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This article continues the theme of the September

2003 Journal: Managing Medical and Behavioral
Changes in Children.

Emergency Medicine in Pediatric

Dentistry: Preparation and Management
Stanley F. Malamed, DDS

A B S T R A C T edical emergencies can
and do occur in the
Medical emergencies can and do occur in the practice of dentistry. Although practice of dentistry.
Most medical emergen-
most emergencies take place in adults, serious problems can also develop in cies develop when the
patient, commonly an
younger patients. The contemporary dentist must be prepared to manage expedi-
adult, is fearful or has inadequate pain
tiously and effectively those few problems that do arise. Basic life support (as control. The most common emergen-
cies noted in adult dental patients in-
necessary) is all that is required to manage many emergency situations, with the clude syncope (less than 50 percent),
non-life-threatening allergy, acute
addition of specific drug therapy in some others. Preparation of the office and anginal episodes, postural hypoten-
sion, seizures, acute asthmatic attacks,
staff includes basic life support (annually), pediatric advanced life support, devel- and hyperventilation.1
In the pediatric patient, the most
opment of an emergency team, consideration for emergency medical services, common emergency situations seen in
dentistry are associated with drug ad-
and the availability of emergency drugs and equipment with the ability to use
ministration, most often local anesthet-
these items effectively. As with the adult patient, effective management of pain ics and/or central nervous system de-
pressants used for sedation. It is this au-
(local anesthesia) and anxiety (behavioral management, conscious sedation) will thors firm belief that the most likely
scenario for a serious drug-related emer-
minimize the development of medical emergencies.
Author / Stanley F. Malamed,
DDS, is a professor of anesthesia
and medicine at the University of
Southern California School of

OCTOBER . 2003 . VOL . 31 . NO . 10 . CDA . JOURNAL 749


gency developing in dentistry is the fol-

lowing: a younger, lighter-weight child
receiving multiple quadrants of dental
treatment in the office of a younger,
less-experienced, nonpediatric dentist
(i.e., general practitioner).2
All dental practices must be pre-
pared to manage potentially life-threat-
ening emergencies, be the patient a
child or adult. The following sections
review the preparation of the dental of-
Figure 1. Mouth-to-mask ventilation. Figure 2. Head tilt-chin lift.
fice and staff to successfully manage
medical emergencies that might arise in
younger patients in the dental office. California has mandated BLS for li- be taught as mouth-to-mask ventila-
The definitions of victims by age3 censure for many years. However, pos- tion, not mouth-to-mouth (Figure 1).
are as follows: session of a valid CPR card is no guar- The importance of BLS as prepara-
Infant: < 1 year antee that BLS can be adequately per- tion for managing medical emergencies
Child: 1 to 8 years formed. In an unpublished study of en- in children is highlighted by the fact
Adult: 8 years tering postdoctoral students (residents that the primary etiology of cardiac ar-
in endodontics, periodontology, rest in children is airway problems, usu-
Preparation prosthodontics, pediatric dentistry, oral ally airway obstruction or respiratory ar-
The following four assets are critical and maxillofacial surgery, orthodon- rest (as might occur with overly deep
in preparing the office and staff to rec- tics, and general practice) at the USC conscious sedation). The young childs
ognize and effectively manage medical School of Dentistry, 30 students chal- heart is normally healthy. Coronary
emergencies: lenged the BLS-recertification course artery disease is essentially nonexistent
The ability to properly perform that is mandatory for them. All had in this age group. However, the healthy
basic life support; been certified in BLS at the health care young heart will cease beating when de-
A functioning dental office emer- provider level within the previous six prived of oxygen for a prolonged period.
gency team; months. 4 The challenge consisted of At the moment a pediatric cardiac arrest
Access to emergency assistance; completing a 25-question written ex- occurs, there is no residual oxygen re-
and amination with a grade of 80 percent or maining in the victims blood (all avail-
The availability of emergency better, and demonstrating adequate able oxygen has been utilized by the
drugs and equipment. performance at one-person BLS on an dying cells). Acidosis and cellular (bio-
adult victim. Only four of the students logical) death develop rapidly. U.S. sur-
Basic Life Support successfully challenged the course (13 vival rates from out-of-hospital cardiac
Basic life support (or cardiopul- percent). Most were unable to perform arrest in pediatric patients is from 3 per-
monary resuscitation) is the single most adequate one-person CPR on an cent to 17 percent, and survivors are
important step in preparation of the of- adult victim for one minute. often neurologically devastated.5,6 By
fice and staff to successfully manage Recertification in BLS is recom- contrast, cardiac arrest in adults usually
medical emergencies. BLS for health mended annually (in most venues, CPR develops secondary to advanced coro-
care providers is defined as: Position, cards have a two-year expiry date). BLS nary artery disease. At the moment the
Airway, Breathing, Circulation, and instructors should be brought into the adult heart goes into arrest, there re-
Defibrillation. Most states mandate BLS dental office, with mannequins placed mains a reservoir of oxygen in the blood
certification for licensure to practice as in the dental chair and on the floor in and tissues that will be utilized before
a dentist. The majority of states also re- the reception room. It should be cellular death occurs.
quire BLS certification for dental hy- mandatory for all office personnel to The very basic step of airway man-
gienists, and some mandate certifica- participate in this training. For health agement (head tilt-chin lift) is critically
tion for dental assistants. care providers, rescue breathing should important in saving the life of a child.

