1. MEDICAL EMERGENCIES IN THE
PEDIATRIC DENTAL PRACTICE;
PREPARATION AND MANAGEMENT
Renu Thapaliya
BDS 4TH year, Roll no: 47
Kantipur Dental college

2. CONTENTS
 Introduction
 Common medical emergencies encountered in
pediatric dental clinic
 Necessary preparations for the emergency
 Identification and management of specific
conditions
 Conclusion
 References

3. 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.

4. COMMON EMERGENCIES ENCOUNTERED
IN DENTAL CLINIC
 Syncope
 Seizures
 Anaphylactic allergic reactions
 Foreign body obstruction
 Local anesthesia overdose
 Acute adrenal insufficiency
 Hypoglycemia
 Acute asthmatic attack

5. 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.

6. 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

7. 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)

8. 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

9. A: Airway
• First, all the secretions in the oral cavity are
cleared 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 tongue
fall (i.e tongue falling on posterior pharyngeal
wall and obstructing airway)
• In case of foreign body obstruction, the airway
has to be cleared using blows or Heimlich
maneuver (to be discussed later)

10. B: Breathing
 Look Listen Feel
 Conscious and breathing
adequately monitor vital
signs and administer
supplemental oxygen
 Unconscious but breathing adequately
administer supplemental oxygen if required
with head tilt- chin lift to ensure open
airway.
 Monitor the vital signs and proceed to
assess circulation (C)

11. •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

12. 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:

13. 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.

15.  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.

16. 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.

17. 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

18. Differences between epileptic seizure and syncope

19. 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.

20. 2) SEIZURES
o Recurrent episode of altered cerebral function
associated with paroxysmal excessive and
hypersynchronous discharge of cerebral neurons.
 Dramatic appearancegeneralized
tonic clonic seizure (GTCS
or grand mal epilepsy)
 Status Epilepticus: a serious
condition that requires
immediate IV administration
of an anticonvulsant.

21. 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

22. 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.

23. 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. …..

24. 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.
…

25.  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.

26. 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

27. 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)

28. 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)

29.  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.

30. 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. ……

31.  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.

32. 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.

33.  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.

34. 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.

35. 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. …..

36.  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.

37. 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.

38. 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

39. 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:

40. 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.

41. 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 airwayby head tilt-chin lift-jaw thrust
maneuver
 Stand next to the child’s
hip.
o Place heel of one hand slightly above
umbilicus ,but below the xiphoid. Place second
hand on top of the first hand. ….

42.  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.

43. 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)

44. 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).

45. 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

46. 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.

47. 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.

48. 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.
….

49.  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.

50. 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

51. 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.

52. 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.

53. 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.

54. 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 patient
PABC assessment and management
 Position (P) patient comfort.
 ABC is assessed Generally adequate at this stage

55. 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.

56. 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.

57. 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)

58. 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.

59. 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.

60. 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.

61. 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.

62.  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)

63. 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. …..

64.  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.
….

65. ….
 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.

66. 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.

67. REFERENCES
 Principles and practice of Pedodontics
Arathi 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.