Emergencies in pediatric dental practice

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emergencies in pediatric dental practice

Transcript of Emergencies in pediatric dental practice

  • 1. Emergencies in pediatricdental practiceMade byFatima GilaniUnder the guidance ofM.K.Jindal

2. ContentsDuties and responsibilities of a dentist during dental emergencyCritical steps in preparation of emergencyFundamental steps in emergency managementTreatment protocols in pediatric emergencyEmergency drugs and equipmentBasic life supportEmergency situations in pediatric dental practiceManagement of unconsciousness/fainting/syncopeManagement of respiratory difficultyManagement of altered consciousness/hyper and hypoglycemic statesManagement of seizuresManagement of drug related emergencies/ allergy/ anaphylaxis / drugtoxicityManagement of bleedingManagement of chest painManagement of cardiac arrest 3. Duties and responsibilities of a dental professionalduring medical emergencies in pediatric dentalpracticeA medical emergency is defined as an unforeseen difficultyexperienced by the patient.It can occur anywhere even in a dental office.Emergencies may due to a variety of causes, including a childspre-existing medical condition, an airway obstruction caused bydental 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 beprepared to recognize a medical emergency & render appropriatecare.Many medical emergencies that occur in a dental office are fear-related.therefore, if fear and apprehension are reduced, thechances of having a medical emergency are also reduced. 4. Medical risk determination The best treatment for medical emergencies isprevention By consulting the physician of the patient,emergency complications can be minimized or theseverity of the complication can be reduced. Hospitalization may be required sometimes due toseriousness of the illness for the dental procedureto be carried out. Emergencies may be related directly to dental therapyor they may occur by chance in the dental officeenvironment. A best practice dictates that dental personnel mustbe prepared to provide effective basic life supportand seek emergency medical services in a timelymanner 5. Rationale in EmergencyManagement Recognize that a problem exists . Diagnose the problem correctly . Activate the emergency medical service (EMS)system immediately. Keep the patient alive until better trained personnelarrives . Remain calm and act swiftly and definitely. Never administer drugs without definite indication 6. Medico legal aspectsFor medico legal aspects, a written record of thefollowing should be kept: Time of onset Vital signs elicited during the emergency Time, Name, Dose and Route of drugsadministered Effects of drugs and therapy provided Time of initiation of CardiopulmonaryResuscitation Status of the patient at the time of transfer toEmergency Medical Services system 7. Steps in the preparation of theemergency 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 andother equipments 8. 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 ofmedical emergencies. All clinical staff members should be trained in Basic Life Support system forhealth care providers. The dental office should be Equipped with emergency equipment and thesupplies should be appropriate for that practice Emergency drills should be conducted at least quarterly. Emergency telephone numbers should be placed prominently near eachtelephone. Oxygen tanks and oxygen delivery system should be checked regularly;other emergency respiratory support equipment should be present; in a goodworking order and located according to the emergency plan. All medical emergency medications should be checked and replacementsshould be ordered for specific drugs before their expiratory dates. One staff member should be assigned the task of ensuring that the aboveprocedures are completed or not. 9. Dental Office Emergency SystemTeammember 1 Remain with the victim Activate office emergency system Basic life support system necessaryTeammember 2 Bring emergency equipment to the sceneTeammember 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 10. TREATMENT PROTOCOLS IN PEDIATRICEMERGENCYPOSITION(P)AIRWAYMAINTENANCE(A)BREATHING(B)CIRCULATION( C )DEFINITIVECARE(D ) EMERGENCYGUIDELINES 11. EMERGENCY GUIDELINESPOSITION (P) For a conscious patient: Whateverposition is comfortable for the patient. For an unconscious patient: Allunconscious patients are placed in aposition to increase cerebral flow withminimal interference with ventilation. Place the patient in a supine position Head at the same level as the body Feet slightly elevated (10-15 angle) 12. Airway maintenance (A)The anatomical factors that increases the riskof 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. 