Medical Emergency in Dentalsetting

Brought to you by
Continuing Education
Management of Pediatric Medical Emergencies

in the Dental Office
Course Author(s): Steven Schwartz, DDS; Jayakumar

Jayaraman, BDS, MDS, FDSRCS, MS, PhD
CE Credits: 2 Hour(s)
Intended Audience: Dentists, Dental Hygienists, Dental
Assistants, Dental Students, Dental Hygiene Students, Dental
Assistant Students
Date Course Online: 05/11/2012
Last Revision Date: 11/18/2021
Course Expiration Date: 11/17/2024
Cost: Free
Method: Self-instructional
AGD Subject Code(s): 430, 142
Online Course: www.dentalcare.com/en-us/professional-education/ce-courses/ce391
Disclaimers:
• P&G is providing these resource materials to dental professionals. We do not own this content nor are we responsible for any material herein.
• Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures into their practice. Only
sound evidence-based dentistry should be used in patient therapy.
Conflict of Interest Disclosure Statement

• Dr. Schwartz was a member of the dentalcare.com Advisory Board. He has no relevant
financial relationships to disclose.
• Dr. Jayakumar Jayaraman reports no conflicts of interest associated with this course. He has no
relevant financial relationships to disclose.
Introduction – Pediatric Medical Emergencies

Successful management of medical emergencies by the Dentist requires preparation, prevention
and knowledge of definitive management. The responsibility is held just not by the dentist but
also by all dental staff members involved in the patient care. Although the primary focus of the
Management of Pediatric Medical Emergencies in the Dental Office is the pediatric dental patient,
adult medical emergencies should also be addressed, as necessary.
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Course Contents The dentist’s successful management of medical
• Overview emergencies requires preparation, prevention, and
• Learning Objectives knowledge of definitive management not just by the
• Introduction dentist but also by all dental staff members involved
• Preparation in the patient care.
• Medical and Dental History
• Staff Training and Duties Learning Objectives
• Emergency Medical Service Contact Upon completion of this course, the dental
• Refresher Training professional should be able to:
• Emergency Equipment and Drugs • Identify predisposing factors for medical
• Emergency Equipment emergencies.
• Emergency Drugs • Structure an effective office medical emergency
• Emergency Treatment team.
• Syncope • Choose the appropriate emergency drug kit
• Allergic Reactions and equipment.
- Anaphylactic Allergic Reactions • Recognize and provide definitive treatment
- Mild or Delayed Allergic Reactions for the following medical emergencies:
• Acute Asthmatic Attack • Syncope
• Anesthetic Toxicity (Overdose) • Mild and anaphylactic allergic reactions
• Allergic Reaction to Local Anesthetics • Acute asthmatic attack
• Anesthetic Reaction to Vasoconstrictors • Local anesthetic and vasoconstrictor toxicity
• Sedatives and Anxiolytic Agents (Overdose) • Hypoglycemia and hyperglycemia
- Benzodiazepine Overdose • Seizures
- Narcotic Overdose • Respiratory distress
• Diabetes Mellitus – Hyperglycemia/ • Drug overdose – benzodiazepines, narcotics
Hypoglycemia • Cardiac arrest
• Glucagon
• Seizures Introduction
- Grand Mal Seizures Although rare, medical emergencies do occur in
- Petit Mal and Absence Seizures the dental office. While the majority of medical
- Status Epilepticus emergencies occur in adult patients, pediatric
• Cardiac Arrest medical emergencies can occur too. Pediatric
• Conclusion medical emergencies occur quickly, without
• Course Test warning, and with possible severe consequences
• References due to the child’s under-developed physiology
• About the Author coupled with small oxygen reserves. Successful
resolution of the emergency requires early
Overview recognition of the problem and swift definitive
Although uncommon, pediatric medical treatment.1
emergencies can occur in the dental office. When
they do happen, they happen quickly without The primary focus of this course is the pediatric
warning and with possible dire consequences. A dental patient. However, adult medical emergencies
child’s under-developed physiology coupled with will also be addressed as adults accompany
small oxygen reserves requires early recognition pediatric patients to their appointments. Although
of the problem and swift definitive treatment. the child is the one receiving dental treatment, there
is a strong possibility it will be the accompanying
Since adults accompany the pediatric patient adult that will experience the emergency. The most
to the dental office, there is a strong possibility common medical emergency seen by dentists is
that the accompanying adult may present with syncope, and the vast majority of these events occur
the emergency. Although the primary focus of in adults.2
this course is the pediatric dental patient, adult
medical emergencies will also be addressed in this The dental office’s successful management of
course. medical emergencies requires preparation,
2
prevention, and response not just by the dentist situations and Basic Life Support (BLS). A
but by all dental staff members involved in the receptionist at the front desk will be the one
patient care. most likely to be alerted to an emergency in
the waiting area. All staff should be familiar
Preparation with the location of the emergency drug kit,
Adequate preparation for emergencies reduces monitoring and resuscitation equipment as
the possibility of an emergency occurring well as Emergency Medical Services (EMS).
and further complications if it does occur. For greater efficiency, each staff member
Preparation steps include: should be assigned a predefined role during
• Taking and reviewing a comprehensive an emergency. Periodically these roles should
medical and dental history. be reassigned to other personnel, so staff
• Providing minimum basic life support (BLS) is familiar with all aspects of emergency
training for providers and staff. management. An efficient emergency team
• Advanced Cardiac Life Support (ACLS) or can be organized with as few as two or three
Pediatric Advanced Life Support (PALS) staff. In offices where sedation and general
training, especially for those administering anesthesia is administered, training in PALS
sedation and general anesthesia. or ACLS is recommended for the Dentist and
• Initiation and coordination of an office in some states, this is required for the clinical
emergency team. staff. A suggested assignment of duties follows:
• Organizing an emergency drug kit and
equipment. Team member #1 is the first person on the
• Retraining on a regular basis. scene when the emergency occurs. Thus, every
staff member should be familiar with the Team
Medical and Dental History Member #1 duties since an emergency can
Taking a comprehensive medical and dental occur in any location within the office. After
history and noting not only contraindications to the initial activation of the emergency team, a
dental treatment but also previous medical and team with advanced training can assume the
psychological experiences that can precipitate role of Team Member #1. Upon discovery of an
a medical emergency is important. This alerts emergency patient:
the clinician and staff to any precautions or
preparations that need to be taken to avert and Team member #1 duties include:
manage an emergency. For example, a diabetic • Alerting other office staff members.
patient may not only have compromised • Activating BLS (Positioning, Circulation, Airway
healing but may undergo a hypoglycemic maintenance, Breathing, Definitive treatment)
incident because of low blood glucose level after assessing the victim’s responsiveness.
due to not eating or excessive stress before • Staying with the victim.
and during treatment. Patients and parents
of pediatric patients with previous negative Team member #2 duties include:
dental experiences may develop syncope prior, • Retrieval of the emergency drug kit, Oxygen
during, and post-treatment due to anticipated cylinder, monitoring equipment and
or unanticipated discomfort, the sight of dental automated electronic defibrillator (AED) to the
instruments, or upon seeing blood drenched emergency site.
gauze. The patient’s medical problems and • Assist with BLS.
related potential emergency situations should • Contact EMS, if deemed necessary and there is
be noted in a prominent location in the patient’s no other team member available.
chart so staff can prepare the necessary • Check the level of Oxygen in the cylinder daily.
emergency drugs and equipment prior to • Check the emergency kit weekly.
seating the patient. • Check the AED and monitoring equipment
weekly.
Staff Training and Duties
All staff involved in direct patient care should Team member #3 duties include:
receive training in recognition of emergency • Assist with BLS.
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• Consult with family accompanying patient Emergency Equipment and Drugs
as to previous history and management of Trained office personal must have the appropriate
emergency. emergency equipment and drugs available to
• Contact EMS, if deemed necessary. render definitive treatment when indicated. All
• Monitor vital signs. staff members should know where emergency
• Prepare emergency drugs for administration. equipment and drugs are located. A specific area
• Meet the rescue team at the building entrance or box can be prepared with the equipment and
and escort them to the office. drugs readily available to be transported to the
site of the emergency.
Emergency Medical Service Contact
Once the determination is made that involvement There are emergency kits produced commercially
of EMS is necessary, their prompt arrival is crucial. for sale to dental and medical professionals,
To facilitate this, the following information should including crash cart (Figure 1).
be given to the EMS operator:
• The location of the emergency with the
names of cross streets and the office and
room number.
• The telephone number from where the call is
being made.
• What happened - an accident, a medical
condition, a reaction during treatment?
• How many people need help?
• What is the condition(s) of the victim(s)?
• What aid is being given to the victim(s) (CPR,
drugs, AED)?
• Any other information requested.
To ensure the EMS personnel have no more

