PEDIATRIC DENTISTRY / Copyright © 1979 by The AmericanAcademy of Pedodontics / Vol. 1, No. 2 / Printed in U.S.A.

Medical emergencies in the pediatric dentalpatientStephen J. Goepferd, D.D.S., M.S.

AbstractA review of the literature on medical emergencies in thedental office revealed that the majority ofrecommendations for treating medical emergencies areoriented towards the adult patient, and recommendationsfor the management of medical emergencies in the childpatient are not available. The potential emergencies thatmay be encountered by the pedodontist are discussed withrespect to their symptoms, treatment, and precautionswith special emphasis given to specific modificationsnecessary for the pediatric patient.

Introduction

Medical emergencies which are life-threatening canand do occur in the dental office. Most of the recom-mendations for treating medical emergencies in thedental office are oriented towards the adult patient, l-17and recommendations for the management of medicalemergencies in the child patient are not readily avail-able. The pedodontist must have equipment specifi-cally for the pediatric dental patient {see precedingarticle, "Basic Emergency Kit for the Pedodontist."The dosages of emergency drugs as well as the tech-niques for providing supportive therapy for the pedi-atric dental patient need to be altered)s-21 Since con-sideration must be given to the persons in the recep-tion room some of whom in a pedodontic practiceapproach the age and size where adult recommenda-tions for emergency therapy may apply, the pedodon-tist must be capable of treating medical emergenciesin adults as well as in children.

This article will discuss the responsibilities of thepedodontist with respect to medical considerations forpatients and then present the potential medical emer-gencies that might occur in the pedodontic office, witha discussion of the symptoms, treatment, and precau-tions for each.

The pedodontist has an obligation to the patient toperform dental treatment in a manner that does notimpose any unnecessary medical risks as a result ofthat treatment. It is the pedodontist’s responsibility to

seek consultation with the patient’s physician prior todental treatment if the patient has an underlyingsystemic condition that could result in complicationswhile undergoing dental treatment)’2’ ~’ 15. 1~ In somecases, minor preventive measures may be recom-mended by the physician prior to dental treatment.Other patients may best be managed in a hospitalenvironment due to the seriousness of the underlyingdisease and the increased potential for a life-threaten-ing episode during dental treatment.

When confronted with a medical emergency, thepedodontist should remain calm and act swiftly anddefinitively in order to provide immediate therapywithout causing undue panic in the patient or theauxiliary personnel. The pedodontist should be con-cerned with maintaining Airway, Breathing, and Cir-culation and then should treat symptomatically.5 Thepedodontist should never administer a drug without adefinite indication for its use and should also avoidmultiple drug therapy since it will complicate thediagnosis for medical personnel.14’ 22

Be aware of modifications in emergencytherapy for children.

The best treatment for medical emergencies is pre-vention. By consulting the physician of patients whohave underlying disease states, the pedodontist canminimize emergency complications, and his beingprepared can reduce the severity of theemergency)’ 2, 5, 6, 9, 14, 15

The following section describes the possible medicalemergencies that may arise in the pedodontic office,their symptoms, and treatment. These recommenda-tions have been collated from an extensive review ofthe dental literature 1-17 and texts on pediatric medi-cine) 8-2~ With the exception of cardiopulmonary re-suscitation (CPR) techniques and resuscitative equip-ment {see preceding article, "Basic emergency kit forthe pedodontist"), most of the modifications for emer-gency treatment of medical emergencies in the childpatient are related to drug dosages. These modifica-

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tions will be italicized through the following section. Aquick reference chart is provided at the end of thisarticle.

The emergencies of cardiovascular accident, cardiacarrest, myocardial infarction, and angina pectoris,which are most likely to occur in adults in the recep-tion area of a pedodontic office, have already beenextensively reported in dental literature and will notbe discussed at this time.

Pediatric dosage schedule

The dosage schedules presented for children in eachof the following emergency situations are reported asa range. The first dose in the range corresponds to theapproximate dose for a 30-pound child, and the seconddose corresponds to a 60-pound child. The milligramsper kilogram dose is listed along with the maximumdose. The adult dose is based on a 150-pound adult.However, the author recommends that a concise ref-erence chart and instructions in an emergency kit listthe doses as a range to facilitate the estimation of theproper dose to be given during an emergency. If thedosages were listed as milligrams per kilogram, itwould be too time-consuming and impractical to cal-culate the exact dose to be given during an emergencyepisode especially if the exact weight of the child isunknown or cannot be readily determined by thepedodontist.

