Download Emergency Plan

Management
of
Medical Emergencies
In the
Dental Office
Hypertension


Defined as blood pressure Greater Than 140/90
Risk factors:
CVA
 MI
 CHF
 Renal Failure

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Hypertension

ASA Risk Status I
 <140 and < 90
 Routine dental
management
 Recheck in 6 months
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3
ASA Risk Status II
 140-160 and 90 to 95
 Recheck BP for next 3
appointments, if
elevated get medical
consultation
 Routine dental care
 Stress reducyion
Hypertension

ASA Risk Status III
 160-200 and 95 to 115
 Recheck BP in minutes
 If elevated, medical
consult before dental
treatment
 Stress reduction
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4
ASA Risk Status IV
 >200/115
 Recheck BP in 5 minutes
 Immediate medical
consultation
 No routine treatment
 Emergency treatment in
hospital
 Rx for pain and infection
Hypertension
Management
 Control BP before elective treatment
 Reasonable control of severe hypertension
before emergency treatment
 Medical consult before treatment for
uncontrolled hypertension
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Management of Medical Emergencies
Common Medical
Emergencies
in the
Dental Office
Vasovagal Syncope
Cause:
Loss of vasomotor tone due to a massive
parasympathetic discharge leading to
decreased pulse rate, and decreased blood
pressure which leads to cerebral hypoxia
and pooling of blood.
Fainting: Vasovagal Syncope
In Dentistry
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The most common cause is psychogenic due to fear
and anxiety; especially from local anesthetic
Most common between the ages of 16 and 35
Males more prone than females
Fainting is considered SERIOUS in PEDIATRIC
patients and patients OVER 40 years of age
Vasovagal Syncope
Signs/Symptoms:
1. Frightened anxious patient.
2. Decreased pulse rate.
3. Decreased blood pressure.
4. Cool, moist, clammy skin.
5. Pale appearance.
Treatment:
1. Place patient in
Trendelenberg’s position.
2. Monitor vital signs.
3. Administer aromatic spirits
of ammonia.
4. Apply cold towel to
forehead.
5. Administer 100% oxygen.
6. Reassurance.
Postural Hypotension
Cause:
 disorder of the autonomic nervous system in
which syncope occurs when the patient assumes
the upright position.
Fainting: Postural Hypotension
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
The second most common cause of transient
loss of consciousness.
Not associated with fear an anxiety
Predisposing factors

Administration of Drugs
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
Antihypertensives
Psychotropics, Sedatives, and Tranquilizers.
Age: increases with increasing age
 Prolonged recumbency

