch (1.3 to 2.5 cm), using the fleshy tips of two or three fingers held in the long axis of the sternum. After 10 cycles (approximately 45 seconds) and periodically thereafter, the patient is reevaluated for the returns of pulse and/or respiration.

Child Resuscitation

For the purpose of basic life support technique, the child is a person between the ages of 1 and 8 years.

Basic procedures for resuscitation of the child are similar to those previously described for the infant. The “shake and shout" maneuver is employed to determine lack of responsiveness, help is called, and the patient is placed in the supine position. The airway of the child is maintained by head tilt-chin lift and is then assessed for the presence of spontaneous respiratory efforts (look, listen, and feel). If absent, two full ventilations are provided.

The carotid pulse is assessed for 5 to 10 seconds, and if absent, the EMS system is activated and external chest compression is begun. Proper hand position for the child is located by placing the middle finger into the lower border of the sternum, and placing the heel of one hand onto the sternum immediately superior to the index finger. The sternum is compressed 1 to 1 1/2 inches (2.5 to 3.8 cm) at ratio for 5 compressions per minute (5 every 3 to 4 seconds). 

After 10 cycles (60 to 87 seconds) and periodically thereafter, the patient should be evaluated for the return of spontaneous pulse and/or respiration.

Febrile Convulsions

Febrile convulsions are usually associated with and are precipitated by marked elevation in temperature. They occur almost exclusively in infants and young children, particularly during the first year of life. Criteria for febrile seizures are: 

Age 3 months to 5 years (most occurring between 6 months and 3 years) 
Fever of 38.80 C (1020 F) 
Non-CNS infection 

Approximately 2% to 3% of children suffer febrile convulsions. Most febrile convulsions are short, lasting less than 5 minutes. Only 2% to 4% of children with febrile convulsions will develop epilepsy in later childhood or adult life. Febrile convulsions are not a major risk factor in dental practice.

The table below presents the most common causes of seizures in children according to the age of the patient. The most likely causes of seizures, of any type or duration, in the dental environment will be:

Seizures in epileptic patients
Hypoglycemia
Anoxia/hypoxia secondary to syncope
Local anesthetic overdose

Causes of seizures-incidence by age

Neonatal (first month)
  1. Birth injury
  2. Metabolic disorders
  3. Infection
  4. Congenital abnormalities
Infancy (1 to 6 month.)
1-4 Same as neonatal 5. Inborn errors of metabolism
Early childhood (6 mo. to 3 yrs.)
  1. Febrile convulsions
  2. Birth injury
  3. Infection
  4. Trauma
  5. Metabolic disorders
  6. Toxins
  7. Cerebral degenerative diseases
Childhood and adolescence
  1. Idiopathic
  2. Birth injury
  3. Trauma
  4. Infection
  5. Cerebral degenerative diseases

Petit Mal (Absence Attacks)

Absence attacks occur primarily in children, with the onset between 3 and 15 years of age. The seizure has an abrupt onset, characterized by a complete suppression of all mental functions, manifested by sudden immobility and a blank stare. Simple automatisms and minor facial clonic movements may be noted. Intermittent blinking at a rate of 3 cycles per second and mouthing movements are examples. The absence attack may last for 5 to 30 seconds, whereas petit mal status may persist for hours or days. There is no prodromal or postictal period, the episode terminating as abruptly as it started. The blank stare is followed by the immediate resumption of normal activity. If the attacks occur during conversation, the patient may miss a few words or may break off in mid-sentence for a few seconds. The impairment of external awareness is so brief that the patient is unaware of it. Amnesia for ictal events is common and patient may experience a subjective sense of lost time.

It is not uncommon for an informal diagnosis of petit mal to occur when a young child first enters school. After a few weeks or months, the child’s teacher may advise the parents that their child daydreams a lot or that he or she goes off into their own world for brief periods of time. Medical evaluation usually provides definitive evidence of petit mal epilepsy. 

 

Source: Malamed SF: Medical Emergencies in the Dental Office, ed 4, St. Louis, 1993, Mosby-Year Books, Inc.

Emergency Medicine in Pediatric Dentistry: Preparation and Management

 

By Stanley F. Malamed, DDS

Abstract: Medical emergencies can and do occur in the practice of dentistry. Although most emergencies take place in adults, serious problems can also develop in younger patients. The contemporary dentist must be prepared to manage expeditiously and effectively those few problems that do arise. Basic life support (as necessary) is all that is required to manage many emergency situations, with the addition of specific drug therapy in some others. Preparation of the office and staff includes basic life support (annually), pediatric advanced life support, development of an emergency team, consideration for emergency medical services, and the availability of emergency drugs and equipment with the ability to use these items effectively. As with the adult patient, effective management of pain (local anesthesia) and anxiety (behavioral management, conscious sedation) will minimize the development of medical emergencies. 

