Emerg in odonto clinica first

Emergenze mediche nello studio odontoiatrico

Claudio Melloni

Specialista in Anestesia e Rianimazione

melloniclaudioliberoit

Essere preparati per le emergenze

bull Storia clinica del pazienteanamnesi con aggiornamento ad ogni visita

bull Identificazione del paziente a ldquorischiordquo presenza dellrsquoanestesista o spostamento in altra sedecasa di curadaysurgHosp

bull Quando si conferma un appuntamento ricordare ai paz di prendere le loro medicine

Essere preparati

bull Staff preparato per CPR

bull Piano di emergenza scritto

bull numero tel di emergenza

ad ogni postazione

bull Kit di emergenza pronto e

tutti sanno dove egrave

bull Verifica routinaria del

contenuto e scadenze

The health history should include information regarding the patientrsquos past and present health status

Physical Status ClassificationsASA

ASA classification of physical status

Classificationswwwasahqorgclinicalphysicalstatushtm accessed april 2007

bull ASA 1 ---Normally healthy patient without medical problems

bull ASA 2 --- Mild well controlled systemic disease --- no functional limitation

bull ASA 3 --- Severe systemic disease that results in functional limitation but non incapacitating

bull ASA 4 --- Severe systemic disease that is a constant threat to life

bull ASA 5 --- Moribund patient not expected to survive regardless of operation

bull ASA 6 --- A declared dead patient whose organs are being removed for donation

Estimated Energy Requirements for Various Activities

NYHA Classification - The Stages of HeartFailure(rivista)

bull La valutazione secondo la NYHA classifica la funzionedisfunzione cardiaca a seconda dei sintomi legati alle normali attivitagrave quotidiane e alla qualitagrave di vita del paziente

bull Classe e sintomibull Classe I (normale) Non limitazioni alla attivitagrave fisicaLe attivitagrave

ordinarie non causano particolare faticapalpitazioni o dispneabull Classe II (Moderata ) Lieve limitazione alla attivitagrave fisica a

riposo OKma attivitagrave routinarie causano faticapalpitazionidispneaangina

bull Class III (Marcata) Marcata limitazione alla attivitagrave fisica a riposo okma attivitagrave meno che routinarie causano faticapalpitazionidispneangina

bull Class IV (Severa) incapacitagrave di eseguire qualsiasi attivitagraveConattivitagrave anche minima sintomi di insufficienza cardiaca anche a riposocon aumento dei disturbi allrsquoinizio del movimento

Classificazione obbiettiva

bull Classificazione con valutazione oggettiva bull A non crsquoegrave evidenza di malattia cardiovascolare non ci sono sintomi negrave

limitazioni alla attivitagrave fisica ordinariabull B evidenza oggettiva di minima malattia cardiovascolareSintomi modesti e

lieve diminuzione attivitagrave durante attivitagrave routinariaA riposo ok bull C evidenza oggettiva di malattia cardiovascolare moderata-severaMarcata

limitazione delle attivitagrave per la comparsa di sintomi anche durante attivitagrave meno che normaliA riposo ok

bull D evidenza oggettiva di malattia cardiovascolare severaLimitazionisevereSintomi anche a riposo

bull For Examplebull A patient with minimal or no symptoms but a large pressure gradient across the aortic valve or severe obstruction of the left

main coronary artery is classifiedbull Function Capacity I Objective Assessment Dbull A patient with severe anginal syndrome but angiographically normal coronary arteries is classifiedbull Functional Capacity IV Objective Assessment A

PREOP ASSESSMENT

ldquoAt Riskrdquo Patients for Sedation or Analgesia

bull The ASA physical status risk classification of 3 or greater

bull Critical care patients

bull Extremes in age (lt1 or gt70 years of age)

bull Patients with chronic respiratory disease chronic obstructive pulmonary disease emphysemaCHRanginahellip

bull History of sleep apnea

bull Mentally and neurologically handicapped patients

bull Patients at risk for aspiration (ie hiatal hernia with regurgitation diabetes with gastroparesis)

bull Altered mental status

Relative Contraindications

Contraindications

bull Physical Examination

ndash Respiratory distress (wheezing stridor etc)

ndash Hypotension

ndash Morbid obesity

ndash OSA

Contraindications (continued)


ndash Craniofacial abnormalities

ndash Short neck

ndash Decreased hyoid-mental distance (lt3cm in adult)

ndash Distorted landmarks on anterior surface of neck



ndash Limited mouth opening

ndash Receding chin

ndash Large tongue

ndash Unable to view base of uvula with mouth open and tongue protruding

Pregnancy

bull Patients who are trying to conceive are pregnant or are breast-feeding must inform their dentist in advance of their appointment

Mallampati Classificationbull Class 1 Full visibility of tonsils uvula and soft palate

bull Class 2 Visibility of hard and soft palate upper portion of tonsils and uvula

bull Class 3 Soft and hard palate and base of the uvula are visible

bull Class 4 Only hard palate is visible

The Mallampati classification is used to

predict the ease of intubation It is

determined by looking at the anatomy of

the oral cavity Specifically it is based

on the visibility of the base of uvula

faucial pillars and soft palate Scoring

may be done with or without phonation

A high Mallampati score (class 3 or 4) is

associated with more difficult intubation

as well as a higher incidence of sleep

apnea

OSA screening

clinical diagnosis of OSA

bull The clinical diagnosis of OSA was defined as AHI(apnea hypopnea) greater than 5 with fragmented sleep and daytime sleepiness

bull According to the American Academy of Sleep Medicine practice guideline the severity of OSA is determined by the AHI 5ndash15 mild greater than 15ndash30 moderate greater than 30 severe

STOPsnoretiredobserved(stopped breathing)pressure

STOP QuestionnaireA Tool to Screen Patients for Obstructive Sleep ApneaAnesthesiology 2008 108812ndash21

Stop tradottoquasi corrisponde

bull SmdashldquoDo you snore loudly (louder than talking or loud enough to be heard through closed doors)rdquoRussi forte+ che parlare a voce alta

tanto da essere udito a porta chiusaSornacchiarebull TmdashldquoDo you often feel tired fatigued or sleepy during daytimerdquoti

senti stancoaffaticato o sonnolento durante il giorno Tiratohelliphellip

bull OmdashldquoHas anyone observed you stop breathing during your sleepNessuno ti ha osservato fermare il respiro durante il sonnoosservato

bull rdquo PmdashldquoDo you have or are you being treated for high blood pressure Hai o sei stato in terapia per ipertensionePressione

