Medical Emergencies in Pediatric Dentistry

Abstract

Medical emergencies that are life threatening can occur in dental practice. Complications may arise because of an underlying disease or a reaction to medication. Reactions to medications may be allergic and toxic. The most common reactions are toxic reactions to local anesthetics, whereas allergies occur mainly as a consequence of the application of antibiotics, usually penicillin. In response to stress, vasovagal syncope typically occurs. Other causes may be related to an underlying disease-specific pathology (such as acute asthma attack, diabetic ketoacidosis, hypoglycemia, or seizures) or accidents (aspiration of a foreign body causing obstruction of the respiratory system). For all the above conditions, guidelines have been established that need to be known. If complications occur or necessary measures are not taken, it can lead to cardiac and respiratory arrest. Therefore, cardiopulmonary resuscitation is needed. All procedures and dosages should be adapted to the age of the child.

Introduction

Life threatening emergencies can occur in the medical dental office. Most recommendations for treatment of emergencies which can be found in the recently published literature refer to adult patients (1). Since children are not miniature adults, it is necessary to adapt the approach (2). Recommendations for treating emergencies in children have not yet been sufficiently addressed.

A dentist should perform each procedure in a way to avoid unnecessary complications. To prevent or reduce complications, it is necessary to take a detailed medical history, document all of the child’s previous and current diseases, and, if necessary, consult with the referring general practitioner (GP) or pediatrician. Sometimes it can be necessary to administer premedication. If a child suffers from a serious illness, which could lead to life-threatening complications during the procedure, the surgery should be postponed and performed in a hospital setting (1).

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 (3, 4).

The equipment used must be adapted to the patient’s age, for example there are different sizes of breathing masks (Figure 1) and oropharyngeal (Figure 2) or endotracheal tubes, which must be properly selected because if the size is not adequate, the efficiency is not adequate.

Figure 1.

Breathing mask

Figure 2.

Oropharyngeal Guedel tubes, sizes marked by colors

An oropharyngeal tube (Figure 3) 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 of an adult patient (5).

Figure 3.

Location of oropharyngeal tube

Ischemic heart disease

Ischemic heart disease includes angina pectoris and myocardial infarction.

Symptoms: sudden retrosternal pain that radiates to the neck, lower jaw, shoulders and arms (Figure 4), and can be manifested as a feeling of tightness and an inability to breathe (6).

Figure 4.

Spreading of retrosternal pain

Treatment: it is necessary to discontinue dental treatment, call an ambulance; administer dose of nitroglycerin 0.4 mg in tablets, sublingually and to stop the pain of angina pectoris; if the pain persists, myocardial infarction must be suspected and the patient given 325 mg aspirin and, if necessary, oxygen, while waiting for an ambulance (7, 8).

Cardiac arrest

Cardiac arrest is the sudden stopping of the heart. Cardiac arrest represents a marked inability to sense a clinical palpation of the pulse, loss of consciousness and apnea. 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 (Figure 5) 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 of 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 (2).

Figure 5.

Opening of airways by tilting the head and lifting the chin

The procedure for external cardiac massage in a small child is as follows (Figure 6): imagine a line that connects the nipples of a child. Put the following three fingers on the chest: index, middle and ring 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 ring fingers feel the zyphoid bone, move the little finger towards the imaginary line.

Figure 6.

Chest compressions in a young child

Procedure for external cardiac massage in a child (Figure 7): feel with the middle finger the zyphoid bone and place the index finger on the sternum, then put hands on the sternum to the point you had touched with the index finger and start the massage. During the massage, the elbows are extended. The zyphoid bone can be easily broken under direct pressure, which may cause profuse internal bleeding because of rupture of the liver and other internal organs. Therefore, for external cardiac massage, the instructions shown in Figures 5 and 6 must be followed.

Figure 7.

Chest compressions in an older child

Diabetic ketoacidosis

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 (9).

Hypoglycemia

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 (4).

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 (10).