750 CDA . JOURNAL . VOL . 31 . NO . 10 . OCTOBER . 2003

Pediatric Advanced Life Support Box
Because children are different from Pediatric Advanced Life Support
adults, the author recommends that the
dentist and staff in offices where signifi- Course Outline
cant numbers of younger patients are The Chain of Survival and Emergency Medical Services for Children*
treated successfully complete a course in Basic Life Support for the PALS Health Care Provider*
pediatric advanced life support.7 Airway, Ventilation, and Management of Respiratory Distress and Failure*
Similar to BLS, PALS stresses basic Fluid Therapy and Medications for Shock and Cardiac Arrest
and advanced life support techniques Vascular Access*
for younger patients. Offered through Rhythm Disturbances
organizations such as hospitals, pedi- Postarrest Stabilization and Transport
atric dental societies, and private edu- Trauma Resuscitation and Spinal Immobilization
cational providers, the course outline is Children with Special Health Care Needs*
presented in the box on this page. Toxicology*
Neonatal Resuscitation
PEDO Rapid Sequence Intubation
PEDO is the acronym for Pediatric Sedation Issues for the PALS Provider*
Emergencies in the Dental Office, a di- Coping with Death and Dying
dactic and clinical course in emergency Ethical and Legal Aspects of CPR in Children*
medicine designed for the entire staff *Denotes subjects of special interest to dentists treating children
of the pediatric dental office.
Sponsored by the American Academy
of Pediatric Dentistry, the course pro- Table 1
vides in-depth, hands-on training in
the prevention and management of Office emergency team
specific emergency situations that arise Team member Responsibilities
more commonly in children.a Member #1 1. Remain with victim
(first person on scene 2. Activate office emergency system
Emergency Team of emergency) 3. Basic life support as necessary
The dental office emergency team Member #2 1. Bring emergency equipment* to scene
consists of three individuals, each as-
signed specific tasks to perform, as out- Member #3 1. Assist as necessary
(and other members of a. Activate emergency medical services
lined in Table 1. the dental office staff) b. Meet and escort EMS to office
All members of the office emer- c. Assist with basic life support
gency team should be interchangeable. d. Prepare emergency drugs for administration
Although the proper and effective man- e. Monitor and record vital signs
agement of the emergency situation is *Emergency equipment includes oxygen supply, emergency drugs, and, when appropriate, an automated external
ultimately the dentists responsibility, defibrillator

emergency management may be per-

formed by any trained individual under
supervision of the dentist. does not know what is happening; In an emergency, the ultimate responsi-
knows, but does not like, what is happen- bility of the treating dentist is to keep
Access to Emergency Medical Services ing; or ever feels uncomfortable with the the victim alive until he or she recovers
Assistance in managing an emer- situation. The dentist should seek help as or help arrives on scene to take over
gency should be sought as soon as the soon as possible in these situations. management of the situation. Though
treating doctor feels it is needed, and a In virtually all situations, the most exceptions may exist, in most areas of
feeling it is indeed. Emergency medical practical course for getting help is to California, EMS can be expected to ar-
services should be sought if the dentist activate the EMS system by calling 911. rive on scene within five to 10 minutes.

