Medical emergencies can also occur in kids!

Adverse medical complications may present themselves in the course of dental treatment. Every dental practitioner should have the knowledge and skill for the diagnosis and management of medical emergencies. Although most are not life-threatening, they could occur with potentially serious conditions. To reduce medical emergencies occurring in dental clinic, the dentist should take the thorough history and conduct general examination of the patient. Practising dentists should have previous knowledge of Basic Life Support (BLS) and should be capable of diagnosing the possible cause(s) of emergencies during a dental visit. In fact, present studies suggests that many dentists on graduation do not feel competent in managing medical emergencies, while some feel insecure in doing so. Therefore, advanced training is needed for both undergraduates and post graduates students.

Medical emergencies can also occur in kids!

Most suggestions for treating emergencies in recently published literature are written for adult patients. Since children are not miniature adults, it is necessary to modify the approach. Suggestions for treating emergencies in children have not yet been sufficiently addressed.

Differences between children and adults are reflected in the size and shape of the body along with emotional and cognitive maturity, but differences in physiology, such as the respiratory, cardiovascular, and immune systems, are also important. The pharmacokinetics of drugs in the body of the child must also be taken into account.

Equipment used must be adaptable to the patient’s age, for example there are different sizes of breathing masks and oropharyngeal or endotracheal tubes, which must be properly selected. An oropharyngeal tube should be introduced directly in children, as opposed to the way of applying the tube in adults in which the tube is concavely applied to the palate to reach the soft palate and then rotated by 180° to put it into position. Rotation is not recommended for children because of the delicate structure of their airway, and because of the size of the tongue in relation to the oral cavity. The dosage of medication to be used in emergency situations, as well as the application techniques, are different from those to an adult patient.

Various emergency conditions and their treatment –

1. Ischemic heart disease consists of angina pectoris and myocardial infarction.

Symptoms: sudden retrosternal pain that radiates to the neck, lower jaw, shoulders and arms, this can be manifested as a feeling of tightness and an inability to breathe.

Treatment

1. discontinue dental treatment
2. call an ambulance
3. administer dose of nitroglycerin 0.4 mg in tablets, sublingually

If the pain persists, myocardial infarction must be suspected and the patient should be given 325 mg aspirin, if necessary, administer oxygen, while waiting for an ambulance.

2. Cardiac arrest is the sudden stopping of the heart. It is represented by the lack of pulse, loss of consciousness and aponea. Cardiac arrest in children may be a consequence of respiratory or circulatory failure, although usually the problem is in the respiratory system.

Therapy: if the child is not breathing or has agonal breathing at times, open the airway and apply five breaths of air; before each breath of air the rescuer should take a deep breath and supply air to the victim as soon as possible, so that oxygen in the inhaled air is not derived from his or her own lungs; if the rescuer is sure that the palpable pulse frequency of the patient is greater than 60 ppm, he or she should continue with artificial ventilation until the arrival of qualified assistance; if there is no pulse, he or she should begin with chest compressions, which are performed in children over the lower half of the sternum, avoiding compression to the zyphoid bone. The procedure should consist of 15 external cardiac massages and two breaths of air; this procedure for reviving children with a rhythm of 15:2 applies to children up to puberty, whereas older children and adolescents receive the reviving procedure similarly to adults.

Procedure for external cardiac massage in a small child:

Imagine a line that connects the nipples of a child. Put the following three fingers on the chest: index, third and fourth finger. The index finger should be close to the imaginary line that joins the nipples. Raise the index finger in the air and start massaging by putting pressure on the sternum with the two remaining fingers. If the fourth fingers feel the zyphoid bone, move the little finger towards the imaginary line.

3. Diabetic ketoacidosis can develop in patients with an absolute or relative insulin deficiency, resulting in high hyperglycemia, the accumulation of ketones and the development of metabolic acidosis.

Symptoms: polydipsia, polyphagia, polyuria, weakness, nausea, vomiting, hyperventilation, red face, and the smell of acetone; it can lead to disorders of consciousness.

Treatment: in the first hour, administer saline at a dose of 10–20 ml/kg body weight, and after 2 h of this treatment, include intravenous insulin.

4. 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: 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.

5. Acute asthma attack is a chronic inflammatory disease of the entire respiratory system in patients with allergic diseases.

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.

Treatment: 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

6. Syncope is a short-term reversible loss of consciousness and postural tonus, which results from a sudden, transient and diffuse disorder of brain function resulting from a sharp reduction in the delivery of blood to the brain.

Symptoms: the patient shows signs of confusion, breaks into a cold sweat, turns pale and usually says that he or she is not well. Later, pupillary dilation appears, along with increased respiration, disorientation and loss of consciousness; breathing becomes irregular, shallow and may be absent; bradycardia occurs; the blood pressure drops and the pulse is weak.

Therapy: if the patient is placed in the Trendelenburg position, the duration of syncope is short and lasts from a few seconds to a few minutes; the patient is conscious and can be given a sweet drink to prevent hypoglycemia. In patients who are unconscious, it is indicated to give 36–50% glucose solution intravenously or intramuscular glucagon; if the staff are not trained to inject drugs or any medications are not available, it is possible to rub honey or a sweet drink in the buccal fold taking care to avoid aspiration.

7. Epileptic seizure (grand mal) attack may be preceded by aura (postictal phase), which is manifested as a change in one of the senses. Aura mainly occurs in the same way in a given patient before each attack and lasts a few seconds. The next phase is termed the ictal phase, which leads to loss of consciousness, followed by tonic contraction of muscles, which takes 10 to 20 sec. Then, the clonic phase occurs, 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. 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.