questions, do not hang up until after the operator
terminates the phone call.
Refresher Training
Since medical emergencies in the dental
office are a rare occurrence, it is easy for staff Figure 1.
members to not remember the process because
of the lack of practice. Although recertification It is essential to have all the medications and
is required usually at two-year intervals, equipment readily available in the emergency
periodic in-office drills are recommended. Some kit. For this purpose, the contents in the crash
suggestions are: cart are marked and labelled. For example,
the top two drawers consist of emergency
• Mock Codes – Medical emergency scenarios medicines, including oral medications (Figure 2)
are presented to staff members. Mannequins and parenteral medications (Figure 3), and
or large life-like dolls can make the exercise the bottom drawers comprises of intubation
more realistic. It can also be done through (Figure 4) and airway equipment (Figure 5).
role playing as staff members can identify Some of the emergency kits may contain
and practice the different member duties equipment and drugs of questionable value in a
and responsibilities for various emergency dental office setting because of limited medical
situations. training of the dentist and staff. For example, an
• Scavenger Hunt – A staff member is given emergency drug kit containing IV resuscitative
a list of items needed for a particular drugs would be of negligible value to an
emergency and is required to obtain and emergency treatment provider with unfamiliarity
prepare them for administration and use in IV placement whether due to lack of training
within a given amount of time.1 or not having the opportunity to practice the
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Figure 2. Figure 3.
Figure 4. Figure 5.
technique due to rare exposure to dental office mask for the apneic patient in both adult and
emergencies. A laryngoscope is not an essential pediatric sizes. The oxygen should be available
piece of emergency equipment for those not as a portable unit with an “E” size cylinder that
trained in intubation technique. can deliver greater than 90% oxygen at a flow
of 5 L/min for a minimum of 60 minutes. For
Office personnel should be able to provide ease of transport and delivery, the oxygen
basic management of airway, breathing and cylinder is usually attached to the emergency
circulation. This can be achieved with basic crash kit trolley (Figure 6). The Dentist must
medical equipment and essential drugs that perform periodic check to ensure that the
dentists without advanced life support training volume and pressure of oxygen in the tank is at
can feel comfortable using. For the Dentist appropriate levels.
and staff members involved in the provision of
sedation or general anesthesia, it is imperative Suctioning equipment - Although usually
to have adequate training in providing pediatric available in the treatment room, a portable
advanced life support in case of emergency. In suction unit is useful for suctioning fluids and
this case, the emergency kit should contain all vomit if the emergency occurs in another area
the medications and equipment to effectively of the office (waiting room).
handle such emergencies.
Automated electronic defibrillator (AED) -
Emergency Equipment The AED is used during cardiac arrest to
Emergency oxygen - The basic goal of nearly all shock a defibrillating heart. Resuscitation with
emergencies in the dental office is to maintain BLS during cardiac arrest is most successful
sufficient oxygenation of the brain and heart. if defibrillation is performed within 3 to 5
Thus, oxygen should be available for every minutes of collapse.2 Manual, automatic or
emergency except hyperventilation. It should semiautomatic defibrillators are available.
be provided with a clear face mask for patients Manual defibrillators require interpretation of
with spontaneous breathing, and a bag-valve a monitor or cardiac rhythm strip by a trained
5
Figure 6. “E” Size Oxygen Cylinder. Figure 7. Automated electronic defibrillator
(AED)
Figure 8. Pulse oximeter connected to a monitoring device on a patient

receiving oral conscious sedation
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rescuer. Automated and semi-automated AEDs For the dentists with advanced training and
analyze the patient’s rhythm and advise the skills in sedation and general anesthesia, the
rescuer to defibrillate if ventricular tachycardia additional emergency drugs in Table 2 may be
or ventricular fibrillation is present or to added to the drug kit.
continue CPR if no pulse is present. The AED
should accept adult and pediatric paddles Emergency Treatment
(Figure 7). The AED should be placed in an The following steps are taken for all
accessible location in the dental office. The emergencies:
Dentist and the staff members should be • Discontinue dental treatment
familiarized with its location for ready access in • Activate the office emergency system
the event of emergency. • Call for assistance
• The oxygen and emergency drug kit are
Pulse oximeter and blood pressure monitor - brought to the site of the emergency
While pulse oximeters are usually found in • Attend to the patient
dental offices where sedation and general • Position the patient to ensure an open and
anesthesia is administered to patients, they unobstructed airway
are useful in monitoring the effectiveness • Monitor vital signs
of CPR efforts. The pulse oximeter monitors • Support respiration and circulation
the patient’s pulse rate and the percent • Provide definitive treatment
oxygenation of the blood. It is important to • Notify 911 if it is determined to be needed2
continuously monitor oxygenation in patients
receiving sedation (Figure 8).3 This will help to The following sections will discuss the definitive
address any deficiencies in oxygenation as most treatment for the most popular emergencies
of the sedation medications may cause some encountered in the dental office.
level of respiratory depression.4
Syncope
Emergency Drugs Vasodepressor syncope is the most
Emergency drugs may be divided into two common emergency seen in dental offices
categories. The first category is drugs that and comprises of approximately 53% of all
are essential and should be part of every emergencies.8 Although it occurs predominately
emergency drug kit. The second category in adults, since an adult accompanies all
consists of drugs that are useful but are pediatric dental patients, it can readily occur
optional depending on the practitioner’s in a pediatric dental office. Syncope occurs
training in emergency medical procedures and because of a “fight or flight” response and
whether sedation and general anesthesia are the absence of patient muscular movement,
used for behavior and anxiety management. leading to a transient loss of consciousness. It is
Thus, emergency drug kits will vary from most common in young adults, most commonly
office to office. A dentist trained to administer between the ages of 16 to 35 years, and in
general and intravenous sedation with men more than women. Pediatric patients
greater proficiency in venipuncture would rarely develop syncope because they do not
have a more comprehensive drug kit than a hide their fears and readily react emotionally
dentist without such training. For dentists not and physically during a stressful situation. If a
proficient in venipuncture, optional drugs that pediatric patient or an adult older than 60 years
can be administered orally, intramuscularly/ exhibits syncope without predisposing factors,
sublingually and intranasally will be discussed. they should be sent for medical consultation.9
For a more comprehensive review, kindly refer
to American Dental Association’s recently Predisposing factors for syncope can be divided
published guide on preparation of a dental into two categories, psychogenic or non-
team for medical emergencies.5 psychogenic factors.
At the very least, a basic dental office Psychogenic factors include:

emergency drug kit should contain the eight • Fright
drugs summarized in Table 1. • Anxiety (due to the anticipation of
7
Table 1. Essential Emergency Drugs.6,7
Table 2. Additional Emergency Drugs.6
8
discomfort or the fee) managing the body’s mechanism to compensate
• Emotional Stress for the decreased circulatory volume in a timely
• Receipt of unwelcome news (treatment or manner leads to:
the treatment fee) • Reflex bradycardia
• Sudden and unanticipated pain (injection or • Decreased cardiac output
during treatment) • Decreased blood pressure
• The sight of blood (gauze, dental • Cerebral ischemia
instruments) • Convulsions
A parent, with a history of negative dental The signs and symptoms of syncope are divided
experiences, accompanying their child for into early and late stages.
an emergency dental extraction, who was
informed of the treatment fee, and is standing In the early stage the patient:
in the treatment room doorway, observing the • Expresses feeling warm
extracted tooth in blood soaked gauze, is a • Exhibits loss of color with an ashen-gray skin
prime candidate to develop syncope. tone
• Perspires heavily
Non-psychogenic factors include: • Reports “feeling bad” or “feeling faint”
• Sitting in an upright position (especially • Reports feeling nauseous
during the injection) or immobility while • Exhibits slightly lower blood pressure and
standing resulting in blood pooling in the tachycardia
peripheral extremities, decreasing the flow
of blood to the brain. In the late stage the patient exhibits:
• Hunger from dieting or missed meals • Pupillary dilation
resulting in decreased glucose supply to the • Yawning
brain. • Hyperpnea
• Exhaustion • Cold extremities
• Poor physical condition • Hypotension
• Hot, humid environments • Bradycardia
• Visual disturbances
The physiological mechanism for the onset of • Dizziness
syncope is: • Loss of consciousness
• Stress causes increased amounts of
catecholines (epinephrine, norepinephrine) Emergency Management
to be released into the circulatory system The first step in the management of syncope is
to prepare the individual for increased prevention. This is accomplished by:
muscle activity (fight or flight reaction in a • Taking a thorough medical and dental
threatening situation). history to identify any predisposing factors
• The responses to the catecholine release that might contribute to syncope, i.e.,
are decreased peripheral vascular resistance previous history of syncope, a fear of dental
and increased blood flow to the peripheral treatment due to previous traumatic dental
skeletal muscles. experiences or pain, and hypoglycemia.
• Patients, especially those that are anxious,
If muscle activity occurs (fight or flight), the blood should eat a light meal prior to treatment to
volume diverted to the muscles is returned to maintain a stable blood glucose level during
the heart. If muscle activity does not occur (sitting stressful treatment.
or standing still), there is increased peripheral • Patients should be treated in a supine
pooling of the blood in the extremities and a or semi-supine position (30-45 degrees),
decreased return of blood to the heart. This leads especially during the injection.
to a decrease in the circulating blood volume, a • Consider the use of anxiety techniques
drop in arterial blood pressure and diminished such as premedication and nitrous oxide
cerebral blood flow resulting in syncope. Not anxiolysis.
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Should a patient experience syncope, the Allergic Reactions
following steps should be taken that includes Allergic reactions are hypersensitive responses
P>C>A>B (Position > Circulation > Airway > by the body’s immune system to antigens
Breathing): that are recognized as foreign bodies, with
• Discontinue treatment subsequent antibody formation. There are four
• Assess the level of consciousness: Evaluate types:
the patient’s lack of response to sensory • Anaphylaxis (immediate, antigenic-induced,
stimulation. antibody mediated)
• Activate the office emergency system: Call • Cytotoxic (antimembrane)
for help and have oxygen and the emergency • Immune complex (serum-sickness like)
drug kit brought to the site of the emergency. • Cell mediated (delayed)
• Position the patient: The patient should be
in a supine position with the feet elevated In this course the discussion will be limited to
slightly. the anaphylactic and cell mediated types.
• Assess airway and circulation: Assess the
patient’s breathing and airway patency and For an allergic reaction to occur, the patient
adjust the head and jaw position accordingly; must have been previously exposed to the
monitor the pulse and blood pressure. antigen (sensitizing dose). The subsequent
• Provide definitive care: exposure to the antigen (challenge dose)
• Administer oxygen causes the reaction. The latent period (the time
• Monitor vital signs between the sensitizing dose and the challenge
• Administer aromatic ammonia ampoules dose) when the IgE antibody is produced varies
(Figure 9). Crush the ampule between the in duration. The duration and severity of the
fingers and position it under the patient’s reaction will vary by the individual.10
nose. The irritating fumes stimulate
movement of the extremities and aids in Anaphylactic Allergic Reactions
blood return from the peripheral areas to An anaphylactic reaction is due primarily to the
the heart and brain. release of histamine from IgE sensitized mast
cells. Histamine produces inflammation and
vascular effects such as:
• Cardiovascular
• Capillary dilation and increased capillary
permeability resulting in blushing and
edema formation.
• Decreased venous return, blood pressure
and cardiac output.
• Stimulation of secretions
• Increased secretions by the mucous,
Figure 9. Ammonia ampoules lacrimal, salivary, pancreatic, gastric and
intestinal glands.
• Postsyncopal management: If recovery • Respiratory
occurs in less than 15 minutes, postpone • The above described effects can lead to
further dental treatment. If recovery is asphyxia from upper respiratory tract
delayed by more than 15 minutes, contact obstruction.
EMS while continuing definitive care until
arrival of trained emergency care providers. It is possible for the patient to develop an
• Determine precipitating factors: Determine anaphylactoid reaction which mimics a true IgE
the cause of the syncope (anxiety, the sight mediated anaphylaxis reaction. An anaphylactoid
of blood, unexpected pain, hypoglycemia, reaction is an idiosyncratic reaction that occurs
etc.).9 when the patient is first exposed to a drug or
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other agent. Although it is not immunologically • Dysrhythmias - as above plus palpitations
mediated, the emergency management is the • Cardiac arrest
same as a true anaphylactic reaction.
The progression of symptoms is:
There are several primary allergic agents used 1. Skin
in dentistry: 2. Eyes, nose, GI
• Antibiotics (penicillins, cephalosporins, 3. Respiratory system
tetracyclines, sulfonamides): Parenterally 4. Cardiovascular system
administered penicillin can cause an
anaphylactic reaction. The incidence of Emergency Management
allergy from Penicillins ranges from 0.7 to Should a patient experience an anaphylactic
10% and around 2.5 million persons have episode, the following steps should be taken:
been estimated to have allergy to Penicillins • Assess the problem: Recognize and
in the United States.11 Orally administered acknowledge itching, hives, edema, flushed skin.
usually causes a delayed reaction. Patients • Discontinue treatment
may not realize they have been previously • Activate the office emergency system: Call
exposed to a sensitizing dose because the for help and have oxygen and the emergency
exposure could have been environmental, drug kit brought to the site of the emergency.
i.e., penicillin mold in the air, meat, and milk. • Position the patient: The patient should be
• Analgesics (aspirin, opioid, NSAIDS): positioned comfortably.
Symptoms can range from mild urticaria • Assess circulation, airway and breathing:
to anaphylaxis. Bronchospasm is the Monitor the patient’s pulse and blood
most common reaction. For patients with pressure. Provide BLS as needed. Assess
a known allergy to the above analgesics, the patient’s airway patency, breathing and
acetaminophen should be prescribed. adjust the head and jaw position accordingly.
• Local anesthetics (esters, procaine, If the patient’s condition continues to worsen,
benzocaine, tetracaine): Injectable and contact EMS.
topical ester local anesthetics have been • Provide definitive care: Administer
primarily implicated in allergic reactions. epinephrine. Epinephrine counteracts most
Reported allergic reactions in amides are of the effects of histamine. It produces
probably due to reactions to preservatives bronchodilation, raises blood and the heart
such as parabens and sodium metabisulfate. rate via its α and ß effects and counters
• Other agents: Acrylic resins (denture repairs) skin rash, urticaria and angioedema by an
and latex (gloves, rubber dams) primarily unknown mechanism.
cause contact dermatitis.
While available in 1 ml ampules of 1:1000 (0.30
An anaphylactic episode is exhibited by the mg/dose) for adults and 1:2000 (0.15 mg/dose)
following reactions: for children that is drawn into and administered
• Skin via a syringe (Figure 10). A more efficient manner
• Urticaria - itching, hives (elevated patches of administration during an emergency is with an
of skin) EpiPen.
• Erythema – rash
• Angioedema - localized swelling
• Respiratory
• Bronchospasm - respiratory distress,
wheezing
• Angioedema to the larynx leading to
airway obstruction
• Rhinitis
• Cardiovascular reactions
• Circulatory collapse due to vasodilation
presented by light headedness, weakness,
Figure 10.
syncope and ischemic chest pain
Epinephrine injection
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EpiPen (0.3 mg epinephrine) and EpiPen Jr (0.15
mg epinephrine) are preloaded epinephrine
autoinjectors. They are extremely easy to use
and are routinely available with prescription to
the public for everyday allergic reactions (insect
bites, food allergies).
Directions for use of EpiPen:

1. Pull off the blue safety release cap.
2. Swing and firmly push the orange tip against
the outer thigh so it “clicks.” HOLD the
EpiPen on the thigh for approximately 10
seconds to deliver the drug. Do not inject
intravenously as this can cause ventricular
tachycardia or into the buttock as this may
reduce drug efficacy.
Epinephrine is administered every 15 minutes

until recovery or help arrives.
Mild or Delayed Allergic Reactions Figure 11. Diphenhydramine for