Medical emergencies can and do occur in the practice of dentistry. Most medical emergencies develop when the patient, commonly an adult, is fearful or has inadequate pain control. The most common emergencies noted in adult dental patients include syncope (less than 50 percent), non-life-threatening allergy, acute anginal episodes, postural hypotension, seizures, acute asthmatic attacks, and hyperventilation.1

In the pediatric patient, the most common emergency situations seen in dentistry are associated with drug administration, most often local anesthetics and/or central nervous system depressants used for sedation. It is this author’s firm belief that the most likely scenario for a serious drug-related emergency developing in dentistry is the following: a younger, lighter-weight child receiving multiple quadrants of dental treatment in the office of a younger,  less-experienced, nonpediatric dentist (i.e., general practitioner).2

All dental practices must be prepared to manage potentially life-threatening emergencies, be the patient a child or adult. The following sections review the preparation of the dental office and staff to successfully manage medical emergencies that might arise in younger patients in the dental office.

The definitions of victims by age3 are as follows:

Infant: < 1 year
Child: 1 to 8 years
Adult: ³ 8 years

Preparation

The following four assets are critical in preparing the office and staff to recognize and effectively manage medical emergencies:

The ability to properly perform basic life support;
A functioning dental office emergency team;
Access to emergency assistance; and
The availability of emergency drugs and equipment.

Basic Life Support

Basic life support (or cardiopulmonary resuscitation) is the single most important step in preparation of the office and staff to successfully manage medical emergencies. BLS for health care providers is defined as: Position, Airway, Breathing, Circulation, and Defibrillation. Most states mandate BLS certification for licensure to practice as a dentist. The majority of states also require BLS certification for dental hygienists, and some mandate certification for dental assistants.

California has mandated BLS for licensure for many years. However, possession of a valid CPR card is no guarantee that BLS can be adequately performed. In an unpublished study of entering postdoctoral students (residents in endodontics, periodontology, prosthodontics, pediatric dentistry, oral and maxillofacial surgery, orthodontics, and general practice) at the USC School of Dentistry, 30 students “challenged" the BLS-recertification course that is mandatory for them. All had been certified in BLS at the health care provider level within the previous six months.4 The challenge consisted of completing a 25-question written examination with a grade of 80 percent or better, and demonstrating “adequate" performance at one-person BLS on an adult victim. Only four of the students successfully challenged the course (13 percent). Most were unable to perform “adequate" one-person CPR on an adult victim for one minute. 

Recertification in BLS is recommended annually (in most venues, CPR cards have a two-year expiry date). BLS instructors should be brought into the dental office, with mannequins placed in the dental chair and on the floor in the reception room. It should be mandatory for all office personnel to participate in this training. For health care providers, rescue breathing should be taught as mouth-to-mask ventilation, not mouth-to-mouth (Figure 1). 

The importance of BLS as preparation for managing medical emergencies in children is highlighted by the fact that the primary etiology of cardiac arrest in children is airway problems, usually airway obstruction or respiratory arrest (as might occur with overly deep “conscious" sedation). The young child’s heart is normally healthy. Coronary artery disease is essentially nonexistent in this age group. However, the healthy young heart will cease beating when deprived of oxygen for a prolonged period. At the moment a pediatric cardiac arrest occurs, there is no residual oxygen remaining in the victim’s blood (all available oxygen has been utilized by the dying cells). Acidosis and cellular (biological) death develops rapidly. U.S. survival rates from out-of-hospital cardiac arrest in pediatric patients is from 3 percent to 17 percent, and survivors are often neurologically devastated.5,6 By contrast, cardiac arrest in adults usually develops secondary to advanced coronary artery disease. At the moment the adult heart goes into arrest, there remains a reservoir of oxygen in the blood and tissues that will be utilized before cellular death occurs. 

The very basic step of airway management (head tilt-chin lift) is critically important in saving the life of a child.

Pediatric Advanced Life Support

Because children are different from adults, the author recommends that the dentist and staff in offices where significant numbers of younger patients are treated successfully complete a course in pediatric advanced life support.7 Similar to BLS, PALS stresses basic and advanced life support techniques for younger patients. Offered through organizations such as hospitals, pediatric dental societies, and private educational providers, the course outline is presented in the box on the next page.

