Modern approaches to providing aid in emergencies in the practice of a pediatric dentist

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Modern approaches to providing aid in emergencies in the practice of a pediatric dentist

Maksymenko A.I., Poltava State Medical University,

Sheshukova O.V., Poltava State Medical University, Kuz I.O., Poltava State Medical University,

Pysarenko O.A., Poltava State Medical University

Introduction

A pediatric dentist, providing qualified help to children of various ages, and performing numerous manipulations in the oral cavity, must be oriented in the prevention and diagnosis of emergency conditions, as well as have clear skills in carrying out treatment measures at the preclinical stage. The correct methods of carrying out special measures before the arrival of an emergency in most cases allow for saving the lives of patients who have been affected by pathological factors [1, 2].

Depending on the strength, duration, and degree of action of the aggression factor on the organism, its appropriate reaction can be kept within the limits of compensatory capabilities, and in the case of imperfect reactivity, it leads to a violation of the hemostasis of the child's body.

The problem of emergency conditions remains relevant in modern pediatric dental practice. Its complexity is associated with several specific features of outpatient admission of patients [3]:

a mass type of specific care, which is very often carried out with concomitant pathology;

the oral cavity is a reflexogenic zone and requires pain relief, which is not always possible;

the dentist cannot always fully examine the patient to detect malfunctions of important organs and systems. Patients

often have a fear of dental manipulations, especially children, which increases their pain sensitivity.

The aim of the work is to generalize modern approaches to emergency care in the practice of pediatric dentistry.

Presenting main material

Cardiovascular disorders manifesting as fainting occur most often in the practice of pediatric dentist. Fainting is a sudden short-term loss of consciousness, provoked by ischemia of the brain due to insufficient blood circulation, which most often occurs because of autonomic regulation of blood vessels in:

using medicaments that lower blood pressure;

sudden changes in body position (from horizontal to vertical);

overstrain;

compression of the carotid artery;

in patients with chronic somatic diseases.

Three periods are distinguished in the development of fainting: the pre-fainting state, fainting, and post-fainting period. Fainting can be:

cerebral, due to a violation of cerebral geodynamics;

cardiac, which develops as a result of the pathology of the cardiovascular system;

reflex fainting develops under the influence of pain, psycho-emotional overstrain (fear);

hysterical fainting occurs because of a conflict situation and has a demonstrative nature [2, 4].

In the dental practice of pediatric dentist, reflexes and hysterical fainting occur most often. In clinical practice, a distinction is made between the pre-conscious state (discomfort, dizziness, ringing in the ears, numbness of the tongue, lips, blurred vision) and actual fainting (loss of consciousness, acute weakness, ringing in the ears, dizziness, pallor of the face and skin, cold sweat, low blood pressure, narrowed pupils with preserved reaction to light, shallow breathing). The average duration of fainting is from 5 seconds to 1 minute. When this condition occurs, first, it is necessary to remove foreign objects from the child's mouth, bring the lower jaw forward to avoid the tongue from sinking in, place the patient in a horizontal position with the legs raised, and ensure the flow of fresh air. Put ammonia on a cotton ball, and let it smell through the nose, avoiding contact with the mucous membranes, especially the eyes. Rinse the face with cold water and touch the child's face with your hands. If the patient does not regain consciousness within 30 seconds, it is necessary to use the medicaments, such as caffeine 10% -- 1 ml subcutaneously or intravenously; cordiamine 25% - 2 ml orally or subcutaneously; atropine 0.1% - 0.5 - 1 ml subcutaneously or intravenously. After bringing the child out of unconsciousness, it is necessary to find out its cause. If there are no organic changes and there is no need for hospitalization, if the patient's condition is satisfactory, dental intervention can be continued with premedication and in a horizontal position [2, 5].

Prevention: taking into account the history and psychoemotional state of the child, and careful observance of the principles of deontology. Provision of adequate psychopharmacological preparation for surgical interventions and painless treatment.

