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  • 10.14219/jada.archive.2010.03512010;141(suppl 1):14S-19SJADA

    Morton RosenbergOffice

    DentalEssential Drugs and Equipment for the Preparing for Medical Emergencies: The

    jada.ada.org (this information is current as of March 26, 2014):The following resources related to this article are available online at

    http://jada.ada.org/content/141/suppl_1/14Sin the online version of this article at:

    including high-resolution figures, can be foundUpdated information and services

    http://jada.ada.org/content/141/suppl_1/14S/#BIBL, 6 of which can be accessed free:16 articlesThis article cites

    http://www.ada.org/990.aspxthis article in whole or in part can be found at: of this article or about permission to reproducereprintsInformation about obtaining

    prohibited without prior written permission of the American Dental Association. Copyright 2014 American Dental Association. All rights reserved. Reproduction or republication strictly

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  • 14S JADA, Vol. 141 http://jada.ada.org May 2010

    Every dentist can expect to beinvolved in the diagnosis andtreatment of medical emergenciesduring the course of clinical prac-tice. These emergencies may be

    related directly to dental therapy, or theymay occur by chance in the dental officeenvironment. Although just about any med-ical emergency can occur during the courseof dental treatment, best practice dictatesthat dental personnel must be prepared toprovide effective basic life support (BLS)and seek emergency medical services in atimely manner.1

    Dentists also must be able to diagnoseand treat common emergent problems (forexample, syncope or hyperventilation syn-drome), as well as respond effectively to cer-tain less common, or even rare, but poten-tially life-threatening emergencies,especially those that may arise as a result ofdental treatment (for example, anaphylacticreaction to an administered drug). Althoughmany medical emergencies can be treatedproperly without drugs, every dental officemust have a basic emergency kit that con-tains drugs and equipment appropriate tothe training of the dentist, state require-ments, the type of patients being treated(for example, geriatric, special-needs, pedi-atric or medically compromised patients),the procedures performed (for example,whether sedation or general anesthesia isinduced) and the geographical location (for

    Dr. Rosenberg is a professor, Oral and Maxillofacial Surgery, and head, Division of Anes-thesia and Pain Control, Tufts University School of Dental Medicine, and an associate pro-fessor of anesthesia, Tufts University School of Medicine, 1 Kneeland St., Boston, Mass.02111, e-mail [email protected]. Address reprint requests to Dr. Rosenberg.

    Preparing for medical emergenciesThe essential drugs and equipment for the dental office

    Morton Rosenberg, DMD

    Background. Acute medical emergencies can and do occurin the dental office. Preparing for them begins with a teamapproach by the dentist and staff members who have up-to-date certification in basic life support for health care providers.The ability to react immediately to the emergency at hand,including telephoning for help and having the equipment anddrugs needed to respond to an emergency, can mean the differ-ence between successful management and failure. Overview. The purpose of this article is to provide a vision ofthe training, basic and critical drugs, and equipment necessaryfor staff members in general dental offices to manage the mostcommon and anticipated medical emergencies. Conclusions and Clinical Implications. Completionof annual continuing education courses and office medicalemergency drills ensure a rapid response to emergency situa-tions. It is the combination of a knowledgeable and skilleddental team with the equipment for basic airway rescue andoxygenation, monitoring equipment, an automated externaldefibrillator and a basic drug emergency kit that make thedental office a safer environment for patients and enhancedental professionals capability to render competent and timely aid.Key Words. Blood pressure; cardiac arrest; dental team;coronary heart disease; automated external defibrillator; dentaloffice staff members; drug therapy; medical emergencies; epinephrine.JADA 2010;141(5 suppl):14S-19S.

    A B S T R A C T

    Copyright 2010 American Dental Association. All rights reserved. Reprinted by permission.

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    example, an urban setting in whichemergency help is close at hand versusa rural location in which there may bea significant delay until help arrives).Many factors determine the degree ofpreparedness needed for medical emer-gencies in a specific dental practice, butall dental offices must be ready at someminimum level. An overall emergencypreparedness plan that includes equip-ment and a drug kit is essential for alldental practices (Box 12).

