Guide for the dental practice
Emergency management Part I
Basic life
support
A collaborative project from 3M ESPE
and Dr. med. Sönke Müller,
Lead emergency doctor for the
Rhine-Neckar region/Germany
Address:
Dr. med. Sönke Müller
Lead emergency doctor
Fischersberg 26
D-69245 Bammental
E-Mail: Soenke.mueller@t-online.de
Internet: www.notfallseminare.de
2
Contents
Contents
Foreword ................................................................................ 5
Realistic emergency management
in the dental practice............................................................. 6
Chain of survival .................................................................. 10
Emergency call..................................................................... 12
Checking for vital signs....................................................... 14
Vital signs............................................................................... 14
State of consciousness .......................................................... 16
Breathing ................................................................................17
Opening airway ...................................................................... 18
Pulse ...................................................................................... 20
Pupils ......................................................................................21
Summary of the check for vital signs ..................................... 22
Rescuing and positioning.................................................... 24
Rautek grip ............................................................................ 24
Recovery position................................................................... 26
Horizontal position / shock position ........................................ 28
Raised upper body position .................................................... 29
Overview of positions ............................................................. 30
Opening airway .................................................................... 32
Head-tilt, chin-lift-maneuver .................................................. 32
Clearing the airway ................................................................ 33
Rescue breathing ................................................................. 34
Mouth-to-nose rescue breathing............................................ 36
Mouth-to-mouth rescue breathing ......................................... 38
Respiratory resuscitation with equipment .............................. 40
Life Key® (from Ambu) .............................................................41
Soft cushion mask (e. g. Seal-Easy) ........................................ 42
Resuscitation bag................................................................... 43
Double-C grip ......................................................................... 46
Oropharyngeal airway (Guedel pattern airway-OPA) ................47
Oxygen therapy ...................................................................... 48
Cardiopulmonary resuscitation (CPR) ................................ 50
Chest compressions ............................................................... 50
Basic life support ................................................................. 54
Basic life support (BLS, adult)................................................. 54
Basic life support algorithm.................................................... 55
Finding a lifeless person......................................................... 56
Bibliography ........................................................................... 58
Notes ..................................................................................... 59
3
Emergency
4
Foreword
Foreword
Emergencies will certainly never become routine in the dental
practice. On the one hand, emergency situations are – thankfully – far too rare and, on the other, the dentist usually does
not have the opportunity of gathering experience and of
training the relevant measures through regular practice.
What must the dentist be able to do as an
emergency doctor?
From the forensic perspective, he should at least
“master” the emergencies that may be directly caused by his
dental-medical actions. Here one of the main legal considerations is allergic reaction to drugs administered during dental
treatment, for example. Others sure to be included would be
isolated cases of asthma or angina attack triggered by
anxiety, stress and pain. It is generally expected from you, as
a medic – at least in your practice, where you have undertaken a special duty of caring for your patients – that you
have the basic knowledge and skills for carrying out
immediate life-saving measures.
Acting in emergency situations is really not difficult. If in
doubt, stick to basic, but also life-saving, things, free yourself and your emergency bag of unnecessary ballast and
take the courage to do what is right:
How and what – that is what this compendium is
designed to teach you.
5
Realistic emergency management in
the dental practice
A dentist cannot and does not need to have the knowledge
and skills of an emergency doctor. From experience, the
knowledge of how to gain venous access is limited to
“inserting a cannula” once or twice into a patient and healthy
fellow student at university. The subject of intubation – at
best attempted on a dummy in a crash course on emergency
medicine – should also remain an alien concept for the
dentist.
For those who really master these invasive measures –
great, but dentists so versed in emergency medicine are just
as rare as emergency doctors who can carry out
professional dental treatment.
However, putting a patient into the recovery position, clearing
the airway, recognising a foreign body as such in the airway
and, in the extreme event, carrying out cardiopulmonary
resuscitation, are things every dentist should master, and
of course somewhat more professionally than the
“man in the street”.
Whether the patient’s thoracic pain is angina or cardiac
arrest or just an acute thoracic spine syndrome is something
the dentist will be just as unable to diagnose as any other
6
Realistic emergency
management
doctor without access to diagnostic equipment. But the fact
that he should position this patient with his upper body
raised, that he can give oxygen and has to call for (emergency) medical assistance should be obvious to every dentist.
The knowledge can be learned by reading, but preferably also
acquired and practiced in practically based emergency
courses.
Which emergency situations are to be expected in
the dental practice?
Statistically, 7 times in your professional career you will be
faced with a patient who does not tolerate the local anaesthetic in one form or another, 1.5 times a patient in your
practice will have a grand mal epileptic fit, one will suffer an
angina attack. An anaphylactic shock – the most severe
scenario among allergic reactions, e. g. to local anaesthetic –
will only have to be experienced by every sixteenth dentist in
his practice, a severe asthma attack by only one in three
dentists. Only every thirteenth of you will have to endure a
resuscitation or acute myocardial infarct, whereas half of you
will experience a case of hypoglycaemia.
