MEDICAL EMERGENCIES IN THE

PEDIATRIC DENTAL PRACTICE;

PREPARATION AND MANAGEMENT

Renu Thapaliya

BDS 4TH year, Roll no: 47

Kantipur Dental college

CONTENTS

Introduction

Common medical emergencies encountered in pediatric dental clinic

Necessary preparations for the emergency

Identification and management of specific conditions

Conclusion

References

INTRODUCTION

Although uncommon as compared to adults, pediatric medical emergencies can occur in the dental office too.

When they do happen, they happen quickly without warning and with dreadful consequences.

As the child has under-developed physiology with small oxygen reserves, early recognition of the problem and definitive management is crucial.

COMMON EMERGENCIES ENCOUNTERED

IN DENTAL CLINIC

Syncope

Seizures

Anaphylactic allergic reactions

Foreign body obstruction

Local anesthesia overdose

Acute adrenal insufficiency

Hypoglycemia

Acute asthmatic attack

PREPAREDNESS FOR AN EMERGENCY

Equipping oneself:

.Taking and reviewing a comprehensive

medical and dental history

. A thorough knowledge about delivering

Basic Life Support (BLS) care

. Understanding of important emergency

drugs, appropriate dosages and their

route of administration

. Learning to administer drugs via desired

parenteral route viz. IM, SC or IV

. Acquiring skills to establish an IV access

and operate emergency equipment like

oxygen cylinder, oxygen mask etc.

EQUIPPING THE DENTAL OFFICE

Emergency oxygen

cylinder with oxygen

Suctioning

equipment

Pulse oximeter and

blood pressure set

Automated external

defibrillator ( AED )

A dental chair that

can be changed to

trendelenberg

position

Ambu bag

Epinephrine 1: 2000

Diphenhydramine

Salbutamol

Normal

saline/Ringer’s

lactate

Hydrocortisone

Diazepam/Lorazepam

Nitroglycerine

Dextrose 50%

glucagon

Ammonia inhalant

ampules

Emergency Equipments Emergency drugs

MANAGEMENT DURING EMERGENCY

1) Recording of vital signs:

. Blood pressure, Pulse rate, Respiratory rate and temperature

. Weight-to calculate the dosage of the emergency drug

2) Life supporting measures:

. Despite the precautions taken, if any medical emergency do occur, the dental surgeon should sustain the patient with BLS.

The golden rule-a) Assessing Position, airway, breathing and

circulation(PABC)b)Cardio Pulmonary Resuscitation(CPR)

A. ASSESSING POSITION AIRWAY BREATHING

AND CIRCULATION(PABC):

P: Position

Any clinical management of a medical emergency on the dental chair calls for a stoppage in the dental procedure. This has to be followed by proper positioning of the child.

There are primarily three positions during an emergency. Supine (Horizontal)

Head low position

Erect/semi supine position

A: Airway

• First, all the secretions in the oral cavity arecleared by a suction

• If the patient is conscious, assess breathing

• If the patient is unconscious, head tilt-chin lift-jaw thrust (mandible is pulled forward)maneuver. This maneuver prevents the tonguefall (i.e tongue falling on posterior pharyngealwall and obstructing airway)

• In case of foreign body obstruction, the airwayhas to be cleared using blows or Heimlichmaneuver (to be discussed later)

B: Breathing

Look Listen Feel Conscious and breathing

adequately monitor vital signs and administer supplemental oxygen

Unconscious but breathing adequatelyadminister supplemental oxygen if required with head tilt- chin lift to ensure open airway.

Monitor the vital signs and proceed to assess circulation (C)

•C:Circulation

•Assess – Carotid artery•Palpate-

•Two important points should be remembered during palpation:

-Artery should not be assessed on both sides at a time.-Thumb should not be used to palpate.

•If carotid pulse felt airway and breathing must be maintained as mentioned earlier.

•If not, external cardiac compression is performed immediately

b)Cardio pulmonary resuscitation(CPR): It is an emergency procedure performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation &breathing in a person in cardiac arrest ( patient with absent carotid pulse)

. It consists of the use of chest compressions and artificial ventilation to maintain circulatory flow and oxygenation during cardiac arrest.

. Fig:

PROCEDURE:

Done in supine position

Rescuer stand (or bend on knee if the victim is on the floor) on side (usually right side), lock one hand over other and provide compression over the lower third of sternum ( 2 fingers above the xiphoid process)

Force generated by compressions should be able to depress sternum by 2 inches.