The most severe form of emergency is collapse, which is characterized by a decrease in vascular tone and blood pressure and leads to acute vascular insufficiency. The main causes of the collapse are allergic reactions, acute blood loss, an overdose of antihypertensive medicaments, and acute adrenal insufficiency. In pediatric dentistry, collapse most often occurs with allergic reactions. The main clinical manifestations of collapse are acute deterioration of the general condition, pallor of the skin, cold sweat, frequent shallow breathing, and possible dizziness. If such symptoms are detected, it is necessary to provide emergency immediately, namely, remove foreign objects from the child's oral cavity, place him in a horizontal position with his legs raised, and ensure an influx of fresh air. It is necessary to use medications to eliminate peripheral spasms, correct circulating blood volume, and improve heart function. The small patient must be warmed (covered with a blanket or covered with warm heating pads), and dental manipulations should be postponed. The child should be hospitalized until the cause of the collapse is determined and specialized medical care is provided [6].

Prevention: medical coverage of surgical interventions (psychopharmacological preparation, provision of adequate analgesia, strengthening, and anti-inflammatory therapy). In the presence of risk factors for the development of collapse, the provision of blood and blood substitutes and means for transfusion should be provided for patients.

Urticaria is one of the urgent conditions that occur during dental manipulations, mainly when anesthetics are used. The main clinical manifestations are itchy blisters on the skin, slight swelling of the face, cough, shortness of breath, noisy breathing, asthma symptoms, increased body temperature, headache, etc. When these symptoms appear, it is necessary to stop dental manipulations until they disappear and carry out medicament therapy, and remove the allergen from the child's body, if possible. It is necessary to use antihistamines (loratadine, claritin, pipolfen 2 ml of 2.5% solution, suprastin 2 ml of 2% solution, etc.), and apply cold compresses to areas of skin rash. In severe cases, short courses of glucocorticoids (prednisolone 20-30 mg for 5-7 days) are effective [7, 8].

One of the severe forms of an allergic reaction is Quincke's edema, which develops a few minutes after the introduction of an allergen and is manifested by swelling of the upper respiratory tract, lips, neck, and larynx. At the same time, there is a cough and laryngospasm. When such a condition occurs, it is necessary first of all to put the child in a horizontal position, then urgently infiltrate the anesthetic injection site with 0.5 ml of a 1% adrenaline solution, use antihistamines (suprastin 2% solution 2 ml or diphenhydramine 1% - 0.5 - 1 mg/kg intramuscularly), Lasix (2% solution -- 1-2 mg/kg intramuscularly), adrenaline (0.1% solution -- 0.2-0.3 ml subcutaneously) and hormonal medicaments (prednisolone 1-2 mg/kg intramuscularly). A bronchodilator is administered to relieve spasms. Tracheotomy is recommended in the case of increasing asphyxia. A small patient needs to be hospitalized in a hospital [2, 9].

Prevention: detailed history taking, consultation with an allergist, preventive administration of desensitizing medications.

Anaphylactic shock is a state of acute increased sensitivity of the body, which develops when re-introduced foreign proteins and serums, medicines when bitten by insects. Any medication that contacts the body, for example, an anesthetic used orally, parenterally, applied to the skin or mucous membrane, or even inhaled in the form of an aerosol with previous sensitization of the body, can cause anaphylactic shock [1, 10].

Clinical symptoms of anaphylactic shock:

mild (from 2 minutes to 2 hours) anaphylactic shock is characterized by significant itching, reddening of the skin, the appearance of rashes, headache, dizziness, tingling in the throat, hypotension, tachycardia, a feeling of heat, increasing weakness, unpleasant sensations in various parts of the body;

average anaphylactic shock is characterized by toxicoderma, Quincke's edema, conjunctivitis, impaired vision, pallor of the skin, noise in the head, a feeling of fear of death, nausea, possibly vomiting, acute pain in the abdomen;

severe anaphylactic shock is manifested by loss of consciousness, acute respiratory and heart failure (shortness of breath, cyanosis, small frequent pulse, decrease of blood pressure);

very severe -- rapidly developing collapse (paleness, cyanosis, threadlike pulse, decrease of blood pressure, loss of consciousness, eye pupil dilation in the absence of reaction to light) [6, 11].