7
Complications induced by dental treatment:
• Orthostatic syndrome, triggered by anxiety, pain
• Hyperventilation tetany, triggered by anxiety, pain
• Allergic reaction to local anaesthetic or other
substances
• Intoxication due to local anaesthetic or other
substances
Complications induced by the patient’s
preexisting diseases:
• Angina attack, heart attack given coronary disease
• Hypertonic crisis given hypertension
• Respiratory distress due to cardiovascular
complications (e. g. acute pulmonary oedema given
heart failure)
• Respiratory distress due to aspiration (choking),
bronchospastic, asthma
• Hypoglycaemia with diabetes mellitus
• Allergic reaction through to anaphylactic shock
8
9
Chain of survival
The chain of survival refers to a series of actions that,
when put into motion, reduce the mortality associated with
cardiac arrest. Like any chain, the chain of survival is only
as strong as its weakest link. The four interdependent links
in the chain of survival are early access, early CPR, early
defibrillation and early advanced care.
Early access
Someone must witness the cardiac arrest and activate the
emergency medical service (EMS) system with an immediate
call to 1-1-2 (or your local emergency number).
Early cardiopulmonary
resuscitation (CPR)
In order to be most effective, bystander CPR should be
provided immediately after collapse of the patient. Properly
performed CPR can keep the heart in ventricular fibrillation
for 10–12 minutes longer.
Early defibrillation
Most adults who can be saved from cardiac arrest are in
ventricular fibrillation or pulseless ventricular tachycardia.
Early defibrillation is the link in the chain most likely to
improve survival. Public access defibrillation may be the key
to improving survival rates in out-of-hospital cardiac arrest,
but is of the greatest value when the other links in the chain
do not fail.
Early advanced care
Early advanced cardiac life support by paramedics is another
critical link in the chain of survival. In communities with
survival rates > 20%, a minimum of two of the rescuers
are trained to the advanced level. In some countries, EMS
delivery may be performed by ambulancemen, nurses, or
doctors.
10
early CPR
to get help
early access
to buy time
early CPR
to buy time
early
early
defibrilation
defibrillation
to restart
restart
to
heart
heart
early
earlyACLS
ACLS
Chain of survival
early
to access
get help
to stabilize
stabilize
to
11
Emergency call
The most common European emergency number is 112.
In all European Union countries it is also the emergency
telephone number for both mobile and fixedline telephones.
Most GSM mobile phones can dial 112 calls even when the
phone keyboard is locked, the phone is without a SIM card,
or instead of the PIN.
112 is used in Austria, Belgium, Bulgaria, Croatia, Cyprus,
Czech Republic, Denmark, Estonia, Finland, France,
Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia,
Liechtenstein, Lithuania, Luxembourg, Republic of Macedonia, Malta, Netherlands, Norway, Poland, Portugal, Romania,
Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland and
the United Kingdom in addition to their other emergency
numbers.
12
Police
Austria
144 and 112
133 and 112
Belarus
103
102
Belgium
112
112
Bulgaria
150 and 112
166 and 112
Croatia
94 and 112
92 and 112
Cyprus
112
112
Czech Republic
155 and 112
158 and 112
Denmark
112
112
Estonia
112
112
Finland
112
112
France
15 and 112
17 and 112
Germany
112
110
Great Britain
999 and 112
999 and 112
Greece
166 and 112
100 and 112
Hungary
104 and 112
107 and 112
Iceland
112
112
Ireland
999 and 112
999 and 112
Italy
118
112 and 113
Latvia
03 and 112
02 and 112
Liechtenstein
144 and 112
117
Lithuania
03 and 112
02 and 112
Luxembourg
112
113 and 112
Macedonia
194 and 112
192 and 112
Malta
112
112
Moldava
903
902
Netherlands
112
112
Norway
113
112
Poland
999 and 112
997 and 112
Portugal
112
112
Romania
112
112
Russia
03
02
Serbia/Montenegro
94 and 112
92 and 112
Slovakia
155 and 112
158 and 112
Slovenia
112
113
Spain
61 and 112
091 and 112
Sweden
112
112
Switzerland
144 and 112
117 and 112
Turkey
112
155
Ukraine
03 and 103
02 and 102
Emergency call
Emergency
Med. Services
Country
13
Checking for vital signs
Seite 10
Vital signs:
• Consciousness (C)
Seite 10
• Breathing (B)
Bewusstsein
• Pulse (P)
Bewusstsein
Atmung
Seite 10/12
Pupillen, Atemwege freimachen, stabile Seitenlage
• Pupils (P)
Atmung
14
Puls
The vital signs can be checked without equipment anywhere
from anyone and help the first aid provider to keep calm
themselves and to follow a plan of action.
