Paediatric ECAT protocol

Dental presentations

P10.1 Published: December 2023. Printed on 15 Jun 2024.

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Any person, 4 weeks to 15 years, presenting with a dental injury and/or dental pain.

This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.

Dental injuries are often associated with concurrent facial and head trauma. Complete A to G assessment before management of dental injury.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

History prompts

  • Presenting complaint
  • Mechanism of injury
  • Time of injury
  • Associated injuries
  • Pain assessment
  • Pre-hospital treatment, including first aid given to the patient, tooth and/or fragment
  • Past admissions
  • Medical and surgical history
  • Dental history, including recent procedures or braces
  • Current medications
  • Known allergies
  • Immunisation status, including tetanus
  • Current weight

Signs and symptoms

  • Head strike
  • Tooth fracture, avulsion or displacement
  • Facial and/or oral injuries
  • Trismus
  • Nausea
  • Pain
  • Bleeding or laceration
  • Localised swelling along the gum
  • Facial swelling or erythema

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Historical

  • Delayed presentation
  • Recent dental surgery

Clinical

  • Bleeding not controlled with simple direct pressure
  • Head strike with loss of consciousness
  • Concomitant neck injury
  • Suspicion of facial fractures
  • Difficulty opening jaw
  • Difficulty breathing or airway compromise
  • Inhaled tooth
  • Swelling of the face and/or neck
  • Difficulty swallowing
  • Trismus
  • Inability to protrude the tongue
  • Signs of sepsis
  • Fever

Remember child or adolescent at risk: patient or carer concern, suspected non-accidental injury or neglect, multiple comorbidities or unplanned return.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

AssessmentIntervention

General appearance/first impressions

Position of comfort

Airway

AssessmentIntervention

Patency of airway

Maintain airway patency

Consider airway opening manoeuvres and positioning

Breathing

AssessmentIntervention

Respiratory rate and work of breathing

Consider auscultation of chest (breath sounds)

Oxygen saturation (SpO2)

Assist ventilation as clinically indicated

Apply oxygen to maintain SpO2 over 93%

Respiratory distress associated with a dental injury may indicate an inhaled tooth/fragment. See specific treatment section

Circulation

AssessmentIntervention

Perfusion (capillary refill, skin warmth and colour)

Heart rate

Blood pressure

Assess circulation

IVC and/or pathology

Insert IV cannula, if trained and clinically indicated

See pathology section

Disability

AssessmentIntervention
AVPU

If AVPU shows reduced level of consciousness, continue to assess GCS, pupillary response and limb strength

GCS, pupillary response and limb strength

Obtain baseline and repeat assessment as clinically indicated

Pain

Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

AssessmentIntervention
Temperature

Measure temperature

Head-to-toe inspection, including posterior surfaces

Check and document any abnormalities

Fluids

AssessmentIntervention

Hydration status

Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses

Nausea and/or vomiting If present, see nausea and/or vomiting section

Glucose

Assessment Intervention

BGL

Measure BGL, where clinically relevant or of concern. See medication table for 40% glucose gel dosing

If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria):

  • give quick-acting carbohydrate:
    • Up to 12 months: milk feed and/or 40% glucose gel, buccal
    • 12 months and over: sugary soft drink or fruit juice or 40% glucose gel, buccal
  • reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L

If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose:

  • give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access
  • escalate as per local CERS protocol

Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.

Focused assessment

Complete a dental focused assessment.

Consider a neurological focused assessment.

Precautions and notes

  • Management of dental injuries will depend on whether it is a primary or secondary (permanent) tooth that is injured.
  • Injured primary teeth should not be replanted, splinted or repositioned and may need removal if displaced or mobile.
  • Injuries to primary teeth are managed to reduce the risk of problems associated with the eruption and formation of permanent teeth, not to save the primary tooth.
  • Avulsed permanent teeth should be replanted into the socket as soon as possible, preferably within 60 minutes.

Interventions and diagnostics

Specific treatment

Avulsion of secondary (permanent) tooth

Complete avulsion of a permanent tooth requires urgent attention. For the best prognosis, the following should be provided as soon as possible, within 60 minutes of avulsion:

  • The tooth should be reinserted into the socket.
  • Do not handle the root of the tooth. Hold by the crown and rinse with sterile saline solution to remove debris.
  • Other teeth should be gently moved back into position.
  • Ask the patient to bite down on folded gauze to keep the tooth in place.
  • Alternatively, the tooth should be placed in dairy milk or 0.9% sodium chloride.
  • If the tooth is not located consider possible ingestion, inhalation or embedded in soft tissue.