OCTOBER . 2003 . VOL . 31 . NO . 10 . CDA . JOURNAL 751


Emergency Drugs and Equipment Table 2

Every dental office must have emer-
gency drugs and equipment, as listed in Recommended Dental Office Emergency Drugs
Tables 2 through 4. Minor modifica- Drug Indication Availability Recommended for kit
tions are necessary in offices where Epinephrine Anaphylaxis 1:1000 (adult) 1 preloaded syringe
children are treated (colored rows in (Adrenalin) (0.3 mg/dose) and 3 x 1 mL
Tables 2 and 4). ampules of 1:1,000
In offices where central nervous sys- Epinephrine Anaphylaxis 1:2,000 (pediatric) 1 preloaded syringe
tem depressant drugs are employed for (Adrenalin) (0.15 mg/dose) and 3 x 1 mL
conscious sedation, antidotal drugs that ampules of 1:1,000
are available for specific sedative agents Diphenhydramine Allergic reactions 50 mg/mL 2-3 x 1 mL ampules
must be included in the emergency (Benadryl) of 50 mg/mL
drug kit (Table 3). If benzodiazepines
Oxygen All emergencies E cylinder + Minimum 1,
are used (e.g., diazepam, midazolam, tri- delivery devices preferable 2, E
azolam), flumazenil must be available. cylinders
Where opioids are employed, naloxone
Albuterol Bronchospasm Metered aerosol 1 aerosol inhaler
must be included in the emergency (Proventil, inhaler
drug kit. Single doses of these drugs Ventolin)
may be ineffective when administered
Sugar Hypoglycemia Orange juice, 12-ounce bottle of
to manage overdosage resulting from insta-glucose orange juice and/or
orally administered or long-acting ben- 1 tube of insta-glucose
zodiazepines and opioids.
Aspirin Suspected 325 mg tablets 1-2 sealed tablets
Basic Management infarction
As described above, basic manage-
Nitroglycerin Angina pectoris Metered spray 1 Nitrolingual
ment of all medical emergencies fol- pumpspray
lows the PABCD acronym, (position-
ing, airway, breathing, circulation, and
definitive care [in the BLS acronym, D Table 3
is defibrillation]).
It is first necessary to determine if
Antidotal Drugs
the patient is conscious or uncon- Drug Indication Availability Recommended for kit
scious. Unconsciousness is defined as Flumazenil Benzodiazepine 0.1 mg/mL 1 x 10mL
the lack of response to sensory stimula- (Romazicon) antagonist multidose vial
tion (e.g., lack of response to the
Naloxone Opioid antagonist 0.4 mg/mL 2 x 1 mL ampule of
shake and shout maneuver).9 (Nascan) 0.4 mg/mL

As the most common cause of loss people in acute respiratory distress (e.g., Seeing the victims chest moving does
of consciousness is hypotension, all un- acute asthmatic bronchospasm) auto- not guarantee that he or she is actually
conscious patients are placed, at least matically assume an upright position to breathing (exchanging air), but simply
initially, in a supine position with their improve ventilation. that he or she is trying to breath.
feet elevated slightly. This position pro- Hearing and feeling the exchange of air
vides an increase in cerebral blood flow Airway and Breathing against the rescuers cheek is the only
with a minimum of interference with In the unconscious person, the head indication of successful ventilation.
respiratory efforts.10 Conscious people tilt-chin lift maneuver must be per- In the absence of spontaneous respi-
experiencing a medical emergency are formed (Figure 2) followed by an assess- ratory efforts (e.g., chest not moving),
placed in whatever position they find ment of ventilation (look, listen, feel). controlled ventilation must be per-
most comfortable. As an example, most An important point to remember: formed as expeditiously as possible. With