Checking for
vital signs
This check allows a very quick and relatively safe assessment of whether a patient only has a slight impairment of
their general condition, whether a serious threat exists or
even an acute danger to life.
15
State of consciousness
Check
Result
Conclusion
Action
Shake his shoulders, ask loudly
“Are you
alright?”
No reaction:
not responsive,
unconscious,
no protective
reflexes
Unconsciousness
Immediately
check breathing
Seite
Seite10
10
Bewusstsein
Bewusstsein
Seite 10
Atmung
Atmung
Puls
Puls
Bewusstsein
Atmung
Seite 10
Check
Result
Conclusion
Action
Reaction:
Not unconscious
Protective
reflexes,
defensive movements, wakable,
answers
Bewusstsein
16
Atmung
Puls
Poss. shock
position, try
to find out what
is wrong with
him
Puls
Breathing
Check
Result
Listen to breath
sounds, feel
expired air, look
or feel for chest
movements
No visible
and palpable
respiratory
movements,
no audible
breath sounds
Seite 10/12
Conclusion
Action
Respiratory
arrest
Immediately
clear the airway
Checking for
vital signs
Pupillen, Atemwege freimachen, stabile Seitenlage
Seite 26
Atmung
Check
Atmung
Puls
stabile Seitenlage
Result
Conclusion
Action
Visible and
palpable
respiratory
movements,
breath sounds
No respiratory
arrest
Recovery
position
Puls
17
Opening airway
• Tilt head, lift chin maneuver
Seite 26
stabile Seitenlage
Tilt head, lift
chin maneuver
Seite 18
Atemwege blockiert
Seite 13/14
Kopf überstrecken, Atemwege freimachen
Tilt head, lift
chin maneuver
Seite 13/14
Kopf überstrecken, Atemwege freimachen
Result
Conclusion
Action
Visible and
palpable
respiratory
movements,
breath sounds
No respiratory
arrest
Recovery
position
Result
Conclusion
Action
Seite 37
Atemspende ein / aus
No breathing
Seite 10/12
Airway blocked? Clear the airway
Pupillen, Atemwege freimachen, stabile Seitenlage
18
• Clearing the airway
Seite 26
stabile Seitenlage
Clearing
the airway
Seite 10
Result
Conclusion
Action
Visible and
palpable
respiratory
movements,
breath sounds
No respiratory
arrest
Recovery
position
Result
Conclusion
Action
No breathing
Respiratory
arrest
Feel pulse
Checking for
vital signs
Clearing
the airway
Seite 14/15
Bewusstsein
Herzdruckmassage und Mund-zu-Mund –
jeweils separat und kombiniert
Atmung
Chest
compressions
Puls
19
Pulse
How?
Result
Conclusion
Action
Feel pulse
on wrist or neck
No pulse
palpable on
either side
Cardiac arrest
• Cardiopulmonary
resuscitation
Pulse reliably
palpable
No cardiac
arrest
Seite 14/15
Herzdruckmassage und Mund-zu-Mund –
jeweils separat und kombiniert
Seite 10
Puls
Seite 10/12
Bewusstsein
Pupillen,
Atemwege freimachen, stabile Seitenlage
Seite 14/15
Herzdruckmassage und Mund-zu-Mund –
jeweils separat und kombiniert
20
• Check
breathing
again
• Clear
airway
again
Atmung
• Rescue
breathing
Puls
Pupils
Pull the eyelids
up, shine light
into the eyes,
if possible
Result
Conclusion
Action
Dilated pupils,
no contraction
when exposed
to light
Cardiac arrest
• Cardiopulmonary
resuscitation
Pupils contract
equally
Cardiac arrest
unlikely
Seite 10/12
Seite 14/15
Pupillen, Atemwege freimachen, stabile
Seitenlage
Herzdruckmassage
und Mund-zu-Mund –
jeweils separat und kombiniert
Checking for
vital signs
How?
Seite 10
Seite 10/12
Bewusstsein
Pupillen, Atemwege freimachen, stabile Seitenlage
• Check
breathing
again
• Clear
airway
again
Atmung
Puls
21
Summary of the check for vital signs
Check
How?
Result
Consciousness
Shake his shoulders,
ask loudly “Are you
alright?”
