MANAGEMENT OF PEDIATRIC EMERGENCIES IN THE DENTAL OFFICE
Medical emergencies can occur anywhere, even a dental office. Although pediatric
emergencies are uncommon during a dental appointment, they may be
life-threatening when they do happen. Emergencies may be due to a variety of
causes, including: a child's pre-existing medical condition, an airway
obstruction caused by dental material, or problems related to a sedation
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
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 +
Administer oxygen at 10 L per minute, and monitor/record vital signs.
WHAT ARE SOME TREATMENT PROTOCOLS FOR PEDIATRIC EMERGENCIES?
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
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.
Myocardial infarction: BLS, EMS, attach AED (automatic external
defribrillator), oxygen mask, IV, provide pain relief, give two 325 mg
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
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?
For pulseless arrest: 0.01 mg/kg q3-5 min IV. Subseq or trach dose 0.1
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
Lidocaine: 1.0 mg/kg rapid IV push. Alternative treatment for VF/pulsless
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
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
WHAT PEDIATRIC EMERGENCY EQUIPMENT SHOULD BE AVAILABLE?
Oxygen source with flowmeter, capable of delivering 10 – 15 L per
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
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).
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.