Screening of patients

Poliambulatorio helliphelliphelliphelliphelliphelliphelliphelliphelliphellip Modulo di consenso informato per procedure chirurgiche ambulatoriali o day surgery Da consegnare al momento della prenotazione e riportare

Si prega di leggere attentamente e riempire con i dati richiesti sopra le parti indicate dai puntini(datacittagravecognomenomeinterventofirma)

Datahelliphelliphelliphelliphelliphelliphellip

Cittagravehelliphelliphelliphelliphelliphelliphellip Io sottoscrittohelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Dichiaro di attenermi alle seguenti disposizioni

I)non assumere alcun cibo nelle 6 ore precedenti linterventone liquidi nelle due ore

precedenti raccomandazioni per il digiuno preoperatorio

MATERIALE INGERITO TEMPO MINIMO DI DIGIUNO

Liquidi chiari (acquacaffegravethe succo senza polpa bibite

gasate)

2 ore

Pasto leggero (toast e bibita) 6 ore

2)di non guidare alcuna automobile o motocicletta o bicicletta od utilizzare qualsiasi

macchinario nelle 24 ore seguenti Ianestesia o sedazione

3)di non assumere alcoolici nelle 24 ore seguenti lanestesia o sedazione

4)di farmi riaccompagnare alla mia residenza da un adulto responsabile

5)di rimanere in compagnia di un adulto responsabile una volta tornato al domicilio

6) di non assumere alcuna decisione importante ne firmare documenti

importanti(testamentoassicurazioni ecc)nelle 24 ore seguenti

7)di vestirmi in modo praticocosicchegrave il vestiario possa essere facilmente rimosso e

indossato e riposto in un armadiettoper estute da ginnastica con maniche larghe e

apertura frontale 8)di non portare gioielli o altri oggetti di valore in ambulatorio

9)di mettermi in contatto con lunitagrave chirurgica ambulatoriale nel caso insorga una

qualsiasi complicanza postoperatoria

10) di assumere o avere giagrave assunto la mia terapia agli intervalli soliticon un poco

di acqua se necessario

FIRMA

IDquest day surg e consensodoc

Screening of patients 2

CM 1312009

DottClaudio Melloni


Via Fossolo 28

40138 Bologna

tel051390048

Questionario preoperatorio di autocompilazione Si prega di barrare la risposta esatta con un segnetto o un cerchietto eo riempire gli spazi sopra i

puntini con le informazioni richiesteTutte le risposte sono confidenziali e coperte dal segreto

professionaleGrazie

Cognome e nomehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

indirizzoviahelliphelliphelliphelliphelliphelliphelliphellipcittagravehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipCaphellip

telhelliphelliphelliphellip

etagravehellip peso in kghellip altezza in cmhellip

Si sente ammalato SI NO

Se Sipercheacutehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Ha o ha avuto una malattia seria SI NO


Ha affanno dopo sforzo SI NO

Ha tosse SI NO

Ha sibili respiratori SI NO

Ha dolore al petto da sforzo SI NO

Ha gonfiore alle caviglie SI NO

Ha o ha avuto malattie di cuore SI NO

Ha o ha avuto malattie dei polmoni SI NO

Ha o ha avuto malattie di fegato SI NO

Ha o ha avuto malattie dello stomaco reflussoulcera SI NO

Ha o ha avuto malattie dei reni SI NO

Ha o ha avuto malattie muscolari SI NO

Ha o ha avuto malattie cerebrali SI NO

Ha assunto farmaci negli ultimi tre mesi SI NO

Se Siqualihelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Prende gocce nasali o oculari SI NO

Egrave allergico a qualche medicinale SI NO

Ersquo allergico a qualche cibo SI NO

Ha subito interventi o anestesie negli ultimi 3 mesi

SI NO


Egrave mai stato operato prima drsquoora SI NO


Ci sono state strane storie in famiglia di incidenti insorti durante o subito dopo anestesia

SI NO

Porta occhiali o lenti a contatto SI NO

Porta protesi dentarie o ponti mobili SI NO Beve piugrave di in bicchiere di vino o di un superalcoolico al giorno

SI NO Fuma SI NO

Se Siquanto Ci sono stati altri problemi di salute fisica o mentale non compresi in questa lista

SI NO


Fa movimento o sport SI NO

Se sigraveche cosa(per es biciclettalavori di casaortoraccolta fruttaecc) helliphelliphelliphelliphelliphelliphelliphelliphellip

Raccolta dati

cM 1195

data sedehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

COGNOME E NOME

INDIRIZZO TELhelliphelliphelliphellip

ETAgrave PESO(KG) ALTEZZA(CM) ASA

INTERVENTO

ANESTESISTACHIRURGO

anestetico locale Si No farmacomg

adrenalina Si No dose

via aerea spont guedel maschera IOT IRT COPA LMA

respirazionespont ass man IPPV O2 si no maschera occhialini

Premedicazioneora

induzione(farmacidosi)

mantenimento

inizio anestesiaora inizio chirurgiaora

Via

venosa

fleboclisi 1 2 3 4 MAC opp

AG

Min PAS PAD Fc SaO2 EtCO2 Osservazioni bas

5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

160

165

170

175

180

totalifarmaciipnoticisedativian algesicimi orilassanti

altri stopanalgesia

fine anestesiaora fine chirurgiaora

apertura occhiora orientamentoorahellip RS orahelliphelliphelliphellipestub orahelliphelliphellip sedutohin piedi

hhelliphelliphelliphelliphellip vestirsi hhelliphellip camminare hhelliphelliphelliphelliphellip mingere hhelliphelliphellip berehhelliphelliphelliphelliphelliphelliphelliphelliphellipeffetti

collateralihelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipPONV se siterapiahelliphelliphelliphelliphelliphellipno dolore se siterapiahelliphelliphelliphelliphelliphelliphellipoppNO

Dimissioneorahelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

ConsensoPoliambulatorio SLucia

Via Murri 164

Bologna

DICHIARAZIONE DI AVVENUTA INFORMAZIONE E CONSENSO ALLrsquoANESTESIA

Io Sottoscrittoahelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip natoa a helliphelliphelliphelliphellip

il

Dichiaro di essere stato informatoa dal Medico Anestesista drhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

che le mie condizioni di salute mi collocano nella classe ASAhelliphellip ed il rischio relativo allrsquointervento

chirurgico al quale io verrorsquo sottopostoa egrave helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Ho compreso le informazioni circa il tipo di anestesia piugrave appropriato nella mia situazione e dopo avere preso in considerazione anche le eventuali alternative dograve il mio consenso al trattamento anestesiologico

concordato che saragrave il seguentehelliphelliphellip helliphelliphelliphelliphelliphelliphelliphelliphellip

