Assessment of perception of oral healthcare professionals in management of medical emergencies in children: A cross-sectional study

Background: Medical emergency is an acute condition which can occur when least expected. It is more common to occur in a dental setup as this environment can be stressful for a patient. Children are more prone to emergencies as their dental procedures usually takes place under sedation. Therefore, it is mandatory for a dentist to have adequate knowledge, proper attitude and good training in handling any medical emergency seen in children during their dental treatment. Objectives: To assess the perception of oral healthcare professionals in management of medical emergencies in children. Method: A cross-sectional survey comprising 270 participants was conducted on oral healthcare professionals including interns, postgraduate students, practising dentists and faculty dentists. An 18-item validated questionnaire containing four domains of professional demographic data, knowledge, attitude and practice were distributed among the participants. Descriptive analysis was used followed by Chi Square test to check for association between age, gender, educational qualification and years of experience. Results: The level of knowledge, attitude and practices was lower in graduate dentists than postgraduate dentists. The correlation between knowledge, attitude and practices was found to be highly statistically significant (p=0.001). _______


Introduction
Medical emergency is an acute condition that may be life-threatening and can occur when least expected. A dental setup is a place where an emergency situation can easily occur 1 . Life threatening situations in a dental office may occur commonly due to the high level of anxiety in patients and a stressful dental environment. Since children are not miniature replica of adults, management of any medical emergencies in them has a different approach altogether 2 . A dental surgeon should have an adequate knowledge of and should be aware of such emergencies and thus be prepared to handle it. A dental set up should be well equipped with a medical emergency kit which could consist of separate paediatric specific dosage to deal with emergencies seen in paediatric patients 3,4 .
Commonly occurring medical emergencies in children in a dental setup include foreign body induced airway obstruction, allergic reactions, anaphylaxis, local anaesthetic drug overdose, acute asthmatic attack, seizures, hypoglycaemic reactions and syncope 5 . In paediatric patients, anxiety, lack of patience and continuous movement during dental treatment can commonly lead to foreign body aspiration. If this enters into the respiratory tract, it can cause airway obstruction and lead to death by asphyxiation 3 . Results of a survey of emergencies in 10-year period indicated that syncope is the most common medical emergency seen in a dental setup. This is followed by hysteria, mild allergy, seizures, airway obstruction, hyperventilation, aspiration, drug and local anaesthetic overdoses and cardiac arrest 6 . Dental procedures under local anaesthesia, sedation and general anaesthesia can contribute to such medical emergencies 7 . Very few studies have been conducted on assessment of knowledge, attitude and practices to handle commonly occurring medical emergencies in children among dental health care professionals. Also, very few studies have been conducted to check training levels of the participating population which was assessed in this study. Thus, we designed a study by means of a questionnaire to evaluate the perception of oral healthcare professionals in management of medical emergencies in children. Also, to spread awareness about emergency situations that can occur and be prevented with proper precaution and to encourage dentists to attend various medical emergency related workshops to update their skills regularly.

Objectives
To assess the knowledge, attitude and practices of oral healthcare professionals in management of medical emergencies in children.  9 . A sample of 267 was obtained which was rounded to 270.

Inclusion and exclusion criteria:
Participants consisted of oral healthcare professionals which included faculty dentists, practising professionals, dental postgraduate students and dental interns. Undergraduate students and participants who did not give their consent were excluded from the study.
A questionnaire consisting of 18 questions covering various aspects essential for this study was prepared by taking references from paediatric dentistry textbooks and articles published in the past 1,3,5,6,8 . The questionnaire had 4 parts. First part included demographic data of the participants, whether they treat children and have attended any medical emergency workshops. Second part dealt with knowledge of medical emergencies seen in children. Third part assessed attitude and last part dealt with the practices of the participants and their training levels to handle a medical emergency. The responses to the questions were measured on a five-point Likert Scale: "strongly agree", "agree", "neutral", "disagree", "strongly disagree".
Validity of the content was approved by a group of professionals. Participants were instructed regarding filling of the questionnaire and a pilot study was conducted among 20 participants to ensure ease and lucidity of answering the questionnaire. The data were collected by circulating the offline questionnaire among the participants who were willing to participate in the study. Reliability of the administered questionnaire was determined and a Cronbach alpha coefficient value of 0.82 was obtained. These participants were then excluded in the final study, and the questionnaire did not require any modifications.