oral use
Mild or delayed allergic reactions present as a
less severe reaction to allergens than anaphylaxis.
They can occur as a reaction to such things as
oral antibiotics, latex and (cold cure) acrylics.
The signs and symptoms are classified as skin
allergies: urticaria (itching), angioedema and,
respiratory allergies: rhinitis, laryngeal edema,
and bronchospasm.12
Treatment consists of
• Discontinuing the source of the allergy.
• Administration of oral diphenhydramine
at a dosage of 1 mg/kg every six hours for
children or 25-50 mg for adults every 6
hours for 24 to 48 hours. Diphenhydramine
Figure 12. Diphenhydramine for parenteral use
is available in an oral form 12.5 mg/5 ml
(Figure 11) and 1 ml ampules or Min-i-jet (50
mg/ml) (Figure 12). In contrast, status asthmaticus is the most
serious clinical condition that manifests with
Acute Asthmatic Attack wheezing, dyspnea, and hypoxia. Patients with
Asthma is defined as a chronic inflammatory this condition do not respond to bronchodilators
disorder that is characterized by reversible and it is considered as a true emergency.
obstruction of the airways. Approximately 9.5%
of children in the United States suffer from Asthma is classified into 2 categories; extrinsic
asthma. Asthma is the most chronic childhood (allergic asthma) and intrinsic (non-allergic
disease that affects around 7.1 million children asthma).
in the United States.13 Half of all cases develop
before patients reach 10 years of age. It Extrinsic asthma occurs more often in children.
appears more frequently in African American It is triggered by specific allergens such as
and Hispanic populations. Most of the acute pollens, dust, molds, and highly allergenic foods
asthmatic episodes are usually self-limiting. such as milk, eggs, fish, chocolate, shellfish,
12
and tomatoes. Drugs and chemicals such
as penicillin, vaccines, aspirin, and sulfites
can trigger an allergic asthmatic attack.
Approximately 50% of asthmatic children
outgrow extrinsic asthma by late teens or early
twenties.14
Intrinsic asthma usually develops in adults older

than age 35 years. Attacks are precipitated
by non-allergic factors, respiratory infection,
physical exertion, environmental and air
pollution. Psychological and physiologic stress
can induce an attack. The stress of disciplinary Figure 13. Ventolin (Albuterol sulphate) for
inhalation.
action by a parent or entering the treatment
area in a dental office can trigger an asthmatic
attack in children and adults. The steps in emergency management of an
acute asthmatic episode are:
With either type of asthma the mechanism for • Terminate treatment and remove all dental
initiating an attack is the same. The allergen materials and instruments from the patient’s
or non-allergen factors stimulates the vagus mouth.
nerve to release acetylcholine which produces • Sit the patient upright or in a comfortable
constriction of the airways and increased position with the arms thrown forward over a
glandular secretions which plug the small chair back.
airways in the lungs leading to bronchial edema • Administer a bronchodilator supplied by the
and airway obstruction. patient or from the emergency drug kit. The
directions for use of the aerosol inhaler are:
The signs and symptoms of an acute asthmatic • The patient holds the inhaler 1 or 2 inches
attack are: in front of their mouth.
• Shortness of breath • The inhaler is placed in the mouth.
• Wheezing and coughing • As the patient breaths in slowly through
• Tightness in the chest their mouth, they press down on the
• Hypoventilation inhaler one time.
• Cyanosis • The patient continues breathing as deep
• Tachycardia as they can and holds their breath for 10
seconds.
The management of an asthmatic patient begins • Improvement should occur within 15
with the pretreatment history. Ask the patient: seconds.
• How attacks occur and their severity • If there is no improvement, the process
• What triggers attacks should be repeated.
• What medications are taken • If after three doses of the bronchodilator
there is no improvement, take additional
If the patient uses a self-administered measures:
bronchodilator aerosol during acute asthmatic • Administer oxygen
attacks e.g., albuterol (Proventil, Ventolin) • Call for medical assistance
isoproterenol (Isuprel) or metaproterenol • Administer epinephrine 1:1000
(Metaprel, Alupent), they should bring it concentration for an adult, 1:2000
to their appointment. The bronchodilators concentration for a child.
produce bronchial smooth muscle relaxation. • If possible, determine the cause of the attack
Albuterol has the least side effects of all the (anxiety, air contaminants).
bronchodilators and should be the drug of • If the attack is resolved quickly, the
choice for inclusion in the emergency drug kit. patient may be discharged on their own. If
(Figure 13). medical assistance or the administration of
13
epinephrine is necessary, the patient should Early subjective symptoms of the central nervous
be discharged to EMS for transport to the system include dizziness, anxiety and confusion
hospital.14 and may be followed by diplopia, tinnitus,
drowsiness and circumoral numbness or tingling.
Anesthetic Toxicity (Overdose)
While rare in adults, young children are more Objective signs include muscle twitching,
likely to experience toxic reactions because of tremors, excessive talking, slowed speech and
their lower weight and inadequate growth and shivering followed by overt seizure activity.
development. Most adverse drug reactions Unconsciousness and respiratory arrest may
occur within 5-10 minutes of injection without occur.
vasoconstrictor and around 30 minutes for
local anesthetics with vasoconstrictor.15 Local Local anesthetic toxicity is preventable by
anesthetic toxicity is caused by high blood levels following proper injection technique, i.e.,
of anesthetic because of: aspiration during slow injection to detect
• Exceeding recommended local anesthetic intravascular injection. Amongst all intraoral
dosages injections, the most positive aspirations were
• Inadvertent intravascular injection recorded for inferior alveolar nerve block
• Repeated injections (11.7%), followed by mental nerve block (5.7%).16
• Idiosyncratic responses Clinicians should be knowledgeable of maximum
• Interactive effects with other agents (sedatives) dosages based on weight (Table 3).
The signs and symptoms of local anesthetic If lidocaine topical anesthetic is used, it should
toxicity are biphasic; initial excitation, followed be factored into the total administered dose
by depression. During the initial excitation stage, of lidocaine as it can infiltrate into the vascular
there is CNS stimulation of the heart rate and system. After injection, the patient should be
blood pressure increases. As blood plasma levels observed for any possible toxic response as
of the anesthetic increase, vasodilatation occurs early recognition and intervention is the key to a
followed by depression of the myocardium with successful outcome.
subsequent fall in blood pressure. Bradycardia
and cardiac arrest may follow.
Table 3. Maximum Recommended Dosage of Local Anesthetic Agents.17
14
Emergency Management in patients with a history of cardiovascular
Should a patient experience local anesthetic disease can cause vasoconstrictor toxicity.
toxicity, the following steps should be taken: Increased vasoconstrictor into the blood stream
• Stop treatment. causes moderate increases in systolic and
• Assess and support the airway, breathing diastolic blood pressures, cardiac output and
and circulation. stroke volume. These actions lead to an overall
• Administer oxygen via mask. decrease in cardiac efficiency.
• Monitor vital signs.
• If the patient exhibits tonic-clonic seizures, After reviewing the pre-operative medical
follow the protocol for seizures (see the history, the vasoconstrictor use should be
section on Seizures). With proper airway avoided or minimized in:
management the seizure should subside • Patients with a blood pressure in excess of
within two minutes as the level of local 200 mm Hg systolic or 115 mm Hg diastolic.
anesthetic decreases and the patient regains • Patients with uncontrolled hyperthyroidism.
consciousness. • Patients with severe cardiovascular disease.
• Contact EMS if consciousness is not • Less than 6 months after myocardial
regained within 2 minutes. infarction, post-coronary bypass surgery
or cerebrovascular incident.
Allergic Reaction to Local Anesthetics • Daily episodes of angina pectoris.
Although allergic reactions to injectable amide • Cardiac dysrhythmias
local anesthetics are rare, patients may exhibit • Patients receiving halogenated general
a reaction to the bisulfite preservative added anesthetic agents.
to anesthetics containing epinephrine. Patients • Patients receiving nonspecific ß-blockers,
with a sulfa allergy should not receive articaine. MAO inhibitors, or tricyclic antidepressants.
Patients may also exhibit allergic reactions to
benzocaine topical anesthetics. Allergies can The signs and symptoms of vasoconstrictor
manifest in a variety of ways including urticaria, toxicity are:
dermatitis, angioedema, fever, photosensitivity • Anxiety
and anaphylaxis. If the patient exhibits an • Tachycardia/palpitations
allergic reaction to a local anesthetic or • Restlessness
any of its additives, follow the protocol for • Headache
management of allergic reactions.15 • Tachypnea (abnormal rapid breathing)
• Chest pain
Anesthetic Reaction to Vasoconstrictors • Cardiac arrest
Vasoconstrictors (epinephrine and
levonordefrin) are added to local anesthetics Emergency Management
to counteract their vasodilatory action by Should a patient experience vasoconstrictor
constricting blood vessels, thus decreasing blood toxicity, the following steps should be taken:
flow to the injection area. The absorption of the • Stop treatment
local anesthetic into the cardiovascular system • Reassure the patient
is slowed resulting in lower anesthetic levels, • Assess and support circulation, airway, and
minimizing the risk of local anesthesia toxicity breathing
and increasing the duration of anesthesia by • Administer oxygen
allowing the local anesthesia to remain around • Monitor vital signs
the nerve for a longer period of time. • Contact EMS
If too much vasoconstrictor is injected or Sedatives and Anxiolytic Agents (Overdose)