Sono stato informato che tale trattamento qualora si verificassero condizioni particolari che mi verranno

spiegate potrebbe essere modificato

Mi egrave stato spiegato che lrsquoanestesia pur essendo fra le metodiche piugrave sicure della medicina moderna puograve

comportare ancora oggi in rarissimi casi complicanze mortali o gravi danni permanenti in particolare di

tipo neurologico Mi ritengo adeguatamente informato e non desidero ricevere ulteriori informazioni

In seguito alla mia richiesta di ulteriori informazioni ho ricevuto e compreso ogni spiegazione sui

trattamenti anestesiologici che verranno adottati prima durante e dopo lrsquointervento In particolare ho

compreso le informazioni circa le complicanze piugrave comuni e prevedibili nel mio caso specifico che

consistono inhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Autorizzo inoltre il Medico Anestesista a comunicare notizie relative al mio stato di salute

ahelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Dichiarazioni particolarihelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

DATA

Firma del Paziente Firma del Medico Anestesista

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip helliphellip

Firma del Tutorehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipdihelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Drugs taken by patientshellip

bull We consistently found associations of antipsychotic and SSRI antidepressant treatment with sudden unexplaineddeath significantly raised risk ratios being found for typicaland atypical antipsychotics the latter including risperidoneand olanzapine individually and the SSRI antidepressants including citalopram fluoxetine and sertraline Individually

bull Br J Clin Pharmacol 2009 November 68(5) 743ndash751bull doi 101111j1365-2125200903496xbull PMCID PMC2791981bull Sudden death in patients receiving drugs tending to

prolong the QT intervalbull Kate Jolly1 Michael D Gammage2 Kar Keung Cheng1 Peter

Bradburn1 Miriam V Banting1 and Michael J S Langman2

J Can Dent Assoc 2009 Feb75(1)41Dental surgery for patients on anticoagulant therapy with warfarin a

systematic review and meta-analysisNematullah A Alabousi A Blanas N Douketis JD Sutherland SE

bull University of Toronto Ontario Canadabull Comment in bull Evid Based Dent 200910(2)52 bull Republished in bull Tex Dent J 2009 Dec126(12)1183-93 bull Abstractbull PURPOSE To evaluate the effect of continuing warfarin therapy on the bleeding risk of patients undergoing elective dental surgical proceduresbull METHODS Data sources were the MEDLINE and EMBASE databases the Cochrane Central Register of Controlled Trials a manual citation review of

the relevant literature content experts and relevant abstracts from the proceedings of the International Association for Dental Research Study selection was carried out independently by 2 reviewers as was quality assessment Data extraction was done by 3 reviewers Differences were resolved by consensus Eligible studies were randomized controlled trials that compared the effects of continuing the regular dose of warfarintherapy with the effects of discontinuing or modifying the dose on the incidence of bleeding in patients undergoing dental procedures

bull RESULTS Five trials (a total of 553 patients) met the inclusion criteria Compared with interrupting warfarin therapy (either partial or complete) perioperative continuation of warfarin with patients usual dose was not associated with an increased risk for clinically significant nonmajor bleeding (relative risk [RR] 071 95 confidence interval [CI] 039-128 p = 065 I2 = 0) or an increased risk for minor bleeding (RR 119 95 CI 090-158 p = 022 I2 = 0)

bull CONCLUSIONS Continuing the regular dose of warfarin therapy does not seem to confer an increased risk of bleeding compared with discontinuing or modifying the warfarin dose for patients undergoing minor dental procedures

Clin Oral Implants Res 2009 Sep20 Suppl 496-106What influence do anticoagulants have on oral implant therapy

A systematic reviewMadrid C Sanz M

bull bull Department of oral surgery Oral Medicine and Hospital Dentistry Department of Ambulatory Care and Community Medicine University of Lausanne

Lausanne Switzerland carlosmadridhospvdchbull Abstractbull OBJECTIVES This systematic review aims to assess the risks (both thromboembolic and bleeding) of an oral anticoagulation therapy (OAT) patient undergoing

implant therapy and to provide a management protocol to patients under OAT undergoing implant therapybull MATERIAL AND METHODS Medline Cochrane Data Base of Systematic Reviews the Cochrane Central Register of Controlled Trials and EMBASE (from 1980 to

December 2008) were searched for English-language articles published between 1966 and 2008 This search was completed by a hand research accessing the references cited in all identified publications

bull RESULTS Nineteen studies were identified reporting outcomes after oral surgery procedures (mostly dental extractions in patients on OAT following different management protocols and haemostatic therapies) Five studies were randomized-controlled trials (RCTs) 11 were controlled clinical trials (CCTs) and three were prospective case series The OAT management strategies as well as the protocols during and after surgery were different This heterogeneity prevented any possible data aggregation and synthesis The results from these studies are very homogeneous reporting minor bleeding in very few patients without a significant difference between the OAT patients who continue with the vitamin K antagonists vs the patients who stopped this medication before surgery These post-operative bleeding events were controlled only with local haemostatic measures tranexamic acid mouthwashes gelatine sponges and cellulose gauzess application were effective Post-operative bleeding did not correlate with the international normalised ratio (INR) status In none of the studies was a thromboembolic event reported

bull CONCLUSIONS OAT patients (INR 2-4) who do not discontinue the AC medication do not have a significantly higher risk of post-operative bleeding than non-OAT patients and they also do not have a higher risk of post-operative bleeding than OAT patients who discontinue the medication In patients with OAT (INR 2-4) without discontinuation topical haemostatic agents were effective in preventing post-operative bleeding OAT discontinuation is not recommended for minor oral surgery such as single tooth extraction or implant placement provided that this does not involve autogenous bone grafts extensive flaps or osteotomy preparations extending outside the bony envelope Evidence does not support that dental implant placement in patients on OAT is contraindicated

bull The following are the latestguidelineshowever every DDS should thinkabouthelliphellip

Guideline TitleSteps to reduce surgical risk In II guidelines for perioperative evaluation

Bibliographic Source(s)Gualandro DM Yu PC Calderaro D Marques AC Pinho C Caramelli B et al Steps to reduce surgical risk In II guidelines for perioperative evaluation Arq Bras Cardiol