Rate of compressions should be 100 compressions/min.

Defibrillation by automatic external

defibrillator (AED) : AEDs are the devices which automatically detects rhythm and give shock if rhythm is shockable.

Since they detect rhythm automatically and gives shock automatically they can be used even by a lay rescuer.

Therefore AEDs are considered as the part of basic life support.

MANAGEMENT OF SOME SPECIFIC MEDICAL EMERGENCIES

1) SYNCOPE : Also known as common faint

• It is defined as a transient self limited loss of consciousness with an inability to maintain posture that is followed by spontaneous recovery. This definition excludes seizures, coma, shock or other states of altered consciousness.

• Causes of syncope

o Fright, anxiety or stress

o Sudden & unanticipated pain

o Sight of blood, sharp dental instruments

o Sitting in upright position for prolonged time

o Hunger , exhaustion

o Hot and humid environments.

Simple ways to prevent syncope

Do not wave needle in front of the patient. Administer LA in supine position. See that the clinic is not hot and humid. Check that patient is not on an empty stomach. Use mild sedatives if required.

Signs and symptoms

EARLY: feeling of warmness, pale color, heavy perspiration esp. on forehead, sense of “feeling bad”, nausea, low BP & tachycardia

LATE: Yawning, cold hands and feet, visual disturbances, bradycardia, loss of consciousness, pupillary dilation

Differences between epileptic seizure and syncope

Management

Discontinue the treatment.

Assess the consciousness level.

Position the patient in supine position with feet elevated slightly. Advice patient to move legs vigorously ( muscle pump can increase venous return to heart, thus the BP increases).

Assess ABC.

Administer oxygen via face mask or nasal prongs.

Monitor vital signs.

Loosen tight cloths or belt, if any.

Administer aromatic Ammonia ampoules after crushing it with fingers and place it under patient’s nose ( irritant ammonia fumes stimulate extremities)

Determine the precipitating factors.

2) SEIZURES

o Recurrent episode of altered cerebral function associated with paroxysmal excessive and hypersynchronous discharge of cerebral neurons.

Dramatic appearancegeneralized

tonic clonic seizure (GTCS

or grand mal epilepsy)

Status Epilepticus: a serious

condition that requires

immediate IV administration

of an anticonvulsant.

Presenting Signs and Symptoms ( GTCS)

Aura (seen before an attack): parasthesia, flash lights, hallucination, sensation of falling, flushing, sweating, fear, piloerection. The patient cannot warn the doctor about the aura as he is

already amnesic at the onset of this stage. If a friend or a relative notices this typical aura during dental

treatment, he should warn the doctor and treatment should be stopped imediately.

Tonic phase (10-20 secs): Loss of consciousness , cyanosis, arms flexed and adducted

Clonic phase ( not >1 min): Violent jerking of face and limbs Bleeding from the mouth (due to tongue bite) and frothing may

be seen.

Post- ictal phase phase where the tonic-clonic movements cease and

consciousness gradually returns (in mins-hrs). Muscular flaccidity is seen.

Urinary and fecal incontinence may occur. Headache ,fatigue, muscle ache, excessive salivation

PABC assessment and management

On the warning of aura, cease treatment and position patient in the supine position.

Remove all dental equipment, appliances and dentures, if any from the mouth of the patient before loss of consciousness.

Maintain airway by head tilt-chin lift on the head-rest of the dental chair . Prevent fall injury to the patient.

Also suction the secretions by placing a flexible suction between the cheek and teeth.

Administer oxygen to aid in breathing (B).

Circulation is usually adequate.

Monitor Vitals regularly.

Check medical history To see if the patient has a history of epilepsy or any

other condition like diabetes which manifests convulsions during a hypoglycemic attack

Definitive therapy

Prevention of injury to the patient is the primary goal Remove instruments like hand pieces, burs and other

instruments from the vicinity of the patient. Do not insert anything in the mouth. If mouth prop is already there, make sure it stays in

position. Loosen clothes Gently restrain the patient’s extremities allowing for

minor movement. Care should be taken not to fix the extremities during

convulsions as this may result in fractures. …..

o In the post-ictal phase, PABC is maintained along with oxygen administration .

Monitor vital signs.

If status epilepticus occurs, call emergency medical assistance.

Administer Lorazepam (0.1mg/kg) IV slowly till patient is shifted or till medical emergency help arrives.

Dental considerations for patient with Seizures

Early morning short appointments should be made.

Hospital waiting time should be reduced.