Not responsive,
motionless
Seite 10
Bewusstsein
Atmung
Puls
Breathing
Listen to breath
sounds, feel expired
air, see or feel for
chest movements
No visible and palpable
respiratory movements, no audible
breath sounds
Pulse
Feel pulse on wrist or
neck Puls
No pulse palpable
on either side
Pull the eyelids up,
shine light into the
eyes, if possible
Dilated pupils, no contraction when exposed
to light
Atmung
Seite 10/12
Pupillen, Atemwege freimachen, stabile Seitenlage
Pupils
Puls
22
Seite 26
stabile Seitenlage
Conclusion
Action
Unconsciousness
• Check breathing
Recovery position,
Checking for
vital signs
Seite 10
Bewusstsein
Atmung
Respiratory arrest
• Immediately check
pulse, only with
certain signs of
pulse
Mund-zu-Mund –
mbiniert
Seite 14/15
check for continous
Puls
breathing
Rescue breathing:
Mouth-to-nose or
mouth-to-mouth
• Not possible to
check the pulse
or no signs of
circulation
Herzdruckmassage und Mund-zu-Mund –
jeweils separat und kombiniert
Cardiac arrest
• Cardiopulmonary
resuscitation
Seite 14/15
Herzdruckmassage und Mund-zu-Mund –
jeweils separat und kombiniert
Cardiac arrest
• Cardiopulmonary
resuscitation
23
Rescuing and positioning
Seite 20
Rautek grip
Rautek-Griff (A, B)
It is generally not possible to
adequately carry out measures
to safeguard the vital functions
or resuscitate while the acutely ill
person is in a sitting position, e. g.
on the dentist’s chair. Therefore
put always the person on his
back on a firm surface.
Seite 20
Rautek-Griff (A, B)
Method:
Try to get behind the victim’s
back. Pull the victim outwards
with a forceful movement of the
hips. Grasp the victim from the
back with both arms passing
under his armpits. Bend one of
the victim’s arms at a right angle
at the elbow, then grip his lower arm with both hands from
above and press the arm against his body at the upper
abdomen.
24
Seite 21
Rautek-Griff (C, D)
Pull the victim on your own thigh.
This distributes the weight favourably and you can then pull
the victim from the chair backwards.
You can also use the Rautek
rescue grip to pick the victim up
from the ground and e. g. remove
him from a danger zone:
Approach the head end of the
victim, place both hands flat
beneath the back of his head.
Now carefully lift the upper body from the back and bend
him forwards. Support the victim’s body with your own knee
from behind. Then you can apply the Rautek grip and pull the
victim away backwards.
Rescuing and
positioning
(C, D)
25
Recovery position
Every unconscious person with
sufficient spontaneous breathing
must be placed in the recovery
position. This position is intended
to avoid aspiration by preventing
the casualty’s tongue from blocking the airway and by promoting
drainage of fluids, such as blood or romit from the mouth.
26
Bring casualty’s far arm across
his chest and hold back of
casualty’s hand against opposite
cheek.
Rescuing and
positioning
26
e Seitenlage
Seite 26
Method:
stabile Seitenlage
Kneel beside the unconscious
person. Place the unconscious
person’s arm nearest you at right
angles to casualty’s body with
palm facing upwards.
Seite 26
Grab and bend the person’s
far
stabile Seitenlage
knee.
Gently roll the person toward you
by pulling the far knee over and to
the ground.
Tilt back the head slightly so that
the airway is open.
Check for breathing.
27
Seite 24
Flachlage, Schocklage
Horizontal position / shock position
Horizontal position
If there is a respiratory or cardiac
arrest, the casualty must be positioned on his back on a firm surface, most simply on the floor.
Only in this position you can perform further measures, such as
chest compression and rescue breathing, to the best effect.
Choose a place where you have sufficient space around the
casualty for your supporting measures.
Seite 24
Flachlage, Schocklage
Shock position
The shock position should be
adopted in the case of injuries or
disorders which lead to major
blood loss or reduce blood flow
(e. g. with vasovagal syndrome or
with anaphylaxis).
The improvement of circulation
especially to the brain and the heart by the additional blood
from the legs can delay, reduce or eliminate the effects of
shock as unconsciousness.
28
Seite 25
auf Zahnarztstuhl, Oberkörper-Hochlage
Seite 26
Method:
stabile Seitenlage
Either move the upper body of the
casualty to a low position, e. g. by
lowering the dentist’s chair into
the shock position, or lay the
victim on the floor and raise his
legs.
If the casualty is unconscious,
the recovery position obviously
takes priority over the shock
position!
eite 25
Rescuing and
positioning
Raised upper body position
uf Zahnarztstuhl, Oberkörper-Hochlage
Raised upper body position
A conscious patient with breathing difficulties with heart disease
or injuries to the upper body or
head should be positioned with
the upper body raised.
Method:
Raise the upper body of the casualty by 15– 45° or
depending on their preference.