Anaphylaxis

Anaphylactic shock is an immediate and explosive,resultant allergic response to the introduction of asubstance to which the patient has been previouslysensitized. The reaction can occur immediately afterthe administration of the offending drug or can bedelayed up to two hours following oral administration.7

Symptoms

The patient may experience itching and develop arash, anxiety, restlessness, an acute fear that some-thing is wrong, headache, nausea, respiratory diffi-culty, wheezing, cyanosis, rapid and weak pulse, asudden drop in blood pressure, cardiac arrhythmia,and cardiac arrest.

Treatment

Keep calm to avoid panic in the patient and yourstaff. While an assistant calls a physician and anambulance, you should administer epinephrine 1:1000in the dose of 0.125-0.25 cc for children (0.01 mg/kgup to a maximum dose of 0.025 mg/kg) and of 0.5 ccfor adults i.v. or inject into the venous area underneaththe tongue.24 It may be of value to inject one-half thedose at the site of the original administration of the

offending drug and one-half the dose i.v. or sublin-gually. Repeat after five min if the first dose is ineffec-tive, up to a maximum of three doses. Following theadministration of epinephrine, the patient should be.placed in a supine position, and Benadryl should beadministered i.m. in the dose of 25-50 mg for children(5 mg/kg/24 hr to a maximum of 300 mg for children)and of 50-100 mg for adults. This will competitivelyinhibit the effects of further histamine release. (It willnot counter the effects of histamine already released.)Oxygen should be given. In the event of severe laryn-geal edema causing respiratory obstruction, a crico-thyroid membrane puncture may be necessary to ob-tain an airway to save the patient’s life. The patientshould be treated by medical personnel as soon aspossible.

Precautions

A thorough medical history is important, and pa-tients with previous reactions to drugs or insect bitesshould be suspect. No unnecessary drugs should beadministered. Any physician or dentist who gives alarge number of injections should have the necessaryemergency equipment, drugs, and knowledge of emer-gency procedures for treating anaphylaxis.

Allergic reaction

An allergic reaction is the specific change in thereactivity of tissues to antigenic substances. Specifi-cally, it is the reaction resulting when a second dose ofantigen reacts with fLxed antibodies.

Symptoms

The patient may experience itching, skin rash, hives,and swelling of the face, hands, and eyelids. Thepatient may have nasal congestion and sneezing and,in severe cases, may experience respiratory difficultyand laryngeal edema.

Treatment

In the case of a mild reaction, the patient should bereferred to a physician immediately. If the reaction ismoderate, the patient should be given Benadryl orallyor i.m. in the dose of 25-50 mg for children (5 mg/kg/24 hr to a maximum of 300 rag) and of 50 mg for anadult. A physician should be consulted, and the patientshould be seen immediately for observation. If thesymptoms progress rapidly and respiratory difficultyensues, treat as outlined for anaphylaxis.

Acute asthmatic attack

Bronchial asthma is a type of pulmonary incompe-tency manifested by a recurrent paroxysm of dyspnea

PEDIATRIC MEDICAL EMERGENCIES116 Goepferd

of a characteristic wheezing type and is caused by anarrowing of the smaller bronchi and bronchioles.

Symptoms

A history of asthma is an important factor in diag-nosing an attack. The patient will exhibit a rapid andfull pulse, wheezing characterized by prolonged expi-rations, a normal or elevated blood pressure, and pos-sible cyanosis.

Treatment

Many asthmatic patients have their own medicalinhalers which they use when an attack arises. If thisis the situation, the patient’s use of the inhaler may beall that is needed for relief. If the inhaler is of thechromalin type, however, it is for the prevention of anattack and not treatment. If the patient has no inhaler,epinephrine 1:1000 should be given subcutaneously inthe dose of 0.125-0.25 cc for children (0.01 mg/kg toa maximum dose of 0.025 mg/kg) and 0.25-0.5 cc foradults. Repeat after 20 rain if there is no relief. Oxygenshould be administered! The patient should be keptsemierect to avoid compromising the airway. The pa-tient should be referred to medical personnel imme-diately for evaluation and further therapy.