Fractured tooth

  • Place fragments in dairy milk until dental review.
  • Fractures with exposed pulp (pink) can be painful. Give analgesia.

Intruded or displaced teeth

  • Give analgesia and await dental review.

Tooth abscess

  • If fever, systemic features, facial swelling or erythema present, give analgesia and await medical or nurse practitioner review.

Analgesia

Select pain score:

Pain score 1–3 (mild)

Give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg

and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg

Pain score 4–6 (moderate)

Give:

oxycodone (immediate release):

  • 1–12 months: 0.05 mg/kg orally once only, maximum dose 0.5 mg
  • 12 months and over: 0.1 mg/kg orally once only, maximum dose 5 mg

and/or paracetamol 15 mg/kg, orally once only, maximum dose 1000 mg

and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg

Pain score 7–10 (severe)

Give one of:

Fentanyl intranasal
  • 12 months and over: 1.5 microg/kg intranasally, maximum single dose 75 microg and, if required, repeat once after 5 minutes, maximum total dose 3 microg/kg or 150 microg, whichever is less. Dose to be divided between nostrils

Note: ensure an extra 0.1 mL is drawn up for the first dose to account for the dead space in the mucosal atomiser device

Morphine IV
  • 1–12 months: 0.05 mg/kg IV, maximum single dose 0.5 mg and, if required, repeat once after 5 minutes, maximum total dose 0.1 mg/kg or 1 mg, whichever is less
  • 12 months and over: 0.1 mg/kg IV, maximum single dose 5 mg and, if required, repeat once after 5 minutes, maximum total dose 0.2 mg/kg or 10 mg, whichever is less

and/or paracetamol 15 mg/kg orally once only, maximum dose 1000 mg

and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg

If pain does not improve with medication, escalate as per local CERS protocol.

Consider non-pharmacological pain relief (appendix).


Nausea and/or vomiting

If nausea and/or vomiting is present and over 6 months give:

ondansetron:

  • 8–15 kg: 2 mg, orally once only
  • 15–30 kg: 4 mg, orally once only
  • Over 30 kg: 8 mg, orally once only.

Tetanus

All patients must be considered for a tetanus booster if they have a tetanus-prone wound. Refer to medical or nurse practitioner or nurse immuniser to consider tetanus immunisation requirements.


Radiology

Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.


Pathology

Not usually indicated. If there is concern for urgent pathology, escalate care as per local CERS protocol.

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

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Drug Dose Route Frequency

12 months and over:
1.5 microg/kg

Maximum single dose 75 microg
Maximum total dose of 3 microg/kg or 150 microg, whichever is less

Intranasal

Pain score 7–10

Repeat once if required after 5 minutes to maximum dose

Glucose 40% gel
(0.4 g/mL)

4 weeks1 year:
200 mg/kg (=0.5 mL/kg)

15 years: 5 g

611 years: 10 g

12 years and over : 15 g

Buccal

Repeat after 15 minutes if required

Ibuprofen H, R

3 months and over:
10 mg/kg

Maximum dose 400 mg

Oral

Pain score 1–10

Once only

1–12 months:
0.05 mg/kg
Maximum single dose 0.5 mg
Maximum total dose 0.1 mg/kg or 1 mg, whichever is less

12 months and over:
0.1 mg/kg
Maximum single dose 5 mg
Maximum total dose 0.2 mg/kg or 10 mg, whichever is less

IV

Pain score 7–10

Repeat once if required after 5 minutes to maximum dose

Over 6 months and 8–15 kg:
2 mg

15–30 kg:
4 mg

Over 30 kg:
8 mg

Oral

Once only

1–12 months:
0.05 mg/kg
Maximum dose 0.5 mg

12 months and over:
0.1 mg/kg
Maximum dose 5 mg

Oral

Pain score 4–6

Once only

Oxygen

0.25–15 L/min, device dependent

Inhalation

Continuous

Paracetamol H

15 mg/kg

Maximum dose 1000 mg

Oral

Pain score 1–10

Once only

Medications with contraindications or requiring dose adjustment are marked:

  • H for patients with known hepatic impairment
  • R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

References

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Evidence informed

Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.

Collaboration

This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.

Currency Due for review: Jan 2026. Based on a regular review cycle.
Feedback Email ACI-ECIs@health.nsw.gov.au

Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/paediatric/dental-presentations

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