29
eite 10
ewusstsein
Seite 10
Overview of positions
Seite 10
Consciousness
Present
Bewusstsein
30
Bewusstsein
Atmung
Breathing
Circulation
Present,
Present
but respiratory
distress Puls
Atmung
Puls
Atmung
Present
Present
Present,
but shock
symptoms
Disturbed
Present
Present
Disturbed
Disturbed
Present
Disturbed
Present
Disturbed
Disturbed
Disturbed
Disturbed
Puls
Type of positioning
Action
Raised upper body
position Seite 26
Oxygen
administration
Monitoring
Oberkörper-Hochlage
stabile Seitenlage
Rescuing and
positioning
Schocklage
Shock position
Recovery position
Seite 24
Flachlage, Schocklage
Horizontal position
Seite 24
Flachlage, Schocklage
Horizontal position,
poss. shock position
Seite 14/15
HerzdruckmassageSeite
und 24
Mund-zu-Mund –
jeweils separat und kombiniert
Horizontal position
Flachlage, Schocklage
Clear the airway:
choking?
• back blows
• Heimlich maneuver
Check for continious
normal breathing, if it
stops.
• Cardiopulmonary
resuscitation
• Cardiopulmonary
resuscitation
31
Opening airway
Seite 13/14
Kopf überstrecken, Atemwege freimachen
Tilt head, lift chin
If a casualty looses consciousness, the tongue may fall back
into the throat and block the passage of air from the mouth into
the lungs. Ensuring the airway
is open, is vital to the casualty’s
survival.
Tilting the head and lifting the chin may reestablish normal
breathing in such cases.
Seite 24
Flachlage, Schocklage
Method:
Pur the victim into the horizontal
position.
Kneel on the side of casualty’s
head.
Seite 13/14
Kopf überstrecken, Atemwege freimachen
Place one hand on the casualty’s
forehead and the other under the
chin.
9
berstrecken, Atemtätigkeit wiederherstellen
Gently tilt back the head and lift
the chin.
Check for normal breathing
again.
32
Clearing the airway
The mouth and throat of every unconscious person and
especially every patient with irregular breathing must be
inspected to exclude blockage due to any foreign bodies
(vomit, saliva, blood, loose dental prosthetics etc.).
Seite 28
Freimachen der Atemwege
Opening airway
Method:
Pull the lower jaw forward by
holding the angles of the lower
jaw with your fingers and the
lower jaw on both sides and then
by applying pressure, push the
mouth forward and open at the
same time (Esmarch grip). Press
the casualty’s cheek with one thumb between the rows of
teeth to keep the mouth open. It is best to turn the patient’s
Seite 10/12
head to the side.
Pupillen, Atemwege freimachen, stabile Seitenlage
Clear the mouth and throat either
by suction or manually by clearing
or wiping out. If there is still disordered breathing or respiratory arrest after tilting the head and
clearing the airway, the circulation
must be checked immediately and
CPR started if necessary.
33
Rescue breathing
The aim of every form of rescue breathing is optimal
oxygenisation of the casualty. The rescuer must, of course,
also act according to the circumstances, i.e. the breathing
frequency and tidal volume, above all, must be matched to
the age group of the patient. If it is not possible to restore
adequate breathing through simple measures, such as tilting
the head and clearing the airway, resuscitation should be
indicated without delay.
Age group
34
Respiratory frequency (min)
Breath volume (ml)
Newborn
40 – 50
20 – 35
Infant
30 – 40
40 – 100
Small child
20 – 30
150 – 200
School child
16 – 20
300 – 400
Adolescent
14 – 16
300 – 500
Adult
10 – 14
500 – 1000
The breath volume should be about 500– 600 ml (6 – 7 ml/
kg) for mouth-to-nose / mouth-to-mouth rescue breathing
and 400 – 600 ml for mask bag resuscitation. Higher
volumes or an excessive breathing frequency not only cause
significantly more pronounced bloating of the stomach, but
even reduce the venous return to the heart due to increasing
the intrathoracic pressure: the survival rate declines as a
result.
Rescue breathing is possible with or without equipment.
• Without equipment:
- mouth-to-mouth
- mouth-to-nose
• With equipment:
- mouth-to-equipment (protective mask)
- breathing bag to mask
Rescue breathing
The simplest form of respiratory resuscitation which can be
carried out without any equipment in every situation is
mouth-to-nose resuscitation.
35
Mouth-to-nose rescue breathing
Mouth-to-nose rescue breathing is the method of choice, as
it is safer and more effective to perform than mouth-tomouth resuscitation.
Seite 24
Flachlage, Schocklage
Method:
Put the unconscious patient into
the horizontal position.
Seite 10/12
Pupillen, Atemwege freimachen, stabile Seitenlage
Kneel to the side of the head,
open the mouth and look to see
whether foreign bodies are in the
mouth or pharynx. If so, remove
them.
Seite 29
Kopf überstrecken, Atemtätigkeit wiederherstellen
Tilt the head. Keep the mouth of
the unconscious person closed
by pushing with your hand on the
region between the upper lip and
tip of the chin.