752 CDA . JOURNAL . VOL . 31 . NO . 10 . OCTOBER . 2003

Table 4 the episode of bronchospasm does not
terminate following two adequate doses
Suggested Dental Office Emergency Equipment of the bronchodilator.
Device Availability Recommended for kit
Automated external Many 1 AED (pediatric AEDs are
Generalized Tonic-Clonic Seizure
defibrillator available)8 (Grand Mal Seizure)
Recognition: Period of muscle
Face masks Various sizes for children Several pediatric masks and
rigidity (about 20 seconds) followed by
and adults adult mask
alternating muscle contraction and re-
Dispoable syringes and 2 mL syringe with 20-gauge 2-3 sterile, disposable laxation lasting for about one to two
needles needle syringes
Spacer for bronchodilator Various manufacturers 1 spacer P: Position supine.
inhaler A, B, C: Assessed as adequate (respi-
ratory and cardiovascular stimulation
a full face mask and positive pressure should be undertaken. If a diagnosis is usually occur during seizure).
oxygen, the patient older than 8 is venti- made but appropriate treatment is not D: (1) Protect victim from injury.
lated at a rate of one breath every five available or if the cause of the problem Keep victim in the dental chair; gently
seconds, whereas a rate of one breath remains unknown, EMS should be hold onto arms and legs, preventing
every three seconds is used for the infant sought immediately. Definitive man- uncontrolled movements, but do not
and child victim.11 Each individual ven- agement of several common pediatric hold so tight as to prevent limited
tilation should cease when the chest is emergencies follows. movement.
seen to rise, as overventilation leads to (2) If parent or guardian is avail-
gastric distension and regurgitation. Specific Emergencies able, bring him or her into the treat-
ment room to assist in assessment of
Circulation Acute Bronchospasm (Asthmatic victim.
In pediatric medical emergencies, it Attack) (3) Summon EMS if parent or
is likely that a palpable pulse will be pre- Recognition: Conscious patient in guardian of patient suggests it, or if the
sent, especially in situations in which acute respiratory distress, demonstrat- seizure continues for more than two
the airway and breathing are adequately ing wheezing, supraclavicular and in- minutes.
and rapidly assessed and supported. tercostal retraction. Remember: Do not place any-
Remember: Airway problems (e.g., P: Position comfortably usually thing between the teeth of a con-
obstruction, apnea) are the most com- upright vulsing person.
mon cause of cardiac arrest in infants A, B, C: Assessed as adequate Most generalized tonic-clonic
and children. (Victim is conscious and able to speak.) seizures will stop within one minute
Palpation of the carotid artery pulse D: (1) Administer bronchodila- and almost always within two minutes
is preferred in children 1 year or older tor. If patients inhaler is available, (thus the recommendation to seek EMS
and adults, whereas the brachial pulse is allow him or her to use it. If the pa- with prolonged seizure activity). At the
preferred in infants younger than 1 year. tient is younger and the parent or termination of the seizure, P, A, B, C, D
In the absence of a palpable pulse, chest guardian is available, bring him or her must be reassessed, as follows:
compression must be commenced, and into the treatment room to assist in P: Position supine.
EMS summoned immediately. administration of bronchodilator. A, B, C: Assessed and managed as
Many younger children require the needed. In most (but not all) post-
Definitive Care use of a spacer to obtain adequate re- seizure situations, A must be managed,
Following assessment and imple- lief with the inhaler. but B and C are assessed as adequate.
mentation of the required steps of BLS, (2) Administer oxygen, via face- D: With help from the parent or
the dentist must seek to determine the mask or nasal canula at a flow rate of 3 guardian, try to communicate with the
cause of the problem (i.e., make a diag- to 5 liters per minute. patient, who is likely in a state similar
nosis). Where a diagnosis is possible (3) Summon EMS if parent or to a deep physiologic sleep. Following a
and appropriate treatment available, it guardian of the patient suggests it, or if generalized tonic-clonic seizure, the

