MEDICAL EMERGENCIES
Emergency according to Dorland’s Medical dictionary is defined as a sudden, urgent, usually unforeseen occurrence requiring immediate action.
Emergency is a condition that warrants for immediate attention by the doctor. This situation is an unexpected one under unforeseen circumstances and calls for an urgent treatment.
EQUIPPING FOR AN EMERGENCY
The practicing clinician and his staff should be upto- date in delivering basic life support (BLS) care to sustain the child till emergency medical service arrives.
It is also very important to learn and practice how to
administer drugs via the desired parenteral route, i.e. SC, IM or IV.
Understanding of the pharmacology of important emergency drugs, their dosage during emergencies and the preferred
route of administration during emergencies is very essential.
A dental chair which can easily be changed into supine position.
A high volume suction to clear oral secretions.
An oxygen cylinder attached to a positive pressure/ demand valve with a clear face mask capable of delivering 5 L/min for at least 30 minutes.
Spirit of ammonia
Adrenaline (1:1000)—for severe immediate allergic and severe asthmatic reactions.
Diphenhydramine—for allergic reactions of slower onset.
Hydrocortisone sodium succinate—to treat acute adrenal insufficiency.
Diazepam—for continuous epileptic seizures (Status Epilepticus).
Flumazenil—for reversal of sedation induced by benzodiazepines.
Nitroglycerin—a vasodilator to treat angina.
A sugar source—in cases of hypoglycemia.
Dextrose 50%—for unconscious hypoglycemic patients to be given IV.
Glucagon—for unconscious hypoglycemic patients to be given IM when IV access cannot be established.
Prearranged emergency medical service which can be called on short notice.
The golden rule is that regardless of the emergency in children, start by assessing and maintaining basic life support, i.e. P,A, B, C.
P Position of the patient on the dental chair.
A Airway should be open and patent.
B Breathing should be maintained, i.e. sufficient oxygen should be reaching the patient's lungs.
C Circulation of blood in carotid artery is assessed to see if the heart is beating and adequately perfusing the brain.
Cardiopulmonary Resuscitation
CPR GUIDELINES FOR CHILDREN
Check Unresponsive: No breathing or no normal breathing (only gasping)
Provide 2 minutes of CPR before calling for help CPR
Push chest at about 2 inches, 30 times just below the nipple line
You may use either 1 or 2 hands for chest pushes
Push at a rate of at least 100 pushes per minute
Allow complete chest recoil between each push
CPR ratio for one-person CPR is 30 pushes to 2 breaths
CPR ratio for two-person CPR is 15 pushes to 2 breaths
In two-person CPR, the rescuers should change positions after every 2 minutes Breathing
Head tilt-chin lift: Tilt the head back and lift the chin
Give 2 breaths. Give each breath over 1 second
The victim’s chest should rise with each breath Continue
• Continue cycles of 30 pushes and 2 breaths
• Rotate compressors every 2 minutes
CPR GUIDELINES FOR INFANTS
Check Unresponsive: No breathing or no normal breathing (only gasping) Provide 2 minutes of CPR before calling for help
CPR
Push chest about 1½ inches, 30 times just below the nipple line
Push with the two-finger push technique
Push at a rate of at least 100 pushes per minute
Allow complete chest recoil between each push
CPR ratio for one-person CPR is 30 pushes to 2 breaths
CPR ratio for two-person CPR is 15 pushes to 2 breaths
Use the two-thumb encircling technique for pushes Breathing
Head tilt-chin lift: Tilt the head back and lift the chin
Give 2 breaths. Give each breath over 1 second
The victim’s chest should rise with each breath Continue
Continue cycles of 30 pushes and 2 breaths
Rotate compressors every 2 minutes
SYNCOPE
It is a transient loss of consciousness due to cerebral anoxia.
It is perhaps the most common untoward accident seen in the dental clinic.
Predisposing factors
Anxiety, fear, and sight of blood, pain, fasting and hot environment.
These emotional stresses lead to release of catecholamine.
Resultantly, there is lower peripheral resistance and hence
peripheral pooling of blood and fall in blood pressure leading
to a sudden decrease in cerebral blood flow.
Signs and symptoms
Patient feels weakness, warmth, nausea and pain in the epigastrium and hunger etc. Following this sweating, dizziness, pallor and light headedness and low pulse pressure develops. If the treatment is not instituted at this stage, unconsciousness develops with ashen gray color of the skin, shallow respiration, low blood pressure and weak pulse.