    Continuing education courses incor-porating task training and high-fidelityhuman simulators (that is, computer-controlled simulated patients) thatemphasize crisis management for life-like practice in managing medicalemergencies are gaining popularityamong dentists and clinical staff mem-bers. No drug can take the place ofproperly trained health care profes-sionals in diagnosing conditions andtreating patients in emergency situa-tions. Nevertheless, having an appro-priate emergency drug kit and equip-ment often plays an integral role in thecourse and outcome of emergency treatment.3-7

    EQUIPMENT

    Oxygen is of primary importance in anymedical emergency and must be avail-able in a portable E cylinder that canbe transported easily to any office loca-tion in which an emergency may arise.A dental office should be equipped with a devicefor the administration of supplemental oxygen toa spontaneously breathing patientsuch as nasalcannulae, nonrebreathing masks with an oxygenreservoir or a nitrous oxide-oxygen nasal hood.

    Every office must have the ability to deliveroxygen under positive pressure for use in situa-tions in which the patient is unconscious and notventilating adequately. Although mouth-to-maskdevices such as pocket masks are useful, the bestand most efficient method of ventilating withhigh concentrations of inspired oxygen in apneicpatients is with a bag-valve-mask device with anoxygen reservoir connected to an oxygen source ora manually triggered oxygen-powered device(Table 1).

    Oropharyngeal airways come in several sizes

    (7, 8 and 9 centimeters for adults) and are auseful adjunct in overcoming airway soft-tissueobstruction in an unconscious patient. Magill for-ceps can be lifesaving in retrieving foreign objectslost in the hypopharynx during dental therapy.

    The immediate availability of an automatedexternal defibrillator (AED) adhering to theAmerican Heart Associations (AHA) 2005 guide-lines8 is an evolving standard of care in all healthcare settings. The AHA has made early defibrilla-tion an integral part of the BLS chain of survival

    ABBREVIATION KEY. ACLS: Advanced cardiac lifesupport. AED: Automated external defibrillator. AHA:American Heart Association. BLS: Basic life support.PALS: Pediatric advanced life support.

    BOX 1

    Emergency preparedness checklist.*dAll staff members have specific assigned duties.

    dContingency plans are in place in case a staff member is absent.

    dAll staff members have received appropriate training in the management ofmedical emergencies.

    dAll clinical staff members are trained in basic life support for health careproviders.

    dThe dental office is equipped with emergency equipment and supplies thatare appropriate for that practice.

    dUnannounced emergency drills are conducted at least quarterly.

    dAppropriate emergency telephone numbers are placed prominently neareach telephone.

    dOxygen tanks and oxygen delivery systems are checked regularly. Otheremergency respiratory support equipment is present, in good working orderand located according to the emergency plan.

    dAll emergency medications are checked monthly and replacements areordered for specific drugs before their expiration dates have passed.

    dAll emergency supplies are restocked immediately after use.

    dOne staff member is assigned the task of ensuring that the above procedureshave been completed and to document this checklist review.

    * Adapted from Fast and colleagues.2

    TABLE 1

    Inspired oxygen concentration with differentdelivery systems.DELIVERY SYSTEM INSPIRED OXYGEN

    CONCENTRATION (%)

    Spontaneous BreathingNasal cannula 25-45Simple face mask 40-60Nonrebreathing mask with oxygen reservoir 90-100

    Positive Pressure VentilationMouth-to-mouth 17Mouth-to-mask (oxygen flow to mask, 10 liters/minute) 80Bag-valve-mask device with room air 21Bag-valve-mask device with supplemental oxygen reservoir 75-95Manually triggered oxygen-powered breathing device 75-95

    Copyright 2010 American Dental Association. All rights reserved. Reprinted by permission.

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  • 16S JADA, Vol. 141 http://jada.ada.org May 2010

    for the treatment of patients in cardiac arrest.9

    Since January 1998, the AHAs BLS health careprovider cardiopulmonary resuscitation courseshave included a mandated module regarding AEDuse. Some states (Florida, Washington, Illinois)have mandated the presence of an AED in dentaloffices. The immediate availability of an AED hasbeen demonstrated to increase the success ofresuscitation.10 Early defibrillation with theseeasy-to-operate devices will convert two of themost common lethal cardiac dysrhythmiasventricular fibrillation and ventricular tachycardiainto a normal sinus rhythm andrestore perfusion to vital organs.