the anesthetic is injected intravascularly, the The number of dental procedures for pediatric
vasoconstrictor is absorbed into the vascular dental patients requiring the use of sedative
system just as the anesthetic (see Table 3). and/or anxiolytic agents has increased in
Overuse of gingival retraction cord, especially the past several decades. Associated with
15
the increase in pharmaceutical management tend to require increased drug dosages.
of pediatric dental patients is an increased • Stomach contents: The presence of food
likelihood of untoward medical emergencies. in the stomach influences the rate of
In recognition of this situation the American absorption of orally administered drugs.
Academy of Pediatrics and the American Patient receiving sedative/anxiolytic drugs
Academy of Pediatric Dentistry published whether enterally or parenterally should be
guidelines for the monitoring and management NPO so as not to affect the absorption rate
of sedated pediatric patients during and after and of importance to reduce the likelihood
treatment.3 However even with the practitioner of vomiting and possible airway obstruction
following these guidelines there is a low but and aspiration. This usually range between 2
occurring rate of potential life threatening hours for clear liquids to 6 hours for a light
events, such as apnea, airway obstruction, meal.3
laryngospasm, pulmonary aspiration, • Ability to titrate: The ability to titrate aids
desaturation and others. in the determination of the proper drug
dosage for a patient. Intravenous and
The sedation of children is different from the inhalation administration allows titration,
sedation of adults. Physiologic functions in while oral, intramuscular, and submucosal
children may vary considerably from those administration does not permit titration.
in adults. The metabolic rate is increased in
pediatric patients. Conversely enzyme systems It is beyond the scope of this course to detail
responsible for the biotransformation of the preoperative preparation (medical, social
specific drugs may not be as functional as in and dental history), required monitoring
adults. This can lead to the increased possibility equipment and personnel, and training of
of higher blood levels of the sedative drugs operator and support staff. Studies have
even when the calculated dosage is reduced shown it is common for children to pass
from the adult dose based on reduced weight. from the intended level of sedation to a
In addition, the effectiveness of particular deeper unintended level of sedation. Those
dosage o administered sedative/anxiolytic practitioners engaged in administering
agents may vary from patient to patient.2 sedative/anxiolytic drugs should have the skills
to rescue a patient from a deeper level than
Factors determining drug dosages in children intended for the procedure. For example, if
include: the intended level is minimal, the practitioner
• Age and weight of the child: In general, the should have the skills to rescue from moderate
older the child, the larger the dosage to level. If the intended level is moderate, the
achieve the desired clinical result. However, practitioner should have the skill to rescue
in very young and pre-cooperative children, from deep level. If the intended level is deep
larger dosages may be needed to overcome level the practitioner should have the skill to
their extreme level of fear. rescue from general anesthesia. These skills are
• Mental attitude: The greater the degree learned from comprehensive instruction that
of anxiety the larger the dose of drugs includes 12-24 hours of didactic and hands on
required. training. In addition, practitioners engaged in
• Level and length of time of sedation desired. sedation/ anxiolytic drug administration should
The depth of sedation (minimal, moderate, be certified in Advanced Cardiac Life support
deep) and the anticipated length of time (ACLS) and/or Pediatric Advanced Life Support
for treatment will influence the required (PALS).
dosage. The depth of sedation will be
dictated by the complexity of treatment. Oral sedation is the most popular route of
A minimally invasive restoration may be administration by pediatric dentists, although
completed with less cooperation than an alternative routes such as the intranasal,
aesthetic full coverage restoration requiring sublingual and buccal routes are becoming
pulp therapy. increasingly popular. Among the oral sedative
• Physical activity of the child: Hyperactive
16
drugs most commonly administered,
benzodiazepines (midazolam, diazepam) and
narcotics (meperidine) are the only drugs
with reversal agents and are preferred over
drugs nonreversibility i.e.: chloral hydrate,
hydroxyzine and promethazine. Therefore our
discussion will be limited to benzodiazepines
and narcotics.
It is important to note the use of local