13. Breathing (B)During the immediate assessment of breathing, it is vital to diagnose and treat lifethreatening breathing problems immediately,i. Clinical signs include Sweating, Central Cyanosis, use of the accessory muscles ofrespiratory and abdominal breathing.ii. Seeing the victims chest moving does not always mean that the victim isbreathing, 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 childs resp.rate is 20-30 breath/min. increase in the breathing rate denotes illness, awarning that a patient may deteriorate and may need medical helpiv. Listen to the patients breath sounds a short distance from their face.v. If the patients depth or rate of breathing is inadequate,use bag and mask orpocket 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 rescuerscheek is the only option of a successful spontaneous ventilation.viii. Hyperventilation and panic attacks are relatively common in general dentalpractice that will be resolved with simple reassurance. 14. Circulation (C)Simple faints or vasovegal episodes are the most likely cause ofcirculation 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 patients hand: Are they coolor warm?iii. Measure the capillary refill time, apply cutaneous pressure for 5seconds on a fingertip held at heart level with enough pressure tocause blanching, check the time how long it takes for the skin toreturn to the color of the surrounding skin after releasing thepressure 15. iv. The normal refill time is less than 2 sec, increase inrefill time indicates poor peripheral perfusion.v. Counter the patients pulse ratevi. Palpation of carotid artery preferred in children andadults, brachial pulse preferred in infantsvii. Weak pulses in a patient with a decreasedconscious level and slow capillary refill timesuggest a low blood pressureviii. In absence of palpable pulse, chest compressionshould be started immediately. 16. DEFINITIVE CAREDefinitive care involves treating thespecific emergency situation, which isusually carried out in a hospital. 17. Emergency drugs and equipmentGeneral principles in using Emergency DrugsTo manage a medical emergency in a dental practice followingdrugs 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 18. Whenever possible, drugs in solutionshould be in a prefilled syringe. The use of intravenous (I V) drugs in dentalpractice should be discouraged.Inhalational, sublingual buccal andintranasal routes should be preferred. All drugs should be kept in an emergencydrug container. Oxygen cylinders should be of sufficientsizes to be easily portable, but also allowadequate flow 19. Specific drugsI. OXYGEN: It is of primary importance in any medical emergencies inwhich hypoxemia might be present. These emergencies include CVS ,Respiratory System ,CNS In the hypoxemic patients, breathing enriched with oxygenelevates the arterial oxygen which increases the oxygen tensionand alters the Hb saturation in these patients Hypoxemia leads to anaerobic metabolism and metabolicacidosis, that diminishes the efficacy of these emergency drugs 20. 2) Epinephrine Single most important injectable drug. Drug of choice for CVS & respiratory systems of acute allergicreactions. Pharmacological actions include bronchodilation, and increasedsystemic vascular resistance, myocardial contractility and cerebralflow. For better response in case of acute allergic reaction epinephrineshould be administered immediately after recognizing the condition. Epinephrine should be available in preloaded syringes or autoinjector to use immediately. Because of its bronchodilating effects, used in case of acute asthmaticattacks that are not relieved by sprays or aerosols. 21. 3) Diphenhydramine Histamine blockers reverse the actions of histamine byoccupying H1 receptor sites on the effector cell and areeffective in patients with mild or delayed onset of allergicreactions. 22. 4) Glucose Glucose preparations are used by the clinicians to treathypoglycemia resulting from fasting in a diabetic patient orin a non-diabetic patient with hypoglycemia. In a conscious patient oral carbohydrates such as orangejuice, choc bar act rapidly in circulating blood sugar. In an unconscious patient if the dentist suspects acutehypoglycemia, oral drugs should not be administered toavoid airway obstruction. 23. 5) Aspirin The antiplatelet properties of aspirin decreases myocardialmortality by preventing further clot formation whenadministered while evolving myocardial infarction. Contraindications to its use include allergy to aspirin andsevere bleeding disorders. 