Pediatric  Dental  Health

• In any pediatric emergency, the ABC’s must be addressed quickly. ABC stands for airway, breathing, circulation.
• Early recognition and management of potential respiratory failure in children is critical. Airway management is the first priority for resuscitating a child who has a medical emergency, or who has an airway obstruction. Respiratory failure is the cause of most pediatric cardiopulmonary arrests, and airway obstruction can eventually lead to cardiopulmonary arrest.
• The airway of a child differs from that of an adult in several respects – increasing the ease with which the pediatric airway can become obstructed. Even a small reduction in the size of a child’s airway can cause a significant increase in airway resistance.
  
  
  BASIC LIFE SUPPORT FOR A CHILD 1-8 YEARS OF AGE:
• Assess consciousness and position the patient.
• Assess and open the airway.
  Head tilt-chin lift (unless there has been trauma).
• Assess and ensure breathing.
  Initial rescue breathing – provide two breaths at 1 second per breath. Create a mouth-to mouth seal and pinch the nose closed.
  Subsequent – 20 breaths per minute for rescue breathing only.
  Activate the EMS (Emergency Medical System).
• Assess and ensure circulation.
  Pulse check – palpate the carotid artery.
  When to compress - if the pulse is less than 60 and there are signs of poor systemic perfusion.
  Depth of compressions – 1/3 of the depth of the thoracic cavity.
  Rate of compressions – 100 per minute.
  Compressions to ventilations – 5:1
  Location – lower 1/3 of the sternum.
  Technique – use the heel of one hand.
• Activate the EMS after 20 cycles (one minute) of compressions + ventilations.
• Administer oxygen at 10 L per minute, and monitor/record vital signs.
  
  
  
• WHAT ARE SOME TREATMENT PROTOCOLS FOR PEDIATRIC EMERGENCIES?
  
  
  
• Airway obstruction:
  For conscious child - perform the Heimlich maneuver.
  For unconscious child - suction the mouth, open the airway using the tongue-and-jaw lift, and attempt to ventilate.
  Give up to 5 abdominal thrusts.
  After 5 abdominal thrusts, check the mouth again for a foreign body. Suction, but do not perform a blind finger sweep. Use Magill forceps to remove the foreign body, if visible.
  Call EMS (emergency medical services) after 1 minute of attempting to clear the obstruction.
  Consider needle cricothyrotomy.
  Repeat these steps of necessary.
  
  
  
  
  
• Laryngospasm: Initiate BLS - ensuring airway breathing and circulation, call EMS, give positive pressure oxygen x 30 seconds, give anectine if necessary - preceeded by 0.02 mg/kg of atropine, and intubate after giving the neuromuscular blocking agent (anectine).Visualize the vocal cords with a straight #2 blade, and use a size 4.5 ET tube in many cases.
  
  
• Bronchospasm: Bronchial dilator spray (Albuterol), BLS, pos. pressure oxygen, epinephrine 1:1,000 SQ at 0.01 ml/kg, call EMS.
  
  
• Emesis and aspiration: Turn patient to side, suction, BLS, EMS, pos. pressure oxygen.
  
  
• Respiratory depression: (Below 15 breaths/min) BLS, EMS, pos. press oxygen, Narcan (naloxone).
  
• Respiratory arrest: (With pulse) BLS, EMS, pos. pressure oxygen, monitors, start IV.
  
  
• Angina pectoris: Oxygen, nitroglycerin spray or tablet – repeat q 5 min, BLS, EMS.
  
  
• Myocardial infarction: BLS, EMS, attach AED (automatic external defribrillator), oxygen mask, IV, provide pain relief, give two 325 mg aspirins.
  
  
• Hypertension: BLS, EMS, propanolol (Inderal) 1 mg/min IV for adults.
  
  
• Hypotension: (Systolic below 90) BLS, EMS, epinephrine 0.01 mg/kg IV.
  
  
• Allergic reaction (anaphylaxis): the child’s face, eyes, and tongue may rapidly swell. Stridor (a high-pitched breathing noise) and/or wheezing may be severe.
  Begin BLS, call EMS, give oxygen by mask, give intramuscular injection of epinephrine 1:1,000 at 0.01 ml/kg. repeated every 15 minutes.
  Then give 30 ml/kg of crystalloid IV.
  Then treat bronchospasm with albuterol 0.5% at 2 puffs, from inhaler.
  Then administer oral or IM Benadryl at 1 mg/kg, up to a maximum of 75 mg.
  Then give systemic corticosteroid, such as methylprednisolone, at 2 mg/kg.
  
  
• Convulsion (seizure): Protect the patient from injury, BLS, EMS, oxygen.
  Never place any objects the the child’s mouth or nose during a seizure.
  During status epilepticus the airway is often obstructed, so the airway must be kept open.
  If a seizure lasts more than 10 minutes, begin treatment with an anticonvulsant, such as Versed 0.1 mg/kg IV.
  
