Umgang mit medizinischen Notfällen in der Zahnarztpraxis

Zahnärzte müssen darauf vorbereitet sein, medizinische Notfälle zu bewältigen, die in der Praxis auftreten können. In Japan wurde zwischen 1980 und 1984 vom Komitee zur Verhütung systematischer Komplikationen während der zahnärztlichen Behandlung der Japan Dental Society of Anesthesiology unter der Schirmherrschaft der Japanese Dental Society eine Studie durchgeführt.1 Die Ergebnisse dieser Studie zeigten, dass überall 19 % bis 44 % der Zahnärzte hatten in einem Jahr einen Patienten mit einem medizinischen Notfall. Die meisten dieser Komplikationen, etwa 90 %, waren leicht, aber 8 % wurden als schwerwiegend eingestuft. Es wurde festgestellt, dass bei 35 % der Patienten eine Grunderkrankung bekannt war. Bei 33 % dieser Patienten wurde eine Herz-Kreislauf-Erkrankung festgestellt.

Medizinische Notfälle traten am häufigsten während und nach der Lokalanästhesie auf, hauptsächlich während der Zahnextraktion und der Endodontie. Über 60 % der Notfälle waren Synkopen, gefolgt von Hyperventilation mit 7 % am zweithäufigsten.

In den Vereinigten Staaten und Kanada haben Studien auch gezeigt, dass Synkopen der häufigste medizinische Notfall sind, der von Zahnärzten gesehen wird.2,3 Synkopen machten etwa 50 % aller Notfälle aus, die in einer bestimmten Studie gemeldet wurden, mit dem zweithäufigsten Ereignis, einer leichten Allergie, machten nur 8 % aller Notfälle aus. Neben der Synkope wurden als weitere Notfälle allergische Reaktionen, Angina pectoris/Myokardinfarkt, Herzstillstand, orthostatische Hypotonie, Krampfanfälle, Bronchospasmus und diabetische Notfälle berichtet.

Der Umfang der zahnärztlichen Behandlung erfordert Vorbereitung, Vorbeugung und gegebenenfalls Behandlung. Die Vorbeugung erfolgt durch eine gründliche Anamneseerhebung mit entsprechenden Änderungen der zahnärztlichen Behandlung nach Bedarf. Der wichtigste Aspekt bei fast allen medizinischen Notfällen in der Zahnarztpraxis ist es, eine unzureichende Sauerstoffversorgung von Gehirn und Herz zu verhindern oder zu korrigieren. Daher sollte bei der Behandlung aller medizinischen Notfälle sichergestellt werden, dass diese kritischen Organe mit sauerstoffreichem Blut versorgt werden. Dies steht im Einklang mit der grundlegenden Herz-Lungen-Wiederbelebung, mit der der Zahnarzt kompetent sein muss. Dies vermittelt die Fähigkeiten zur Bewältigung der meisten medizinischen Notfälle, die mit der Beurteilung und gegebenenfalls Behandlung der Atemwege, der Atmung und des Kreislaufs (das ABC der HLW) beginnen. Normalerweise sollte der Zahnarzt erst nach diesen ABCs den Einsatz von Notfallmedikamenten in Betracht ziehen.

Medikamente, die dem Zahnarzt sofort zur Verfügung stehen sollten, lassen sich in zwei Kategorien einteilen.4 Die erste Kategorie stellt diejenigen dar, die als wesentlich erachtet werden können. Diese Medikamente sind in Tabelle 1 zusammengefasst. Die zweite Kategorie enthält Medikamente, die ebenfalls sehr hilfreich sind und als Teil der Notfallausrüstung in Betracht gezogen werden sollten. Diese ergänzenden Medikamente sind in Tabelle 2 zusammengefasst. Die genaue Zusammensetzung des Medikamentenkits kann variieren, da das Vorhandensein der Medikamente in dieser letzteren Gruppe von der Art der Zahnarztpraxis abhängen kann.


The following will summarize the drugs which should be part of a dentist’s emergency kit.4 There are 6 drugs which should be considered essential for all dentists.

1. Oxygen

Oxygen is indicated for every emergency except hyper-ventilation. This should be done with a clear full face mask for the spontaneously breathing patient and a bag-valve-mask device for the apneic patient. Therefore whenever possible, with the exception of the patient who is hyperventilating, oxygen should be administered. For the management of a medical emergency it should not be withheld for the patient with chronic obstructive lung disease, even though they may be dependent on low oxygen levels to breathe if they are chronic carbon dioxide retainers. Short term administration of oxygen to get them through the emergency should not depress their drive to breathe.

Oxygen should be available in a portable source, ideally in an “E”-size cylinder which holds over 600 liters. This should allow for more than enough oxygen to be available for the patient until resolution of the event or transfer to a hospital. If the typical adult has a minute volume of 6 liters per minute, then this flow rate should be given as a minimum. If the patient is conscious, or unconscious yet spontaneously breathing, oxygen should be delivered by a full face mask, where a flow rate of 6 to 10 liters per minute is appropriate for most adults. If the patient is unconscious and apneic, it should be delivered by a bag-valve-mask device where a flow rate of 10 to 15 liters per minute is appropriate. A positive pressure device may be used in adults, provided that the flow rate does not exceed 35 liters per minute.