201196(3 Suppl 1)23-41 [379 references]

bull Antiplatelet Agents (AAS)bull Recommendations for antiplatelet agents before noncardiac surgeriesbull Degree of Recommendation Ibull Patients with coronary artery disease and noncardiac surgery scheduled should maintain the use of

AAS at a low dose of 75 to 100 mgday except in neurosurgeries and transurethral resection of the prostate Level of Evidence B

bull Patients using dual antiplatelet therapy by means of recent angioplasty with stent should keepreceiving AAS throughout the perioperative period with discontinuation of thienopyridine 5 daysbefore surgery and reintroduction as early as possible ideally before the patient completes 10 daysof discontinuation Level of Evidence C

bull Patients receiving antiplatelet therapy only with thienopyridine and surgery scheduled with moderate to high-risk of bleeding should discontinue medication 5 days before Level of EvidenceC

bull Degree of Recommendation IIabull Keep dual antiplatelet therapy in procedures with low risk for bleeding Level of Evidence Cbull Patients receiving antiplatelet therapy only with thienopyridine and surgery scheduled with low risk

of bleeding should continue medication in the perioperative period Level of Evidence C

bull Procedures with Low Risk of Bleedingbull Cataract surgerybull Minor dermatological proceduresbull Dental procedures - hygiene simple extraction restoration endodontic and

prosthetic proceduresbull Recommendationsbull Patients at High Risk of Thromboembolismbull Degree of Recommendation IIa Level of Evidence Cbull Discontinue warfarin 5 days before surgery and wait for INR lt15 to perform the procedurebull UFH or prophylactic LMWH can be used in the preoperative period if indicatedbull Postoperatively use UFH or prophylactic LMWH if indicated by the type of procedure and resume warfarin 12 to 14 hours after surgerybull Patients at Low Risk of Thromboembolismbull Degree of Recommendation I Level of Evidence Cbull Discontinue warfarin 5 days before surgery and wait for INR lt15bull Start full-dose UFH or LMWH when INR lt20bull Discontinue intravenous UFH 4 hours before surgery and subcutaneous LMWH 24 hours before surgerybull Postoperatively restart full-dose UFH or LMWH and warfarin and 12 to 24 hours after the procedure and discontinue heparin only when the INR is within

therapeutic rangebull Patients at Intermediate Risk of Thromboembolismbull Degree of Recommendation IIa Level of Evidence Cbull Depending on the individual assessment of each patient the guidelines can be followed either for the high or low risk to the discretion of the physician in

chargebull Procedures with Low Risk of Bleedingbull Degree of Recommendation I Level of Evidence Cbull Perform the procedure with an INR within the therapeutic range ndash it is not necessary to discontinue the anticoagulantbull If INR gt3 discontinue anticoagulation therapy one or two days before surgery and reintroduce it the night after surgery

Endocarditis Prophylaxis

bull Dental Procedures and Prevention of Infective Endocarditisbull Dental procedures with higher risk for bacteremia are subgingival placement of antibiotic fibers or strips dental extractions dental implants or reimplants endodontic and periodontal

procedures placement of orthodontic bands and procedures with significant bleeding Whenever high-risk patients undergo these procedures should receive antibiotic prophylaxis Degree of Recommendation I Level of Evidence C It is likely that low-income populations with little access to health care with heart diseases other than those cited in Table 2 (below) also benefit from infective endocarditis (IE) prophylaxis before dental procedures Degree of Recommendation IIa Level of Evidence C

bull Table 2 Patients at Risk of Acquiring Severe Infective Endocarditisbull Patient with prosthetic heart valvebull Valvular heart disease corrected with prosthetic materialbull History of infective endocarditisbull Acquired valvular heart disease in patient who underwent heart transplantbull Uncorrected cyanotic congenital heart diseasebull Corrected cyanotic congenital heart disease that evolves with residual lesionbull Congenital heart disease corrected with prosthetic materialbull Surgical Procedures and Prevention of Infective Endocarditisbull Indications for Endocarditis Prophylaxisbull Degree of Recommendation Ibull Prophylaxis for patients at high risk for severe IE (see Table 2 above) and who will be subjected to dental procedures with a high probability of significant bacteremia (see Table 3 below)

Antibiotic regimen (see Table 10 in the original guideline document) Level of Evidence Cbull Table 3 Dental Procedures and Indication of Infective Endocarditis Prophylaxisbull Indicated Not Recommended ndash Any Patients Who Will Undergo the Procedures Belowbull For patients at risk for severe infective endocarditis and who will undergo procedures involving manipulation of gingival tissue periodontal region or perforation of oral mucosa Local

anesthesia in non-infected tissuebull Dental X-raybull Placement or removal of bracesbull Adjustment of bracesbull Placement of parts in bracesbull Natural loss of milk toothbull Bleeding originated from the trauma of the oral mucosa or lipsbull Degree of Recommendation IIabull Prophylaxis for patients with valvular heart disease or congenital heart disease that do not meet the criteria on Table 2 (above) and who will undergo dental procedures with a high

probability of significant bacteremia (see Table 3 above) Antibiotic regimen (see Table 10 in the original guideline document) Level of Evidence Cbull Prophylaxis for patients at high risk for severe IE (see Table 2 above) and who will undergo genitourinary or gastrointestinal procedures associated with mucosal lesion Antibiotic

regimen (see Table 11 in the original guideline document) Level of Evidence Cbull Prophylaxis for patients at high risk for severe IE (see Table 2 above) and who will undergo esophageal or respiratory tract procedures associated with mucosal lesion Antibiotic regimen

(see Table 10 in the original guideline document) Level of Evidence Cbull Degree of Recommendation IIbbull Prophylaxis for patients with valvular heart disease or congenital heart disease that do not meet the criteria in Table 2 (above) and who will undergo dental procedures that do not meet

the criteria on Table 3 (above) Antibiotic regimen (see Table 10 in the original guideline document) Level of Evidence Cbull Prophylaxis for patients with valvular heart disease or congenital heart disease that do not meet the criteria in Table 2 (above) and who will undergo genitourinary or gastrointestinal

procedures associated with mucosal lesion Antibiotic regimen (see Table 11 in the original guideline document) Level of Evidence Cbull Prophylaxis for patients with valvular heart disease or congenital heart disease that do not meet the criteria in Table 2 (above) and who will undergo esophageal or respiratory tract

procedures associated with mucosal lesion Antibiotic regimen (see Table 10 in the original guideline document) Level of Evidence Cbull Degree of Recommendation IIIbull There is no indication for IE prophylaxis in patients with interatrial communication alone interventricular communication or corrected patent ductus arteriosus and without residual

flow myocardial revascularization surgery mitral valve prolapse without regurgitation after placement of stents innocent heart murmurs patients with pacemakers or implantablecardioverter-defibrillators (ICDs) history of Kawasaki disease or rheumatic fever without valve dysfunction who will undergo dental esophageal respiratory tract genitourinary or

