medical emergencies in the dental office
TRANSCRIPT
Medical Emergencies in the Medical Emergencies in the
Dental Office Dental Office
Tomas J. Barrios DDSTomas J. Barrios DDS
Associate Clinical Professor of Associate Clinical Professor of
Oral & Maxillofacial Surgery, Oral & Maxillofacial Surgery,
St. Josephs Regional Medical Center, St. Josephs Regional Medical Center,
Jersey City Medical Center Jersey City Medical Center
•• Prevention & Preparation Prevention & Preparation
•• Syncope Syncope
•• HypoglycemiaHypoglycemia
•• Epileptic episodeEpileptic episode
•• AnginaAngina
•• Myocardial infarctMyocardial infarct
•• Anesthetic overdoseAnesthetic overdose
•• Drug allergy anaphylaxisDrug allergy anaphylaxis
•• AsthmaAsthma
Prevention & PreparationPrevention & Preparation
•• BLS Certification doctors and staffBLS Certification doctors and staff
•• ACLS certification : any type of sedation ACLS certification : any type of sedation
techniquestechniques
•• Emergency KitsEmergency Kits
•• Staff drillsStaff drills
Emergency KitsEmergency Kits
•• Contents VaryContents Vary
•• Purchase from any Purchase from any
manufacturermanufacturer
•• Refill Refill
Components of emergency kitsComponents of emergency kits
Emergency drillsEmergency drills
•• Most important : Keep it Most important : Keep it simple !simple !
•• Designate a specific task to Designate a specific task to each staff membereach staff member
1.1. Assistant : gets kit and assist Assistant : gets kit and assist Dr.Dr.
2.2. Receptionist : calls 911 and Receptionist : calls 911 and make sure EMS arrives , make sure EMS arrives , clears area for patientsclears area for patients
3.3. Additional staff : go between, Additional staff : go between, records vitals,records vitals,
event timingevent timing
ABC of any emergencyABC of any emergency
•• Supine positionSupine position
•• 100 % Oxygen100 % Oxygen
•• Evaluate Airway, breathing , circulationEvaluate Airway, breathing , circulation
•• VitalsVitals
Emergency management & Emergency management &
resuscitation planresuscitation plan
•• Primary surveyPrimary survey
1.1. ABCDEABCDE
2.2. Purpose : Identify & Purpose : Identify & treat life threatening treat life threatening problemsproblems
3.3. HistoryHistory
4.4. Resuscitation measures Resuscitation measures are institutedare instituted
•• Secondary surveySecondary survey
1.1. Head to toe by region Head to toe by region examexam
2.2. Purpose : Identify & Purpose : Identify & treat life threatening treat life threatening problemsproblems
3.3. History : data gatheringHistory : data gathering
4.4. System specific testSystem specific test
5.5. Re evaluation: repeat Re evaluation: repeat surveys untill cause is surveys untill cause is identifiedidentified
6.6. Definitive care Definitive care
Vitals, Clinical signs and Vitals, Clinical signs and
symptoms of potential illnesssymptoms of potential illness
Tenets of primary surveyTenets of primary survey
•• Proceed rapidlyProceed rapidly
•• Err on the side of aggressivenessErr on the side of aggressiveness
•• When in doubt When in doubt ““dodo””
•• Stay in sequenceStay in sequence
•• Know what to look for , recognize and treatKnow what to look for , recognize and treat
•• Look for likely, treatable problemsLook for likely, treatable problems
•• Make decisions based on direct examinationMake decisions based on direct examination
•• Initiate only simple test and proceduresInitiate only simple test and procedures
Generalized treatment protocolGeneralized treatment protocol
DocumentationDocumentation
•• Brief history of the eventBrief history of the event
•• Positive findings of primary & secondary Positive findings of primary & secondary
surveysurvey
•• Treatment providedTreatment provided
•• Time of important eventsTime of important events
•• DispositionDisposition
Medical legal issuesMedical legal issues
•• What if its not a patient in the office ?What if its not a patient in the office ?