    Monitoring equipment that provides basicinformation for primary assessment shouldinclude a stethoscope and a sphygmomanometerwith adult small, medium and large cuff sizes. Anautomated vital signs monitor can provide physio-logical data, including systolic, diastolic andmean blood pressure, along with the patientsoxygen saturation level, heart rate and tempera-ture. A wall clock with a second hand is invalu-able in assisting with the determination of heartrate and in documenting contemporaneous eventsand interventions (Box 2).

    EMERGENCY DRUG KITS

    Practitioners can organize emergency kits them-selves or purchase them. Many dentists are notcomfortable choosing and purchasing individualdrugs for their emergency kits, and a high-quality,commercially available emergency drug kit modi-fied for dentistry can provide consistent drugavailability (an automatic drug updating serviceoften is included) in an organized fashion.11 Emer-gency drugs generally are powerful, rapidly acting

    compounds. The correct approach to using drugsin any medical emergency essentially should besupportive and conservative.

    BASIC EMERGENCY DRUGS

    All dentists must keep a fresh supply of criticaldrugs in the office for immediate administration(Table 2). Dentists must know reflexively when,how and in what doses to administer these specificagents for life-threatening situations. The drugsdescribed should be included in a basic medicalemergency kit for the general dental practice.They consist of agents that are noninjectable orcan be administered via subcutaneous, intramus-cular or sublingual routes, and, for dentists withadvanced training, via intravenous orintraosseous routes.

    Oxygen. Oxygen is of primary importance inany medical emergency in which hypoxemiamight be present. These emergencies include, butare not limited to, acute disturbances involvingthe cardiovascular system, respiratory systemand central nervous system. In the hypoxemicpatient, breathing enriched oxygen elevates thearterial oxygen tension, which, in turn, improvesoxygenation of peripheral tissues. Because of thesteepness of the oxyhemoglobin dissociationcurve, a modest increase in oxygen tension cansignificantly alter hemoglobin saturation in thehypoxemic patient. Hypoxemia leads to anaerobicmetabolism and metabolic acidosis, which oftendiminish the efficacy of pharmacological interven-tions in emergencies.

    Epinephrine. Epinephrine is the single mostimportant injectable drug in the emergency kit.Epinephrine is an endogenous catecholamine withboth - and -adrenergic receptorstimulatingactivity. It is the drug of choice for treating car-diovascular and respiratory manifestations ofacute allergic reactions. The beneficial pharmaco-logical actions of epinephrine, when administeredin resuscitative dosages, include bronchodilata-tion and increased systemic vascular resistance,arterial blood pressure, heart rate, myocardialcontractility, and myocardial and cerebral bloodflow.12

    For effective treatment of life-threatening signsand symptoms of an acute allergic reaction, theclinician must administer epinephrine immedi-ately after recognizing the condition. He or shecan inject the drug subcutaneously (0.3 to 0.5 mil-ligram of a 1:1,000 solution) or intramuscularlyfor a more serious emergency (0.4 to 0.6 mg of the

    BOX 2

    Suggested basic emergencyequipment for the dental office.dPortable oxygen cylinder (E size) with regulator

    dSupplemental oxygen delivery devicesdNasal cannuladNonrebreathing mask with oxygen reservoirdNasal hood

    dBag-valve-mask device with oxygen reservoir

    dOropharyngeal airways (adult sizes 7, 8, 9 centimeters)

    dMagill forceps

    dAutomated external defibrillator

    dStethoscope

    dSphygmomanometer with adult small, medium and large cuff sizes

    dWall clock with second hand

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    same solution). Epinephrine should be availablein preloaded syringes or autoinjectors for imme-diate use, as well as in ampules.13 Because of itsprofound bronchodilating effects, epinephrine alsois indicated for the treatment of acute asthmaticattacks that are unrelieved by sprays or aerosolsof 2-adrenergic receptor agonists.14

    Diphenhydramine. Histamine blockers reversethe actions of histamine by occupying H1 receptorsites on the effector cell and are effective in patientswith mild or delayed-onset allergic reactions.

    Nitroglycerin. Although nitroglycerin isavailable in many preparationslong-acting oraland transmucosal preparations, transcutaneouspatches and intravenous solutionsthe appro-priate forms for the dental office are the sublin-gual tablet or translingual spray. Nitroglycerin isthe treatment of choice for an episode of acutechest pain in a patient with a history of anginapectoris. It acts primarily by relaxing vascularsmooth muscle, dilating systemic venous andarterial vascular beds, and leading to a reductionin venous return and systemic vascular resis-tance. These actions combine to reduce myocar-dial oxygen consumption.

