DR.SHIFAYA NASRIN

Medical emergencies

BE PREPARED……..

The meaning 0f the motto is that a Scout must prepare himself by Previous thinking out and practicing how to act on any Accident or emergency so that he never taken by surprise - Robert Baden Powell

INTRODUCTION

A medical emergency is an injury or illness that is acute and possess an immediate risk to a person’s life or long term health

The dental office’s successful management of medical emergencies requires preparation, prevention and response not just by the dentist but by all dental staff.

Adequate preparation for emergencies reduces the possibility of an emergency occurring and further complications if it does occur. .

PREPARATION STEPS INCLUDE:

Taking and reviewing a comprehensive medical and

dental history.

Providing minimum basic life support (BLS) training for

providers and staff.

Advanced Cardiac Life Support (ACLS) or Pediatric

Advanced Life Support (PALS) training especially for

those administering sedation and general anesthesia.

Initiation and coordination of an office emergency team.

Organizing an emergency drug kit and equipment.

Retraining on a regular bas

 

INTERACTING WITH CHILD PATIENT

Smile Touch or hold child’s

hand or foot Do not use equipment

without first explaining what you will do with it

Let child see your face Stop occasionally to find

out if child understands Never lie to child

PEDIATRIC AGE CATEGORIES

Newborns and infants: birth to 1 year Toddlers: 1–3 years Preschool: 3–6 years School age: 6–12 years Adolescent: 12–18 years

PREPARATION

Four steps critical in preparing the office and staff to recognize and effectively manage medical emergencies

The ability to properly perform BLS functioning dental office emergency team Ready access to emergency assistance The availability of emergency drugs and

equipment

PEDIATRIC BASIC LIFE SUPPORT

Defined as position -Head tilt chin lift Airway Breathing Circulation defibrillation

AIRWAY AND BREATHING

ASSESSMENT OF VENTILATION Look-chest moving listen and feel –exchange of air against rescuer

cheekIN ABSENCE OF SPONTANEOUS BREATHING Rescue breath are delivered infant and child :12 – 20 breath per minute(1

breath every 3-5 seconds) Pubescent patient :10 – 12 breath per minute

(one breath every 3-5 seconds)

AIRWAY, BREATHING AND CIRCULATION

CIRCULATION

Palpation of carotid artery(>1 year) Brachial pulse in infants(<1 year) Radial pulse in childIn absence of palpable pulse: Chest compression should be

performed with EMS

DEFINITIVE CARE

Determine the cause of the problem Implement the appropriate treatment

PEDIATRIC ADVANCED LIFE SUPPORT

EMERGENCY TEAM

Team member responsibilities

Member 1 (first person on scene of emergency)

Remain with victimActivate office emergency teamBLS as necessary

Member 2 Bring emergency equipment to scene

Member 3(and other members of dental offices staff)

Assist as necessaryActivate EMSMeet and escort EMS to officeAssist with BLSPrepare emergency drugs for administrationMonitor and record vital signs

EMERGENCY DRUGS AND EQUIPMENT

EMERGENCY DRUGS AND EQUIPMENT

Drug Indication Availability Recommended for kit

Epinephrine Anaphylaxis 1:2000(0.15 mg\dose)

1 pre loaded syringe +3x1 ml ampoules of 1:1000

Diphenhydramine hcl

Mild allergy 50 mg\ml 2-3 x1 ml ampules of 50 mg\ml

Oxygen All emergencies “E” cylinder +delivery devices

Minimum 1 ;preferably 2

Albuterol Bronchospasm Metered aerosol inhaler

1 aerosol inhaler

Sugar Hypoglycemia Orange juice; instant glucose

12 ounce bottles of orange juice or 1 tube of insta glucose

Aspirin Suspected myocardial infarction

325 mg tablets 1-2 sealed tablets

Nitro glycerin Angina pectoris Metered spray 1 nitro lingual spray

ANTIDOTAL DRUGS

Drug Indication Availability Recommended for kit

Flumazenil Benzodiazipine antagonist

0.1mg\ml 1x10 ml multidose vial

Naloxone Opioid antagonist

0.4 mg/ml 2x1 ml ampule of 0.4 mg/ml

EMERGENCY EQUIPMENT

Automated external defibrillator

Face masks Disposable syringes

and needles Spacer for

bronchodilator inhaler

SPECIFIC EMERGENCIES

COMMON MEDICAL EMERGENCIES

Foreign body induced airway obstruction

Allergic reaction or anaphylaxis Drug over dosage acute asthmatic attack Seizures Hypoglycemic attack syncope

INCIDENCE OF SPECIFIC EMERGENCY SITUATIONSituation # Incidents

Syncope (fainting) 75 (mostly parents)

Hysteria 23 (mostly children)

Allergy, mild 22

Seizures 13

Hypoglycemia 9

Hyperventilation 7

Aspiration 5

Respiratory distress 4

Bronchospasm 3

Airway obstruction 3

Allergy, anaphylaxis 1

Drug overdose 1

Local anesthesia overdose 1

Cardiac arrest 1

Source: 2004 AAPD, “Pediatric Emergencies in the Dental Office”

BRONCHOSPASM(ACUTE ASTHMATIC ATTACK)