•• Death or Hospital transfer by EMS , is a Death or Hospital transfer by EMS , is a
reportable event to the State Boardreportable event to the State Board
SyncopeSyncope
Types of syncopeTypes of syncope
Vasodepressor SyncopeVasodepressor Syncope
•• Most common medical emergency in Most common medical emergency in
dentistrydentistry
•• 30 % of adult population30 % of adult population
•• Accounts for 3% of ER visitsAccounts for 3% of ER visits
EtiologyEtiology
•• Decreased cerebral blood flow (CBF)Decreased cerebral blood flow (CBF)
Differential diagnosisDifferential diagnosis
Anxiety attacks Anxiety attacks
hyperventilation syndromehyperventilation syndrome
MIMI
HypoglycemiaHypoglycemia
EpilepsyEpilepsy
HypotensionHypotension
Clinical manifestation presyncopalClinical manifestation presyncopal
•• EarlyEarlyNauseaNausea
WarmthWarmth
PerspirationPerspiration
loss of colorloss of color
Baseline Blood pressBaseline Blood press
TachycardiaTachycardia
•• LateLateHypotensionHypotension
BradycardiaBradycardia
HyperpneaHyperpnea
Pupillary dilationPupillary dilation
Peripheral coldnessPeripheral coldness
Visual disturbanceVisual disturbance
Loss of consciousnessLoss of consciousness
Syncopal phaseSyncopal phase
•• All secondary to decreased CBFAll secondary to decreased CBF
•• Loss of consciousnessLoss of consciousness
•• Loss of postural toneLoss of postural tone
•• Any syncope lasting > a few minutes can Any syncope lasting > a few minutes can
induce seizures and cerebral ischemia induce seizures and cerebral ischemia
TreatmentTreatment
•• Trendelenburg positionTrendelenburg position
•• Pregnant patient lateral decubitusPregnant patient lateral decubitus
•• Asses consciousness Asses consciousness
•• ABCABC
•• 100 % oxygen100 % oxygen
•• Spirits of ammoniaSpirits of ammonia
•• Vitals ( Bradycardia < 60 administer Atropine .5mg IV Vitals ( Bradycardia < 60 administer Atropine .5mg IV 1mg IM every 5 minutes until max dose of 3 mg1mg IM every 5 minutes until max dose of 3 mg
•• EMS if loss of consciousness is > 5 min or if recovery is EMS if loss of consciousness is > 5 min or if recovery is > 20 min> 20 min
PostsyncopePostsyncope
•• Evaluate discharge home with escort or Evaluate discharge home with escort or
EMSEMS
Dependent on recovery and VitalsDependent on recovery and Vitals
Recovery > 20 min Recovery > 20 min
Underlying medical conditions Underlying medical conditions
HypotensionHypotension
HypotensionHypotension
•• Following syncope it is the most common Following syncope it is the most common
cause of loss of consciousness in the cause of loss of consciousness in the
dental officedental office
What affects perfusion ?What affects perfusion ?
Causes of hypotensionCauses of hypotension
Orthostatic HypotensionOrthostatic Hypotension
•• Most common cause of hypotension in the Most common cause of hypotension in the
dental officedental office
•• It is Syncope when the patient is placed It is Syncope when the patient is placed
quickly from a supine to upright positionquickly from a supine to upright position
( < CBF )( < CBF )
Why Most likely in elderly ?Why Most likely in elderly ?
•• Aging decreases baroreflex mechanism Aging decreases baroreflex mechanism
which impairs cardioacceleratory response which impairs cardioacceleratory response
to preload reduction during upright to preload reduction during upright
postureposture
•• May be on medications May be on medications
•• Most susceptibleMost susceptible
Vasovagal Hypotension (syncope)Vasovagal Hypotension (syncope)
•• Initiated by stressful physical , Initiated by stressful physical ,
psychological or surgical stimuli ( coughing psychological or surgical stimuli ( coughing
pain, gagging )pain, gagging )
•• The impulses are transmitted directly to The impulses are transmitted directly to
the medulla in area closely related to the the medulla in area closely related to the
nuclei of the vagus nervenuclei of the vagus nerve
Clinical sign and symptomsClinical sign and symptoms
•• Bradycardia results from Vagal stimulation Bradycardia results from Vagal stimulation
and parasympathetic toneand parasympathetic tone
•• Vasodilation results from diminished Vasodilation results from diminished
sympathetic tonesympathetic tone
TreatmentTreatment
•• Removing the initiating stimuliRemoving the initiating stimuli
•• Trendelenburg positionTrendelenburg position
•• OxygenOxygen
•• VitalsVitals
Routine treatment for a patient Routine treatment for a patient
with hypotension and inadequate with hypotension and inadequate
perfusionperfusion
TreatmentTreatment
•• Place in Trendelenburg positionPlace in Trendelenburg position
•• OxygenOxygen
•• VitalsVitals
•• ABCABC
•• Evaluate BPEvaluate BP
( if no BP monitor present , remember palpate ( if no BP monitor present , remember palpate pulse, correlated to a systolic of: Radial 80 mm pulse, correlated to a systolic of: Radial 80 mm Hg , Brachial 70 mm Hg , Carotid 60 m Hg )Hg , Brachial 70 mm Hg , Carotid 60 m Hg )
•• Administer: Phenylephrine spray 0.25Administer: Phenylephrine spray 0.25--0.5 mg IV 0.5 mg IV 22--3mg IM , Ephedrine 103mg IM , Ephedrine 10--25 mg IV25 mg IV
•• What if patients are receiving BWhat if patients are receiving B--Blockers ?Blockers ?