PEDO

PEDO is the acronym for Pediatric Emergencies in the Dental Office, a didactic and clinical course in emergency medicine designed for the entire staff of the pediatric dental office. Sponsored by the American Academy of Pediatric Dentistry, the course provides in-depth, hands-on training in the prevention and management of specific emergency situations that arise more commonly in children.8

Emergency Team

The dental office emergency team consists of three individuals, each assigned specific tasks to perform, as outlined in Table 1.

Pediatric Advanced Life Support

Course Outline

The Chain of Survival and Emergency Medical Services for Children*
Basic Life Support for the PALS Health Care Provider*
Airway, Ventilation, and Management of Respiratory Distress and Failure*
Fluid Therapy and Medications for Shock and Cardiac Arrest
Vascular Access*
Rhythm Disturbances
Post arrest Stabilization and Transport
Trauma Resuscitation and Spinal Immobilization
Children with Special Health Care Needs*
Toxicology*
Neonatal Resuscitation
Rapid Sequence Intubation
Sedation Issues for the PALS Provider*
Coping with Death and Dying
Ethical and Legal Aspects of CPR in Children* * Denotes subjects of special interest to dentists treating children

 

Table 1. Office Emergency Team

Team member Responsibilities 
Member #1 (first person on scene of emergency)  1. Remain with victim 
 2. Activate office emergency system
 3. Basic life support as necessary 
Member #2  1. Bring emergency equipment* to scene
Member #3 (and other members of the dental office staff) 1. Assist as necessary
a. Activate emergency medical services
b. Meet and escort EMS to office
c. Assist with basic life support d. Prepare emergency drugs for administration
e. Monitor and record vital signs
*Emergency equipment includes oxygen supply, emergency drugs, and, when appropriate, an automated external defibrillator.

All members of the office emergency team should be interchangeable. Although the proper and effective management of the emergency situation is ultimately the dentist’s responsibility, emergency management may be performed by any trained individual under supervision of the dentist.

Access to Emergency Medical Services

Assistance in managing an emergency should be sought as soon as the treating doctor “feels" it is needed, and a “feeling" it is indeed. Emergency medical services should be sought if the dentist does not know what is happening; knows, but does not like, what is happening; or ever feels uncomfortable with the situation. The dentist should seek help as soon as possible in these situations. In virtually all situations, the most practical course for getting help is to activate the EMS system by calling 911. 

In an emergency, the ultimate responsibility of the treating dentist is to keep the victim alive until he or she recovers or help arrives on scene to take over management of the situation. Though exceptions may exist, in most areas of California, EMS can be expected to arrive on scene within five to 10 minutes.

Emergency Drugs and Equipment

Every dental office must have emergency drugs and equipment, as listed in Tables 2 through 4. Minor modifications are necessary in offices where children are treated (highlighted rows in Tables 2 and 4).

In offices where central nervous system depressant drugs are employed for conscious sedation, antidotal drugs that are available for specific sedative agents must be included in the emergency drug kit (Table 3). If benzodiazepines are used (e.g., diazepam, midazolam, triazolam), flumazenil must be available. Where opioids are employed, naloxone must be included in the emergency drug kit. Single doses of these drugs may be ineffective when administered to manage over dosage resulting from orally administered or long-acting benzodiazepines and opioids.

Table 2. Recommended Dental Office Emergency Drugs

Drug Indication Availability Recommended for Kit

Epinephrine (Adrenalin)

Anaphylaxis

 

1:1000 (adult) (0.3 mg/dose)

1 preloaded syringe and 3 x 1 mL ampules of 1:1,000

Epinephrine (Adrenalin)

Anaphylaxis (0.15 mg/dose)

1:2,000(pediatric) 3 x 1 mL

1 preloaded syringe and ampules of 1:1,000

Diphenhydramine

(Benadryl)

Allergic reactions

50 mg/mL

2-3 x 1 mL ampules of 50 mg/mL

Oxygen

All emergencies

“E” cylinder + delivery devices

Minimum 1, preferable 2, “E” cylinders

Albuterol (Proventil, Ventolin)

Bronchospasm

Metered aerosol  inhaler

1 aerosol inhaler

Sugar

Hypoglycemia

Orange juice, “Insta-Glucose”

12-ounce bottle of orange juice and/or 1 tube of “Insta-Glucose”

Aspirin

Suspected Myocardial infarction

325 mg tablets

 

1-2 sealed tablets

Nitroglycerin

Angina pectoris

Metered spray

1 Nitrolingual pump spray

Basic Management

As described above, basic management of all medical emergencies follows the PABCD acronym, (positioning, airway, breathing, circulation, and definitive care [in the BLS acronym, D is defibrillation]). 