MANAGEMENT OF SYNCOPE-
Position of the patient: Made to lie own in supine position with legs raised to improve venous return. In case the patient is sitting in the dental chair, the back of the chair should be immediately lowered so the head of the patient is at lower level than the feet. It helps in venous return to the heart and oxygenated blood to the brain
Loosening of the clothes:Tight clothing should be loosened
A patent airway should be maintained. Any foreign body should be removed manually or with suction apparatus
Inhalation of the aromatic spirit of ammonia or application of cold sponges to the face helps in securing reflex stimulation
100 percent oxygen should be administered
Dental treatment considerations-
Delay further dental treatment 24 hours especially if the patient lost consciousness.
ANAPHYLAXIS
It is defined as a hypersensitive state acquired through exposure to a particular allergens, re-exposure to which produce a heightened capacity to react.
Type1 anaphylactic reaction is most unanticipated and actually life threatening.
Pathophysiology-
For any true allergic reaction to occur the patient must have previously been exposed to the antigen.
With subsequent exposure to the antigen resulting in antigen- antibody reaction leading to release of chemical mediators like histamine, eosinophilic , etc.
Anaphylaxis manifests with acute hypotension, bronchospasm, urticarial rashes and angiodema.
Signs and symptoms-
Cardiovascular shock including; pallor, syncope, palpitations, tachycardia, hypotension, arrhythmias, and convulsions Respiratory symptoms include: sneezing, cough, wheezing, tightness in chest, bronchospasm, laryngospasm
Skin is warm and flushed with itching, urticaria, an angioedema Nausea, vomiting, abdominal cramps, and diarrhea also
possible.
Management-
ABC’s
Maintain airway, administer oxygen, and determine possible need for intubation or surgical airway
Monitor vital signs
If in shock put patient in a horizontal or slight Trendelenburg position Mild reactions
Antihistamines usually effective. (Benadryl 50–100 mg or Chlorpheniramine maleate 4–12 mg PO, IV, or IM)
Identify and remove allergen
Follow-up medications in 4–6 hours Severe reactions
If available start IV fluids
Epinephrine is drug of choice. Usually prepackaged 1:1,000 in 1 mg vials or syringe.
Respiratory emergencies
Acute airway obstruction is the major cause of nontraumatic cardiac arrest in infants and children.
Signs and symptoms
First phase (1–3 minutes): Conscious, universal choking, struggling paradoxical respirations without air movement or voice, increased blood pressure and heart rate
Second phase (2–5 minutes): Loss of consciousness, decreased respiration, blood pressure, heart rate.
Third phase (>3–5 minutes): Coma, absent vital signs, dilated pupils
Management:
If assistant is present—patient placed into supine or Trendelenburg position, use magill intubation forcep or suction to remove foreign body
If assistant not present—instruct patient to bend over arm of chair with their head down and encourage patient to cough
Management of swallowed objects
Consult radiologist—obtain radiographs to determine location of object and initiate medical consultation with appropriate specials
Management of aspirated foreign bodies
Place patient in left lateral decubitus position—encourage patient to cough
If foreign body is retrieved, initiate medical consultation before discharge
If foreign body is not retrieved—consult with radiologist and obtain radiographs, perform bronchoscopy to visualize and retrieve foreign body.
Bronchospasm
Patients with a history of bronchial asthma may develop acute bronchospasm. It may be triggered by emotional stress and anxiety during the course of treatment.
Types of asthma
Extrinsic: Allergic asthma, younger patients
Intrinsic: Older patients, nonallergic factors, cold temperatures, exercise, stress.
Signs and symptoms of an asthma attack
Sense of suffocation, patient will sit up like they are fighting for air
Pressure or tightness in chest
Nonproductive cough
Expiratory and inspiratory wheezes
Expiration is prolonged and harder than inspiration
Chest is distended
Thick stringy mucous. At termination of a period of intense coughing the patient will expectorate this mucous
Severe asthma attack
Cyanosis of the nail beds
Perspiration and flushing of the skin
Use of accessory muscle of respiration: Sternocleidomastoid, and shoulder/abdominal muscles
Patient may also appear confused and agitated
Management of an asthma attack
Discontinue dental treatment
Place patient in easiest position for them to breath. This is usually upright with arms outstretched
Albuterol inhaler (Proventil) 2 puffs every 2 minutes Supplemental oxygen at 10 L/minute.
Monitor vital signs
If no improvement call EMS
Consider epinephrine 1:1,000, 0.3 g every 20 minutes
Dental treatment considerations for the asthmatic patient
Take a good medical history prior to treatment; determine how often the patient has an asthma attack and what precipitates it
Consider scheduling morning appointments
If patient uses an inhaler they should have it on hand during treatment.
Consider prophylactic use prior to treatment.
Shock
It is a phenomenon marked by circulatory deficiency which is either cardiac or vasomotor in origin exhibiting marked hypotension.