Postural Hypotension
Signs/Symptoms:
 Decrease in BP and loss of
consciousness without
prodromal signs and
symptoms
 Heart rate is normal, unlike
Bradycardia in Vasovagal
Syncope.
 All manifestations of
unconsciousness
 When patient is placed in the
supine position,
consciousness rapidly
returns.
Treatment:
 Stop treatment
 Assess consciousness
 Place patient in the supine
position with legs elevated
 Oxygen
 Monitor vital signs
 Slowly reposition patient
Fainting: Postural Hypotension
Pregnancy (2 forms of hypotension)
1.
Postural hypotension: during the first trimester when
2.
Supine hypotensive syndrome of pregnancy occurs
getting out of bed in the morning; does not reoccur
during the day.
in the third trimester. If the patient is in the supine
position for more than 3 to 7 minutes, the uterus can
compress the inferior vena cava decreasing venous
return from the legs. Turning the patient on her left or
right side will alleviate the pressure and blood flow
returns to normal.
Hyperventilation
Causes:
 Acute
anxiety attack,
 Metabolic and endocrinologic disorders
(hypoglycemia, hyperthyroidism, Cushing’s
syndrome, pheochromocytoma).
Hyperventilation
Signs/Symptoms:
1. Tachypnea.
2. Tachycardia.
3. Parasthesia around mouth
and fingers.
4. Tetany, cramps.
5. Nausea.
6. Faintness.
7. Diaphoresis.
8. Acute anxiety.
9. Shortness of breath.
Treatment:
1. Assure patient airway.
2. Reassure patient.
3. Have patient “re-breathe” in a
paper bag.
Hypovolemic Syncope
Causes:
 External
fluid loss;
 Internal sequestration of fluid;
 Decrease in cardiac output;
 Arrhythmias;
 Hypocapnia (hyperventilation);
 Hypoglycemia.
Hypovolemic Syncope
Signs/Symptoms:
1. Blood pressure low
normal or elevated;
Tachycardia.
2. Orthostatic hypotension
and increased pulse rate.
3. Altered mental states;
anorexia; apathy,
weakness.
4. Cold clammy skin.
Treatment:
1. Maintain patient airway –
turn head to one side to
prevent aspiration.
2. Administer 100% oxygen.
3. DO NOT use aromatic
spirits of ammonia because
it stimulates the sympathetic
system and augments
arrythmogenicity.
Acute Angina Pectoris
Cause:
Diminished blood supply to myocardium
due to an imbalance between myocardial
oxygen supply and demand.
Acute Angina Pectoris
Signs/Symptoms:
1. Chest pain –
substernal pressure or
crushing sensation.
May radiate to neck,
left shoulder and
down arm, and left
side of jaw.
Treatment:
1.
2.
3.
4.
5.
6.
Place patient in supine position.
Assure patient airway.
Administer nitroglycerine – if patient’s
prescription not available – administer
0.3 mg sublingually.
If pain persists five minutes after
nitroglycerine dose, repeat
administration.
If still no response, repeat nitroglycerine
and administer 100% oxygen.
If angina does not subside – concerned
that myocardial infarction is developing.
Transfer to emergency room.
Myocardial Infarction
Cause:
Inadequate supply of oxygen to
myocardium.
Myocardial Infarction
Signs/Symptoms:
1. Chest pain – substernal pressure or
crushing sensation, may radiate to
neck, left shoulder, down arm, left
side of jaw.
2. Feeling of impending doom;
3. Nausea.
4. Pale and diaphoretic.
Treatment:
1. Usually does not respond to
nitroglycerine.
2.
Administer 100% oxygen.
3. Position patient in semi-sitting
position.
4. Transport to medical facility
immediately.
 Note: Narcotics for pain should be
avoided initially, so as not to
interfere with differential
diagnosis, but if desired give
Demerol 25-75 mg IM or IV.
Cardiopulmonary Arrest
Causes:
 Hypoxia;
 myocardial
infarction;
 anesthesia – local or general;
 anaphylaxis;
 excessive vagal tone.
Cardiopulmonary Arrest
Signs/Symptoms:
1. Absence of pulse.
2. Absence of blood pressure.
3. Absence of heart beat.
4. Absence of respiration.
5. Coma.
6. Cyanosis.
7. Dilated pupils.
Treatment:
1. Rule out aspiration.
2. “Precordial Thump” within
one minute of arrest.
3. Assure patient airway.
4. Provide CPR – do not
interrupt CPR for more than
5 seconds, for any reason.
5. Transport to medical
facility.
Acute Congestive Heart Failure
Cause:
Primary “pump” problem.
Acute Congestive Heart Failure
Signs/Symptoms:
1. Right Sided CHF
a.
b.
c.
d.
e.
f.
2.
a.
b.
c.
d.
e.
f.
g.
Systemic congestion
Ankle swelling
Jugular vein distention
Pleural effusion
Dsypnea
Accumulation of fluids in peritoneum.
Left Sided CHF
Pulmonary congestion
Dsypnea
Orthopnea
Great anxiety
Very labored breathing
Productive cough
Cyanosis
Treatment:
1. Place patient in semi-sitting position.
2. Assure patient airway.
3. Administer 100% oxygen.
4. Transport to medical facility
immediately.
Asthmatic Attack
Cause:
Reversible bronchospasm.
Two Subtypes:
 Extrinsic
or allergic type is caused by
environmental allergens.