Unnecessary and sudden noises should be avoided.

…

Patient with poorly controlled disease or stress-induced seizures may require sedative prior to treatment; patient’s physician consultation should be taken beforehand.

Use of dental floss-secured mouth props and a rubber dam is recommended.

Placement of metal fixed prostheses is recommended rather than the removable prostheses.

Patients under medication especially phenytoin, carbamazepine may require laboratory evaluation prior to dental treatment, including a complete blood counts with differential to assess white blood cell and platelets counts and coagulation studies to assess clotting ability.

Aspirin and NSAIDS should be avoided.

3) ANAPHYLACTIC ALLERGIC REACTIONS

Allergic reactions are hypersensitivity response by a body’s immune system to antigens that are recognized as foreign bodies, with subsequent antibody formation against that specific antigen.

For allergic reaction to occur the patient must have been previously exposed to antigen (sensitizing dose). The subsequent exposure to antigen cause allergy.

ANAPHYLAXIS: a form of allergic reaction

It is an acute, potentially fatal, multi organ system reaction caused by the release of chemical mediators like histamine from Mast cells and Basophils.

Histamine produces inflammation & vascular effects

Potential allergic agents used in dentistry

1)Antibiotics : Penicillins (parenterally administered dose, oral penicillin cause delayed reaction) and Sulphonamides e.g Cotrimoxazole

2) Analgesics: Aspirin, Codeine (opiod analgesic), NSAIDs

3) Local anesthetics (LAs):

Most commonly by topical ester LAs such as Benzocaine, Procaine

Amide LA toxicities ( by Lidocaine, Bupivacaine) are less likely but can occasionally occur due to added preservatives like Sodium metabisulphite and Methylparaben

3) Other agents: Acrylic resins ( dental repairs) & latex (eg. Gloves)

Physical signs and symptoms

SKIN:

Localized area of erythema.

Urticaria or hives: elevated areas of skin which are erythematous, indurated and frequently pruritic.

Angiodema ( localized swelling) of skin and lip.

RESPIRATORY:

Wheezing, dyspnoea,

cyanosis, nasal flaring,

use of accessory respiratory muscles

Due to Bronchospasm (constriction of bronchial smooth muscles)

Stridor (high pitch harsh sound)

Tachypnoea & dyspnoea

Cyanosis

Due to laryngeal edema (Angiodema of vocal cords causing partial or total airway obstruction)

CARDIOVASCULAR REACTIONS:

Light headedness & weakness

Hypotension( low BP), tachycardia & palpitations

Ischemic chest pain

Arrhythmias & cardiac arrest

Due to severe vasodilation that results in myocardial hypoxia and decrease in cardiac output.

Management

Activate office emergency medical system

Discontinue the dental treatment (stop the LA if used)

For severe anaphylactic reaction (Anaphylactic shock), always consider definite medical treatment 1st rather than PABC assessment, as drug can be life saving.

_Administer 0.15 ml Epinephrine (1: 1000) IM.

_Injected sub-lingually to the floor of mouth( to increase perfusion).

_Repeat the dose after 5 mins. if patient does not

improve clinically. Clinical improvement is said to occur if there is increased BP, increased air entry to the lungs, resolution of tachycardia and regain of consciousness. ……

Monitor vital signs every 5 mins.

Consider chest compressions if cardiac arrest occur.

Administer Diphenhydramine (antihistaminic) & Hydrocortisone (steroid) IM to prevent recurrence.

Hospitalize the patient and consider further investigations.

4) FOREIGN BODY(FB) OBSTRUCTION

Risk factors for FB obstruction

Use of stainless steel crown

Endodontic instruments

Conscious sedation

Small oral cavity of a child

Fate of a FB

o If a foreign body is swallowed, it will either lodge

into the GI tract (pharynx/esophagus/stomach) or

will be retrieved spontaneously by coughing. There

will be no signs of respiratory distress.

If the foreign body is inhaled ( ie FB in airway)

SMALL FB By passes the larynx pass into trachea to Right bronchus (right bronchus is more vertical and wide than the left one)

-In such case, the sign and symptoms of respiratory distress may not appear and on Chest X-ray, collapse of a part of lung can be seen.

LARGE FB can get lodged in the trachea, larynx or main bronchus, causing partial or total airway obstruction.

-In such case, varying severity of signs and symptoms appear depending upon degree of block.