Treatment: move all of the instruments away from the patient and remove everything from the mouth; lower the seat as close to the floor as possible; the patient should lie on their side to reduce the possibility of aspiration of secretions or dental materials in the mouth; do not restrain the patient or put your fingers into the patient’s mouth; measure the duration of the seizure; if the seizure lasts more than 3 minutes, call an ambulance; if a seizure lasts longer than 5 minutes or frequent seizures occur, administer 0.25 mg/kg of diazepam IV; do not allow the patient to leave the clinic until the level of consciousness is fully restored; perform a brief examination of the oral cavity to establish the existence of new injuries; the patient may go home accompanied by an adult or legal guardian.

8. 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 sensitised 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.

Symptoms: respiratory (coughing, chest tightness, dyspnea and whistling sound, laryngeal edema, bronchospasm); cardiovascular (headaches, palpitations, syncope, tachycardia, dysrhythmia, orthostatic hypotension and shock); gastrointestinal (cramps, abdominal pain, nausea, vomiting and diarrhea); cutaneous and mucosal signs (rash, erythema and pruritus, angioedema usually occurs at periorbital, perioral and intraoral sites and on the extremities.

Therapy: Adrenaline (epinephrine vials are diluted at a ratio of 1:1000 in an amount of 1 mL; the dose for children is 0.01 ml/kg body weight, so a 20 kg child has an epinephrine dose of 0.2 ml; the dose can be repeated every 5–10 min; intravenous epinephrine is administered at a dilution of 1:10,000, so 9 mL of saline is added to 1 ml of the factory dilution, and the dose for children is 0.1 ml/kg); antihistamines (ideally, an antihistamine should be administered parenterally and quickly; in practice, the parenterally administered compound is diphenhydramine or chlorpheniramine; Croatia has registered only an oral form of diphenhydramine; regarding parenteral formulations, only chloropyramine (Synopen) has been registered, which is not suitable for children, although the manufacturer can provide half ampoules to be administered slowly and intravenously; inhalation of β2- agonists (used when there is anaphylaxis and bronchospasm, and should be administered carefully in cases of hypotension because β2 agonists have a vasodilatory effect; given at a dose of 2.5 mg for children up to 5 years, and at 5 mg for children over 5 years of age); oxygenation (oxygen is essential in cases with respiratory symptoms or hypotension); corticosteroids (corticosteroids are not the drug of first choice, but they are effective in reducing the late-phase allergic response). Notably, corticosteroids may be administered, with a dose of 1–2 mg/kg methylprednisolone or 4 mg/kg hydrocortisone administered intravenously.

EMERGENCIES IN PEDIATRIC PATIENTS POST GA/CONSCIOUS SEDATION (4,5)

Pediatric patients with a very young age, or those suffering physical, mental, cognitive or emotional immaturity or disability or those with extreme anxiety who need extensive rehabilitation are treated using GA or Conscious sedation.

Here are some problems inherently associated with paediatric anaesthesia –

1. Children may have enlarged tonsils and adenoids thus increasing chances of respiratory obstruction
2. They are uncooperative and communication may be challenging
3. Many medical conditions can co-exist such as epilepsy, reflux, and cardiac anomalies
4. They are needle phobic and highly anxious
5. High autonomic activity thus increasing chances of arrhythmias and vasovagal response
6. Gastric emptying may be delayed
7. Problems of ambulatory anesthesia.
8. As airway is shared by the anesthesiologist and dentist, it may be soiled with blood or debris and stimulation of trigeminal nerve increases chances of arrhythmia during surgery.

Intraoperative complications include –

• Arrhythmias,
• Disloged or obstructed endotracheal tube,
• IV infiltrates or disconnects,
• edema of the tongue or lips and
• nasal bleeding
• Inexperienced staff and/or inadequate machines and equipment may lead to adverse events, in rare cases, even death.

To maintain skills and minimize the risk of adverse events or optimally eliminate it, it is needed to follow guidelines and participate in standard and regular training courses.

Keeping all the above factors, one should thoroughly prepare the patient after complete pre-anesthetic check-up and after proper examination of airways, cardiorespiratory system, and any congenital abnormalities. The general/pediatric dentist should keep a anaesthetist instead of inducing anaesthesia himself/herself. Another one of the most important problems is position in the dental chair. It becomes very difficult to resuscitate the patient if something unwanted happens suddenly. All types of drugs and resuscitative measures should be there in case of any emergency.

Conclusion

Most of the regulations and guidelines for emergency responses refer to adults. Working with children is more challenging because of their age and differences in the physiological and psychological senses. Every dentist should know the therapeutic dose and procedures adapted to children to avoid complications or reduce them to a minimum and should be equipped with a defibrillator.

References

1. Goepferd SJ. Medical emergencies in the pediatric dental patient. Pediatr Dent. 1979 Jun;1(2):115–21.
2. Degoricija V. Hitna medicina. Zagreb: Libar; 2011.
3. Malamed SF. Medical emergencies in the dental office. 7nd ed. St. Louis: Mosby; 2015
4. Ramazani. Different Aspects of General Anesthesia in Pediatric Dentistry: A Review. Iran J Pediatr. 2016 Apr; 26(2): e2613.
5. Attri et al. Conscious Sedation: Emerging Trends in Pediatric Dentistry. Anesth Essays Res. 2017 Apr-Jun; 11(2): 277–281.