Precautions

A history of asthma and previous attacks stimulatedby anxiety is important. Consultation with the pa-tient’s physician may be indicated, and premedicationmight be considered. If the patient has an attack,dental treatment should be terminated and should notbe resumed until consultation with the child’s physi-cian has been accomplished. If the patient beginswheezing and has no history of asthma, an anaphylac-tic reaction must be suspected.

Syncope

Syncope, the common faint, is characterized by asudden drop in blood pressure and bradycardia (40-60beats per min} via neurogenic mechanisms. There iscapillary pooling of blood and dilation of the vascularbed leading to decreased cerebral perfusion.

Symptoms

The patient may exhibit a slow and weak pulse, adecreased or normal blood pressure, increased respi-ratory rate, pallor, cold and clammy skin, dilated pu-pils, eyes rolled upwards, and loss of consciousness.

Treatment

Place the patient in Trendelenburg’s position, ad-minister oxygen, loosen tight clothing around the neck,

place a cold towel on the forehead, and pass an am-monia inhalant under the nose for stimulation. If thepatient does not respond, get immediate medical helpand institute supportive therapy as necessary untilhelp arrives.

Precautions

Patient positioning, i.e., as it is employed in four-handed dentistry, can reduce the likelihood of faintingas it is more apt to occur with the patient in an uprightor semiupright position. The incidence of fainting ishigher in males than females and greatest in malesunder 25 years of age.25 A common predisposing factorhas been suggested to be lack of food.

Respiratory obstruction

This emergency arises when the upper respiratorypassages become obstructed by one of several means.The obstruction may be caused by the tongue, vomi-tus, blood, or a foreign object lodged in the region ofthe glottis.

Symptoms

If an object or foreign material becomes lodged inthe oropharynx, the patient’s attempts to dislodge theobject will be manifested by choking, coughing, andwheezing. Laryngeal spasm may occur. The patientwill make a violent attempt to breathe, may becomecyanotic, and will lose consciousness if the obstructionis severe.

Treatment

Attempts should be made to remove the object.First, suction the oral cavity. Then, if the obstructionpersists, attempt removal by delivering four sharpblows to the back between the shoulder blades whilesupporting the patient’s chest with the other hand. Asmall child may be held upside down for this proce-dure. Additional attempts at dislodging the object maybe made via the Heimlich maneuver. If these attemptsfail, position the head for maximum opening of theairway and attempt to ventilate the patient, utilizingoxygen. If visual access can be obtained, attempt toremove the object with properly contoured forceps. Ifthe obstruction cannot be dislodged, a cricothyroidmembrane puncture will be necessary to open anairway to save the patient’s life. If the foreign bodypasses, the patient must be referred immediately forradiographic examination to determine the location ofthe object and for immediate treatment if the objectis found to be in the lungs.

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Epileptic seizure

An epileptic seizure is an intermittent disorder ofthe nervous system presumably caused by a suddendischarge of cerebral neurons resulting in an almostinstantaneous disturbance of sensation, loss of con-sciousness, and convulsive movements.

Symptoms

Many epileptic patients will experience an aura ofimpending seizure. Grand mal seizures are character-ized by clonic-tonic convulsions, loss of consciousness,oozing of saliva from the mouth, incontinence, andcyanosis. Petit mal seizures are usually characterizedby a trance-like state with a lack of motor distur-bances.

Treatment

If the patient has an aura of impending seizure or ifa seizure begins, place the patient on the floor awayfrom equipment and instruments to avoid injury tothe patient. Restrictive clothing should be loosened,an adequate airway should be maintained, and thepatient should be allowed to rest after the seizureterminates. The patient may experience irritabilityand confusion upon regaining consciousness andshould be observed until there is a return to a normalstate. The dental treatment should be discontinuedfor the day, and the patient should be escorted fromthe office by a responsible individual and evaluated bya physician as soon as possible. If the seizure is pro-longed (4 min or more), immediate medical assistanceis needed, and i.v. Valium (5 mg increments) may necessary to terminate the seizure.

Insulin shock

Diabetic hypoglycemia usually occurs in a patientwho has a history of diabetes. The reaction is theresult of a net excess of insulin due either to anoveradministration of insulin or to the patient nothaving eaten properly, perhaps having skipped a meal.