36
Seite 33
Mund-zu-Nase, Mund-zu-Mund
Seite 37
Atemspende ein / aus
Rescue breathing
Breath in normally and place your
opened mouth over the nostrils
of the unconscious person such
that your lips seal tightly around
the nose.
Blow your expired air
Seite 37
Atemspende
ein / aus
quickly
in approx.
1 second into
the patient’s nose.
Draw breath on the side, at the
same time observing whether the
thorax excursions are visible and
whether expired air escapes from
theSeitepatient’s
nose.
18
Atemwege
blockiert
Repeat rescue breathing a second time and either continue
chest compressions or – if the
pulse is clearly present – go on
with rescue breathing with a
respiratory frequency of approx.
10 – 14 times a minute.
37
Mouth-to-mouth rescue breathing
Especially if mouth-to-nose rescue breathing is impossible,
e. g. due to blockage or injury to the nose, mouth-to-mouth
rescue breathing is applied.
Seite 24
Flachlage, Schocklage
Method:
Put the unconscious patient on to
his back on a firm flat surface.
Seite 10/12
Pupillen, Atemwege freimachen, stabile Seitenlage
Kneel next to the person close
to his head and open the mouth.
Look and remove any obvious
obstructions.
Seite 29
Kopf überstrecken, Atemtätigkeit wiederherstellen
Tilt the head back. Open the
patient’s mouth.
38
ase, Mund-zu-Mund
The thumb and forefinger of the
hand, placed on the patient’s
forehead, hold the nostrils from
above and close them with gentle
pressure.
Seite 33
Mund-zu-Nase, Mund-zu-Mund
Take a normal breath and place
your mouth over the patient’s
mouth. Blow your exhaled air
into the person’s mouth for one
second.
Seite 37
Atemspende ein / aus
Seite 37
Atemspende ein / aus
Rescue breathing
Draw breath on the side, at the
same time watching whether the
person’s chest rises and whether
air escapes. Repeat rescue breathing
for a second time and either
Seite 18
Atemwege
blockiert
start
chest
compressions or – if
the pulse is clearly present – go
on with rescue breathing with a
respiratory frequency of approx.
10 – 14 times a minute.
39
Respiratory resuscitation with equipment
Wherever possible, respiratory resuscitation should be
carried out using equipment. This saves the helper overcoming the aversion that may exist or fear of infections.
The simplest, cheapest equipment available include the Life
Key® and the soft cushion masks; the breathing bag with
breathing mask is not quite so cheap and not quite so simple
to use.
Advantages of respiratory resuscitation with
equipment:
• No direct helper-patient contact required – better infection
control
• Not an invasive measure
• Enrichment of the breathing air with oxygen may
be possible
Disadvantages of respiratory resuscitation with
equipment:
• Difficulty of ventilation, especially with the breathing bag is
underestimated; there is the risk of incorrect resuscitation
(e. g. bloating of the stomach).
Therefore, familiarise yourself sufficiently with the correct
use of your equipment!
40
Seite 37
Life Key
Life Key® (from Ambu)
Mouth-to-nose
Mouth-to-mouth
Rescue breathing
The Life Key – semi-transparent
face should packed in soft woven
case, carried on a key chain and
therefore generally available
and deployable everywhere – is
relatively easy to handle. In an
emergency, the mask is removed
from the case, unfolded, placed
over the patient’s face and fixed
behind his ears. You can then
use standard mouth-to-mouth
or mouth-to-nose resuscitation
via the one way valve without
modification.
41
Soft cushion mask (e. g. Seal-Easy)
The advantage of the soft cushion mask is that it fits for small
children over 18 months through
for adolescents and adults irrespective of their size. It is also
easy to use with bearded or dentureless patients or those with
facial trauma. The mask can be used with the valve for direct
mouth-to-mask resuscitation or without the valve for bag-tomask resuscitation.
Seite 38
Weichkissenmaske
Seite 38
Weichkissenmaske
42
To use in the one helper method,
the helper kneels beside the
casualty, in the two-helper
method preferably behind the
casualty. Tilt the head and lift
the chin. At the same time, the
mask opening is placed over the
casualty’s nose. Now the mask
is gently pressed on the face and
air insufflated through the valve
attachment. Any air escaping
from the side can be eliminated
by gently correcting the pressure
on the soft cushion mask.
Resuscitation bag
Although the use of resuscitation bags is a standard for
resuscitation in the dental
practice, the difficulty and risk
of incorrect usage should not be
underestimated.
The advantages of avoiding direct contact with the patient
and the possibility of enriching the breathing air with
additional oxygen are countered by defective material (e. g.
porous resuscitation masks) and the dentist’s lack of practice and lack of experience. Especially the insufficient “seal”
of the mask, the inadequate reclining of the head and the
associated “bloating of the stomach” can make the use of
the breathing bag difficult.