  
• Syncope: (Cold sweat, nausea) Place patient in Trendelenburg position, BLS, oxygen, ammonia stimulant.
  
  
• Bradycardia: (Below 80 beats/min and poor perfusion) BLS, EMS, chest compressions, give low dose epinephrine (0.01 mg/kg q3-5 min IV), then high dose epinephrine (0.1 mg/kg IV), then atropine (0.02 mg/kg IV).
  
  
• Insulin shock: (Hypoglycemia – cool and moist skin) BLS, EMS, mucosal cake icing, 25 cc of 50% dextrose.
  
  
• Cardiac arrest: Start CPR (2 breaths, then 5 comp:1 vent for children 1-8 years old) 100 compress/min, EMS, IV. For children older than 8, use AED.
  
  
  
• WHICH EMERGENCY DRUGS ARE COMMONLY USED DURING PEDIATRIC EMERGENCIES?
  
• Epinephrine:
  For pulseless arrest: 0.01 mg/kg q3-5 min IV. Subseq or trach dose 0.1 mg/kg.
  For bradycardia: 0.01 mg/kg IV. Subseq or trach dose 0.1 mg/kg.
  For anaphylaxis: 0.01 mg/kg IM, SQ, IV. Repeat q15 min. if needed.
  
  
• Atropine: Give after the epinephrine administration. Give atropine 0.02 mg/kg IV.
  
  
• Lidocaine: 1.0 mg/kg rapid IV push. Alternative treatment for VF/pulsless VT.
  
  
• Naloxone: 0.1 mg/kg IV/IM/SQ to reverse narcotic toxicity.
  
  
• Flumazenil: 0.02 mg/kg IV to reverse benzodiazepine toxicity.
  
  
• Antihistamine: I.M. Benadryl at 1 mg/kg, up to a max. of 75 mg.
  
  
• Corticosteroid: Adrenal crisis. Prednisolone 1 mg/kg/day IV. Or Decadron at 0.3 mg/kg.
  
  
• Nitroglycerin: One sublingual tab every 5 min. Or use spray 1 second q5 min. for angina.
  
  
• Bronchial dilator: Treat bronchospasm with albuterol 0.5% at 2 puffs, from inhaler.
  
  
• Antiemetic: Hydroxyzine pamoate 25 mg oral suspension preop; or give hydroxizine 1.1 mg/kg IM injection.
  
  
• Anectine: 4.0 mg/kg IM. Or 1 mg/kg IV. Neuromuscular blocking agent for laryngospasm. Duration is 10 minutes.
  
  
• 50% Dextrose: 1-2 ml/kg. for confirmed hypoglycemia. Maximum 25cc in children.
  
  
  
• WHAT PEDIATRIC EMERGENCY EQUIPMENT SHOULD BE AVAILABLE?
  
• Oxygen source with flowmeter, capable of delivering 10 – 15 L per minute.
  
  
• Pediatric and adult bag-valve-mask combinations, each with a pop-off valve that can be occluded. Variety of pediatric and adult masks for assisted ventilation.
  
  
• Suction devices – powered and manual backup.
  
  
• Suction tips and catheters – Yankauer, 8, 10, 14 F.
  
  
• Oropharyngeal airways – infant, child, adolescent, and adult sizes.
  
  
• Intubation equipment – laryngoscope handle with batteries, extra bulb, Miller (straight) blades 1-2-3, and endotracheal uncuffed tubes sizes 3.0 – 8.0 .
  Endotracheal tube size should be: mm i.d. = AGE/4 + 4
  
  
• Stylets (small and large) – which should never extend beyond the distal end of the endotracheal tube.
  
  
• Adhesive tape to secure the endotracheal tube.
  
  
• Needle cricothyrotomy kit.
  
  
• Intraosseous needles - 15 or 18 guage.
  
  
• IV catheters, short, over the needle 18, 20, 22, 24 – guage.
  
  
• Butterfly needles – 23 guage.
  
  
• IV board, tape, alcohol swabs, touniquet.
  
  
• Pediatric drip chambers and tubing.
  
  
• Isotonic fluids (normal saline or lactated Ringers’s solution).
  
  
• Automatic blood pressure cuffs - infant, child adult.
  
  
• Sphygmomanometer (manual) – child and adult.
  
  
• Nasogastric tubes – 8, 10, 14 F.
  
  
• Stethoscope.
  
  A pediatric emergencies provider manual has been published by the U.S. Department of Health and Human Services. It covers topics such as: preparation for emergencies, mock codes, protocols for specific emergencies, preventing emergencies at home, office equipment list, office medication list, and various forms used during an emergency.
  
  Frush K, Cinoman M, Bailey B, Hohenhaus S: Office preparedness for pediatric emergencies provider manual. Department of Health and Human Services.
  
  
  Copyright ©2003 Daniel Ravel, DDS
  
  
  

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