2. Epinephrine

Epinephrine is the drug of choice for the emergency treatment of anaphylaxis and asthma which does not respond to its drug of first choice, albuterol or salbutamol. Epinephrine is also indicated for the management of cardiac arrest, but in the dental office setting, it may not be as likely to be given, since intravenous access may not be available. Its administration intramuscularly is not as likely to be very effective in this latter emergency, where adequate oxygenation and early defibrillation is most important for the cardiac arrest dysrhythmias with the relatively best prognoses, namely ventricular fibrillation or pulseless ventricular tachycardia.

As a drug, epinephrine has a very rapid onset and short duration of action, usually 5 to 10 minutes when given intravenously. For emergency purposes, epinephrine is available in two formulations. It is prepared as 1 : 1,000, which equals 1 mg per ml, for intramuscular, including intralingual, injections. More than one ampule or pre-filled syringe should be present as multiple administrations may be necessary. It is also available as 1 : 10,000, which equals 1 mg per 10 mL for intravenous injection. Autoinjector systems are also present for intramuscular use (such as the EpiPen) which provides one dose of 0.3 mg as 0.3 mL of 1 : 1,000, or the pediatric formulation which is 1 dose of 0.15 mg as 0.3 mL of 1 : 2,000.

Initial doses for the management of anaphylaxis are 0.3 to 0.5 mg intramuscularly or 0.1 mg intravenously. These doses should be repeated as necessary until resolution of the event. Similar doses should be considered in asthmatic bronchospasm which is unresponsive to a beta-2 agonist, such as albuterol or salbutamol. The dose in cardiac arrest is 1 mg intravenously. Intramuscular administration during cardiac arrest has not been studied, but would appear to be unlikely to render significant effect.

Epiniphrine is clearly a highly beneficial drug in these emergencies. Concurrently, however, it can be a drug with a high risk if given to a patient with ischemic heart disease. Nevertheless, it is the primary drug needed to reverse the life-threatening signs and symptoms of anaphylaxis or persistent asthmatic bronchospasm.

3. Nitroglycerin

This drug is indicated for acute angina or myocardial infarction. It is characterized by a rapid onset of action. For emergency purposes it is available as sublingual tablets or a sublingual spray. One important point to be aware of is that the tablets have a short shelf-life of approximately 3 months once the bottle has been opened and the tablets exposed to air or light. The spray has the advantage of having a shelf-life which corresponds to that listed on the bottle. Therefore, if a patient uses his/her own nitroglycerin, there is a possibility of the drug being inactive. This supports the need for the dentist to always having a fresh supply available. With signs of angina pectoris, one tablet or spray (0.3 or 0.4 mg) should be administered sublingually. Relief of pain should occur within minutes. If necessary, this dose can be repeated twice more in 5-minute intervals. Systolic blood pressures below 90 mmHg contraindicate the use of this drug.

4. Injectable Antihistamine

An antihistamine is indicated for the management of allergic reactions. Whereas mild non-life threatening allergic reactions may be managed by oral administration, life-threatening reactions necessitate parenteral administration.

Two injectable agents may be considered, either diphenhydramine or chlorpheniramine. They may be administered as part of the management of anaphylaxis or as the sole management of less severe allergic reactions, particularly those with primarily dermatologic signs and symptoms such as urticaria. Recommended doses for adults are 25 to 50 mg of diphenhydramine or 10 to 20 mg of chlorpheniramine.

5. Albuterol (Salbutamol)

A selective beta-2 agonist such as albuterol (salbutamol) is the first choice for management of bronchospasm. When administered by means of an inhaler, it provides selective bronchodilation with minimal systemic cardiovascular effects. It has a peak effect in 30 to 60 minutes, with a duration of effect of 4 to 6 hours. Adult dose is 2 sprays, to be repeated as necessary. Pediatric dose is 1 spray, repeated as necessary.

6. Aspirin

Aspirin (acetylsalicylic acid) is one of the more newly recognized life-saving drugs, as it has been shown to reduce overall mortality from acute myocardial infarction.

The purpose of its administration during an acute myocardial infarction is to prevent the progression from cardiac ischemia to injury to infarction. There is a brief period of time early on during a myocardial infarction where aspirin can show this benefit. For emergency use there are relatively few contraindications. These would include known hypersensitivity to aspirin, severe asthma or history of significant gastric bleeding. The lowest effective dose is not known with certainty, but a minimum of 162 mg should be given immediately to any patient with pain suggestive of acute myocardial infarction.

7. Oral Carbohydrate

An oral carbohydrate source, such as fruit juice or non-diet soft-drink, should be readily available. Whereas this is not a drug, and perhaps should not be included in this list, it should be considered essential. If this sugar source is kept in a refrigerator it may not be appreciated that it is a key part of the emergency equipment. Therefore, consideration should be given to making this part of the emergency kit. Its use is indicated in the management of hypoglycemia in conscious patients.

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