Rescue breathing
Resuscitation with the breathing bag must be a “matter
for the boss”. The responsibility must not be passed to
a less experienced employee (e. g. assistant).
Material
Various breathing bags and breathing masks can be used
depending on the age and size of the patient.
43
Mask sizes
• Size 5 for adults
• Size 3 for children / adolescents
• Size 1 for infants
Generally, a standard adult bag combined with e. g. two
common mask sizes (size 5 for adults, size 3 for children/
adolescents) should be sufficient.
Different types of resuscitation bags
Adult bag
Over 30 kg
Child bag
7 – 30 kg
Baby bag
Under 7 kg
44
Seite 41
Beatmungsbeutel / C-Griff
Method:
Place the mask with your left
hand over the mouth and nose
and fix it using the C-grip:
Thumbs and
forefingers form a
Seite 41
/ C-Griffface, the
C over theBeatmungsbeutel
casualty’s
other fingers tilt the head and left
the chin. The correct use of the
C-grip ensures an adequate seal
given the correct choice of mask.
Now compress the breathing bag
with the right hand. The rising
and falling of the thorax indicates
effective breathing.
Rescue breathing
During resuscitation, generally make sure that the air is not
expelled too strongly, as otherwise there are pressure peaks
in the upper airway that can cause the oesophagus to open
and the stomach to be bloated.
45
Double C-grip
The most common problem
with mask resuscitation is the
leakage between the mask and
patient, whereby the attempt is
often made to counter this with
too fast and forceful air insufflation, which often causes the
opposite, i.e. bloating of the stomach and even worse quality
of breathing. In this case you should fix the mask on from
behind or from the side using a double C-grip to completely
seal the mask with compression of the breathing bag taken
over by the second helper. Then it should be possible in most
of the cases to achieve a good seal and efficient resuscitation.
46
Oropharyngeal airway (Guedel pattern airway-OPA)
Oropharyngeal airways can keep the airway open by preventing the tongue from covering the epiglottis. They are
mainly used for facilitating the insufflations with any kinds of
resucitation masks.
Age group
Oropharyngeal airway size
Adult (man)
4
Adult (large)
5
Rule of thumb for oropharyngeal airway:
Seite 43
Length = approx. distance corner of the mouth
– earlobe
Rescue breathing
Guedeltubus
The precondition for precise positioning of the airway is the selection of the correct size; here the
distance from the earlobe to the
corner of the oral opening should
be taken as a guide. The airway
is inserted into the mouth upside
down. Once contact is made with
the back of the throat, the airway in rotated 180°.
The OPA does not prevent suffocation by liquid or the closing
of the glottis, but it facilitates the insufflations.
47
Oxygen therapy
Every patient with respiratory distress, heart complaints and
of course every resuscitated patient should always be given
additional oxygen as a simple, effective and low risk medication. Depending on the type of oxygen supply, up to 100 %
oxygen concentration can be achieved for the air breathed by
the patient!
48
Resuscitation technique
Inspiratory
O2 concentration
Mouth-to-nose ventilation
(expired air)
Spontaneous and bag mask
ventilation (room air)
Bag-mask ventilation with
10 l/min oxygen supply
Bag-mask ventilation using a
reservoir bag, 10 – 15 l/min O2
17 %
21 %
up to 40 %
up to 95 %
Rescue breathing
For example, a 1 l oxygen cylinder (200 bar) would be useful
for the dental practice either with a set pressure regulator
(e. g. 4 l/min) or better still, a flexible pressure regulator
(e. g. 1 – 15 l/min). It is best to connect a breathing mask
ready at hand.
49
Cardiopulmonary resuscitation (CPR)
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Herzdruckmassage und Mund-zu-Mund –
jeweils separat und kombiniert
Chest compressions
The updated guidelines of the
European Resuscitation Council
(ERC) of 2005 call for 30 chest
compressions, delivered hard and
fast. Especially in the early phase
of resuscitation and before any
ventilation breaths the oxygen
supply to the brain can be re-established very effectively
through distribution of the residual oxygen from blood that is
still well oxygenated. The death of brain cells due to lack of
oxygen can be delayed by several minutes as a result and,
if effective resuscitation is also performed, for a very much
longer period.
Evidence did show, that multiple interruptions to chest compressions reduces the chances of survival, pausing compressions means blood flow stops within a couple of seconds.
Chest compressions is therefore the first and most important
part of CPR and should be applied without any delay to an
unconscious and non-breathing patient.
Chest compressions is a skill, which must be practiced
and mastered by every employee in the practice.
50
Seite 47
Schema Brustschnitt
Principle:
Two mechanisms are viewed
as significant in the blood flow
generated by chest compression:
• The compression of the heart
between the sternum and the
spine
• Generation of thoracic pressure fluctuations
Even with the best possible chest compression technique,
the generated stroke volume is still only approx. 20 – 40 % of
the normal resting value!