Symptoms

There is usually a history of diabetes, and a historyof the events of the day may indicate a potentialproblem. The patient may have a rapid pulse, a normalor decreased blood pressure, and an increased respi-ration rate with shallow respirations. The patient maybe hungry, experience dizziness and weakness, mentalconfusion, disorientation, and irritability. Severe re-actions include nausea and vomiting, delusions, apha-sia, ataxia, and a loss of consciousness.

Treatment

With a patient history of diabetes and a determi-nation that the patient is not acting normally and

seems to be out of sorts, the pedodontist should ad-minister oral sugar in whatever form available. Arecommendation is a commercially available, concen-trated glucose solution (glutose). If the patient haslapsed into unconsciousness, which is rare in the dentaloffice, 50% dextrose should be given intravenously,

20-30 cc for children and 50 cc for adults.

Precautions

Diabetics should be questioned as to how they feeland whether or not they are controlled. If the patientis controlled, it should be determined if the properroutine has been adhered to. If the patient is anuncontrolled diabetic or seems to be reactingstrangely, treatment should be postponed until thepatient has been evaluated and cleared by his physi-cian for dental treatment.

Diabetic acidosis

The opposite reaction in the diabetic with inade-quate insulin is ketone production which gives rise toketosis, clinically manifested as diabetic acidosis. Thediabetic patient with an infection, e.g., acute dentalabscess, is more susceptible to this type of reaction.

Symptoms

The following symptoms take a relatively long pe-riod of time to develop, and the chances of suddendevelopment in the dental office are quite rare. Alongwith a history of diabetes, the patient will exhibitexcessive thirst, frequent urination, malaise, loss ofappetite, acetone (fruity) breath, and nausea. In latestages, the patient experiences vertigo and abnormallydeep respirations and finally lapses into a coma.

Treatment

If the above symptoms are present after question-ing a diabetic patient, the pedodontist should refer thepatient immediately to medical personnel. The patientshould be kept warm, placed in a supine position, andgiven oxygen. Supportive therapy should be carriedout as necessary.

Drug toxicity

The patient undergoes symptoms manifested as aresult of overdose or excessive administration of adrug. Complications depend upon a sufficient concen-tration of the drug in the blood stream resulting frominadvertent injection intravascularly at a rate greaterthan the body’s capacity for neutralization or elimi-nation of the drug, or the administration of too largea dose. Example: the toxic dose of Xylocaine for anadult is 300-500 mg and for the child is 3.5 mg/lb, orapproximately 100 mg for a small child.

PEDIATRIC MEDICAL EMERGENCIES118 Goepferd

Symptoms

General symptoms are excitement of the centralnervous system followed by depression. The symp-toms of stimulation of the central nervous system areapprehension, anxiety, restlessness, confusion, tremors(not present with Xylocaine), rapid breathing, in-creased blood pressure and heart rate, and visualdisturbances. The symptoms of the depression stageare stupor, unconsciousness, convulsions, inefficientrespiration progressing to respiratory failure, cyanosis,weak and rapid pulse, a drop in blood pressure, andfinally, peripheral vascular collapse.

Treatment

Place the patient in a supine position and suctionmouth and throat. Administering oxygen for this mayprevent occurrence of severe symptoms and allow thebody to metabolize the drug excess. Get medical help.

The following emergency situations may occur asthe results of dental treatment. However, with ade-quate medical history records, the pedodontist shouldeasily recognize their possibility and consult with theproper medical personnel. Most often, patients withthe potential risks listed below should be treated in anenvironment where immediate and specialized medicalattention can be obtained, and the patient can bemonitored closely before, during, and after treatment.

Angioneurotic edema (nonhereditary)

This form of giant urticaria is characterized by localpainless swellings of subcutaneous tissues or submu-cosal tissue of various parts of the body. The pasthistory will include prior episodes and food and drugallergies.

Symptoms

The patient will most often exhibit single, localized,painless swellings (can be multiple) on the face, hands,and genitalia with the tongue and pharynx rarelyaffected. The disease is caused by an allergic responseto foods, drugs, infection, or emotional stress.