    If the patient does not bring his or her ownnitroglycerin to the dental office, the clinicianshould administer one tablet or metered spray(0.4 mg). This dosage may be repeated twice atfive-minute intervals for a total of three doses.Relief should occur within one to two minutes; if

    the discomfort is not relieved, the dentist mustconsider a diagnosis of evolving myocardialinfarction. If the patient has never received adiagnosis of angina pectoris and develops symp-toms of a possible acute myocardial infarction,such as chest pain or chest pressure, the clinicianshould consider administering 0.4 mg of sublin-gual nitroglycerin if the patients systolic bloodpressure is acceptable (> 90 to 100 millimeters ofmercury) after first calling 9-1-1 and adminis-tering aspirin.

    Contraindications to the administration ofnitroglycerin are chest pain and hypotension ortreatment with drugs prescribed for erectile dys-function, such as sildenafil (Viagra, Pfizer, NewYork City), tadalafil (Cialis, Lilly USA, Indi-anapolis) or vardenafil (Levitra, Bayer Health-Care, Leverkusen, Germany). The combination ofnitroglycerin and these compounds may lead toprofound hypotension and unconsciousness.

    Bronchodilator. Inhalation of a 2-adrenergicreceptor agonist such as metaproterenol oralbuterol is used to treat acute bronchospasmthat may be experienced during an asthmaticattack or anaphylaxis. This results in bronchialsmooth muscle relaxation and the inhibition ofchemical mediators released during hypersensi-tivity reactions. Albuterol is an excellent choicebecause it is associated with fewer cardiovascularadverse effects than are other bronchodilators.

    Glucose. Clinicians use glucose preparations

    TABLE 2

    Suggested basic emergency drugs for the general dental office.INDICATION DRUG ACTION ADMINISTRATION

    Bronchospasm (Severe Allergic Reaction)

    Epinephrine - and -adrenergicreceptor agonist

    Autoinjectors or preloaded syringes, ampules; 1:1,000 solution subcutaneously, intramuscularlyor sublingually; adults, 0.3 milligram; children,0.15 mg

    Mild Allergic Reaction Diphenhydramine Histamine blocker 50 mg intramuscularly; 25 to 50 mg orally everythree to four hours

    Angina Nitroglycerin Vasodilator Sublingual tablet: one every five minutes up tothree doses; translingual spray: one spray everyfive minutes up to three times

    Bronchospasm (Mild Asthma)

    Bronchodilator such as albuterol

    Selective 2- adrenergicreceptor agonist

    Two or three inhalations every one to two minutes, up to three times if needed

    Bronchospasm (Severe Asthma)

    Epinephrine - and -adrenergicreceptor agonist (bronchodilator)

    Autoinjectors or preloaded syringes, ampules; 1:1,000 solution subcutaneously, intramuscularlyor sublingually; adults, 0.3 mg; children, 0.15 mg

    Hypoglycemia Glucose, as inorange juice

    Antihypoglycemic If the patient is conscious, ingest

    Myocardial Infarction Aspirin Antiplatelet One full-strength tablet (165-325 mg) chewedand swallowed

    Syncope Aromatic ammonia Respiratory stimulant Inhalant crushed and held four to six inchesunder nose

    Copyright 2010 American Dental Association. All rights reserved. Reprinted by permission.

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  • 18S JADA, Vol. 141 http://jada.ada.org May 2010

    to treat hypoglycemia resulting from fasting or animbalance between insulin and carbohydrate in apatient with diabetes mellitus or in nondiabeticpatients with hypoglycemia. If the patient is con-scious, oral carbohydrates such as orange juice, achocolate bar, cake icing or a cola drink actrapidly to restore circulating blood sugar. On theother hand, if the patient is unconscious and thedentist suspects acute hypoglycemia, he or shenever should administer oral drugs because of thepotential for airway obstruction and/or aspiration.There is no place for insulin in the vast majorityof dental offices.