Seite 24
Flachlage, Schocklage
Cardiopulmonary
resuscitation
Method:
Immediately put the patient onto
a firm surface in the horizontal
position. Undo the clothing over
the rib cage and kneel by the side
of the patient. Feel the patient’s
rib cage and search for the
pressure point in the centre of
the victim’s chest.
51
Seite 48
Herzdruckmassage
Place the heel of one hand in the
centre of the chest.
Place the heel of your other hand
on top of the first hand interlock
fingers.
Seite 48
Herzdruckmassage
Position yourself vertically above
the victim’s chest and, with your
arms straight, press down on the
sternum 4 – 5 cm.
After each compression, release
all the pressure on the chest
without losing contact between
your hands and the sternum.
Repeat at a rate of about 100/
min. (a little less than 2 compressions/sec.).
If possible change CPR-operator every 2 min.!
52
53
Cardiopulmonary
resuscitation
Basic Life Support
Seite 10
Check Response
• Shake gently
• Shout loudly
9
Shout for help
berstrecken, Atemtätigkeit wiederherstellen
If not responsive
Open airway
Check breathing
• Tilt head back and lift chin
• Look
• Listen
• Feel
• Take no more than 10s
Bewusstsein
Seite 48
Herzdruckmassage
If not breathing normally
Call 112
Hands in the centre of the chest
Seite 48
Herzdruckmassage
Deliver 30 chest compressions
Frequency of chest compressions: 100/min.
Seite 33
Deliver 2 rescue breaths:
• Seal your lips around the
mouth
• Blow steadily until chest rises
• Give next breath when the
chest falls
54
Mund-zu-Nase, Mund-zu-Mund
Basic life support algorithm
Continue CPR 30 : 2 until
qualified help arrives
The algorithm applies the same for the one helper as well as
the two-helper method!
Unresponsive?
Shout for help
Open airway
Breathing normally?
Always make emergency call
Basic life support
30 chest compressions
2 rescue breaths
30 chest compressions
55
Finding a
Consciousness?
Talk loudly
Shake gently
on the shoulder
Look out for visible injuries when
touching/shaking!
If unconscious:
immediate emergency call
Breathing?
See: chest movements
Hear: breat sounds
Feel: flow of air on the helper’s
cheek
Clear airway
Remove any visible foreign bodies
from the oropharynx
Circulation?
Look for signs of circulation
Signs of circulation are:
normal breathing, coughing or
movements
If there are no signs of circulation: Lay victim on a firm surface, exstart cardiopulmonary resuscitation pose rib cage, perform 30 chest
compressions alternated with 2
rescue breaths
56
Seite 10
lifeless person
If responsive:
help as required
Seite 52
Notruf
Emergency numbers
see page 13.
age
Atmung
In most European
countries 112
Seite 10
If breathing is
normal:Recovery position, monitor breathing
Seite 14/15
If no breathing:
if possible check circulation,
otherwise immediately
Herzdruckmassage und Mund-zu-Mund –
jeweils separat und kombiniert
Bewusstsein
If there are certain signs
of circulation:check
breathing,
signs of circulation every
60 sec.
Seite 33
Mund-zu-Nase, Mund-zu-Mund
Atmung
Puls
Seite 14/15
Herzdruckmassage und Mund-zu-Mund –
jeweils separat und kombiniert
30 : 2
Atmung
Puls
Basic life support
n
Bewusstsein
57
Bibliography
Anthony J. Handley, Rudolph Koster, Koen Monsieurs,
Gavin D. Perkins, Sian Davies, Leo Bossaert
European Resuscitation Council Guidelines
for Resuscitation 2005
Section 2. Adult basic life support and use
of automated external defibrillators
Resuscitation (2005), 67 p.1, p. 7 – p. 23
Jerry P. Nolan
European Resuscitation Council Guidelines
for Resuscitation 2005
Section 1. Introduction
Resuscitation (2005), 67 p.1, p. 7 – p. 23
Jerry P. Nolan, Charles D. Deakin, Jasmeet Soar,
Bernd W. Böttiger, Gary Smith
European Resuscitation Council Guidelines
for Resuscitation 2005
Section 4. Adult advanced life support
Resuscitation (2005), 67 p.1, p. 7 – p. 23
BÄK
Reanimation: Nationaler Konsens
Deutsches Ärzteblatt 103, Issue 34 – 35 of 28.8.2006,
Page A-22 08
ERC-Leitlinien für die Wiederbelebung 2005,
Stand: 24.03.2006
Deutsches Ärzteblatt 103, Issue 14 of 7.4.2006,
Page A-960 / B-813 / C-785
58
Notes
59
70200955899/01 (7.2008)
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