anesthetics in concurrence with sedative/
anxiolytic agents can increase respiratory
depression in patients and therefore the Figure 14. Diazepam Figure 15. Midazolam
amount of local anesthesia administered to the (Valium) tablets (Versed) syrup
sedated patient should closely monitored and
kept well below the maximum recommended • Respiratory depression
dose. • Apnea
• Respiratory arrest
Benzodiazepine Overdose • Cardiac arrest
The two most common benzodiazepine used
in dentistry are midazolam (Versed) and The treatment for benzodiazepine overdose is:
diazepam (Valium) (Figure 14). The dosage 1. Discontinue dental treatment
ranges from 0.25 to 0.30 mg/kg with an onset 2. Call for assistance; someone to bring oxygen
of around 15 to 60 minutes. Midazolam is most and emergency kit
commonly used in pediatric dentistry as a 3. Position the patient to ensure an open and
sedative/anxiolytic agent. It provides anxiolysis, unobstructed airway
sedation, hypnosis, skeletal muscle relaxation, 4. Assess and support circulation, airway, and
anterograde amnesia, respiratory depression breathing
and an anticonvulsant effect but has no 5. Administer oxygen
analgesic properties (Figure 15). It has a wide 6. Monitor vital signs
margin of safety between the therapeutic and 7. If there is severe respiratory depression,
toxic doses and has a rapid onset of action. Its establish intravenous (IV) access and
administration is usually combined with nitrous reverse with flumazenil (Romazicon). If
oxide/oxygen to enhance the above effects and IV access is not available, the flumazenil
provide analgesia. It is usually given orally, as may be administered intramuscularly
syrup, at a dosage of 0.25 mg/kg-1.0 mg mg/ (IM). The dosage of flumazenil is 0.01 mg/
kg, depending on age and anxiety level of the kg with maximum dose is 0.2 mg. It may
patient, with an onset of sedation in 20-30 be repeated at 1 minute intervals, not to
minutes. The intranasal dosage is 0.25mg/kg exceed a cumulative dose of 0.05 mg/kg or 1
with an onset of sedation in 10 to 15 minutes. mg, whichever is lower.
The time available for treatment will vary from 8. Monitor recovery for at least 2 hours
20 minutes to 40 minutes. Benzodiazepines after the last dose of flumazenil and
are metabolized by the hepatic microsomal call for emergency medical services
enzyme system and presence of other agents, with transportation for advanced care if
for example, grapefruit juice may result in indicated.
adverse drug reactions.
Narcotic Overdose
The signs and symptoms of benzodiazepine The most common oral narcotic used as a
overdose are: sedative in pediatric dentistry is meperidine
• Somnolence (Demerol) (Figure 16). It has analgesic, sedative
• Confusion and euphoric properties and potentiates
• Diminished reflexes the action of other sedatives. After oral
17
administration its analgesic effects are call for emergency medical services
detected after 15 minutes, reaching a peak and transportation for advanced care if
effect in 2 hours. Therefore, it tends not to indicated.2,3,4,5
be administered as a standalone sedative
agent, but to increase treatment time, depth Diabetes Mellitus – Hyperglycemia/
of sedation and provide analgesic effects. The Hypoglycemia
recommended dosage of oral meperidine is 1.0 Diabetes mellitus is a disorder characterized by
mg/kg – 2.0 mg/kg. inadequate insulin production by the pancreas
leading to compromised carbohydrate, fat,
The signs and symptoms of narcotic overdose and protein metabolism. If untreated, it leads
are: to hyperglycemia (increased blood glucose
• Decreased responsiveness levels). The most common type of diabetes in
• Respiratory depression children is Type I diabetes (juvenile diabetes). It
• Respiratory arrest is diagnosed in about 1 in 400 to 600 children
• Cardiac arrest and adolescents in the United States.18 There is
little, or no pancreatic ß cell function and thus
The treatment for narcotic overdose is: daily injections of insulin are required. Blood
1. Discontinue dental treatment glucose levels are difficult to control leading
2. Call for assistance; someone to bring oxygen to emergencies involving hyperglycemia or
and emergency kit hypoglycemia (decreased blood glucose levels).
3. Position the patient to ensure an open and
unobstructed airway In hyperglycemia, blood glucose levels are
4. Assess and support circulation, airway, and extremely elevated due to low or absent plasma
breathing insulin levels for a long period of time. Because
5. Administer oxygen of the absence of insulin, glucose cannot enter
6. Monitor vital signs cells, forcing the cells to metabolize fat and
7. If there is severe respiratory depression, proteins to produce glucose. In the process
establish IV access and reverse with ketones and other metabolic acids are produced
naloxone (Narcan) (Figure 17). If IV leading to a condition known as diabetic
access is unavailable the naloxone may ketoacidosis which, if not treated over a period
be administered intramuscularly (IM) or of days, can lead to coma and death. Because
subcutaneously (Sub). The dosage for it takes several days for ketoacidosis to occur,
naloxone is 0.1 mg/kg up to 2 mg and may hyperglycemic patients do not exhibit acute
be repeated every 2-3 minutes until the emergency symptoms.
patient becomes responsive.
8. Monitor recovery for at least 2 hours The emergency most likely encountered in the
after the last dose of naloxone and dental office is a patient with hypoglycemia
or insulin shock. This condition is caused by
an excessively high level of insulin due to the
patient taking their daily dose of insulin with
inadequate intake of carbohydrates. It can also
occur when excessive amounts of carbohydrates
are utilized during increased exercise and stress
leading to low blood glucose levels. As glucose
and oxygen are the primary metabolites for
brain cells, the decreased serum glucose level
leads to neurologic symptoms. If a diabetic
patient, who is doing well, suddenly develops
symptoms, it is most likely due to hypoglycemia
rather than hyperglycemia.19
Figure 16. Meperidine Figure 17. Naloxone
(Demerol) oral solution nasal spray
18
The signs and symptoms of hypoglycemia are: If you’re not sure if the patient’s blood glucose
• Lethargy level is too low or too high, give the glucose.
• Change in mood There is no danger of giving too much.
• Nausea
• Strange behavior Glucagon
• Tachycardia Glucagon, a hormone secreted by the pancreas,
• Hypertension raises blood glucose levels. It has an effect
• Anxiety opposite that of insulin, which lowers blood
• Sweating glucose levels. The pancreas releases glucagon
when blood sugar levels fall too low. Glucagon
Emergency Management causes the liver to convert stored glycogen
Should a patient experience hypoglycemia, the into glucose, which is released into the
following steps should be taken: bloodstream. It is available in injectable form
• Recognize and acknowledge the signs and (Glucagon) for intramuscular administration.
symptoms.
• Discontinue treatment A glucagon emergency kit contains a bottle
• Activate the office emergency system. Call of glucagon (dry powder) and a syringe of
for help and have oxygen and the emergency clear liquid.
drug kit brought to the site of the emergency.
• Position the patient so the patient is The directions for use are:
comfortable. • Remove the flip-off seal from the bottle of
• Monitor patient’s circulation by assessing glucagon.
pulse and blood pressure. Provide BLS as • Remove the needle protector from the
needed. Assess the patient’s airway and syringe and inject the entire contents of the
breathing patency and adjust the head and syringe into the bottle of glucagon.
jaw position accordingly. If the patient’s • Remove the syringe and shake the bottle
condition continues to worsen, contact EMS. gently until the liquid is clear.
• Provide definitive care: • Hold the bottle upside down, reinsert the
• Administer glucose needle and withdraw all the solution from
• If the patient is conscious, the source the bottle.
of glucose (sugared soft drink, juice, • For children under 44 lbs, give 0.5cc (1/2
Instaglucose) may be administered orally the syringe) to start and then the remaining
(Figure 18). 0.5cc 20 minutes later.
• If the patient is unconscious, having • Older children and are given 1cc (the entire
uncontrolled seizures or can’t swallow, syringe).
administer 50% dextrose intravenously • Give the injection in a large muscle such as
or Glucagon intramuscularly until the buttocks, thigh or arm.
consciousness is regained. • As glucagon can cause vomiting, place the
patient on their side prior to the injection to
prevent choking.
• When the patient regains consciousness
and can swallow, give small sips of a
carbohydrate fluid (fruit juice).
• If tolerated, follow with 15 grams of a
carbohydrate and a fat containing food
(crackers and cheese).19
Seizures
Seizures are temporary alterations in brain
function resulting in an abrupt onset of motor,
Figure 18. Insta-Glucose sensory or psychic symptoms. Except when
19
seizures follow one another closely for an changes that may be evident only to a relative,
extended period, they are not considered life such as increased anxiety or depression. A
threatening. Emergency management of a patient with a history of seizures may recognize
patient experiencing a seizure is essentially the development of an “aura” consisting of
preventing injury during the seizure and olfactory, visual, gustatory, or auditory changes.
supportive therapy post seizure. While all If the aura is noted by the patient or the
patients with epilepsy have seizures, many more dental staff, treatment should be terminated
patients have a single seizure during life and do immediately before it progresses to the preictal
not have epilepsy. phase.
Around 10% percent of the U.S. population The preictal phase is clinically manifested by:
have been estimated to have least one seizure • A loss of consciousness.
in their lifetime, while the overall incidence of • If standing, falling to the floor (most
epilepsy is less than 1%.20 There are multiple prevalent time for injuries).
causes of seizures: • Myoclonic jerks.
• Congenital abnormalities • Increase in heart rate and blood pressure.
• Perinatal injuries • Diaphragmatic muscles go into spasm.
• Metabolic and toxic disorders
• Head trauma The ictal phase (tonic component) is clinically
• Tumors manifested by:
• Vascular diseases • Alternating muscular relaxation and violent
• Degenerative disorders contractions.
• Infectious diseases • Frothing at the mouth due to mixing of saliva
• Elevated body temperature (febrile seizures) and air.
• Most commonly occurs between 6 months • Bleeding from the mouth due to biting the
and 3 years lateral borders of the tongue.
• Fever of 38.8° C (102°F) • Lasting 2 to 5 minutes.
• Infection not associated with the CNS
• Seizures are short (<5 minutes) The postictal phase is clinically manifested by:
• Are insignificant in the dental setting • Tonic-clonic movements cease.
• Breathing returns to normal.
There are three major forms of seizures: • Consciousness gradually returns with
• Grand mal (tonic-clonic seizure) disorientation.
• Petit Mal (absence seizure) • Relaxation occurs.
• Status epilepticus • Muscular flaccidity resulting in urinary or
fecal incontinence.
Grand Mal Seizures • Total amnesia of the seizure.
Grand mal seizures (tonic-clonic seizures) are
the most common form found in epilepsy. They Emergency Management
can also be brought on by cerebrovascular Should a patient exhibit a grand mal seizure, the
accidents, meningitis, encephalitis, drug following steps should be taken:
withdrawal, photic stimulation, fatigue and
intoxicants. The entire seizure may be broken PRODROMAL AND PREICTAL PHASE
down into prodromal, preictal, itcal and post- • Recognize aura.
itcal phases which last no more than 5 to 15 • Discontinue treatment and move bracket
minutes. However, it may take up to 2 hours for table and instruments out of the way.
normal, preictal cerebral function to return. A
grand mal seizure that lasts for hours or days is ICTAL PHASE
termed status epilepticus and can lead to death • Activate the office emergency team.
if not managed. • Position the patient in a supine position with
the feet elevated or roll patient on their side
In the prodromal phase the patient may exhibit to prevent aspiration.
20
• Protect the patient from bodily injury, 2. Recognize the problem (lack of response to
however do not place objects in the mouth to stimulation).
prevent soft tissue injury. 3. Discontinue dental treatment.
• Assess and perform BLS as needed. 4. Activate the office emergency team.
5. If the patient is standing allow them to
POSTICTAL PHASE continue to do so. If positioned supine in the
• Administer oxygen. dental chair do not change the position except
• Monitor vital signs. to elevate the feet.
• Reassure patient and permit recovery. 6. Once the seizure ceases (<5 minutes) reassure
• Depending on the patient’s history and if the patient.
accompanied by an adult discharge patient 7. Discharge patient once fully recovered with a
to home or to the hospital or physician. responsible adult.
If the seizure lasts more than 15 minutes: If the seizure lasts more than 5 minutes:
• Activate EMS. 1. Activate EMS.
• Assess and perform BLS as needed. 2. Perform BLS as needed.
• Protect the patient from injury until EMS 3. If intravenous (IV) access is available
arrives. administer diazepam (Valium) IV:
• If available and the staff is trained in • Child up 5 years 0.2-0.5 mg slowly every 2-5
venipuncture, administer an IV anticonvulsant. minutes with a maximum of 5mg.
• If intravenous (IV) access is available • Child up to 5 years and up 1 mg every 2-5
administer diazepam (Valium) IV: minutes with a maximum of 10 mg.
• Child up 5 years 0.2-0.5 mg slowly every 2-5
minutes with a maximum of 5mg. Status Epilepticus
• Child up to 5 years and up 1 mg every 2-5 Status epilepticus is defined as a continuous
minutes with a maximum of 10 mg. seizure or a repetitive recurrence of any type of
seizure without recovery between attacks. It is life
Petit Mal and Absence Seizures threatening. Patients in status epilepticus exhibit
Petit mal seizures occur in 25% of all epilepsy the same clinical signs and symptoms as those in
patients and 5% of pediatric epilepsy patients the convulsive phase of tonic-clonic seizure. The
(are most common between ages 3-15 years). major difference is while a tonic clonic seizure may
They occur frequently (multiple daily episodes) last 2 to 5 minutes, status epilepticus may last for
usually shortly after awakening or during hours or days and may lead to death.
periods of inactivity. The clinical manifestations are:
• Any clonic-tonic seizure lasting more than 5
The clinical manifestations are: minutes
• Unresponsiveness • Nonresponsiveness or unconsciousness
• Eyelid clonus (rapid or cyclic blinking) • Cyanotic, diaphoretic
• Tonic or atonic features • Generalized clonic contractions with brief or
• If standing, the patient will remain standing absent tonic phase
• There is no aura or postictal state • Elevated body temperature (41°C, 106°F)
• The duration does not exceed 10 seconds • Tachycardia and dysrhythmias
• Elevated blood pressure
Emergency Management
Management of petit mal seizure and absence Unterminated status epilepticus may lead to the
seizures is to protect the victim from injury. following:
Even with no assistance from staff there is • Death as a result of cardiac arrest
little or no danger of death to the victim. Most • Irreversible neuronal damage from cerebral
seizures last from five seconds to two minutes. hypoxia
Should a seizure last longer than this, the • A decrease in cerebral blood flow in response
following steps should be taken: to increased intracranial pressure
1. Recognize the problem based on the • A significant decrease in blood glucose
patient’s medical history.
21
levels as the brain uses large amounts for response system, obtains an AED, and starts
metabolism CPR. This approach is the same as for adult
with cardiac arrest.
Management • If the cardiac arrest is unwitnessed, the lone
Management of status epilepticus follows the rescuer should first perform two minutes of
same protocol as grand mal seizures (see above). CPR, activate the emergency response system,
However, if the seizure continues beyond 5 and obtain an AED.
minutes activate emergency services and if • This approach differs from that recommended
the office staff is properly trained administer for adult cardiac arrest, which is call for help,
intravenous anticonvulsive drugs. Assess and activate the emergency response system and
perform basic life support until emergency initiate CPR and obtain an AED.
medical support with advanced training arrives.20 • For the summary of high-quality CPR for
infants, children, and adolescents, kindly
Cardiac Arrest refer to American Heart Association guideline
Every year, around 350,000 people in the (Figure 19).
United States suffer from cardiac arrest and
receive attempted resuscitation. Cardiac arrest, Comprehensive CPR training is not within the
although common in adults, is a rare occurrence scope of this course, and it is recommended
in the pediatric population. When it does occur, the reader seek out formal BLS instruction.
the outcome can be devastating. Death may It is important for BLS providers to realize
result or if the patient is not resuscitated on because of different etiologies for cardiac
time, permanent brain damage may occur. arrest in adults (cardiac disease) and children
The etiology of cardiac arrest in a child differs (depleted oxygen in the myocardium) there is a
from an adult. Cardiac arrest in the pediatric significant difference in BLS protocols for adults
patient is the result of prolonged respiratory and children. In adults, after initial assessment
depression and apnea. These situations are of the unresponsive patient, EMS is activated
often associated with local anesthesia toxicity immediately (before starting BLS) so access to
because of overdose or intravascular injection trained personnel and defibrillation equipment
and with the administration of CNS depressant is available as soon as possible. In children, since
drugs for behavior management. the likely cause of cardiac arrest is lack of oxygen
Comprehensive BLS training is not within the in cardiac muscle, BLS is started immediately,
scope of the course, and it is recommended and EMS is contacted after delivery of BLS for 2
the reader seek out formal BLS instruction. The minutes.
etiologies for cardiac arrest differ for adults
(cardiac disease) and children (depleted oxygen Conclusion
in the myocardium). For unwitnessed and In summary, although pediatric medical
witnessed cardiac arrests with two or more emergencies are a rare occurrence in the dental
rescuers present, assess the patient, initiate office, when it does occur, it is important that the
CPR, activate the emergency response system Dentist and the staff members are well-trained
and obtain an automated external defibrillator in emergency management so efficient and
(AED) simultaneously. timely treatment is administered to the physically
For unwitnessed and witnessed cardiac arrests and physiologically immature pediatric patient.
with two or more rescuers present, assess the Preparation includes the use of comprehensive
patient, initiate CPR, activate the emergency medical and dental histories, at minimum BLS
response system and obtain an automated training for staff and providers, initiation of
external defibrillator (AED) simultaneously. an office emergency team, organization of an
For the lone rescuer, the sequence varies: emergency drug kit and equipment, and periodic
• If the cardiac arrest is witnessed, the lone reviews and simulation.
rescuer first activates the emergency
22
Figure 19. Summary of high-quality CPR components for BLS providers.21
23
Course Test Preview
To receive Continuing Education credit for this course, you must complete the online test. Please
go to: www.dentalcare.com/en-us/professional-education/ce-courses/ce391/start-test
1. The most common medical emergency in a dental office is _______________.