Isoproterenol 0.2mg IV slowly at 1 min Isoproterenol 0.2mg IV slowly at 1 min
interval and monitor patients responseinterval and monitor patients response
HypoglycemiaHypoglycemia
DiabetesDiabetes
EpidemiologyEpidemiology
•• Incidence 15.7 million or 5.9% of Incidence 15.7 million or 5.9% of
population of U.Spopulation of U.S
•• Incidence of undiagnosed 5.4 million or Incidence of undiagnosed 5.4 million or
34% of diabetic population34% of diabetic population
Why is glucose important ?Why is glucose important ?
•• Primary energy Primary energy
substrate for all substrate for all
functionsfunctions
PathophysiologyPathophysiology
•• Type 1 IDDM : little or no insulin is secreted Type 1 IDDM : little or no insulin is secreted
uptake of glucose or conversion into glycogen in uptake of glucose or conversion into glycogen in
the liver does not occur, therefore liver glucose the liver does not occur, therefore liver glucose
production is elevated. Gluconeogenesis production is elevated. Gluconeogenesis
acceleratesaccelerates
•• Type 2 NIIDM : Insulin resistance causes the Type 2 NIIDM : Insulin resistance causes the
liver to continue glucose production and liver to continue glucose production and
prohibits glucose uptake by musclesprohibits glucose uptake by muscles
Clinical factors of diabetesClinical factors of diabetes
Type II NIDDM MedsType II NIDDM Meds
Type I IDDM MedsType I IDDM Meds
•• Need to know or quick reference Need to know or quick reference
MonitoringMonitoring
•• Hemoglobin A1CHemoglobin A1C
•• FructosamineFructosamine
•• Home monitoringHome monitoring
How are patients going to become How are patients going to become
hypoglycemic ?hypoglycemic ?
•• Too much insulinToo much insulin
•• Alcohol consumptionAlcohol consumption
•• Excessive exerciseExcessive exercise
•• Missed delayed mealsMissed delayed meals
•• Reduced mealsReduced meals
•• Medication errorMedication error
•• Other illnessOther illness
SymptomsSymptoms
•• Autonomic Autonomic
1.1. Sweating Sweating
2.2. TremblingTrembling
3.3. PalpitationsPalpitations
4.4. AnxietyAnxiety
5.5. NauseaNausea
•• NeuroglycopenicNeuroglycopenic
1.1. DizzinessDizziness
2.2. ConfusionConfusion
3.3. Difficulty speakingDifficulty speaking
4.4. HeadacheHeadache
5.5. Inability to concentrateInability to concentrate
6.6. WeaknessWeakness
7.7. Blurred visionBlurred vision
TreatmentTreatment
Alternative TXAlternative TX
•• Glucose tabletsGlucose tablets
•• 4 teaspoons of sugar in water4 teaspoons of sugar in water
•• 5 oz of regular soft drink5 oz of regular soft drink
•• Orange juiceOrange juice
•• Glucagon dosage : 0.5Glucagon dosage : 0.5--1mg IM or IV1mg IM or IV
SeizuresSeizures
SeizuresSeizures
•• Manifestation of brain Manifestation of brain
dysfunctiondysfunction
•• Excessive neuronal Excessive neuronal
cortical dischargecortical discharge
•• Secondary to toxins, Secondary to toxins,
drugs, cerebral drugs, cerebral
hypoxia, or metabolic hypoxia, or metabolic
disturbancesdisturbances
Prevention & preparationPrevention & preparation
•• HistoryHistory
1.1. What type of seizure disorder do you have ?What type of seizure disorder do you have ?
2.2. Are you on any medications for the disorder ?Are you on any medications for the disorder ?
3.3. Are you taking the medications as prescribed ? Are you taking the medications as prescribed ?
4.4. Have you had serum level of the medication done ? If Have you had serum level of the medication done ? If so when ?so when ?