    Aspirin. The antiplatelet properties of aspirindecrease myocardial mortality dramatically bypreventing further clot formation when adminis-tered to patients during an evolving myocardialinfarction.15 There is no substitute for aspirin forthis indication, and contraindications to its useinclude allergy to aspirin and severe bleeding dis-orders. Patients who exhibit chest pain suggestiveof ischemia and an evolving myocardial infarctionshould chew the aspirin and then swallow it.

    Aromatic ammonia. Aromatic ammonia is acommonly used respiratory stimulant in den-tistry. It is a general arousal agent that cliniciansadminister to patients experiencing vasode-pressor syncope after ascertaining the patency ofthe patients airway, repositioning him or her andadministering oxygen.

    SUPPLEMENTAL INJECTABLE DRUGS AND EQUIPMENT

    Dentists with advanced training may considerincluding drugs and equipment in addition to

    those described earlier. These might include thefollowing injectable drugs:danalgesics;danticholinergics;danticonvulsants;dantihypertensives;dantihypoglycemics;dcorticosteroids;dvasopressors.

    ADJUNCTIVE GENERAL ANESTHESIA DRUGSAND EQUIPMENT

    Educationally qualified dentists16 who use deepsedation and general anesthesia must have addi-tional emergency drugs immediately available(for example, if they use depolarizing neuromus-cular blocking agents, they must have dantrolenesodium, as well as other drugs specific to thesepractices, such as those for advanced cardiac lifesupport [ACLS]), and additional equipment, suchas advanced monitoring systems and airwayrescue equipment.

    REVERSAL DRUGS

    If dentists administer opioids or benzodiazepinesto induce moderate or deep sedation, generalanesthesia or both, they must include antidotaldrugs in the emergency kit. Naloxone is a specificopioid antagonist that reverses opioid-inducedrespiratory depression.17 Flumazenil is a specificbenzodiazepine antagonist that reverses sedationand respiratory depression resulting from benzo-diazepine administration.18

    INJECTABLE DRUG ACCESS

    The injection of many emergency drugs into thevascular system is crucial to speed drug action.The intravenous route is rapid but requires skillin venipuncture. The intramuscular route, eitherinto the vastus lateralis or mid-deltoid regions,results in slower uptake but perhaps easieraccess for many dentists, as does the sublingualapproach. Establishing intravenous access maybe difficult or impossible during medical emergen-cies. As advocated in the AHAs ACLS/PALSguidelines, intraosseous access often can save asignificant amount of time, which can benefitpatients in medical emergencies by decreasingthe time needed to achieve access and administermedications and other fluids, especially in pedi-atric patients.19-21 Establishing intraosseousaccess requires specialized equipment andtraining (Figure). All of these routes of adminis-

    Figure. Intraosseous injection. Reproduced with permission ofVidacare, San Antonio.

    Copyright 2010 American Dental Association. All rights reserved. Reprinted by permission.

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    tration require adequate circulation for the drugsto be effective.

    ADVANCED CARDIAC LIFE SUPPORT

    ACLS for adults and pediatric advanced life sup-port (PALS) for children are the standards of carefor comprehensive resuscitation by health careproviders with advanced skills and training.Pharmacotherapy plays an important role in thetreatment of these patients, with guidelines forspecific drug therapies centering on the use ofmany antidysrhythmic and vasoactive drugs.8,19

    ADVANCED AIRWAY DEVICES

    Dentists with advanced training may wish toinclude advanced airway devices in their emer-gency kits. The indications for, the technique inusing, and ensuring correct placement of thesedevices require training and clinical experience.Endotracheal intubation is accomplished with theuse of a laryngoscope and an endotracheal tube.Gaining in popularity in airway rescue are supra-glottic devices such as the laryngeal mask airway.22

    CONCLUSION

    Urgent and emergent medical emergencies canand do occur in the dental office. Early diagnosis,telephone calls for help and proper managementwill increase the likelihood of a successfulresponse. Accomplishing this depends on the com-bination of training and preparation by the den-tist and staff members and the immediate avail-ability of basic and critical emergency drugs andequipment.

    Disclosure. Dr. Rosenberg did not report any disclosures.