Guideline on antibiotic prophylaxis for dental patients at risk for infection

Bibliographic Source(s)Clinical Affairs Committee Council on Clinical Affairs Guideline on

antibiotic prophylaxis for dental patients at risk for infection Chicago (IL) American Academy of Pediatric Dentistry (AAPD) 2011 5 p [27

references]bull Major Recommendationsbull The conservative use of antibiotics is indicated to minimize the risk of developing resistance to current antibiotic regimens Given the increasing number of organisms that have

developed resistance to current antibiotic regimens as well as the potential for an adverse anaphylactic reaction to the drug administered it is best to be judicious in the use of antibiotics for the prevention of infective endocarditis (IE) and other distant-site infections

bull Patients with Cardiac Conditionsbull Dental practitioners should consider prophylactic measures to minimize the risk of IE in patients with underlying cardiac conditions The risk of developing IE can arise from a combination

of high-risk patients and dental procedures However at-risk patients with poor oral hygiene and gingival bleeding after routine activities (eg toothbrushing) also have shown an increased potential for developing complications of IE It therefore is recommended to encourage daily good oral hygiene practices to reduce gingivitis as part of the prophylacticregimen These patients andor parents need to be educated and motivated to maintain personal oral hygiene through daily plaque removal including flossing Greater emphasis shouldbe placed on improved access to dental care and oral health in patients with underlying cardiac conditions at high risk for IE and less focus on a dental procedure and antibiotic coverage Professional prevention strategies should be based upon the individuals assessed risk for caries and periodontal disease

bull Specific recommendations from the latest American Heart Association (AHA) guideline on prevention of IE are included in the tables below The AHA recommends antibiotic prophylaxisonly for those whose underlying cardiac conditions are associated with the highest risk of adverse outcome (see Table 1 below) Such conditions include prosthetic heart valves previoushistory of IE unrepaired or incompletely repaired cyanotic congenital heart disease (CHD) completely repaired congenital heart defect with prosthetic material or device during the first 6 months after the procedure repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or device and cardiac transplantation recipients who developcardiac valvulopathy In addition to those diagnoses listed in the AHA guidelines patients with a reported history of injection drug use may be considered at risk for developing IE in the absence of cardiac anomalies Although quite rare complications from intraoral tongue piercing can include IE among patients with a pre-existing cardiac valvular condition andor history of injection drug use Consultation with the patients physician may be necessary to determine susceptibility to bacteremia-induced infections

bull Antibiotics are recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa (see Table 2 below) Specific antibiotic regimens can be found in Table 3 in the original guideline document Practitioners and patientsparents can review the entire AHA guidelines in the AHA CirculationJournal archives httpcircahajournalsorgcgicontentfull116151736 for additional background information as well as discussion of special circumstances (eg patients already receiving antibiotic therapy patients on anticoagulant therapy)

bull Patients with Compromised Immunitybull Patients with a compromised immune system may not be able to tolerate a transient bacteremia following invasive dental procedures These non-cardiac factors can place a patient with

compromised immunity at risk for distant-site infection from a dental procedure This category includes but is not limited to patients with the following medical conditionsbull Immunosuppression secondary tobull Human immunodeficiency virus (HIV)bull Severe combined immunodeficiency (SCIDS)bull Neutropeniabull Cancer chemotherapybull Hematopoietic stem cell or solid organ transplantationbull Head and neck radiotherapybull Autoimmune disease (eg juvenile arthritis systemic lupus erythematosus)bull Sickle cell anemiabull Asplenism or status post splenectomybull Chronic steroid usagebull Diabetesbull Bisphosphonate therapybull Consultation with the childs physician is recommended for management of patients with a compromised immune system Discussion of antibiotic prophylaxis for patients undergoing

chemotherapy irradiation and hematopoietic cell transplantation appears in a separate American Academy of Pediatric Dentistry (AAPD) guideline (see the National GuidelineClearinghouse [NGC] summary Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy Hematopoietic Cell Transplantation andor Radiation)

bull Patients with Shunts Indwelling Vascular Catheters or Medical Devicesbull The AHA recommends that antibiotic prophylaxis for nonvalvular devices including indwelling vascular catheters (central lines) and cardiovascular implantable electronic devices (CIED)

is indicated only at the time of placement of these devices in order to prevent surgical site infection The AHA found no convincing evidence that microorganisms associated with dentalprocedures cause infection of CIED and nonvalvular devices at any time after implantation The infections occurring after device implantation most often are caused by Staphylococcusaureus and coagulase negative staphylococci or other microorganisms that are non-oral in origin but are associated with surgical implantation or other active infections The AHA furtherstates that immunosuppression is not an independent risk factor for nonvalvular device infections immunocompromised hosts who have those devices should receive antibioticprophylaxis as advocated for immunocompetent hosts Consultation with the childs physician is recommended for management of patients with nonvalvular devices

Cardiac Conditions Associated with the Highest Risk of AdverseOutcome from Endocarditis for Which Prophylaxis with Dental

Procedures Is Reasonable

bull Prosthetic cardiac valve or prosthetic material used for cardiac valve repair

bull Previous infective endocarditisbull Congenital heart disease (CHD)bull Unrepaired cyanotic CHD including palliative shunts and conduitsbull Completely repaired congenital heart defect with prosthetic

material or device whether placed by surgery or by catheterintervention during the first 6 months after the procedure

bull Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibitendothelialization)

bull Cardiac transplantation recipients who develop cardiac valvulopathy

Dental Procedures for which Endocarditis ProphylaxisIs Reasonable for Patients in Table 1

bull All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa

bull The following procedures and events do not needprophylaxis routine anesthetic injections throughnoninfected tissue taking dental radiographs placement of removable prosthodontic or orthodonticappliances adjustment of orthodontic appliances placement of orthodontic brackets shedding of deciduous teeth and bleeding from trauma to the lipsor oral mucosa

Considerations for Perioperative Anticoagulationarfarin therapy - management during invasive procedures and

surgeryBibliographic Source(s)