5.5. When was your last seizure ?When was your last seizure ?
6.6. What provokes it ?What provokes it ?
7.7. Do you have an Aura ?Do you have an Aura ?
8.8. Where you hospitalized ?Where you hospitalized ?
9.9. How long was your seizure ?How long was your seizure ?
Treatment protocolTreatment protocol
•• Most seizures last < 2 minMost seizures last < 2 min
•• EMS activatedEMS activated
•• Assure patient & staff safetyAssure patient & staff safety
•• Administer oxygenAdminister oxygen
•• Manage airwayManage airway
•• Monitor vitals , pulse oxymetryMonitor vitals , pulse oxymetry
•• Suction availableSuction available
•• If seizure is lasting > 2 minutes , establish IV, If seizure is lasting > 2 minutes , establish IV, administer Medsadminister Meds
BenzodiazepineBenzodiazepine
•• Diazepam Diazepam
Adult : 5 to 10 mg Adult : 5 to 10 mg
IV/IMIV/IM
Pediatric : 0.2 to 0.5 Pediatric : 0.2 to 0.5
mg/kg IV/IMmg/kg IV/IM
•• MidazolamMidazolam
0.05 to 0.1 mg/kg IV0.05 to 0.1 mg/kg IV
0.2 mg/kg IM ( Max 0.2 mg/kg IM ( Max
10 mg)10 mg)
Pharmacologic managementPharmacologic management
•• EMS not arrived > 5 min EMS not arrived > 5 min
Adult : Dextrose 50 ml bolus of 50% Adult : Dextrose 50 ml bolus of 50%
glucose glucose
Pediatric : 2ml/kg 25% dextrose solutionPediatric : 2ml/kg 25% dextrose solution
•• Evaluate airway maintenanceEvaluate airway maintenance
•• Evaluate cardiac rhythmEvaluate cardiac rhythm
PostictalPostictal
•• LethargyLethargy
•• DisorientationDisorientation
•• Apnea, obstructed airwayApnea, obstructed airway
•• Cardiac arrhythmiasCardiac arrhythmias
•• Evaluate patient injuryEvaluate patient injury
Chest painChest pain
•• Angina : Latin for spasmodic , choking or Angina : Latin for spasmodic , choking or
suffocating painsuffocating pain
•• Pectoris :Latin for chestPectoris :Latin for chest
Differential DiagnosisDifferential Diagnosis
•• AnginaAngina
•• Myocardial infarctionMyocardial infarction
•• Dyspepsia, GERDDyspepsia, GERD
•• MusculoskeletalMusculoskeletal
•• Pulmonary embolusPulmonary embolus
•• Spontaneous pneumothoraxSpontaneous pneumothorax
•• Aortic dissectionAortic dissection
•• Esophageal ruptureEsophageal rupture
•• Panic disorderPanic disorder
Relevant factorsRelevant factors
•• Onset : time, associated Onset : time, associated
eventevent
•• LocationLocation
•• Radiation absence or siteRadiation absence or site
•• Type of pain: deep Type of pain: deep
visceral, superficial, visceral, superficial,
pleuriticpleuritic
•• Exacerbating or Exacerbating or
alleviating factorsalleviating factors
What occurs ?What occurs ?