 Intrinsic (endogenous) type – mechanism
inducing attacks is unknown.
Asthmatic Attack
Signs/Symptoms:
1. Wheezing
2. Effortless inspiration, prolonged
expiration.
3. Distended chest.
4. Severe attack:
a. Tachypnea (>35) or Bradypnea
(<12) Tachycardia (>30)
b. Exhaustion; altered
consciousness
c. Use of accessory muscles of
respiration.
d. Cyanosis.
e. Silent chest (i.e. no wheezing
with dyspnea and tachypnea)
5. Hydration
Treatment:
1. Put patient in sitting position;
assure patient airway; give 100%
oxygen.
2. Two inhalations of isoproterenol
HCl.
3. If no response to isoproterenol,
and in severe attacks, administer
epinephrine (1:1,000), sublingually,
0.3 to 0.5 ml over 5 minutes. May
be repeated every 30 minutes up to
3 doses. Children’s dose:
epinephrine (1:1,000) 0.01 mg/kg
(0.02 mg/lb) repeat only once after
one hour.
4. Contact patient’s physician.
Seizures
Causes:
 Neurologic
disorders;
 Syncope;
 Drug
toxicity;
 Hypoxia.
Seizures
Signs/Symptoms:
1. Involuntary or bizarre
movements.
2. Tongue biting.
3. Loss of consciousness
Treatment:
1.
Assure patient airway.
2. Administer 100%
oxygen.
3. Place soft/padded bite
protector.
4. Transport to medical
facility.
Insulin Shock
Cause:
Hypoglycemia
Insulin Shock
Signs/Symptoms:
1. Rapid fall in blood glucose level.
A. May see parasympathetic
response: hunger, nausea
B. Catecholamine release
a. Anxiety
b. Tachycardia
c. Palpitation
d. Diaphoresis
2. Slow fall in blood glucose level.
A. Increasing lethargy
B. Slurred speech
C. Lassitude
D. Progressive decreasing mental
status
Treatment:
1. If conscious – give oral
glucose (orange juice, candy,
sugar cubes).
2. If unconscious – patient is in
need of IV administration of
50% dextrose – transport to
medical facility immediately.
Diabetic Coma
Cause:
Hyperglycemia
Diabetic Coma
Signs/Symptoms:
1. Frequent urination.
2. Loss of appetite.
3. Thirst.
4. Acetone odor of breath.
5. Hyperpnea.
6. Nausea and vomiting.
7. Warm, dry skin.
8. Rapid pulse.
9. Decreased blood pressure.
10. Coma.
Treatment:
1. Place patient in supine
position.
2. Assure patient airway.
3. Administer 100% oxygen.
4. Call 911.
5. Transport to medical facility.
Anaphylaxis
Cause:
Antigen interaction with antibody coated
target cells.
Anaphylaxis
Signs/Symptoms:
1. Sense of impending doom;
2. Bronchial obstruction: wheezing,
laryngeal edema.
3. Hypoxia.
4. Hypotension.
5. Prutitis, urticaria, angioedema.
6. Nausea, vomiting, diarrhea,
abdominal pain.
7. Convulsions may occur.
Treatment:
1.
2.
3.
4.
5.
Place patient in Trendelenberg
position.
Airway maintenance.
Administer 100% oxygen.
Administer epinephrine 1:1,000
sublingually 0.3 to 0.5 ml over 5
minutes. May be repeated every
30 minutes up to 3 doses.
Children: epinephrine 1:1,000
sublingually 0.01 mg/kg (0.02
mg/lb). Repeat only once after
one hour.
Transport to medical facility.
Allergic Reaction
Cause:
Delayed hypersensitivity reactions.
Allergic Reaction
Signs/Symptoms:
1. Mild Reaction
a. Urticaria
b. Pruritis
c. Skin eruptions
d. Mild angioneurotic
edema
2. Severe Reaction
a. Bronchial congestion
b. Respiratory depression
c. Edema
Treatment:
1. Place patient in supine
position.
2. Assure patient airway.
3. Give 100% oxygen.
4. Mild reaction: 50mg
diphenhydramine HCl
(Benadryl) orally.
5. Severe reaction: 50mg
diphenhydramine HCl
(Benadryl) intramuscularly.
6. Transport to medical facility.
Equipment List
In order to successfully manage a dental emergency in the dental office
you must be properly equipped with the necessary armamentarium which
should include:
1.
2.
3.
4.
5.
6.
Sphygmomanometer with
various cuff sizes: a.) children,
b.) average adult, c.) large adult.
Stethoscope.
100% oxygen, E size compressed
cylinder, portable unit, flow rate
indicator.
Clear resuscitation face masks (to
allow for recognition of
vomiting) of various sizes: a.)
children, b.) average adult, c.)
large adult.
Self-inflating resuscitation bag
(amber type bag).
Small paper bags.
7.
8.
10.
11.
12.
13.
14.
15.
Gauze 4x4.
Alcohol pads.
1” adhesive tape.
Tourniquet.
Oropharyngeal airways – various
sizes.
Soft plastic bite protector.
Backboard for CPR in dental chair.
Medical emergency kit (Benadryl,
Epinephrine, glucose,
Isoproterenol Inhaler,
Nitroglycerin, and Aspirin).
Emergency Drugs and
Equipments
A.
1.
2.
3.
4.
5.
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ATROPINE SULFATE
Actions
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Parasympatholytic agent
Indications
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Symptomatic bradycardia
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Sinus bradycardia with hypotension
Dosage
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0.5 to 1 mg IV bolus (every 5 minutes)