Acute respiratory insufficiency resulting from obstruction of the airways

Upper and lower airways can be obstructed, and depending upon where the cause of the obstruction occurs, different symptoms will appear. Symptoms: obstruction of the upper airways is clinically manifested by coughing, cyanosis and inspirational stridor, while in the lower respiratory tract obstruction, cough is present along with shortness of breath, inspiratory - expiratory wheezing, shortness of breath and cyanosis. If obstruction persists it can cause loss of consciousness.

Treatment: If the child is coughing, encourage the child to do so, because a spontaneous cough is more effective in the treatment of obstruction than any other external process. Interventions are needed when coughing becomes ineffective, so when the child cannot talk, cry or breathe between coughs, do the following: first proceed with 5 strokes on the back with an open palm (Figure 8); if the obstruction is not resolved, apply the Heimlich maneuver (Figure 9) five times (the Heimlich maneuver is performed with the rescuer standing behind the victim and clasping his hands; one hand is made into a fist and placed on the child’s abdomen above the navel while the palm of the other hand holds the fist as they strongly press against the child’s belly and move upwards); if the child becomes unconscious and is not breathing, the child needs to be ventilated. If there are no signs of circulation, then chest compression is required (4). If the object causing the obstruction is not ejected with the above treatment procedures, it is necessary to perform a tracheotomy (11).

Figure 8.

Hitting the back with the open hand

Figure 9.

Heimlich maneuver

Tracheotomy procedure:

1. Determine the location of the section (Figure 10)

   1. With a thumb and forefinger, locate the hyoid bone

   2. Move the thumb and middle finger down to feel the thyroid cartilage

   3. Place the fingers even lower and locate the cricoid cartilage

   4. Pass the index finger over the cricothyroid membrane, which is located exactly in the middle, between the thumb and middle finger

2. Make a vertical incision in the thyroid cartilage to the cricoid (Figures 10 and 11)

3. In this section, feel the cricothyroid membrane with the finger

4. Make a horizontal incision through the membrane and turn the blade to expand the cut.

Figure 10.

Determination of vertical incision

Figure 11.

Site of vertical incision

Acute asthma attack

Asthma 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 (12). 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 (13, 14).

Syncope

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, has 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 (15).

Therapy: if the patient is placed in the Trendelenburg position (Figure 12), 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 there are not any medications available, it is possible to rub honey or a sweet drink in the buccal fold taking care to avoid aspiration (16).

Figure 12.

Patient in the Trendelenburg position

Epileptic seizure (grand mal)

The 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 (Figure 13). Then, the clonic phase occurs, which is characterized by contraction of the whole musculature (Figure 14). 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 (17). Treatment: move all of the instruments away from the patient and remove everything from the mouth that is there at the moment; 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 (Figure 15); 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 is required to go home accompanied by his or her parents (18).

Figure 13.

Tonic phase

Figure 14.

Clonic phase

Figure 15.

Patient in the lateral position

Toxic reactions

The most common cause of toxic reactions is local anesthetics (19). Toxic reactions occur because of rapid absorption of the drug into the blood stream, overdosing and intravascular injection (20, 21). Symptoms: confusion, slurred speech, tremors of the face and limbs, high blood pressure, rapid heartbeat and breathing, dizziness, nystagmus, headache, tinnitus, disorientation, loss of consciousness, tonic-clonic seizures. Following the first phase of excitation, the patient subsequently passes through a depression of the nervous system and experiences a reduction in blood pressure, heart rate and respiratory rate (22, 23).

Treatment: place the patient in a supine position, check circulation, breathing and air flow; if the patient exhibits tonic-clonic convulsions, it is necessary to ensure the supply of oxygen; then the clonic phase lasts less than one minute. If the supply of oxygen is not secured, the patient enters acidosis because of CO₂ retention; be sure to secure the airway and allow for normal breathing; if any phase lasts longer than two minutes and the patient is not breathing, call an ambulance (24, 25).

Anaphylactic reaction

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 sensitized 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) (26, 27).

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 (28, 29).

Conclusion

Most of the regulations and guidelines for emergency responses refer to the adult population. Working with children is more difficult because of their young 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 also have a defibrillator (30).