24. 6) Bronchodilator Inhalation of a Beta2 adrenergic receptor agonist such asmetaproterenol or albuterol are used to treat bronchospasmthat is experienced during an asthmatic attack oranaphylaxis. Albuterol is an excellent choice because it is associated withfewer cardiovascular adverse effects than otherbronchodilator. 25. 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, extrabulb 26. Stylets (small and large )-which should never extend beyondthe 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 ringers solution ) Automatic blood pressure cuff- infant , child , adult Nasogastric tubes -8,10,14 F Sphygmomanometer with adult small, medium and largecuffs Wall clock with second hand. 27. Basic life support for a child Assess consciousness and position the patient Assess and open the airway: Head tilt-chin lift (unless therehas been trauma) Assess and ensure breathing : Initial rescue breathing-provide two breaths at 1second/breath Create a mouth-to-mouth seal and pinch the nose closed Subsequent 20 breath/min for rescue breathing only Activate EMS only 28. Assess and ensure circulation : Pulse check palpate the carotid artery/brachial artery, the pulse ischecked 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 poorsystemic perfusion Depth of compressions-one third deep of thoracic cavity Rate compressions-100per min. Compressions to ventilations ratio for children 30:2 for singlerescuer 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 29. Emergency situations encountered in apediatric dental practiceThey are classified as follows :1. Unconsciousness Syncope Orthostatic hypotension Adrenal insufficiency2. Respiratory difficulty Airway obstruction Hyperventilation Asthma Chf3. Seizures4. Cardiac arrest 30. 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 31. Management ofunconsciousness/fainting/syncope Unconsciousness is rarely noticed in younger children exceptin the presence of disease Psychogenic reactions are infrequent in this age group,because children are unable to express their feelings towardsdentist. Causes of fainting are : Vasovegal syncope Orthostatic hypotension Adrenal insufficiency 32. Vasovegal syncope It is a loss of consciousness secondary to stress and anxiety. Defined as transient loss of consciousness due to cerebralischemia 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 33. Management of syncope Lie the patient flat in trendelenburg position Relieve any compression on the neck and maintain an airway Raise patients 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 andreassured Once pulse and blood pressure recover, slowly raise patient toseated position 34. ORTHOSTATIC HYPOTENSIONDrugs 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 35. Management Place the patient in supine position Airway maintenance Slowly elevate the patient monitor 36. Acute adrenal insufficiency More dangerous than orthostatic hypotension or vasovegalsyncope. Def. of glucocorticosteroid hormone can causeunconsciousnessMANAGEMENT OXYGEN AND SUPPORTIVE THERAPY DECADRON (IV OR IM) 1-4mg (child ) 4-6mg (adult) 37. Management of respiratory difficultyCauses : Airway obstruction Hyperventilation Asthma CHFFOREIGN BODY : UPPER AIRWAY OBSTRUCTIONSevere or complete upper airway obstruction due to a foreign bodyrapidly progresses to unconsciousnessMANAGEMENT1. Partial obstruction2. Complete obstruction3. Unconscious obstruction 38. Hyperventilation Prolonged rapid deep breathing often seen in anxious patients, thatleads to metabolic changes and result in unconsciousness. Fall in arterial co2 that causes cerebral vasoconstriction and resp.alkalosis 39. MANAGEMENT Reassure patient If conscious patient, rebreath into paper bag to increase inspiredco2 If unconscious patient, maintain airway until patient regainsconsciousness. Place in stable side position and reassure patient, whilerebreathing into paper bag 40. AsthmaAsthma 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. 41. Congestive heart failureIn this condition, blood is pooled in the venous system and causedifficulty in breathing.SIGNS AND SYMPTOMS Pallor Sweating Narrow BP Sleeps semi-sitting Dyspnoea Cyanosis Frothly pink sputum 42. 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. 