    1. American Heart Association. BLS for Healthcare Providers: Student Manual. Dallas: American Heart Association; 2006.

    2. Fast TB, Martin MD, Ellis TM. Emergency preparedness: a surveyof dental practitioners. JADA 1986;112(4):499-501.

    3. Boyd BC, Hall RE. Drugs for medical emergencies in the dentaloffice. In: Ciancio SG, ed. The ADA/PDR Guide to Dental Therapeutics.5th ed. Montvale, N.J.: PDR Network; 2009:363-385.

    4. Malamed SF. Medical Emergencies in the Dental Office. 6th ed. St.Louis: Mosby; 2007:51-92.

    5. Haas DA. Emergency drugs. Dent Clin North Am 2002;46(4):815-830.

    6. Rosenberg MB. Drugs for medical emergencies. In: Yagiela JA,Dowd FJ, Neidle EA, eds. Pharmacology and Therapeutics for Den-tistry. 5th ed. St. Louis: Mosby; 2004:857-864.

    7. Saef SN, Bennett JD. Basic principles and resuscitation. In: Bennett JD, Rosenberg MB, eds. Medical Emergencies in Dentistry.Philadelphia: Saunders; 2002:3-60.

    8. ECC Committee, Subcommittees and Task Forces of the AmericanHeart Association. 2005 American Heart Association Guidelines forCardiopulmonary Resuscitation and Emergency Cardiovascular Care.Circulation 2005;112(24 suppl):IV1-203.

    9. Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survivalfrom sudden cardiac arrest: the chain of survival concepta state-ment for health professionals from the Advanced Cardiac Life SupportSubcommittee and the Emergency Cardiac Care Committee, AmericanHeart Association. Circulation 1991;83(5):1832-1847.

    10. White RD, Russell JK. Refibrillation, resuscitation and survivalin out-of-hospital sudden cardiac arrest victims treated with biphasicautomated external defibrillators. Resuscitation 2002;55(1):17-23.

    11. ADA Council on Scientific Affairs. Office emergencies and emer-gency kits. JADA 2002;133(3):364-365.

    12. Joint Task Force on Practice Parameters; American Academy ofAllergy, Asthma and Immunology; American College of Allergy,Asthma and Immunology; Joint Council of Allergy, Asthma andImmunology. The diagnosis and management of anaphylaxis: anupdated practice parameter (published correction appears in J AllergyClin Immunol 2008;122[1]:68). J Allergy Clin Immunol 2005;115(3 suppl 2):S483-S523.

    13. Brown AF. Anaphylaxis gets the adrenaline going. Emerg Med J2004;21(2):128-129.

    14. McFadden ER Jr. Acute severe asthma. Am J Respir Crit CareMed 2003;168(7):740-759.

    15. Henneke CH. Update on aspirin in the treatment and preventionof cardiovascular disease. Am Heart J 1999;137(4, part 2):S9-S13.

    16. American Dental Association. ADA positions and statements. Theuse of sedation and general anesthesia by dentists. 2007. www.ada.org/prof/resources/positions/statements/useof.asp. Accessed March 17,2010.

    17. Longnecker DE, Grazis PA, Eggers GW Jr. Naloxone for antago-nism of morphine-induced respiratory depression. Anesth Analg 1973;52(3):447-453.

    18. Klotz U, Kanto J. Pharmacokinetics and clinical use of flumazenil(Ro 15-1788). Clin Pharmacokinet 1988;14(1):1-12.

    19. International Liaison Committee on Resuscitation. The Interna-tional Liaison Committee on Resuscitation (ILCOR) consensus on sci-ence with treatment recommendations for pediatric and neonatalpatients: pediatric basic and advanced life support. Pediatrics 2006;117(5):e955-e977.

    20. Fowler R, Gallagher JV, Isaacs SM, Ossman E, Pepe P, Wayne M.The role of intraosseous vascular access in the out-of-hospital environ-ment (resource document to NAEMSP position statement). PrehospEmerg Care 2007;11(1):63-66.

    21. Part 7.2: Management of cardiac arrest. Circulation 2005;112:IV-58IV-66. http://circ.ahajournals.org/cgi/reprint/112/24_suppl/IV-58.pdf. Accessed March 9, 2010.

    22. Samarkandi AH, Seraj MA, el Dawlatly A, Mastan M, BakhameesHB. The role of laryngeal mask airway in cardiopulmonary resuscita-tion. Resuscitation 1994;28(2):103-106.

    Copyright 2010 American Dental Association. All rights reserved. Reprinted by permission.

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