•• Increased Myocardial DemandIncreased Myocardial Demand
1.1. Elevated heart rateElevated heart rate
2.2. Elevated BPElevated BP
3.3. Elevated endogenous catecholaminesElevated endogenous catecholamines
•• Decreased Myocardial Oxygen deliveryDecreased Myocardial Oxygen delivery
1.1. Decreased diastolic fillingDecreased diastolic filling
2.2. Myocardial vessel occlusionMyocardial vessel occlusion
3.3. HypoxiaHypoxia
4.4. anemiaanemia
TreatmentTreatment
•• ABCABC
•• oxygenoxygen
•• Position patient comfortPosition patient comfort
•• VitalsVitals
•• EMSEMS
•• Nitroglycerin : spray or tab .4mg repeat three Nitroglycerin : spray or tab .4mg repeat three
times every 5 min ( systolic BP>90 mm Hg )times every 5 min ( systolic BP>90 mm Hg )
•• AspirinAspirin
Myocardial infarctMyocardial infarct
•• If chest pain > 20 min consider MIIf chest pain > 20 min consider MI
•• Cardiac monitorCardiac monitor
•• Morphine 2 Morphine 2 –– 4 mg IV4 mg IV
•• EMS transportEMS transport
Adverse drug reactions with Adverse drug reactions with
local anestheticslocal anesthetics
Types of local anesthetic reactionsTypes of local anesthetic reactions
•• Local anesthetic toxicityLocal anesthetic toxicity
•• Drug interactionsDrug interactions
•• Vasoconstrictor interactionsVasoconstrictor interactions
•• MethemoglobinemiaMethemoglobinemia
DosagesDosages
How Anesthetic overdose can How Anesthetic overdose can
occur?occur?
Clinical Signs Clinical Signs
TreatmentTreatment
•• ABCABC
•• OxygenOxygen
•• VitalsVitals
•• EMSEMS
•• Monitor seizuresMonitor seizures
•• Monitor respirationMonitor respiration
•• Cardiac monitorCardiac monitor
Drug interactionsDrug interactions
Vasoconstrictor interactionsVasoconstrictor interactions
TreatmentTreatment
•• ABCABC
•• Patient comfortPatient comfort
•• VitalsVitals
•• EMSEMS
•• Reassurance reaction will passReassurance reaction will pass
•• If BP becomes >170 systolic consider If BP becomes >170 systolic consider
nitroglycerin nitroglycerin
MethemoglobinemiaMethemoglobinemia
•• Dose dependent reactionDose dependent reaction
•• Administration of Nitrates, amide Administration of Nitrates, amide
containing drugs ( prilocaine, Benzocaine )containing drugs ( prilocaine, Benzocaine )
•• Pathophysiology : oxidation of the iron Pathophysiology : oxidation of the iron
within hemoglobin producing within hemoglobin producing
methemoglobinmethemoglobin
Clinical signsClinical signs
•• Cyanosis at methemoglobin levels of 10% Cyanosis at methemoglobin levels of 10%
to 20%to 20%
•• Dyspnea and tachycardia at metHb level Dyspnea and tachycardia at metHb level
of 35% to 40%of 35% to 40%
TreatmentTreatment
•• ABCABC
•• OxygenOxygen
•• EMSEMS
•• Monitor patient vitals , CardiacMonitor patient vitals , Cardiac
•• Most healthy adults drugs and metabolites Most healthy adults drugs and metabolites
are eliminatedare eliminated
•• Methylene blue 1Methylene blue 1--2 mg/kg IV2 mg/kg IV
AirwayAirway
AllergyAllergy
ObstructionObstruction
Asthma Asthma
HyperventilationHyperventilation
Allergy and anaphylaxisAllergy and anaphylaxis
Drug allergy & AnaphylaxisDrug allergy & Anaphylaxis
•• Adverse drug reactions occur in 1% to Adverse drug reactions occur in 1% to
15% of drug regimens15% of drug regimens
•• Drug allergy < 2% overall except for some Drug allergy < 2% overall except for some
common agents : penicillin , common agents : penicillin ,
cephalosporin, and trimethoprimcephalosporin, and trimethoprim--
sulfamethoxazole ( Sulfa )sulfamethoxazole ( Sulfa )
Risks FactorsRisks Factors
•• Multiple intermittent exposuresMultiple intermittent exposures
•• Parenteral vs oral Parenteral vs oral
•• Children less chance of developing reactions to Children less chance of developing reactions to meds because of shorter exposure timesmeds because of shorter exposure times
•• Women higher incidence of cutaneous reactions Women higher incidence of cutaneous reactions secondary to their increased exposure to secondary to their increased exposure to cosmetics and latex glovescosmetics and latex gloves