Treatment

These episodes can be prevented by consultationwith the physician and proper antihistamine therapy.If an episode occurs, Benadryl should be given i.m. inthe dose of 25-50 mg for a child (5 mg/kg/24 hr to300 mg maximum dose) and 50-100 mg for an adult.The patient should be referred immediately for medi-cal attention.

Angioneurotic edema (hereditary-familial)

This type is a frequently recurring edema of tissueand is triggered by trauma to patients who have a

family history of this type of reaction. The traumainduces histamine release either locally or widespread.

Symptoms

Again, a good history can alert the dentist to thepossibility, and precautions can be taken via consul-tation with the physician and close cooperation withmedical facilities. The onset of symptoms may take upto several hours. The lips, face under the eyes, tongue,and neck are the first areas to manifest obvious swell-ing after trauma, i.e., extraction. Edema of the necktissues, uvula, epiglottis, soft palate, and vocal cordscauses difficulty in breathing and asphyxia in severecases.

Treatment

Again, adequate history, precautions, and preven-tive therapy is a must. With the onset of symptoms, aphysician and an ambulance should be summoned,and Benadryl should be given i.m. in the dose of 25-50 mg for a child 5 mg/kg/24 hr to a maximum of 300mg) and 50-100 mg for an adult. If symptoms continueand the patient experiences respiratory difficulty, Ep-inephrine 1:1000 should be given i.v. or by sublingualinjection in the dose of 0.125-0.25 cc for children(O.01mg/kg to a maximum dose of 0.025 mg/kg) andof 0.5 cc for adults. If the patient continues to haverespiratory difficulty which progresses to respiratoryobstruction, a cricothyroid membrane puncture maybe necessary to establish an airway.

Adrenal crisis

This condition comes about as the result of insuffi-cient corticosteroid output during a stimulus such asa stressful situation. The cause of the condition maybe destruction of the adrenal glands, i.e., Addison’sdisease, tuberculosis, or adrenal tumor, or atrophy ofthe adrenal glands in situations requiring long-termsteroid therapy, i.e., asthma, the leukemias, or rheu-matoid arthritis. Consultation with the physician forthe maintenance dose of the steroids for dental treat-ment is necessary before any treatment is performed,and it may be advantageous to perform the treatmentin an environment where immediate emergency med-ical assistance is available.

Symptoms

An adequate medical history and history of pastepisodes should alert the dentist to potential problems.During a crisis, the patient will exhibit weakness,pallor, perspiration, and a weak and rapid pulse. Asevere reaction can progress to hypotension and car-diovascular collapse.

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Treatment

Administer oxygen and supply necessary supportive

therapy while an assistant phones for medical help

and an ambulance. A trained practitioner can inject

Decadron (dexamethasone sodium phosphate) i.v. i.m. in a dose of 1-4 rng for children and 6-10 mg for

adults.

Remember: treatment of patients with a history of

angioneurotic edema or adrenal insufficiency due to

pathologic changes or chronic steroid therapy might

best be performed in a hospital setting where imme-diate emergency help is available. It is always wise to

consult the patient’s physician when treating someone

with an underlying disease that could lead to serious

complications.

Summary

The pedodontist is obligated to have the necessary

equipment, drugs, and knowledge to provide immedi-

ate and proper emergency therapy when a medical

emergency arises in the office. The equipment andemergency kit should be inspected; drugs should be

replaced as needed; and a record should be kept of the

MEDICAL EMERGENCY--QUICK REFERENCEEmergency Signs and symptoms

1. Anaphylaxis Acute anxiety, rash, itching, respiratory dis-tress, wheezing, cyanosis, severe drop inblood pressure

Allergic reaction Itching, swelling of face, hands, and eyelids,rash

3. Acute asthmatic at-tack

Wheezing, rapid and full pulse, prolonged ex-pirations

4. Syncope

5. Respiratory Ob-struction

Epileptic seizure

7. Insulin shock

Diabetic acidosis

9. Drug toxicity

10. Cerebrovascularaccident (CVA)

11. Angina pectoris

12. Myocardial infarc-tion

13. Cardiac arrest

14. Adrenal crisis

Slow, weak pulse, drop in blood pressure,cold, clammy skin, dilated pupils, loss of con-sciousness