Physical signs symptoms (FB in pharynx or

esophagus)

Foreign body sensation

Inability to swallow, difficulty in swallowing

(Dysphagia) or pain on swallowing (Odynophagia) Gagging, vomiting, neck or throat pain

Excessive salivation

Retrosternal pain

Fever occasionally

Patient may present with vague symptoms such as fever, abdominal pain or vomiting if the FB has already reached stomach or small intestine.

Management ( FB in digestive tract)

Most children who have swallowed a FB do not require specialized care. Providing comfort while transporting to the emergency department (ED) is all that is required.

The 1st thing to carry out in the ED is to send radiological investigation to localize the site of FB impaction (at airway or GI tract)

-X-ray soft tissue neck (STN): AP & lateral views

-Chest X-ray : AP & lateral views

-X-ray abdomen: erect view

If the FB has already reached the stomach or intestine, it is less likely to cause complications. In 90% of cases it passes uneventfully. Patient is asked to locate FB in feces. …..

Patient with drooling may require suction.

Keep the child along with their parents.

In a spontaneously breathing patient Do not attempt to dislodge the FB by giving abdominal thrust or any syrup. There is a risk of esophageal tearing or Perforation.

NB: esophageal perforation can lead to dreadful complication like Mediastinitis.

Definitive treatment: If the FB is seen impacted pharynx or esophagus, it must be removed immediately using a Pharyngoscope or a Oesophagoscope.

FB in the airway tract

a) Partial airway obstruction

Physical signs and symptoms:

Child will cough forcefully; reflex coughing. Wheezing may be seen between coughs. Child is able to breathe, though with some

difficulty . Gagging may be present. No signs of cyanosis appear.

PABC assessment and management

Position lateral decubitus position with head down.

The child will cough spontaneously which may be adequate to clear out the aspirated object and clear the airway (A).

Once a patent airway is obtained, the signs and symptoms cease on their own.

b)Total airway Obstruction

Physical signs and symptoms:

Patient grasps the throat (universal sign of choke)

Inability to speak (aphonia)

Inability to cough

Inability to breathe in spite of

respiratory movements

Cyanosis

Loss of consciousness if not

managed on time

Cardiac arrest finally

PABC assessment and management

The management differs depending on the child is conscious or unconscious.

The goal is to remove the foreign body from the airway.

a. Conscious child

The abdominal thrust or the Heimlich maneuver is used to expel the foreign body.

It acts like an artificial cough rapid increase in intra-thoracic pressure thus helping expel the foreign body.

Procedure:

NB: Heimlich maneuver employed for adults or children> 1 year old.

Studies have shown that the Heimlich maneuver has improved the mortality of the patients with complete airway obstruction but use of it in partial obstruction can produce complete obstruction.

Other Procedures employed in children:

Infant Chest Thrust: 4 blows given on sternum with thrust by heel of hand.

Back blows: 4 blows on the middle of back.

b. Unconscious child

o Position Trendelenburg position Open airwayby head tilt-chin lift-jaw thrust

maneuver

Stand next to the child’ship.

o Place heel of one hand slightly above umbilicus ,but below the xiphoid. Place second hand on top of the first hand. ….

Perform 5 thrusts in an inward and upward direction.

This should be followed by a finger sweep in child’s mouth to look for FB, if any.

If the object is still not dislodged and the patient is in respiratory distress, Cricothyroidotomy should be considered.

Cricothyroidotomy: It is an incision made through skin and cricothyroid membrane to establish a patent airway.

5.Local Anesthesia (LA) Over dosage Most commonly used drugs in dentistry are LAs. Self-limiting. Young children are likely to experience toxic

reactions because of their low weight and immature physiology.

Maintenance of ABC and oxygen are probably the only measures indicated

Causes of LA toxicity

Exceeding recommended LA dosages

Accidental IV injection

Repeated injection

Rapid injection

Idiosyncratic reaction (not related to drug dosages)

Simple measures to prevent an LA overdose

reaction are :

o Calculating the proper dose for each individual (max dose =4.4 mg/kg body weight for 2% Lidocaine with 1:100,000 adrenaline )

Aspiration before injecting ( to detect intravenous injection)

Slow rate of injection (1 ml/minute) Proper systemic history.

Clinically LA overdose reactions are manifested as: Slurred speech, dizziness,anxiety,confusion,

convulsions

followed by a proportional phase of depression (drowsiness, shallow breathing,unconsiousness).

a. Mild Over dosage Reaction:

Mild over dosage reaction of rapid onset is seen within 5-10 minutes of administration.

Causes: intravascular injection or administration of a large dose.