Medical Services Commission Warfarin therapy - management during invasive procedures and surgery Victoria (BC) British Columbia Medical Services Commission 2010 Oct 1 7 p [8 references]

bull Note Always consult with the surgeon and anesthesiologist aboutbull Risk of bleedingbull Goal INRbull Acceptable INR for surgerybull Baseline INR is recommended in every case and this will guide further therapybull Always discuss with surgeon and anesthesiologist what the INR should be before surgery (goal INR)bull An INR lt15 is generally acceptable except for neurosurgery ocular surgery and procedures requiring spinal anesthesia or epidural analgesia (Horlocker et al

2003)bull Risk of bleedingbull In general the type of procedure determines the risk of bleeding and how long anticoagulation must be withheld post-operativelybull Discontinuation of warfarin is essential for these procedures associated with a high risk of bleeding

ndash Procedures that the body cavity is entered eg open thoracic abdominal or pelvic surgeryndash Percutaneous needle procedures in non-compressible sites including organ biopsiesndash Any type of prostatic surgeryndash Surgery sites where minor bleeding can cause significant morbidity (eg central nervous system [CNS] and intraocular procedures)ndash Major arthroplasty surgery eg hip or knee replacement

bull Discontinuation of warfarin is usually not necessary for these procedures associated with a low risk of bleedingndash Percutaneous needle procedures in readily compressible sites (eg peripheral venous access)ndash Many skin proceduresndash Routine dental procedures (eg hygiene simple extractions restorations endodontics prosthetics)

ndash Endoscopy without biopsy

bull Assess the risk of bleeding from the procedure with the assistance of the surgeon and anesthesiologistC

Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgeryBibliographic Source(s)

Task Force for Preoperative Cardiac Risk Assessment and Perioperative [trunc] European Society of Anaesthesiology Poldermans D Bax JJ Boersma E De Hert S Eeckhout E Fowkes G Gorenek B Hennerici MG Iung B Kelm M Kjeldsen KP Kristensen SD Lopez-Sendon J Pelosi P Philippe F Pierard L Ponikowski P Schmid JP Sellevold OF Sicari R Van den Berghe G Vermassen F Guidelines for pre-operative cardiac risk

assessment and perioperative cardiac management in non-cardiac surgery Eur Heart J 2009 Nov30(22)2769-812 [238 references] PubMed

bull Pre-operative Evaluationbull Surgical Risk for Cardiac Eventsbull Although patient-specific factors are more important than surgery-specific factors in predicting the cardiac risk for noncardiac surgical procedures

the type of surgery cannot be ignored when evaluating a particular patient undergoing an intervention With regard to cardiac risk surgicalinterventions can be divided into low-risk intermediate-risk and high-risk groups with estimated 30-day cardiac event rates (cardiac death and myocardial infarction [MI]) of lt1 1ndash5 and gt5 respectively (see table below) Although only a rough estimation this risk stratification providesa good indication of the need for cardiac evaluation drug treatment and assessment of risk for cardiac events

bull Table Surgical Riska Estimatebull Low-risk lt1 Intermediate-risk 1-5 High-risk gt5bull Breastbull Dentalbull Endocrinebull Eyebull Gynaecologybull Reconstructivebull Orthopaedic-minor (knee surgery)bull Urologic-minor Abdominalbull Carotidbull Peripheral arterial angioplastybull Endovascular aneurysm repairbull Head and neck surgerybull Neurologicalorthopaedic-major (hip and spine surgery)bull Pulmonary renalliver transplantbull Urologic-major Aortic and major vascular surgerybull Peripheral vascular surgerybull aRisk of MI and cardiac death within 30 days after surgery Modified from Boersma et al Perioperative cardiovascular mortality in noncardiac

surgery validation of the Lee cardiac risk index Am J Med 20051181134ndash1141

Segni vitali

bull Prima di ogni trattamento dovrebbero essere misurati i segni vitaliPAFCrespirazione e temperatura

Inserire fot Omron

IMG_6728JPG

ContecVital Signs Monitor PatientMonitor with CE Certificate

(CMS5000)

Riconoscere una emergenza

bull Segni e sintomi di emergenza incipiente

ndash Dolore toracico

ndash Cute pallida

ndash Sudorazione

ndash Vomito(nausea)

ndash RESPIRAZIONE IRREGOLARE

ndash SENSAZIONI STRANE O INSOLITE

ndash Modificazioni delle frequenza e o della pressione

Codice di deontologia medica

bull Art 7 ndash Obbligo drsquointervento drsquourgenza Il medico

e devetempestivamente attivarsi per assicurare ognispecifica adeguata assistenza

Procedure iniziali nellrsquoemergenzabull Interrompere la procedura

bull Chiamare aiuto

bull Chiamare il kit di emergenza

bull Valutare lo stato di coscienzase incoscienteabbassare la poltrona trendelemburg

bull Somministrare O2se coscienteocchialinise incosciente ma respira maschera se incosciente e non respira pallone e maschera

Algoritmo di base

bull PABCDbull Posizionare

bull A airway

bull B breathing

bull Ccirculation

bull Ddefinitivo o diagnosi

Come valutare lo stato di coscienza

1 come definirlo cosciente

vigile

soporoso

coma

2 come riconoscerlo stimolo verbale

stimolo doloroso

3 come valutarlo risposta verbale

apertura occhi

risposta motoria

Valutare le vie aereeaprire la bocca

estendere il capo e sostenere il mentoimpiegare lrsquoaspirazione se necessario

Valutare la respirazionese non respiradai due respiri con ossigeno 100

se in apneainserisci la cannula orofaringea chiama per lrsquoAED

Valutare la circolazionecerca il polsocarotide(radiale)

in assenza di polsopreparati per CPRmettere il paziente in pianomeglio al suolo iniziare MCE

applicare lrsquoAED se crsquoegrave il polsovalutare la frequenza e la forza

Distress

bull Respiratoriobroncospasmoasma

bull ToracicodoloreanginaMI

bull Psicologicoagitazioneconvulsioni

bull Prevenire il distress

ndash Ambiente accoglientetranquillorilassato

ndash Minimizzare la paurail freddo

ndash Mantenere PA e FC e respirazione nei limiti

ndash Non interrompere la terapia

Valutare il paz e la situazionebull Controllare i segni vitali del pazientePAFCrespirazionecolorebull Non tentare di trasportare il paziente da solibull Chiama immediatamente il 118 se

ndash Arresto cardiacondash Arresto respiratoriondash incoscienzagt 1 minndash Stato confusionale prolungatondash Dolore toracico gt 5 min non alleviato dal venitrinndash Difficoltagrave respiratoriandash Convulsionindash Ipotensione grave o tachicardia()

bull Tratta il paziente in emergenza finchegrave non arriva il soccorsobull Tieni pronta la cartella e quanto fatto finora per la squadra di soccorsobull Compila la scheda delle emergenze in studio