Choking, coughing, wheezing, violent at-tempts to breathe, cyanosis

Grand mal--clonic-tonic convulsions, frothingat mouth, unconsciousness

Hunger, weakness, dizziness, mental confu-sion, disorientation, irritability

Thirst, frequent urination, loss of appetite,fruity (acetone) breath, vertigo, coma

Central nervous system excitement, then cen-tral nervous system depression-convulsions,unconsciousness

Hemiplegia, slow, deep breathing, eyes de-viate to one side, speech impairment

Substernal and precordial pain radiating toarm, rapid pulse

Severe, persistent substernal pain radiating toleft arm, possible cyanosis, cold clammy skin,no relief with nitroglycerin

20-30 seconds of gasping respirations, respi-ratory arrest, no pulse, cyanosis, pupils di-lated, centric, and fixed

Past history of episodes, weakness, pallor,

TreatmentEpinephrine 1:1000 i.v. or intralingual, 0.125-0.25 cc(child), 0.5 cc (adult), oxygen, Benadryl i.m. 25-50 mg(child), 50-100 mg (adult)--hospitalization

Mild--Benadryl orally 25-50 mg (child), 50-1 O0 mg(adult)--physician. Moderate--Benadryl i.m. 25-50mg (child), 50-100 mg (adult),--physician

Mild--patient use own medical inhaler, oxygen. Se-vere-Epinephrine 1:1000 subcutaneously O. 125-0.25 cc (child), 0.25-0.5 cc (adult), semierect position,oxygen--physician

Trendelenburg position, oxygen, loosen clothing, coldtowel on forehead, ammonia stimulant

Blows on back, Heimlich maneuver, suction, ventilate,attempt removal with forcep, cricothyrotomy

Patient on floor, protect from injury, loosen clothing--physician

Oral sugar if conscious, 50% dextrose, i.v., 20-30 cc(child), 50 cc (adult), if unconscious--physician

Keep warm until hospitalized

Supportive treatment until hospitalized

Avoid unnecessary movements, keep warm, oxygenuntil hospitalized

Oxygen, sublingual nitroglycerin tablet, repeat 3 min-utes (x 3), hospitalization

Oxygen, supportive therapy, keep warm until hospital-ized

Place patient on floor, CPR until hospitalization

perspiration, weak and rapid pulseOxygen and supportive therapy unlil hositalized. De-cadron i.v. or i.m. 1-4 mg, (child) and 4-6 mg (adult)

PEDIATRIC MEDICAL EMERGENCIES120 Goepferd

inspections.5, 6, 14. 15 Having the proper training, emer-gency equipment, and drugs will be of limited value inan emergency situation if the office staff are unfamiliarwith the emergency procedures, and confusion pre-vails. Practice sessions on emergency procedures areimperative so that each person is responsible for adesignated procedure and knows when it is to beperformed.

For medicolegal purposes when an emergencyarises, someone should be responsible for keeping awritten record of the following: (1) the time of onset;(2) vital signs during the emergency; (3) time, dose,and route of drug administration; (4) the effects ofdrugs and therapy provided; and (5) time of initiationof any therapy, e.g., CFR. Following the emergencyepisode, the pedodontist should immediately record asummary of events and patient reactions to drugs andtherapy.

The best form of emergency therapy is prevention.Thorough medical histories and follow-up consulta-tions for underlying disease states can be invaluablein avoiding potential medical emergencies. There canbe no argument against practicing defensively. A val-uable adjunct toward preventing medical emergenciesis a good rapport and proper consultation with thelocal medical personnel.

It is important to have a manual on the treatmentof potential medical emergencies which includes theduties required of the various members of the officestaff available for periodic review. In addition, a quickreference on emergency therapy should be readilyavailable.

References

1. Grouse, V. L.: "Dental Treatment of the Patient with Cardio-vascular Disease," in Current Therapy in Dentistry, Vol. 5, ed.Goldman, H. M., Gilmore, H. W., Irby, W. B., and Olsen, N. A.,St. Louis: The C. V. Mosby Company, 1974.

2. Grouse, V. L.: "Resuscitation Preparation and Equipment in theDental Office," in Current Therapy in Dentistry, Vol. 5, ed.Goldman, H. M., Gilmore, H. W., Irby, W. B., and Olsen, N. A.,St. Louis: The G. V. Mosby Company, 1974, pp. 464-469.