A. Mild allergy
B. Seizures
C. Syncope
D. Local anesthesia overdose
2. A duty of the first person on the scene of an emergency is _______________.

A. Alerting other staff members
B. Contacting EMS
C. Retrieving the emergency drug kit
D. Direct EMS to the site of the emergency
3. Essential emergency equipment includes:

A. Laryngoscope
B. Various sized intubation tubes
C. An “E” sized tank of oxygen
D. Atropine
4. Epinephrine is primarily recommended for managing _______________.

A. Anaphylaxis
B. Myocardial infarction
C. Seizures
D. Hypoglycemia
5. Glucagon is used in the management of _______________.

A. Seizures
B. Anaphylaxis
C. Hypoglycemia
D. Psychogenic syncope
6. Flumazenil is used in the management of _______________.

A. Status epilepticus
B. Benzodiazepine overdose
C. Local anesthesia overdose
D. Narcotic overdose
7. The drug of choice for treating status epilepticus is _______________.

A. Lorazepam
B. Atropine
C. Hydrocortisone
D. Naloxone
8. A non-psychogenic predisposing factor for syncope is _______________.

A. The sight of bloody gauze
B. Sitting upright during local anesthesia administration
C. Sudden and unanticipated pain
D. Receipt of the treatment fee
24
9. A symptom during the early stage of syncope is _______________.
A. Warm feeling
B. Cold extremities
C. Bradycardia
D. Pupillary constriction
10. A patient experiencing syncope should be positioned _______________.

A. In a semi-supine position at a 30-to-45-degree angle
B. With the head and upper body pushed forward
C. In a supine position with the feet elevated
D. In a vertical standing position
11. The order of treating a patient with syncope is _______________.

A. Airway>Breathing>Circulation
B. Circulation>Airway>Breathing
C. Circulation>Breathing>Airway
D. Airway>Circulation>Breathing
12. Anaphylactic reactions are caused by _______________.

A. Release of catecholamines into the circulatory system
B. Intravascular injections
C. Release of histamine from IgE sensitized mast cells
D. Increased insulin production
13. The appropriate dose of epinephrine to a 5 year old child experiencing asthmatic attack
is _______________.
A. 1 ml of 1:1000 epinephrine
B. 1 ml of 1:10,000 epinephrine
C. 1 ml of 1:2000 epinephrine
D. 1 ml of 1:20,000 epinephrine
14. Mild allergic reaction in a 5 year old child is treated by administering _______________.
A. Oral diphenhydramine 1 mg/kg every six hours
B. A one-time dose of oral diphenhydramine 25 mg
C. 1 ml of 1:1000 epinephrine intramuscularly
D. 1 ml of 1:2000 epinephrine intramuscularly
15. The position for managing a patient experiencing an acute asthmatic episode is
_______________.
A. A supine position with legs elevated
B. Upright with arms thrown forward over a chair
C. A semi-supine position at a 30 to 45 degree angle
D. Supine with the head tilted to the side
16. The signs and symptoms of acute asthma attack include_______________.