Signs and symptoms
The patient is unconscious with ashen gray face and cold, clammy skin
Mucous membrane is pale whereas lips, nails finger tips and lobules of the ear are grayish blue. Face is expression less with sunken eyes
Pupils are dilated but react feebly to light
Pulse is weak and thready
Shallow and irregular respiration
Temperature is subnormal.
Management
Position: Put the patient in a shock position with head at the lower level than feet 15 degree trendlenberg postion
Maintain the body heat by covering the patient with blanket and keep a hot water bottle.
Check for any airway obstruction and patency of airway be maintained
Control the loss of blood in hemorrhage shock by pressure packs
Restore the lost body fluids. Infusion with plasma expanders or Ringer’s lactate solution should be carried out to maintain the intravenous line and restore the volume loss.
Administer 100 percent oxygen
The blood pressure, pulse rate and respiratory rate should be constantly monitored to assess the vitals.
Chest pain/angina
The development of central chest discomfort frequently results from stressful situations in patients with coronary artery disease. In angina episodes, the coronary artery narrowed by atherosclerosis is unable to supply the heart muscle with adequate amounts of oxygenated blood, causing chest pain.
Signs and symptoms
Central, substernal discomfort
May radiate to shoulder, neck, jaw or epigastric region
Dull heavy pressure sensation of short duration
Prompt relief with rest or nitroglycerin
Treatment
Position patient semi-upright or upright
Administer oxygen
Administer nitroglycerin 0.5 mg SL every 5 minutes.
Monitor, assess and record vital signs
Diabetic emergencies
There are two types of problems associated with diabetes getting treatment in dental office.
Hypoglycemia or insulin shock.
Diabetic coma or ketoacidosis or hyperglycemia.
Signs and symptoms
Hypoglycemia is presented by pallor, sweating and tremors. There is palpitation, generalized weakness and hunger pains. Patient exhibit symptoms like tachycardia, headache, confusion, visual and disturbances of speech. Ultimately coma may develop.
Hyperglycemia is characterized by dry skin and hypotension.
There is history of polydipsia, polyurea and polyphagia. Patient has typical acetone breath with a rapid deep breathing. Patient looks ill, dehydrated with dry skin, dry mouth and enophthalmos.
Ultimately diabetic coma will develop.
Management
Hypoglycemia
In a conscious patient administer 20 gm of oral glucose
In an unconscious patient 50 cc 50 percent glucose given IV
Adrenalin: 0.5 cc of 1:1000 adrenalin is given subcutaneously.
It stimulates hepatic gluconeogenesis and counteracts hypoglycemia
Glucocorticoid: 100 mg of hydrocortisone hemisuccinate IV
Glucagon: 1–2 mg IM raises blood sugar.
Hyperglycemia
Circulating insulin present is ineffective because of poor
tissue perfusion. Hence, tissue perfusion must be improved.
One liter of fluid can be given in the first half hour and subsequently 1 liter per hour till dehydration is corrected
Insulin therapy forms the main stay of hyperglycemia. It not only lowers the blood sugar but also prevents further lipolysis thereby preventing accumulation of ketones and hydrogen ions.
Epilepsy
This is a central nervous system disturbance involving convulsions followed by loss of consciousness. Majority of the patients are conscious of their problem and should be warned about the importance of medicine which is generally recommended on long-term basis. An emergency can arise in the dental clinic when the epileptic seizures occur during treatment.
Generalized seizures Tonic-clonic
Clonic seizures Tonic seizures Atonic seizures Myoclonic seizures
Absence (petit mal) seizures
Partial seizures
Simple partial seizures Complex partial seizures
Partial seizures secondarily generalized
Management
Most seizures last < 2 minutes
EMS activated.
Assure patient and staff safety.
Administer oxygen.
Manage airway.
Monitor vitals, pulse oxymetry.
If seizure is lasting > 2 minutes, establish IV, administer medicines.
Diazepam
Adult: 5 to 10 mg IV/IM
Pediatric: 0.2 to 0.5 mg/kg IV/IM
Midazolam 0.05 to 0.1 mg/kg IV 0.2 mg/kg IM (Max 10 mg)
EMS not arrived > 5 minutes
Adult: Dextrose 50 mL bolus off 50 percent glucose.
Pediatric: 2 mL/kg 25 percent dextrose solution.
Evaluate airway maintenance.
Evaluate cardiac rhythm.
REFERENCES
1.
TEXTBOOK OF PEDIATRIC DENTISTRY- NIKHIL MARWAH.
2.
AMERICAN HEART ASSOCIATION. CPR-ECC GUIDELINES 2010.
3.