Physical signs and symptoms

Confused, talkative. Slurred speech Ringing ears (tinnitus) Facial muscle twitching Blurred vision Dizziness

PABC assessment and management

Position based on patient comfort; usually supine.

ABC is usually adequate. If PaCO2 gets low, patient should be asked to

hyperventilate by deep breathing of room air or breathe oxygen via a full face mask.

Definitive Therapy

Monitor the vital signs. No other drug treatment is indicated. Self-limiting with time.

b. Severe Over dosage Reaction

Severe over dosage reaction of rapid onset– seen in seconds.

Can occur during the injection. Intravascular injection is the likely cause.

Physical signs and symptoms

Signs and symptoms appearing almost immediately. Generalized tonic clonic seizures. Loss of consciousness.

PABC assessment and management

Shift the patient to supine position with legs elevated. Assess ABC quickly. Administer oxygen as quickly as possible. Good ventilation helps in termination of the seizure

along with adequate oxygenation of the brain.

Definitive therapy

If loss of consciousness was the only sign, proper positioning will return consciousness rapidly and syncope was probably the cause.

If patient does not regain consciousness, dial emergency medical care as a precautionary measure.

Monitoring vital signs with adequate ventilation is usually sufficient because anesthetic blood level will gradually fall below the seizure threshold and seizures will cease.

Prevention of injury due to seizures is the primary aim of seizure management.

….

Drug administration like diazepam is unnecessary in most cases because the period of excitement will be followed by a period of depression. This phase of depression will be magnified by the administration of a depressant drug like diazepam.

Generally adequate maintenance of PABC will gradually return the consciousness, BP, Pulse rate to base line levels.

6.Acute Adrenal Insufficiency Usually manifests in children receiving or who

have received corticosteroid therapy continuously for two weeks or longer.

In these children, normal release of increased amounts of endogenous glucocorticosteroids during stressful situations is prevented resulting in an acute adrenal attack.

Physical Signs and Symptoms

o weakness Mental confusion. Intense pain in the abdomen, lower back and

legs. Nausea and vomiting. Loss of consciousness if not managed. Low blood pressure

PABC Assessment

Position: supine position with legs elevated slightly. Assess ABC quickly. Administer oxygen.

Definitive Therapy

Dial medical assistance.

Administer 2 ml of 100 mg hydrocortisone sodium succinate preferably IV

Administer IV fluids ( 1 lit normal saline within an hour)

Monitor vital signs especially for hypertension.

Dental considerations for patient undergoing

long term corticosteroid therapy

Early morning appointments (cortisol level is highest in the morning).

Anxiety control.

Increased administration of glucocorticoids (double the dose) before any surgical procedure.

Systemic antibiotic therapy.

7.Hypoglycemia

Diabetic patient -Type I or II

Dental treatment modifications are required specially for type I diabetes patient.

Chances are that he /she might miss or avoid his meal before his dental appointment after taking his daily dose of insulin = Most common cause of hypoglycemia

Patient should be asked to take his usual dose of insulin &normal meal before visit.

If daily insulin dose > 40 units daily ,then a medical consultation should be arranged before dental appointment.

Antibiotic regimen –before undergoing surgical procedures.

Type II diabetic patient less prone to acute fluctuations in blood glucose

Any known diabetic who is unconscious should be treated for hypoglycemia.

Presenting signs and symptoms:

Weakness Dizziness Confusion Headache Palpitation, tremors Moist skin (sweating) Altered level of consciousness i.e bizarre behaviour

or change in personality Loss of consciousness and GTCS if not managed.

Conscious patientPABC assessment and management

Position (P) patient comfort. ABC is assessed Generally adequate at this stage

Definitive therapy

Oral carbohydrate like orange juice, sugar or a candy repeated every 5 minutes till recovery.

Unconscious patient

PABC assessment and management:

Position( P) supine position with legs elevated slightly

Assess and maintain ABC.

Administer oxygen if necessary. But the underlying problem of low blood sugar has to be corrected for consciousness to be regained.

Definitive therapy

Dial medical emergency care.

Give 50 % dextrose IV over 1 minute.

If patient doesn’t respond to glucose, administer glucagon 1mg IM. Repeat same dose after 20 mins. if required. Glucagon leads to elevation of blood glucose level by breaking down glycogen stores in liver. Recovery in 20- 40 minutes.

If glucagon or glucose is not available immediately, a thick paste of concentrated glucose (cake, cream, honey or syrup) can be placed in the buccal fold safely

Once conscious ,the individual is administered oral source of carbohydrates.