•• Individuals with multiple illnesses , Individuals with multiple illnesses , polypharmacypolypharmacy
•• Allergies to foodsAllergies to foods
Gell & Coombs ClassificationGell & Coombs Classification
•• Type 1 ( IgE Type 1 ( IgE –– Mediated Hypersensitivity)Mediated Hypersensitivity)
most life threatening most life threatening
few minutesfew minutes
•• Type 2 ( Cytotoxic / Cytolytic antibody Type 2 ( Cytotoxic / Cytolytic antibody mediated) IgM or IgG antibodies mediatemediated) IgM or IgG antibodies mediate
•• Type 3 ( Immnune complex mediated )Type 3 ( Immnune complex mediated )
11-- 4 weeks, IgM 4 weeks, IgM –– IgG soluble metaboliteIgG soluble metabolite
•• Type 4 (delayed Hypersensitivity ) Type 4 (delayed Hypersensitivity )
sensitized T cell lymphocytessensitized T cell lymphocytes
Signs & Symptoms of minor allergic Signs & Symptoms of minor allergic
reactionsreactions
Signs & Symptoms of AnaphylaxisSigns & Symptoms of Anaphylaxis
TreatmentTreatment
•• ABCABC
•• Establish reaction typeEstablish reaction type
•• Activate EMS Activate EMS
•• IV accessIV access
Medications for treatmentMedications for treatment
Minor reactionsMinor reactions
AnaphylaxisAnaphylaxis
Management of allergic scenariosManagement of allergic scenarios
MedicationsMedications
•• Diphenhydramine 50 mg IM , IVDiphenhydramine 50 mg IM , IV
•• Epinephrine: .3ml 1/1000 ( 0.3mg )Epinephrine: .3ml 1/1000 ( 0.3mg )
•• Dexamethasone : 20 mg IM , IVDexamethasone : 20 mg IM , IV
Obstructed airwayObstructed airway
EtiologyEtiology
•• Foreign body aspirationForeign body aspiration
•• Laryngeal edemaLaryngeal edema
Basics treatment of obstructed Basics treatment of obstructed
airway airway
CricothyrotomyCricothyrotomy
AsthmaAsthma
Types of AsthmaTypes of Asthma
•• Extrinsic : allergic asthma, younger Extrinsic : allergic asthma, younger
patients , Type 1 hypersensitivity Rxpatients , Type 1 hypersensitivity Rx
•• Intrinsic : older patients, nonallergic Intrinsic : older patients, nonallergic
factors , cold temperatures, exercise, factors , cold temperatures, exercise,
stressstress
Asthma medicationsAsthma medications
What is asthma ?What is asthma ?
•• Basically it is slow Basically it is slow
progressing progressing
BronchospasmBronchospasm
TreatmentTreatment
•• Terminate therapyTerminate therapy
•• Position patientPosition patient
•• Administer B agonist spray AlbuterolAdminister B agonist spray Albuterol
•• OxygenOxygen
•• EMSEMS
•• Epinephrine SC or IM 0.3ml ( 1/1000 Epinephrine SC or IM 0.3ml ( 1/1000
dilution) Epipen dilution) Epipen
HyperventilationHyperventilation
•• Usually a patient which suffers from: Usually a patient which suffers from:
panic, phobias, psychiatric disorderpanic, phobias, psychiatric disorder
•• Identify patient earlyIdentify patient early
Signs and symptomsSigns and symptoms
•• SighingSighing
•• TachypneaTachypnea
•• Shortness of breathShortness of breath
•• Pain on respirationPain on respiration
•• TachycardiaTachycardia
•• Nonradiating chest painNonradiating chest pain
•• Lungs clear to Lungs clear to auscultationauscultation
•• Normal oxygen saturationNormal oxygen saturation
•• DizzinessDizziness
•• faintnessfaintness
•• Altered consciousnessAltered consciousness
•• Muscle crampMuscle cramp
•• TremorTremor
•• MyalgiaMyalgia
TreatmentTreatment
•• ReassuranceReassurance
•• Slow down breathingSlow down breathing
•• Comfortable positionComfortable position
•• Remove any visual stimuliRemove any visual stimuli
•• VitalsVitals
•• Full rebreathing bagFull rebreathing bag
•• Anxiolytic meds , Diazepam ?Anxiolytic meds , Diazepam ?
BibliographyBibliography
•• Handbook of Medical Emergencies in the Handbook of Medical Emergencies in the
Dental Office, Stanley F. MalamedDental Office, Stanley F. Malamed
•• Medical Emergencies in Dentistry, Jeffrey Medical Emergencies in Dentistry, Jeffrey
D. Bennett , Morton B. RosenbergD. Bennett , Morton B. Rosenberg
•• ACLS provider manual , American Heart ACLS provider manual , American Heart
AssociationAssociation