3. Donaldson, D., and Wood, W. W.: "Recognition and Control ofEmergencies in the Dental Office," J Can Dent Assoc 41:228,1975.

4. Frame, J. N.: "An Emergency Drug Cabinet for Use in GeneralDental Practice," Br Dent J, 132:363, 1972.

5. Freeman, N. S., King, R. A., Plezia, R. A., and Shearer, H. T.:"Office Emergencies: An Outline of Causes, Symptoms, andTreatment," J Am Dent Assoc, 94:91, 1977.

6. Funke, F. W.: "Diagnosis and Treatment of Common SystemicEmergencies," in Current Therapy in Dentistry, Vol. 5, ed.

Goldman, H. M., Gilmore, H. W., Irby, W. B., and Olsen, N. A.,St. Louis: The C. V. Mosby Company, 1974, pp. 456-463.

7. Glauda, W. M., Henefer, E. P., and Super, S.: "Non-fatal Ana-phylaxis Caused by Oral Penicillin: Report of a Case," J AmDent Assoc, 90:156, 1975.

8. Harrison, J. B.: "Faints and Spells," Dent Clin North Am, 17:461, 1973.

9. Hendler, B. H., and Rose, L. F.: "Common Medical Emergencies:A Dilemma in Dental Education," J Am Dent Assoc, 91:575,1975.

10. Irby, W. B., and Baldwin, K. H.: Emergencies and UrgentComplications in Dentistry, St. Louis: The C. V. Mosby Com-pany, 1965.

11. McCarthy, F. M.: Emergencies in Dental Practice, Preventionand Treatment, Philadelphia: W. B. Saunders Company, 1972.

12. McGimpsey, J. G.: "Fainting in the Dental Surgery," Br DentJ, 143:53, 1977.

13. Perks, E. R.: "The Diagnosis and Management of Sudden Col-lapse in Dental Practice," Br Dent J, 143:Pt. 1, 196-200; Pt. 2,235-237; Pt. 3, 307-310; 1977.

14. Schizatschky, M.: "Basic Emergency Kit," Quintessence Int, 3:71, 1975.

15. Zetz, M. R.: "Some Observations on Dental Office Emergen-cies," In Current Therapy in Dentistry, Vol. 6, ed. Goldman, H.M., Gilmore, H. W., Irby, W. B., and McDonald, R. E., St. Louis:The C. V. Mosby Company, 1977, pp. 417-423.

16. "Recognition and Treatment of Emergencies in the DentalOffice," in Accepted Dental Therapeutics, 36th ed, Chicago:American Dental Association, 1975, pp. 18-33.

17. Staples, A. F.: "Cardiopulmonary Crises in the Dental Office,"Dent Clin North Am, 17:473, 1973.

18. Gellis, S. S., Kagan, B. M.: Current Pediatric Therapy, Phila-delphia: W. B. Saunders Company, 1971, pp. 658-675.

19. Nelson, N. E.: Textbook of Pediatrics, 8th ed., Philadelphia: W.B. Saunders Company, 1966.

20. Varga, C.: Handbook of Pediatric Medical Emergencies, 4thed., St. Louis: The C. V. Mosby Company, 1977.

21. "Standards for Cardiopulmonary Resuscitation (CPR) andEmergency Cardiac Care (ECC)," JAMA 227:Suppl 7, 1974.

22. Tarsitono, J. J.: "Children, Drugs and Local Anesthesia," J AmDent Assoc, 70:1153, 1965.

23. Robinson, J. S.: "Cardio-respiratory arrest during Dental An-esthesia," Br Dent J, 128:232, 1970.

24. Nichols, W. A., and Cutright, D. E.: "Intralingual Injection Sitefor Emergency Stimulant Drugs," Oral Surg, 32:677, 1971.

Dr. Stephen Goepferd received his un-dergraduate and postgraduate trainingat the University of Minnesota, Schoolof Dentistry, Division of Pediatric Den-tistry. He is presently an Assistant Pro-fessor, Department of Pedodontics,University of Iowa. Requests for re-prints may be addressed to Dr. S. J.Goepferd, Department of Pedodontics,The University of Iowa School of Den-tistry, Iowa City, Iowa 52242.

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