What types of emergencies can be expected in the dental office

Ostruzione delle vie aeree

bull Segni e sintomindash Sensazione di soffocamentoimprovvisaafferrare la gola(segno universale)ndash Stridorendash Tosse violentandash Dispneaspasmindash Cianosi

bull Trattamentondash Tosse forzatandash Compressione addominalendash Percussione dorsale con paziente curvo in avanti ndash Ossigenazione ndash Ispezione delle prime vie aereendash laringoscopiopinza di Magillaspiratorendash Chiamare aiutondash Trasferimento in ospedale per broncoscopia in urgenza

How to Perform the Heimlich Maneuver You tubehttpyoutubekJDpr05zmB4

bull How to Perform the Heimlich Maneuver

bull Edited by Bob Robertson Rob S Nicole Willson Travis Derouin and 37 others

bull Googlewikihow

Airway obstruction management

Asmabroncospasmo

bull Segni e sintomindash Sensazione di soffocamentondash Sensazione di peso sul toracendash stridorendash Tossendash Dispneandash Cianosi

bull Trattamentondash Posizionare il pazsedutobraccia in avantindash Ossigenondash Spray con salbutamol 2 puffripeti dopo 5 min se inefficacendash Chiamare aiutondash Valutare i segni vitali e riferire al personale di emergenza

bull httpyoutubekff3co6xwik

bull httpyoutubeEK8nzKzdnIM

bull httpyoutubewlygTaY4ioc

Arresto cardiaco

bull Segni e sintomibull Non rispondebull Non respirabull Non ha polsobull Trattamento

ndash Mettere il paz supinotavola sotto il torace o stendere sul pavimento

ndash Chiamare aiutondash Attaccare AED e seguire le istruzionindash Iniziare CPRndash Ossigenare ventilazione con pallone e maschera

bull httpyoutubeI-eFjl2G9vg

Emerg Med J 2012 Nov29(11)890-3 Accuracy of a feedback device for cardiopulmonary resuscitation on a dental chair

Segal N Laurent F Maman L Plaisance P Augustin P

bull Source

bull Emergency Department Lariboisiegravere Hospital Paris 7 University (Paris Diderot) Paris France drnicolassegalgmailcom

bull Conflicting studies exist about the effectiveness of cardiopulmonary resuscitation (CPR) on a dental chair In some situations dental surgeons are obliged to perform CPR with the patient on the chair Feedback devices are supposed to guide the compression depth in order to improve the quality of CPR but some devices are based on an accelerometer that can theoretically report erroneous results because of the lack of rigidity of a dental chair

bull OBJECTIVE

bull The aim of this study was to evaluate the accuracy of these devices to guide chest compressions on a dental chair

Accuracy of a feedback device for cardiopulmonary resuscitation on a dental chair

bull METHODSbull A prospective randomised crossover equivalencenon-inferiority study was conducted to compare

the values of compression depths provided by the feedback device (Real CPR Help(reg) delivered by Zollcopy Medical Corporation Chelmsford MA USA) with the real measurements provided by the manikin (Resusci Anne(reg) Advanced SkillTrainer Laerdal Medical AScopy Norway) Chest-compression-only CPR was performed by 15 Basic Life Support instructors who carried out two rounds of continuous CPR for 2 min each Data were analysed with a correlation test a Bland-Altman method and a Wilcoxon test Statistical significance was defined as plt005

bull RESULTSbull A significant difference was found between the mean depths of compression measured by the

feedback device and the manikin on a dental chair and on the floor (plt00001) The feedback device overestimated the depth of chest compressions and Bland-Altman analysis demonstrated poor agreement

bull CONCLUSION

bull This study indicates that feedback devices with accelerometer technology are not sufficiently reliable to ensure adequate chest compression on dental chairs

Angina

bull Segni e sintomindash Dolore o sensazione di oppressione sottosternale irradiato

alle spalledorsoepigastriocollomandibolahellipndash sollievo con NTGsi spera ndash Ansiapalloresudorazionetachicardia

bull Trattamentondash Seduto ndash NTG sublinguale ogni 5 minNatispraysublinguale ndash Ossigenondash Chiamare aiutondash Valutare i segni vitali e riferire al personale di emergenza

Localizzazioni del dolore anginoso

Sharplocalized

radiating or notmay radiate to

teeth

You tube3 IUSB angina attack

bull httpyoutubeufyxHSSvcG8

bull Molto pertinente

bull httpyoutubejd-9DSDWSsI

bull Angina pectoris medical emergency

Infarto miocardico

bull Segni e sintomindash Dolore o sensazione di oppressione sottosternale irradiato alle

spalledorsoepigastriocollomandibolahellipndash Mancato sollievo con NTG ndash Dispneasincopediaforesimorte improvvisa

bull Trattamentondash Seduto ndash NTG sublinguale ogni 5 minndash Ossigenondash Aspirina 165-325 mgndash AnalgesicomorfinabuprenorfinaN2Ondash Chiamare aiutondash Posizionare AED ndash Valutare i segni vitali e riferire al personale di emergenza

ndash MONAMorfinaossigenonitroglicerinaaspirina

Fattori di rischio per cardiopatia ischemica

bull Etagravebull Sesso maschilema = gt 65 annibull Ipertensionebull DislipidemieColestTGHDL lowbull Diabetebull Fumobull Familiaritagravebull Malattie infiammatorie sistemiche collagenopatiebull Obesitagrave bull Metabolic syndrome This has been characterized by the presence of

hyperinsulinemia (fasting glucose level ge 100 mgdL) abdominal obesity (waist circumference gt40 in for men or gt35 in for women) decreased HDL cholesterol levels (lt 40 mgdL for men or lt 50 mgdL for women) hypertriglyceridemia (gt150 mgdL) and hypertension (ge 13085 mm Hg) Based on data from the 2000 US census an estimated 47 million Americans have the metabolic syndrome Patients with the metabolic syndrome have a 3-fold increased risk for coronary atherosclerosis and stroke compared with those without this syndrome