It is first necessary to determine if the patient is conscious or unconscious. Unconsciousness is defined as the lack of response to sensory stimulation (e.g., lack of response to the “shake and shout" maneuver).9

Position

As the most common cause of loss of consciousness is hypotension, all unconscious patients are placed, at least initially, in a supine position with their feet elevated slightly. This position provides an increase in cerebral blood flow with a minimum of interference with respiratory efforts.10 Conscious people experiencing a medical emergency are placed in whatever position they find most comfortable. As an example, most people in acute respiratory distress (e.g., acute asthmatic bronchospasm) automatically assume an upright position to improve ventilation.

Airway and Breathing

In the unconscious person, the head tilt-chin lift maneuver must be performed (Figure 2) followed by an assessment of ventilation (“look, listen, feel").

An important point to remember: Seeing the victim’s chest moving does not guarantee that he or she is actually breathing (exchanging air), but simply that he or she is trying to breath. Hearing and feeling the exchange of air against the rescuer’s cheek is the only indication of successful ventilation. 

In the absence of spontaneous respiratory efforts (e.g., chest not moving), controlled ventilation must be performed as expeditiously as possible. With a full face mask and positive pressure oxygen, the patient older than 8 is ventilated at a rate of one breath every five seconds, whereas a rate of one breath every three seconds is used for the infant and child victim.11 Each individual ventilation should cease when the chest is seen to rise, as over ventilation leads to gastric distension and regurgitation.

Circulation

In pediatric medical emergencies, it is likely that a palpable pulse will be present, especially in situations in which the airway and breathing are adequately and rapidly assessed and supported.

Remember: Airway problems (e.g., obstruction, apnea) are the most common cause of cardiac arrest in infants and children. 

Palpation of the carotid artery pulse is preferred in children 1 year or older and adults, whereas the brachial pulse is preferred in infants younger than 1 year. In the absence of a palpable pulse, chest compression must be commenced, and EMS summoned immediately.

Definitive Care

Following assessment and implementation of the required steps of BLS, the dentist must seek to determine the cause of the problem (i.e., make a diagnosis). Where a diagnosis is possible and appropriate treatment available, it should be undertaken. If a diagnosis is made but appropriate treatment is not available or if the cause of the problem remains unknown, EMS should be sought immediately. Definitive management of several common pediatric emergencies follows.

Specific Emergencies

Acute Bronchospasm (Asthmatic Attack)

Recognition: Conscious patient in acute respiratory distress, demonstrating wheezing, supraclavicular, and intercostal retraction. 

P: Position comfortably — usually upright 

A, B, C: Assessed as adequate (Victim is conscious and able to speak.) 

D: (1) Administer bronchodilator. If patient’s inhaler is available, allow him or her to use it. If the patient is younger and the parent or guardian is available, bring him or her into the treatment room to assist in administration of bronchodilator. Many younger children require the use of a spacer to obtain adequate relief with the inhaler.

(2) Administer oxygen, via facemask or nasal cannula at a flow rate of 3 to 5 liters per minute. 

(3) Summon EMS if parent or guardian of the patient suggests it, or if the episode of bronchospasm does not terminate following two adequate doses of the bronchodilator. 

Generalized Tonic-Clonic Seizure (“Grand Mal" Seizure)

Recognition: Period of muscle rigidity (about 20 seconds) followed by alternating muscle contraction and relaxation lasting for about one to two minutes.

P: Position supine. 

A, B, C: Assessed as adequate (respiratory and cardiovascular stimulation usually occur during seizure). 

D: (1) Protect victim from injury. Keep victim in the dental chair; gently hold onto arms and legs, preventing uncontrolled movements, but do not hold so tight as to prevent limited movement. 

(2) If parent or guardian is available, bring him or her into the treatment room to assist in assessment of victim. 

(3) Summon EMS if parent or guardian of patient suggests it, or if the seizure continues for more than two minutes. 

Remember: Do not place anything between the teeth of a convulsing person.

Most generalized tonic-clonic seizures will stop within one minute and almost always within two minutes (thus the recommendation to seek EMS with prolonged seizure activity). At the termination of the seizure, P, A, B, C, D must be reassessed, as follows: 

P: Position supine. 

A, B, C: Assessed and managed as needed. In most (but not all) post seizure situations, A must be managed, but B and C are assessed as adequate. 