CONSCIOUS PATIENT DEMONSTRATE: WHEEZING SUPRACLAVICULAR AND

INTERCOSTAL RETRACTION PRIOR HISTORY OF ASTHMA

MANAGEMENT

PABCD Sit patient upright or in a comfortable position Administer 02 via face mask or Nasal

cannula at a flow rate of 3-5 l/min Administer bronchodilator If bronchodilator is ineffective, administer

epinephrine Call for emergency medical services with

transportation for advanced care if indicated

GENERALIZED TONIC CLONIC SEIZURE

Period of muscle rigidity followed by muscle contraction and relaxation lasting for 1 -2 minutes

Positive medical history Typical pre seizure appearance –aura Loss of consciousness

MANAGEMENT

P position supine A,B,C (respiratory and cardiovascular

stimulation noted during seizure) D(definitive care) Protect victim from injury gently hold arms

and legs preventing uncontrolled movements do not hold so tightly

If convulsion last for >5 minutes or reappear at short interval dial EMC

Administer Diazepam 0.3 mg/kg IV

ANAPHYLACTIC SHOCK

Sudden and generalized manifestation of symptoms: Skin : urticaria

Erythema

pruitis Respiratory system : dyspnoea

stridor GI System : nausea

vomiting

GI pain Urinary incontinence Tachycardia cyanosis of nail beds Unconsciousness Cardiac arrest

;

MANAGEMENT

D PABC Administer 0.15ml 1:1000 adrenaline sc

or IM Dial EMC to shift child to the hospital Maintain PABC Monitor vital signs Repeat adrenaline in five minutes

LOCAL ANAESTHESIA OVERDOSAGE

Manifestation appearing suddenly or during L.A administration

Inarticulate and confuse state of mind Dizziness Generalized seizures unconsciousness

MANAGEMENT

Reassure patient Assess and support airway, breathing,

and circulation (CPR if warranted) Administer oxygen Monitor vital signs Call for emergency medical services

with transportation for advanced care if indicated

OVERDOSAGE OF BENZODIAZEPINES

Somnolescence Confusion Diminished reflexes Respiratory depression Apnoea Respiratory arrest Cardiac arrest

MANAGEMENT

Assess and support airway breathing and circulation

Administer oxygen Monitor vital signs Establish iv access and reverse with Flumazenil

0.01 mg/IV at a rate not to exceed 0.2 mg/min Monitor recovery (for at least 2 hours after the

last dose of flumazenil) and call for emergency medical services with transportation for advanced care if indicated

OVER DOSAGE OF NARCOTIC

Decreased responsiveness Respiratory depression Respiratory arrest Cardiac arrest

DEFINITIVE TREATMENT

ABC Monitor vital signs Reverse with naloxone 0.01 mg/kg

IV ,IM subq Monitor recovery Administer oxygen

ACUTE AIRWAY OBSTRUCTION

Child grasps his throat –universal sign of choking

Unable to breathe cough speak

Cyanosis Unconsciousness Cardiac arrest if not

managed

DEFINITIVE TREATMENT

Clearing the airway If child is able to

cough then child is turned to a left lateral position on the dental chair with face down

Cough encouraged in this position by back blow between the scapulae

This expel the foreign body

PEDIATRIC CHOKING TREATMENT ALGORITHM

If child is conscious but choking an attempt is made to expel the foreign body with upward thrust using Heimlich maneuver

If unconscious –dial EMC ,place the child n supine position give inward and upward thrust 5 times

Finger sweep in oral cavity

If unsuccessful -cricothyrotomy

ACUTE HYPOGLYCEMIC ATTACK

Positive medical history type 1 diabetes mellitus Bizarre and confused behaviour Loss of consciousness convulsions

DEFINITIVE TREATMENT

If conscious-oral carbohydrate If unconscious-dial EMC Administer glucagon 1mg IM 50% dextrose IV

SYNCOPE

Extremely tense and rigid Cold extremities Nausea and dizziness Loss of consciousness

DEFINITIVE TREATMENT

No drugs usually indicated Proper supine position with feet

elevated slightly Loosen clothing Cold towel at the back of neck Respiratory stimulant –ammonia Maintain ABC

FOR ALL EMERGENCIES….

Discontinue dental treatment Call for assistance/someone to bring oxygen and

emergency kit Position patient: ensure open and unobstructed

airway Monitor vital signs Be prepared to support respiration, support

circulation, provide cardio pulmonary resuscitation (CPR), and call for emergency medical services

CONCLUSION

The dentist and the staff must be trained to handle any emergency which can arise in a dental set up . Having medical personnel on call is very useful under such circumstances . However ,one should always remember that the best form of managing a medical emergency is by prevention.

REFERENCES

Malamad.S.F . Medical Emergencies In The Dental Office ,6th Edition, 2007, Mosby Elsevier

Pediatric Advanced Life Support: 2010 American Heart Association Guidelines For Cardiopulmonary Resuscitation And Emergency Cardio-vascular Care

Jimmy R.Pinkham ,Pediatric Dentistry Infancy Through Adolescence 4th Edition,2005

Emergency Medicine in Pediatric Dentistry: Preparation and Management ,Stanley F. Malamed, DDS,October 2O10,VOL:31,NO:10 CDA journal

M.S. Muthu,pediatric Dentistry Principles And Practice,2nd Edition,2011

THANK YOU