Total dose is 2.0 mg for cardiac patients
Side effects

Dry mouth
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Blurred vision
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Aggravates blindness in patients with glaucoma
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Difficulty in urination with older males
Contraindications

Atrial flutter or fibrillation with rapid ventricular response

Patients with closed angle glaucoma
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Tachycardia
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Emergency Drugs and
Equipments
Diazepam
B.
Actions
1.
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2.
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4.
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Minor tranquilizer
CNS Depressant
Anticonvulsant
Muscle relaxant
Indications
Status epilepticus
Hysteria/anxiety
Dosage
2 to 15 mg slowly IV(5mg/min maximum in larger veins)
Given in small doses initially
May give more if patient’s condition requires
Side effects
Respiratory depression
Sleepiness
Hypotension
CNS depression
Dysrhythmias
Contraindications
Hypotension
Ventilatory insufficiency
Pregnancy
Alcohol intoxication
Narrow angle glaucoma
40
Emergency Drugs and Equipments
Diphenhydramine HCI
C.
Actions
1.
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2.
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3.
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4.
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5.
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Antihistamine – binds to histamine receptor sites to prevent further action
Antiemetic
Mild central nervous system depressant
Reverses actions of phenothiazines
Indications
Anaphylaxis
i.
Preferred before encountering allergen to keep reaction from occurring
ii.
Will not reverse effects of histamine once histamine is active in system, but will keep from further histamine effects
Delayed hypersensitivity reactions
Dosage
25 to 50 mg IM or IV
Side effects
Drowsiness
Blurring of vision
Respiratory depression
Dry mouth
Wheezing
Urinary retention
Hypotension
Contraindications
Hypotension
Alcohol intoxication
Closed angle glaucoma
Ulcer disease with GI obstruction
Pregnancy
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Emergency Drugs and Equipments
Epinephrine
D.
1.
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2.
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3.
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4.
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5.
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Action – alpha and beta sympathomimetic drug
Increases heart rate
Increases contractile state of heart
Bronchodilates
Vasoconstricts
Increases blood pressure
Indications
Cardiac arrest
i.
Ventricular fibrillation
ii.
Asystole
Asthma
Anaphylaxis
Dosage
Cardiac arrest
i.
0.5 to 1.0 mg of a 1:10,000 concentration IV
ii.
May be repeated every 5 to 10 minutes
Asthma
i.
0.3 to 0.5 mg of a 1:1,000 concentration SQ
ii.
May be repeated every 10 minutes as necessary
Anaphylaxis
i.
0.5 mg of a 1:1,000 concentration SQ
ii.
May be repeated as required
Side effects
Ventricular dysrhythmias
Angina
Hypertension
Ectopic beats
Nausea
Dilated pupils
Contraindications
Angina
Hypertension
Hyperthyroidism
No contraindications for patients in cardiac arrest or anaphylaxis
42
Emergency Drugs and Equipments
Morphine Sulfate
E.
Actions
1.