Forms of anaphylactic shock:

quick form: occurs 1-2 seconds after the introduction of the allergen, is characterized by loss of consciousness, convulsions, dilated pupils, lack of reaction to light, a decrease of blood pressure, difficulty breathing, and dull heart sounds up to complete extinction. After 8-10 minutes, death occurs;

severe form: occurs 5-7 minutes after the introduction of the allergen, is characterized by a feeling of burning in the body, difficulty breathing, headache, weakening of heart sounds, lowering of blood pressure, dilation of eye pupils;

moderate form: develops approximately 30 minutes after the introduction of the allergen. Allergic rashes and itching appear on the skin. The following variants of this form of anaphylactic shock are possible:

cardiogenic with myocardial ischemia and impaired peripheral microcirculation;

asthmoid or asphyxic with bronchospasm, laryngeal edema, hypoxia;

cerebral with psychomotor excitement, convulsions, loss of consciousness, cardiac and respiratory arrest;

abdominal, which is manifested by symptoms of acute pain in the abdomen [11,12].

Emergency care for an anaphylactic shock:

Stop the further entry of the allergen into the child's body: stop the use of medicaments that caused anaphylactic shock. Apply a tourniquet above the injection site (if localization allows) for 30 minutes, cross-cross the injection site with a 0.1% solution of adrenaline at a dose of 0.1 ml/year of life in 5.0 ml of isotonic sodium chloride solution and apply to it ice for 10-15 min. In the case of droplet contact of the allergen into the nose and eyes, rinse the nasal passages and conjunctival sac with running water.

Put the child on his back, turn his head to the side, stick out his lower jaw, open his mouth, and fix his tongue. Provide access to fresh air or carry out inhalation of 100% oxygen through a breathing mask or nasal catheter in the amount of 10-12 l/min.

Immediately inject intramuscularly a 0.1% adrenaline solution at a dose of 0.05-0.1 ml/year of life (no more than 1 ml) and a 3% solution of prednisolone at a dose of 5 mg/kg into the muscles of the floor of the oral cavity; antihistamines: 1% solution of diphenhydramine at a dose of 0.05 ml/kg (no more than 0.5 ml for children under 1 year and 1.0 ml - over a year) or 2% solution of suprastin at a dose of 0.1-0.15 ml/year of life.

If necessary, make a complex of cardiopulmonary resuscitation.

Hospitalization after a complex of emergency medical measures.

Prevention: considering the ability of local anesthetics to provoke allergic reactions. Appointment of samples for anesthetics and consultation with an allergist [2, 6].

Bronchial asthma is a disease, characterized by attacks of suffocation that occur suddenly and are repeated during a more or less long period of life. An attack can occur during the child's stay in the dental office, being provoked by the presence of any medication in the form of aerosols [8, 11].

A harbinger of bronchial asthma can be the sudden appearance of watery discharge from the nose, sneezing, cough without sputum, which is accompanied by suffocation, the appearance of noisy breathing with difficult exhalation, the restlessness of the child and a characteristic sitting posture with support on the arms, the appearance of cyanosis of the skin,

tachycardia. Breathing is noisy, whistling. It can last from several minutes to several hours and end with a cough with the release of a significant amount of transparent, viscous sputum [2, 5].

Emergency care for patients with bronchial asthma:

inhalation of P-adrenomimetics. For 1 inhalation - no more than 2 doses of the medicament, no more than 3 inhalations with an interval of 10 minutes;

provide access to fresh air. It is possible to conduct reflexology with intensive point massage of the middle of the sternum and the area of the xiphoid process;

in case of treatment inefficiency and progression of respiratory failure call the ambulance team. While waiting inject slowly euphyllin in 2.4% solution 10 ml; a solution of prednisolone (90 mg) or dexamethasone (8 mg).

Prevention: careful anamnesis collection, and premedication of patients. Carrying out dental interventions only in the inter-attack period with the use of bronchodilator, cardiac and sedative medications recommended by the pediatrician. The child should have an inhaler with a bronchodilator [7, 9].

An epileptic seizure can occur in patients with epilepsy during an appointment with a pediatric dentist.