Statistical analysis:
The collected forms were analysed in MS Excel sheet (Microsoft Corp.). Data were entered using IBM SPSS software (version 21.0 Chicago IL, USA) and 'p' value of <0.05 was taken as significant. Data were then subjected to statistical analysis. Association of knowledge, attitude and practice with respect to gender, age, education and years of experience was carried out using Chi square test. Descriptive statistics were generated for all questions, and for each answer, frequency distributions and percentages were examined.

Results
The data for this study was based on the responses received from 270 participants. These belonged to various age groups, gender, specialities and designations. Of the participants 63% were females and 37% were males. The mean age of this population was 26.83 ± 4.77 years. Of the participants 60.4% were postgraduates and 39.6%. were graduates.
Oral healthcare professionals were subjected to a wide variety of questions that tried evaluating their knowledge, attitudes and practices about medical emergencies seen in children in a dental setup. Out of the total participants, 90.7% treated children in a dental setup. Association between participants attending basic life support (BLS) workshops with age, gender, educational qualification and experience was calculated using the Chi-square test; 63.2% postgraduates had undergone BLS training compared to 38.3% graduates which was statistically significant (p-value = 0.0001). In age group 21-25 years, 45% had attended BLS workshops compared to 64% in age group of 26 years and above which was statistically significant (p-value = 0.016).
On evaluation of knowledge, 95.2% of the total participants agreed that BLS workshops should be attended at a regular interval of 2 years. Of the respondents 89.6% were unaware of emergency management of foreign body aspiration in children during dental treatment. The postgraduates and participants with greater year of experience were aware of the treatment with statistically significant 'p' values of 0.01 and 0.02 respectively (Table 1); 74.1% of participants were aware about the symptoms of absence seizures seen in children on a dental chair. It was also observed that postgraduates had higher level of knowledge about BLS protocols which was indicated by a statistically significant 'p' value of 0.0001 (Table 1). On evaluation of the attitude regarding emergency management, 66.3% of participants were unaware that vital signs should be obtained from all patients undergoing a dental treatment. This was found to be statistically significant when comparison was done between postgraduates and graduates with a 'p' value of 0.028 (Table 2); 90.7% of participants agreed that a dental setup should be equipped with paediatric specific medical kits. This was supported by a statistically significant 'p' value of 0.042 among postgraduates and 'p' value of 0.013 among population with greater experience (Table 2). It was found that postgraduates were more aware about retrieving foreign body from oral cavity than graduates with a statistically significant 'p' value of 0.01 (Table 2). than graduates with statistically significant 'p' value of 0.001. Higher level of practices was seen among the participants who had an experience of 11 years and above (77%) than those who had 6-10 years of experience (54.8%) and the least were found in those having less than 5 years of experience. (Figure 1)

Table 1: Comparison of degrees with responses of knowledge of respondents in each question
Correlation between knowledge, attitude and practice scores by Karl Pearson's correlation method was found to be highly statistically significant with 'p' value of 0.0001, 0.0008, 0.0020 respectively. (Figure 2).
Binominal logistic regression was performed between knowledge, attitude and practice with sociodemographic characteristics. There was no significant association between knowledge, attitude and practice scores with age ('p' values = 0.315, 0.449, 0.161 respectively). There was a significant association between practices and gender ('p' value= 0.001) and males have 0.34 times increased odds of having better practice than female population. There was a significant association between the practice and the designation ('p' value = 0.003). Postgraduates had 3.91 times increased odds of having better practice levels than the graduate population. (Table 3)