43. Management of seizuresEpilepsyStages of epilepsy Aura prodrome Ictal phase Rigidity Cyanosis Cheek or tongue biting Urinary/fecal incontinence Loss off consciousness Postictal Disorientation, confusion, amnesia Somnolence guilt 44. Sign and symtoms 45. Management Remove dangerous objectives from the mouth and aroundthe patient, e.g. dental cart Loosen tight clothing Avoid restraining the patient Mouth should not be forced open, nor attempts should bemade to insert anything into the mouth Turn the victim into a stable side-position as soon seizurestops, open and maintain a clear airway and avoidaspiration, check for breathing. Most tonic clonic seizures stops within a minute andalmost always within 2 min. Allow the victim to sleep under supervision. On recovery, give reassurance. 46. 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 recurrentattacks 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. 47. Management of drug-related emergencies/allergy/anaphylaxis/drug toxicityDrug 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 48. 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 ofantibodiesSIGNS 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 49. 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 50. 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 forambulance.There are no contraindications to epinephrine when given foranaphylactic shock (death can occur with anaphylactic shock) Up to 3 injections of epinephrine may be needed before arrivalof emergency medical technician team Oxygen If you have doubt, give the epinephrine Call for emergency medical service 51. 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/plateletdisorders, clotting disorders, drugs and toxins and liverdisordersMANAGEMENT Pressure application for min 5 min. If bleeds from sockets and compression is ineffective, pack thesocket with gel foam for 7 days Suturing 52. Hemophilic patients form loose, friable clots that may bereadily dislodged or quickly dissolved, antifibrinolyticsprevent lysis of clots within oral cavity They are used as an adjunct to factor concentratereplacement to prevent or control oral bleeding with orwithout factor replacement. Epsilon aminocaproic acid (EACA) administration : 100mg/kg every 6hrs for 7 days to prevent secondaryhemolysis for children 5g every 6hrs for 5-7 days for children greater than 30kg. 53. Management of chest pain Myocardial infarction Myocardial infarction usually begins with varying degree ofatheromatous 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 theruptured surface. The hemodynamic effects of this thrombus formation maylead to prolonged ischemic symptoms and pain at rest. If the clot occludes the coronary artery, a myocardialinfarction occurs. 54. Sign and symptoms : Persisting central chest pain, with possible radiation to theleft 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, tachycardiaand possibly pulmonary edema. 55. Sign and symtoms 56. ManagementIf 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 sprayunder 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 notallergic Continue monitoring level of consciousness and beprepared to initiate adult collapse guidelines, if patientbecomes unconscious 57. ANGINA PECTORIS Symptoms of myocardial infarction are similar to that of anginapectoris, but pain is usually relieved by nitroglycerine. BP is usually raised in Angina while in Myocardial infarction it islowMANAGEMENT OF CARDIAC ARREST Heart does not pump blood in cardiac arrest namely cardiacstandstill and ventricular fibrillationSIGN Gasping for air Pupils dilate Syncope No pulse, BP breathing 58. Principle Of Cardio PulmonaryResuscitation When the heart stops, there is still blood (oxygen) in thetissues This is what gives us the few min. before permanent tissuedamage 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, thatsurvival rate jumps to 86% Most cardiac arrests on children are due to lack of adequaterespiration, therefore open the airway first, before youattempt CPR or attempt to call emergency Most cardiac arrests on adults are due to a diseased heart, socall emergency first, and then do CPR 59. AUTOMATED EXTERNALDEFIBRILLATOR Easy to use If used within min of cardiac arrest, survival rate is86 % Survival rate decreases with each passed minute by10% AEDs cause the heart to go to flat-line and then thebody will adjust to the normal heart rhythm The AED is 90% accurate in reading and diagnosingthe patients correct cardiac condition AEDs cost is high 60. Use of AED 61. Precautions: Do not touch the patient, while AEDis reading the heartbeat/rhythm- can confuse themachine After shocking the patient, do CPR for 2min. If you witness the cardiac arrest(CA), Shock thepatient right away If you do not witness the CA, do 2 min of CPRand then shock 62. THANK YOU