Clinical symptoms: sudden loss of consciousness, tonic convulsions changing to clonic ones, redness, or paleness of the face. Dilation of the eye pupils, the disappearance of the corneal reflex, the pulse is frequent, sufficiently full. There is a lot of salivation in the child's mouth. The muscles of the face, limbs, and trunk are tense. Spasm of the respiratory muscles with respiratory arrest. An epileptic attack lasts from a few seconds to a few minutes, changing into a coma, which turns into a sopor, and later into a deep sleep. Complete amnesia can be observed after the attack.

Emergency care for convulsive conditions in children.

Lay the child on a flat surface on his back, put a roller under it

neck, unbutton tight clothes, and turn your head to the side.

Remove all damaged items.

Provide access to fresh air.

Calm the child (remove sound and light stimuli).

Measure the body temperature (if it exceeds 38.5 °C, give antipyretic medicaments and cool the child).

Anticonvulsant therapy: first-line medications for treatment seizures in children are benzodiazepines, namely, diazepam (seduxen, sibazone, relanium) in age-related doses intramuscularly.

Hospitalization to the neurological department, in case of violation of vital functions - to the resuscitation and intensive care unit [8, 11].

Prevention: detailed history taking, consultation with a neurologist, and taking antiepileptic pills before dental intervention. If there is a history of frequent attacks, dental manipulations should be performed in the presence of a neurologist and an anesthesiologist. As an analgesic medicament, the most effective is the use of articaine.

Hyperglycemic (diabetic) coma is a complication of diabetes mellitus in which the blood sugar level rises rapidly (over 5.5 mmol/l). It develops slowly, except for isolated cases when a coma occurs within 1-2 hours (at a young age). There are disorders of consciousness, sometimes complete loss of consciousness; acidotic breathing (Kussmaul breathing), a possible smell of acetone from the mouth; the skin and mucous membranes are dry, the eyeballs are soft; tachycardia, arterial hypotension; hyperglycemia.

Emergency care for hyperglycemic (diabetic) coma.

Intravenous infusion of isotonic solutions of glucose (5%) or NaCl (0.9%) in the volume of 1 l/h.

Intravenous jet or deep intravenous injection of fast-acting insulin (simple insulin) in a single dose of 10 units.

Further infusion of simple insulin at a rate of 10 units per hour [7, 12].

Hypoglycemic coma is a complication of diabetes that occurs when the blood sugar level is less than 2.8 mmol/l. As a rule, this condition is caused by exogenous factors, accompanied by rapid loss of consciousness, and convulsions. The child has severe hunger, sweating, headache, restlessness, tachycardia, increased blood pressure, psychosis or delirium, neurological symptoms [5, 6].

The rapid development of hypoglycemia leads to loss of consciousness and the development of coma. To provide first aid to the child, it is necessary to check the presence of breathing and, if necessary, carry out resuscitation measures (perform artificial respiration); put a little sugar under the tongue of a conscious child or give him liquids with a high glucose content (juices, sweet tea, sweet water). It is necessary to put the child on his side and ensure warmth and access to fresh air [3, 5].

Medical care consists of intravenous infusion of 40% glucose 20-40-100 ml. The criterion of the sufficiency of the dose is the restoration of consciousness. Then they switch to an infusion of 5% glucose solution. Hypoglycemia can recur. In this case, the intramuscular injection of 1 ml of 1% glucagon is effective, repeat the injection after 10 minutes. 0.5-1.0 ml of 0.1% adrenaline solution is administered subcutaneously, and 150-200 mg of hydrocortisone is administered intravenously or intramuscularly [4, 8].

Preventive measures include regular administration of insulin preparations, adherence to the diet, and dosed physical activity. Children who belong to the group of increased risk are recommended to always carry specific devices that constantly monitor the level of sugar in the blood and signal their decrease.

In addition, it is advisable to wear medical bracelets that contain contact phone numbers, information about the child's diagnosis, and the medications taken by him. Thus, it is possible to get the necessary help even if the attack of hypoglycemia occurred on the street and no one of his parents was near the patient. With severe symptoms of coma, an ambulance should be called immediately.

Conclusions

insulin anaphylactic shock

A pediatric dentist must be ready to provide emergency care to small patients if there are some complications during a dental appointment. It is necessary to have special equipment and a suitable set of medicines, the quality, shelf life, and quantity of which must be monitored every month.

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