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