OCTOBER . 2003 . VOL . 31 . NO . 10 . CDA . JOURNAL 753


victim is quite disoriented. As the par- to a dose of 1.0 mg if an opioid was ad- anesthetic-induced seizure often ceases
ent or guardian has seen this and done ministered. Naloxone may be adminis- in less than one minute. In the absence
this before, allow him or her to talk tered intramuscularly, in a dosage of of an adequate airway and ventilation,
with the patient to reorient the patient 0.01 mg/kg every two to three minutes carbon dioxide is retained, the patient
to both space and time. until the patient is responsive. becomes acidotic, and the seizure
Remember: Most morbidity and Remember: Specific antidotal ther- threshold of the local anesthetic de-
mortality associated with seizures oc- apy may not be effective following the creases, leading to more prolonged and
curs in the postseizure period because oral administration of central nervous more intense seizure.13
the rescuer does not do enough for the system depressants; and antidotal (2) Unconsciousness the basic
victim (P, A, B, C) therapy should be administered intra- protocol for management of the un-
venously, if possible. Naloxone may be conscious patient is followed when a
Sedation Overdose administered intramuscularly. local anesthetic overdose manifests it-
Recognition: Lack of response to self as loss of consciousness. Proper
sensory stimulation. management of airway and breath-
Consider. An overdose of sedation ing, as needed, will minimize occur-
is general anesthesia. Effective manage- Basic life support rence of cardiac arrest. As the cerebral
ment of a patient receiving general concentration of the local anesthetic
anesthesia is predicated on airway man- (as necessary) is decreases (through redistribution of
agement and breathing. Therefore, this the drug out of the brain) conscious-
should not represent an emergency in all that is required ness returns.
the office of a doctor who is trained to (3) Summon EMS if consciousness
administer general anesthesia to chil- to manage many is not restored in two minutes or if the
dren or adults. patient is not breathing.
P: Position supine. emergency
A, B, C: Assessed and managed as Final comments
necessary. In most cases, A alone is re- situations, with the Medical emergencies can and do
quired; whereas A and B will be needed occur in the practice of dentistry.
in a few situations. C will generally be addition of specific Although most emergencies take place in
present if A and B are properly assessed adults, serious problems can also develop
and managed. drug therapy in in younger patients. The contemporary
D: (1) Monitor patient, using pulse dentist must be prepared to manage ex-
oximeter b (and blood pressure and some others. peditiously and effectively those few
heart rate/rhythm). problems that do arise. Basic life support
(2) Stimulate patient periodically (as necessary) is all that is required to
(verbally and/or squeezing the trapez- manage many emergency situations,
ius muscle) seeking response. Local Anesthetic Overdose with the addition of specific drug thera-
3) Antidotal therapy: If sedative A true overdose of local anesthetic py in some others. Preparation of the of-
drugs were administered parenterally, should be always preventable.2 fice and staff includes basic life support
and intravenous access is available, ad- Recognition. Generalized tonic- (annually), pediatric advanced life sup-
minister flumazenil IV in a dose of 0.2 clonic seizure or unconsciousness, gen- port, development of an emergency
mg (2 mL) in 15 seconds waiting 45 erally developing five to 40 minutes team, consideration for emergency med-
seconds to evaluate recovery where after local anesthetic administration. ical services, and the availability of emer-
benzodiazepines were administered. If P: Position supine. gency drugs and equipment with the
recovery is not adequate at one minute, A, B, C: Assessed and administered ability to use these items effectively. As
an additional dose of 0.2 mg may be as needed. with the adult patient, effective manage-
administered. Repeat every minute D: (1) Generalized tonic-clonic ment of pain (local anesthesia) and anxi-
until recovery occurs or a dose of 1.0 seizure follow protocol for ety (behavioral management, conscious
mg has been delivered. Titrate nalox- seizures (above). With proper airway sedation) will minimize the development
one IV at 0.1 mg. (0.25 mL) per minute management and ventilation, a local of medical emergencies. CDA

754 CDA . JOURNAL . VOL . 31 . NO . 10 . OCTOBER . 2003

Notes / a. PEDO contact the American Academy
of Pediatric Dentistry for dates of future PEDO
courses. www.aapd.org, 800.544.2174.
b. The doctor using oral sedation (in children
younger than 13) or parenteral (intramuscular or
intravenous) sedation must have a pulse oximeter
in the dental office, as per the Dental Practice Act,
Part 3, California Code of Regulations.

References / 1. Malamed SF, Managing medical

emergencies. J Am Dent Assoc 124:40-53, 1993.
2. Malamed SF, Allergic and toxic reactions to
local anesthetics. Dent Today 22:114-21, 2003.
3. International Consensus on Science.
Guidelines 2000 for cardiopulmonary resuscitation
and emergency cardiovascular care. Circulation
102(suppl):1-23, 2000.
4. Malamed SF, Retention of BLS skills by post-
doctoral students at a US dental school.
Unpublished results, 1999.
5. Pitetti R, Glustein JZ, Bhende MS,
Prehospital care and outcome of pediatric out-of-
hospital cardiac arrest. Prehosp Emerg Care 6:283-
90, 2002.
6. Schindler MB, Bohn D, Cox PN, et al,
Outcome of out-of-hospital cardiac or respiratory
arrest in children. N Engl J Med 335:1473-9, 1996.
7. American Heart Association, PALS Provider
Manual. American Heart Association, Dallas, 2002,
8. Malamed SF, Automated external defibrilla-
tors, part 2: application. Dent Today 22:52-5, 2003.
9. American Dental Association, Council on
Dental Education, Guidelines for teaching the
comprehensive control of pain and anxiety in den-
tistry. J Dent Educ 36:62-7, 1972.
10. Erie JK, Effect of position on ventilation.
In Faust RJ, ed, Anesthesiology Review. Churchill
Livingstone, New York, 1991.
11. American Heart Association. Handbook of
Emergency Cardiovascular Care for Healthcare
Providers. American Heart Association, Dallas,
12. Bachmann-MB, Biscoping J, et al,
Pharmacokinetics and pharmacodynamics of local
anesthetics (in German), Anaesthesiol Reanim
16:359-73, 1991.

To request a printed copy of this article, please

contact / Stanley F. Malamed, DDS, USC School of
Dentistry, 925 W. 34th St., Los Angeles, CA 90089-
0641, malamed@usc.edu.

OCTOBER . 2003 . VOL . 31 . NO . 10 . CDA . JOURNAL 755