Discussion
The chances of occurrence of medical emergencies in children in a dental setup is low but can occur when least expected 5 . A dentist should be well prepared and trained to handle medical emergencies seen in their patients. This will happen only when he/she is aware and trained enough to manage such medical emergencies. As it is rightly said, "The eyes see what the mind knows". Thus, our study aimed to assess knowledge, attitude and practices of dental health care professionals to handle paediatric medical emergencies in a dental setup.
Medical emergency workshops were attended by 63.2% postgraduates whereas only 38.3% of graduates have attended BLS workshops. This was found to be in accordance with a study by Varma LSC et al 9 . According to American Heart Association (AHA), BLS courses should be attended regularly every 2 years and the course certificate is valid for 2 years, to which 95.2% of total participants of this study agreed 10 .
Only 10.4% participants were aware about the correct line of treatment of foreign body aspiration which was found to be less than the percentage of population knowing the treatment in study by Ahmed R,et al 11 . Absence seizures are usually seen in children aged 4-10 years with maximum incidence in 5-7-year-old children and common symptoms of these are blank staring or staring spells 12 ; 74.1% of the population agreed to this question; 67.4% of participants were aware about correct order of activation of BLS. This was found to be higher than a similar study by De Mauro LM, et al 8 . This could have been probably because of higher knowledge observed in the current study population.
As recommended by AAPD in accordance with AHA, compression ventilation ratio in presence of 2 or more rescuers in children aged between 1 to 13 years is 15:2, chest compression rate in children and infants is 100-120 compressions/minute and the correct hand positioning to perform chest compressions in a child aged 1 year to puberty is lower half of breastbone 15 . When the participants were asked about recommended steps, ratios and techniques to perform cardiopulmonary resuscitation in children, including activation of BLS like correct algorithm, compression ventilation ratio, rate of chest compressions and correct hand positioning, only 56.5% of them had appropriate knowledge of these protocols.
Only 33.7% of the participants agreed upon taking medical history and recording vital signs from all patients before undergoing dental treatment. However, this percentage was found to be less than that of studies by Čuković-Bagić I, et al 3 , Ahmed R, et al 11 and Tasleem AS, et al 13 . Of the participants, 90.5% agreed that a medical emergency kit with essential drugs consisting of paediatric specific dosage and required equipment should be readily available in a dental office 3,4 . In case of upper respiratory tract obstruction, suctioning of foreign body should be done. If this does not help, emesis manoeuvre should be performed 14 ; 64.1% of the participants were aware about it. Blind finger sweeps are contraindicated to retrieve a foreign body from oral cavity as it may further push the body into oropharyngeal region 14 . However, only 40.7% of the participants were aware about this.
Of the participants, 81.9% were not trained to administer drugs parenterally in a child. This was in accordance with a study by Jodalli PS, et al 1 in which 69.5% and 58.1% did not know how to administer intravenous and intramuscular injections respectively. However, the postgraduate participants had better training in parenteral drug administration than graduate participants with a significant 'p' value of 0.0001 which was similar to the findings of Varma LSC, et al 9 where 78.9% of postgraduate students could administer intramuscular injections and 75.2% could administer intravenous injections. This was found to be in contrast to a study by Tasleem AS, et al 13 in which 20% of dental interns were aware about how to administer intravenous injections.
Heimlich manoeuvre should be performed when the patient is choking. Since this condition can be common in children, dentists treating children in their dental setup should be trained to relieve patient from choking 3 ; 77.8% of total respondents were not found to be trained in performing Heimlich manoeuvre in children which was found to be in contrast to a study by Ahmed R, et al 11 where 52.9% of the population knew the correct management of choking in children. Of the participants, 75.2% were not trained to perform CPR in children and infants and the percentage was comparatively higher in the graduate population and this was in accordance with studies by Devishree RA, et al 7 and De Mauro LM, et al 8 ; 32.4% of undergraduates were not trained and were less confident on using oxygen face mask which was found in accordance with a study by Jodalli PS, et al 1 .
It is very important for every oral health care professional to be trained in handling a medical emergency. This training should be an integral part of the BDS and MDS curriculum. A compulsory hands-on training programme should be mandatorily taught to the students. Dentists should update their skills by attending BLS workshops and courses regularly. It is recommended that a study be done on a larger sample size in a larger geographical area.

Conclusions
The majority of participants had adequate knowledge and attitude towards various medical emergencies and handling them in a dental setup. However, the practice levels of the participants were not adequate.