Analgesic
Vasodilator
Reduces preload
Reduces afterload
Stimulates parasympathetic nervous system
Indications
To reduce pain and anxiety associated with acute myocardial infraction
Pulmonary edema from congestive heart failure
Dosage
2.0 to 5.0 mg IV bolus
Side effects
Respiratory depression or arrest
Hypotension
Sleepiness
Bradycardia
Increased intracranial pressure
Contraindications
Respiratory depression
Head injuries
Trauma to chest or abdomen
Uncontrolled bleeding
Alcohol intoxication
Use with caution when giving to patients with inferior or posterior wall myocardial infarction as morphine may cause bradycardia
i.
ii.
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2.
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3.
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4.
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5.
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Emergency Drugs and Equipments
F.
Naloxone
1.
Actions
Narcotic antagonist; blocks the effects of narcotics on the central nervous system
Indications
Overdose of opiate and opioid drugs
Common opiates and opioids:
Morphine
Heroine
Codeine
Darvon
Lomotil
Percodan
Methadone
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2.
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Dosage
3.
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4.
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5.
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5/9/2017
0.4 to 2.0 mg initially given only to point of stimulating patient’s respiratory rate
Side effects
May precipitate withdrawal in patients who are addicted to narcotics
When it wears off, patient may lapse back into coma
Contraindications
None
44
Emergency Drugs and Equipments
Nitroglycerin
G.
Actions
1.
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2.
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Vasodilator – dilates both arteries and veins
Reduces cardiac workload
i.
Reduces preload
ii.
Reduces afterload
Reduces oxygen demand by myocardium
Indication
Angina
Acute myocardial infarction
Congestive heart failure with pulmonary edema
Dosage
3.
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4.
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5.
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0.3 mg given SL, and may be repeated at 5 minute intervals three times
Side effects
Headache
Burning under the tongue
Hypotension
Weakness
Dizziness
Contraindications
Myocardial infarction with hypotension
Hypotension
Increased intracranial pressure
Glaucoma
45
Emergency Drugs and Equipments
H.
1.
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2.
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3.
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4.
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5.
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Nitrous Oxide
Actions
Analgesic
Indications
Pain related to acute myocardial infarction
Dosage
Mixture of 50% nitrous oxide and 50% oxygen
Patient self-administers to prevent overdose
Side effects
Light-headedness
Drowsiness
Nausea and vomiting
Contraindications
Head injuries
COPD
Pulmonary edema
Abdominal distention
Shock
46
Emergency Drugs and Equipments
I.
Oxygen
1.
Actions
Increased arterial oxygen tension
Increased hemoglobin saturation
Increased oxygen delivery to tissues
Indications
Hypoxemia of any cause
Acute myocardial infarction
Trauma
Shock
Cardiopulmonary arrest
Dosage
Nasal cannula – 2 to 6 liters per minute
Simple mask – not less than 6 liters per minute
Reservoir mask – 10-15 liters per minute
Side effects
Decreased rate and depth of ventilations if patient has COPD
No side effects when given in high concentrations over short periods of time
Drying of mucous membranes if not humidified
Contraindications
None
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2.
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3.
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4.
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5.
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REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Medical Emergencies: Prepare Your Team for A Quick Response. Fast, T.B. Dental
Management. Jan. 1987, 32-6.
Managing Emergencies in the Dental Office. Terezhlamy, G.T.
When the Patient’s Life in Your Hands. Dental Management. Aug. 1976.
Medical Emergencies: The Team Approach. Malamed, S.F. Alpha Omega. Fall 1984,
29-36.
Medical Emergencies in Dental Practice Part I – Preparation. Gobetti, J.P., et al.
Journal of Michigan Dental Assoc. Vol. 61, Feb. 1979.
Emergency Preparedness: A Survey of Dental Practitioners. Fast, T.B., et al. JADA.
Vol. 112, Apr. 1986, 499-501.
Emergency Kits for the Dental Practitioner. Jastak, J.T. J. Oreg. Dentl. Assoc. Winter
1983/84.
Medical Emergencies in Dental Practice Part III – Cardiovascular Emergencies.
Dworin, A.M. and Gobetti, J.P. J. of Michigan Dental Assoc. Vol. 61, July-Aug. 1979.
Medical Emergencies in Dental Practice Part V: Miscellaneous Medical Emergencies.
Dworin, A.M. and Gobetti, J.P. J. of Michigan Dental Assoc. Vol. 61, July-Aug. 1979.
Office Emergencies: An Outline of Causes, Symptoms, and Treatment. Freeman, N.S.
et al. JADA. Vol. 94, Jan. 1977, 91-96.
Emergency Medical Therapy. Eisenberg and Copass. W.B. Saunders 2nd Ed. 1982.
Medical Emergencies in Dental Practice Part IV: The Dyspenic Patient. Dworin, A.M.
and Gobetti, J.P. J. of Michigan Dental Assoc. Vol. 61, July-Aug. 1979.