D: With help from the parent or guardian, try to communicate with the patient, who is likely in a state similar to a deep physiologic sleep. Following a generalized tonic-clonic seizure, the victim is quite disoriented. As the parent or guardian has seen this and done this before, allow him or her to talk with the patient to reorient the patient to both space and time. 

Remember: Most morbidity and mortality associated with seizures occurs in the post-seizure period because the rescuer does not do enough for the victim (P,A, B, C).

Sedation Overdose

Recognition: Lack of response to sensory stimulation. 

Consider. An overdose of sedation is general anesthesia. Effective management of a patient receiving general anesthesia is predicated on airway management and breathing. Therefore, this should not represent an emergency in the office of a doctor who is trained to administer general anesthesia to children or adults.

P: Position supine. 

A, B, C: Assessed and managed as necessary. In most cases, A alone is required, whereas A and B will be needed in a few situations. C will generally be present if A and B are properly assessed and managed. 

D: (1) Monitor patient, using pulse oximeterb (and blood pressure and heart rate/rhythm). 

(2) Stimulate patient periodically (verbally and/or squeezing the trapezius muscle) seeking response. 

(3) Antidotal therapy: If sedative drugs were administered parenterally, and intravenous access is available, administer flumazenil IV in a dose of 0.2 mg (2 ml) in 15 seconds waiting 45 seconds to evaluate recovery where benzodiazepines were administered. If recovery is not adequate at one minute, an additional dose of 0.2 mg may be administered. Repeat every minute until recovery occurs or a dose of 1.0 mg has been delivered. Titrate naloxone IV at 0.1 mg. (0.25 ml) per minute to a dose of 1.0 mg if an opioid was administered. Naloxone may be administered intramuscularly, in a dosage of 0.01 mg/kg every two to three minutes until the patient is responsive.

Remember: Specific antidotal therapy may not be effective following the oral administration of central nervous system depressants; and antidotal therapy should be administered intravenously, if possible. Naloxone may be administered intramuscularly.

Local Anesthetic Overdose

A true overdose of local anesthetic should be always preventable.2

Recognition. Generalized tonic-clonic seizure or unconsciousness, generally developing five to 40 minutes after local anesthetic administration.

P: Position supine. 

A, B, C: Assessed and administered as needed. 

D: (1) Generalized tonic-clonic seizure–follows protocol for seizures (above). With proper airway management and ventilation, a local anesthetic-induced seizure often ceases in less than one minute. In the absence of an adequate airway and ventilation, carbon dioxide is retained, the patient becomes acidotic, and the seizure threshold of the local anesthetic decreases, leading to more prolonged and more intense seizure.13 

(2) Unconsciousness–the basic protocol for management of the unconscious patient is followed when a local anesthetic overdose manifests itself as loss of consciousness. Proper management of airway and breathing, as needed, will minimize occurrence of cardiac arrest. As the cerebral concentration of the local anesthetic decreases (through redistribution of the drug out of the brain) consciousness returns. 

(3) Summon EMS if consciousness is not restored in two minutes or if the patient is not breathing.

Final Comments

Medical emergencies can and do occur in the practice of dentistry. Although most emergencies take place in adults, serious problems can also develop in younger patients. The contemporary dentist must be prepared to manage expeditiously and effectively those few problems that do arise. Basic life support (as necessary) is all that is required to manage many emergency situations, with the addition of specific drug therapy in some others. Preparation of the office and staff includes basic life support (annually), pediatric advanced life support, development of an emergency team, consideration for emergency medical services, and the availability of emergency drugs and equipment with the ability to use these items effectively. As with the adult patient, effective management of pain (local anesthesia) and anxiety (behavioral management, conscious sedation) will minimize the development of medical emergencies.

Notes

  1. PEDO – contacts the American Academy of Pediatric Dentistry for dates of future PEDO courses. www.aapd.org, 800.544.2174.
  2. The doctor using oral sedation (in children younger than 13) or parenteral (intramuscular or intravenous) sedation must have a pulse oximetry in the dental office, as per the Dental Practice Act, Part 3, California Code of Regulations. 

Author

Stanley F. Malamed, DDS, is a professor of anesthesia and medicine at the University of Southern California School of Dentistry.

REFERENCES

  1. Malamed SF, Managing medical emergencies. J Am Dent Assoc 124:40-53, 1993.
  2. Malamed SF, Allergic, and toxic reactions to local anesthetics. Dent Today 22:114-21, 2003.
  3. International Consensus on Science. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 102(suppl):1-23, 2000.
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Reprinted with permission. CDA Journal. Oct. 2003. Vol. 31, No. 10. Reprinted with permission. CDA Journal. Oct. 2003. Vol. 31, No. 10.