A. Bradycardia
B. Hyperventilation
C. Lightness in the chest
D. Shortness of breath
25
17. The amount of vasoconstrictor in 1.7ml cartridge of Lidocaine 2% with 1:100,000
Epinephrine is _______________.
A. 0.017 mg
B. 0.17 mg
C. 0.034 mg
D. 0.34 mg
18. Emergency management of local anesthesia toxicity in a five-year-old includes:

A. Administer 1 ml epinephrine 1:1000
B. Administer oxygen via a mask
C. Administer 1 ml of flumazenil 0.1 mg IV
D. Administer oral diphenhydramine 1 mg/kg
19. Vasoconstrictor should be avoided or minimized in patients with the following condition:
A. Blood pressure of 120 mm Hg systolic or 80 mg Hg diastolic
B. Blood pressure of 80 mm Hg systolic or 50 mg Hg diastolic
C. Uncontrolled hyperthyroidism
D. Uncontrolled hypothyroidism
20. An initial dose 0.5cc of glucagon IM is the drug of choice for treating _______________.
A. A conscious 23 lb patient exhibiting hypoglycemia
B. An unconscious 23 lb patient exhibiting hypoglycemia
C. A conscious 23 lb patient exhibiting signs of hyperglycemia
D. An unconscious 23 lb patient exhibiting signs of hyperglycemia
21. The ictal phase of Grand Mal seizures usually lasts for _______________.
A. Less than 1 minute
B. 1 to 2 minutes
C. 2 to 5 minutes
D. More than 5 minutes
22. Febrile Seizure occurs when the temperature exceeds _______________.

A. 99°F
B. 100°F
C. 101°F
D. 102°F
23. The proper sequence of BLS for a child in cardiac arrest, witnessed by 2 rescuers, is:
A. Assess the patient, obtain an AED, initiate CPR, activate the emergency response system.
B. Assess the patient, initiate CPR, activate the emergency response system, and obtain an AED
simultaneously.
C. Initiate CPR, assess the patient, activate the emergency response system, obtain an AED.
D. Activate the emergency response system, assess the patient, initiate CPR, obtain an AED
24. The drug of choice for treating narcotic overdose is ____________

A. Atropine
B. Flumazenil
C. Phenobarbital
D. Naloxone
26
25. The compression-ventilation ratio for a 2-year-old child using 2 rescuers is ____________.
A. 15:2
B. 30:2
C. 60:2
D. 90:2
27
References
1. Rosenberg M. Preparing for medical emergencies: the essential drugs and equipment for the
dental office. Journal of the American Dental Association. 2010; 141: S14-9.
2. Haas DA. Management of medical emergencies in the dental office: conditions in each country,
the extent of treatment by the dentist. Anesthesia Progress. 2006; 53: 20-4.
3. Coté CJ, Wilson S. Guidelines for monitoring and management of pediatric patients before,
during, and after sedation for diagnostic and therapeutic procedures. Pediatric Dentistry. 2019;
41: 26E-52E.
4. Weyland W, Bräuer A, Weyland A, Janitzki AS, Braun U. The effect of sedation on oxygen uptake
during spontaneous breathing. Anaesthesist. 1993; 42: 391-5.
5. American Dental Association. Medical Emergencies in Dental Office. 2019.(Assessed on October
25, 2021).
6. Malamed SF. Medical Emergencies in the Dental Office, 7th Edition, St. Louis, MI. Elsevier Health
Sciences. 2014. pp. 74-75.
7. Nowak A, Christensen JR, Mabry TR, Townsend JA, Wells MH, editors. Pediatric Dentistry: infancy
through adolescence, 6th Edition, Philadelphia, PA. Elsevier Health Sciences. 2018. pp. 148-149.
8. Fast TB, Martin MD, Ellis TM. Emergency preparedness: a survey of dental practitioners. Journal
of the American Dental Association. 1986; 112: 499-501.
Sciences. 2014. pp. 144-146.
Sciences. 2014. pp. 385-390.
11. Sicherer SH, Leung DY. Advances in allergic skin disease, anaphylaxis, and hypersensitivity
reactions to foods, drugs, and insect stings. Journal of Allergy and Clinical Immunology. 2004;
114: 118-24.
Sciences. 2014. pp. 396.
13. Bisgaard H, Bønnelykke K. Long-term studies of the natural history of asthma in childhood.
Journal of Allergy and Clinical Immunology. 2010; 126: 187-97.
Sciences. 2014. pp. 214-217.
Sciences. 2014. pp. 347-349.
16. Bartlett SZ. Clinical observations on the effects of injections of local anesthetic preceded by
aspiration. Oral Surgery, Oral Medicine, Oral Pathology. 1972 Apr 1;33(4):520-6.
17. American Academy of Pediatric Dentistry. Use of local anesthesia for pediatric dental patients.
The Reference Manual of Pediatric Dentistry. Chicago, III. American Academy of Pediatric
Dentistry; 2020: 318-23. Accessed October 25, 2021
18. Danaei G, Finucane MM, Lu Y, Singh GM, Cowan MJ, Paciorek CJ, Lin JK, Farzadfar F, Khang YH,
Stevens GA, Rao M. National, regional, and global trends in fasting plasma glucose and diabetes
prevalence since 1980: systematic analysis of health examination surveys and epidemiological
studies with 370 country-years and 2· 7 million participants. The Lancet. 2011: 31-40.
Sciences. 2014. pp. 270-272.
Sciences. 2014. pp. 315-318.
21. American Heart Association. Basic life support (BLS) provider manual. American Heart
Association; 2020.
28
About the Authors
Steven Schwartz, DDS

The P&G team wishes to express its sadness over the loss of our colleague and friend,
Dr. Steven Schwartz, who passed away on October 25, 2018. He was a tremendous
help on impacting thousands of dental professionals through CE, making dentalcare.
com one of the best CE providers in the world. He was a wonderful person! We will
miss him.
Dr. Steven Schwartz was the former director of the Pediatric Dental Residency
Program at Staten Island University Hospital and was a Diplomate of the American
Board of Pediatric Dentistry.
Jayakumar Jayaraman, BDS, MDS, FDSRCS, MS, PhD

Dr. Jayaraman is a Pediatric Dentist with clinical and research training from
India, Hong Kong, England and the United States. He obtained master’s degrees
in Pediatric Dentistry from the University of Hong Kong and the University of
Texas Health San Antonio. Dr. Jayaraman also received his Diploma in Pediatric
Dentistry and Fellowship at the Royal College of Surgeons of Edinburgh, United
Kingdom where he also serves as an Examiner. For the past 10 years he has
taught Pediatric Dentistry and supervised research projects for pre-doctoral, post-
doctoral and PhD students in different countries. His research involves topics in
Evidence-Based Dentistry, Forensic Dentistry, Human Biology & Anthropology. Dr. Jayaraman has
published over 50 peer-reviewed scientific articles and reviewed articles for several leading pediatric,
forensic, and multi-disciplinary journals. He serves as an Associate Editor for the Frontiers in Dental
Medicine Journal and an Editorial Board Member of the International Journal of Pediatric Dentistry.
Dr. Jayaraman is currently Associate Professor of Pediatric Dentistry at Virginia Commonwealth
University, Richmond.
Email: jayakumar83@hotmail.com
29

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Management of Pediatric Medical Emergencies

Course Author(s): Steven Schwartz, DDS; Jayakumar

Online Course: www.dentalcare.com/en-us/professional-education/ce-courses/ce391

Conflict of Interest Disclosure Statement

Introduction – Pediatric Medical Emergencies

To ensure the EMS personnel have no more

Figure 8. Pulse oximeter connected to a monitoring device on a patient

At the very least, a basic dental office Psychogenic factors include:

Table 2. Additional Emergency Drugs.6

Directions for use of EpiPen:

Epinephrine is administered every 15 minutes

Mild or Delayed Allergic Reactions Figure 11. Diphenhydramine for

Intrinsic asthma usually develops in adults older

Table 3. Maximum Recommended Dosage of Local Anesthetic Agents.17

If too much vasoconstrictor is injected or Sedatives and Anxiolytic Agents (Overdose)

It is important to note the use of local

1. The most common medical emergency in a dental office is _______________.

2. A duty of the first person on the scene of an emergency is _______________.

3. Essential emergency equipment includes:

4. Epinephrine is primarily recommended for managing _______________.

5. Glucagon is used in the management of _______________.

6. Flumazenil is used in the management of _______________.

7. The drug of choice for treating status epilepticus is _______________.

8. A non-psychogenic predisposing factor for syncope is _______________.

10. A patient experiencing syncope should be positioned _______________.

11. The order of treating a patient with syncope is _______________.

12. Anaphylactic reactions are caused by _______________.

16. The signs and symptoms of acute asthma attack include_______________.

18. Emergency management of local anesthesia toxicity in a five-year-old includes:

22. Febrile Seizure occurs when the temperature exceeds _______________.

24. The drug of choice for treating narcotic overdose is ____________

Steven Schwartz, DDS

Jayakumar Jayaraman, BDS, MDS, FDSRCS, MS, PhD

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