Dental considerations for diabetic patients

Morning appointments should be made.

For patients receiving insulin therapy, appointments should be made in such a way that the dental considerations for a diabetic patient doesn’t coincide with the peaks of insulin activity.

It should be ensured that proper diet has been taken before each visit.

Measurement of blood glucose before treatment. If <70mg/dl- oral carbohydrate should be given. If blood glucose is high, physician consultation before

any surgery.

Antibiotic coverage for patients with overt infection or those undergoing extensive oral surgical procedures.

Aspirin and aspirin containing compounds should be avoided (salicylates like aspirin inhibit glucose production)

8. Acute asthmatic attack:

It is a common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm.

Asthma is classified into 2 categories; extrinsic (allergic asthma) and intrinsic (non-allergic asthma).

Extrinsic asthma occurs more often in children. It is triggered by specific allergens such as pollens, dust, molds and highly allergenic foods such as milk, eggs, fish, chocolate, shellfish and tomatoes.

Drugs and chemicals such as penicillin and aspirin can trigger an allergic asthmatic attack.

The goal of management relieve the bronchospasm associated with the attack.

Physical signs and symptoms

Rapid onset of severe breathlessness with use of accessory muscles of respiration.

Tightness or heaviness in the chest. Coughing spell with or without sputum production. Characteristic expiratory wheeze Dyspnea Sits up fighting for air (air hunger) Tachypnea Anxiety Cyanosis of mucous membrane and nail beds. Eventual loss of consciousness if not managed.

PABC management

Suspend the dental procedure and raise the patient to a comfortable position.

Clear all dental materials and secretions from the oral cavity

Position (P)erect /semi erect. Assess Breathing(B) and circulation(C) quickly.

The management of an asthmatic patient begins with the pretreatment history. Ask the patient:

• How attacks occur and their severity

• What triggers attacks

• What medications are taken.

Definitive therapy

2 puffs of salbutamol containing 100ugm/puff through an inhaler

Can also use his own bronchodilator; the one the patient carries with him.

Procedure:

o The inhaler is placed in the mouth.

o As the patient breaths in slowly

through their mouth, they press

down on the inhaler one time.

The patient continues breathing as deep as they can and holds their breath for 10 seconds.

Improvement should occur within 15 seconds.

o If after three doses of the bronchodilator there is no improvement, take additional measures:

Administer 100 % oxygen

Call for medical assistance

Administer epinephrine 0.3 ml 1:2000 concentration.

If possible, determine the cause of the attack (anxiety, air contaminants)

Dental considerations for asthmatic patient

Steroid prophylaxis needs to be used with patients who are taking long term corticosteroid therapy.

The dental office must be comfortable & warm enough. Cold air & sub-normal temperatures can trigger asthmatic attack.

Patient must continue the usual dose of regularly taken bronchodilator. Abrupt withdrawal before any dental procedure can precipitate the attack.

Chest infections must be treated adequately by antibiotics before any surgical procedure. …..

Use technique to reduce patient stress:

Avoid prolonged supine positioning

Avoid nitrous oxide in people with severe asthma.

Avoid using barbiturates and narcotics

Most of the asthmatics are allergic to aspirin so a careful history concerning the use of these types of drugs should be elicited. Drugs like beta blockers, ACE inhibitors, sulphites (used in sanitizers) should also be avoided.

Avoid dental materials that may precipitate an attack. Materials without methylmethacrylate should be considered. ….

….

Rubber dams should be used cautiously.

Avoid using LA containing sodium metabisulfite.

Care should be used in positioning suction tips as it may elicit cough reflex.

Use vasoconstrictor judiciously.

If specific allergens are known to cause an attack, the dentist should make attempts to eliminate these elements from the office.

Conclusion

Although pediatric medical emergencies are a rare occurrence in the dental office, when it does occur, it is important the dental doctor is well trained in emergency management and timely treatment is administered to the physically and physiologically immature pediatric patient.

Preparation includes:

the use of comprehensive medical and dental histories

at minimum BLS training

initiation of an office emergency team

organization of an emergency drug kit and equipment

periodic reviews and simulation.

REFERENCES

Principles and practice of PedodonticsArathi Rao 2nd Edition

Burket’s oral medicine 11th edition

Nelson textbook of pediatrics

Medical emergencies in dental office

Stanley.F Malamed 6th edition

PEDIATRIC DENTISTRY: © The American Academy of Pedodontics.