Fattori precipitanti lrsquoischemia

bull Sforzo fisico

bull Basse temperature

bull Digestione

bull Tachicardiafebbreipertiroidismo

bull Emozionistressndash Psichico(pauracontatto

ravvicinatooppressionecostrizioneinpossibilitagrave di muiversidi parlareodori sgradevolivista irritante o sgradevole

ndash dolore

bull Innalzamento vita media

bull Miglioramento condizioni socio-economiche ()

bull Procedure odontoiatriche sempre piugrave conservative

Maggiore frequenza di cardiopatici nella pratica odontoiatrica

Fattori stressantistressors

bull Malattiapersonale o di amici o famigliaribull Morte di un famigliare o di una persona amatabull Problemi di relazioni interpersonalibull Sovraccarico di lavorobull Inizio di un lavoro nuovobull disoccupazionebull pensionebull gravidanzabull affollamentobull traslocobull problemi della vita di tutti i giornirdquocopingrdquobull Problemi legalibull Problemi finanziaribull Perfezionismobull Eccecc

Quindinel paziente cardiopatico(ma anche negli altri)

Sedazione con BZD (short antagonizzabili)

bull Sedazione cosciente con N2O

bull empatia

bull Buona analgesia

Fin qui nov 10

bull httpyoutubeSuFvAbf_uJs

bull anginal and heart attack

Puntata ipertensiva

bull Segni e sintomindash Cefaleavertiginironziindash Disturbi della vistandash Cardiopalmo(tachicardia)ndash (dispnea)ndash Epistassi

bull Trattamentondash Nifedipina(nifedicor)5-15 gtt sublingualiOppndash Clonidina(catapresan) mezza1 fiala im o ev lentaOppndash Furosemide(Lasix) 1 2 fl im o ev lentandash Ossigenoterapia(occhialini)

Aritmie

bull Senza ECG

bull ipocineticheipercinetiche

Allergia

ndash Limitata ad un sistema o generalizzatandash Faringe e prime vie aereeedema angioneuroticondash Tratto respiratorioasmabroncospasmostridorendash Cuteorticariapruritondash Anafilassitutti i precedenti+collasso cardiocircolatoriondash DDangioedema ereditario

ndash Segni e sintomindash Pruritoarrossamentopomfiedema labbramucose boccafaringehellipndash Distress respiratorioasmandash Ipotensionepolso piccolofrequentepallore

bull Ossigenobull Chiamare aiutobull Valutare i segni vitali e riferire al personale di emergenza

anafilassi

bull Posizione supina

bull Ossigenazione

bull Adrenalina im 05mg

bull Liquidi evndash Antistaminico trimeton 10 mg im

ndash Cortisone

bull Chiamare aiuto

bull In caso di arrestoCPR

Cause di allergia

bull Materiali implantari e amalgama metallititanioporcellane e metalli nobili mercurio

bull Latexdighebull Acrilatibull Formaldeidebull Clorexidinabull AL e conservanti (metilparaben)

bull patch testing prick testing and blood tests for allergen-specific IgE

Sincope vasovagalesvenimentobull Segni e sintomi

ndash Svenimentondash Nausea ndash Debolezzandash Pallorendash Cute fredda e sudatandash Polso rallentatoma prima tachindash Ipotensionendash Discomfort addominalendash Midriasindash sbadiglio

bull Trattamentondash Posizione supinandash Elevare gli arti infndash Ossigenondash Monitorizzare ndash Atropina 05 mg im o iv

Fattori scatenanti psicogenipauraansiastress emotivocattive notiziedolorespecie se improvviso ed inaspettatovista del sanguestrumenti chirurgicisiringhe

Fattori scatenanti non psicogeniStazione erettaFame da salto del pasto o da dietaEsaurimentostanchezzaCattive condizioni fisicheAmbiente caldo-umidoAffollamentoSesso maschileGiovani16-35 anni

Pathophysiology

Stress

Catecholamines release

Decreased peripheral vascular resistance amp uarr blood flow to peripheral muscles

darr venous return

darr circulatory blood vol amp drop in arterial BP

Activation of Compensatory mechanisms

Reflex bradycardia develops (lt 50)

Significant drop in cardiac output associated with fall in BP below the critical level

Cerebral ischemia amp loss of consciousness

Assess consciousness (loss of response to sensory stimulation)

Activate office emergency system

P- Position patient supine with feet elevated slightly

ArarrBrarrC ndash Assess amp open airway (head tilt ampchin lift) assess airway patencyamp breathing assess circulation (palpation of carotid pulse)

D ndash Definitive care

Administer O2

Monitor vital signs

Perform additional procedures

Administer aromatic ammonia

Administer atropine if bradycardia persists

Do not panic

Post syncopal recovery- delayed recovery-

Postpone dental treatment Activate EMS

Determine precipitating factors

POSTURAL HYPOTENSION

Predisposing factors

bull Administration and ingestion of drugs eg antihypertensives like sodium depleting diuretics calcium channel blockers ampganglion blocking agents sedatives and narcotics histamine blockers levo dopa

bull Prolonged period of recumbency or convalescence

bull Inadequate postural reflex

bull Late stage pregnancy

bull Advanced age

bull Venous defects in legs (eg varicose veins)

bull Recovery from sympathectomy

bull Addissonrsquos disease

bull Physical exhaustion and starvation

bull Chronic postural hypotension (Shy ndash Drager syndrome)

Clinical manifestations

bull Precipitous drops in blood pressure and lose consciousness whenever they stand or sit upright

bull Do not exhibit any prodromal signs and symptoms

bull May become lightheaded or develop blurred vision

bull Clinical signs and symptoms - precipitating drugs

bull Blood pressure during syncopal period is quite low

bull Un like vasodepressor syncope heart rate during postural hypotension remain at the baseline level or somewhat higher

bull Consciousness returns rapidly once the patient is returned to the supine position

PathophysiologyWhen patient moves into an upright position

SBP drops and approaches 60 mm Hg in one minute

DBP also drops

Slight changes in heart rate and not at all

Cerebral blood flow drops below the critical level

May lose consciousness

Once the patient is placed into supine position reestablishment of

cerebral blood flow occurs




Administer O2

Monitor vital signs

Patient recovers consciousness-

slowly reposition chair delayed recovery -activate EMS

Continue BLS as needed and discharge patient

iperventilazione

bull Segni e sintomindash Dispnea

ndash Respirazione rapida

ndash Svenimento

ndash Parestesia delle estremitagrave

ndash Palpitazioni

bull Trattamentondash Calmare

ndash Incoraggiare respirazione lenta

ndash Rebreathing( rirespirazione in un sacchetto di carta)

Epilessia(convulsioni)

bull Segni e sintomindash Incoscienza improvvisandash Apnea transitoriandash Cianosi(nella fase tonica)ndash Movimenti involontari degli artindash Assenza

bull Trattamentondash Assumere decubito lateralendash Proteggere dai dannilasciare spaziospostare dai pericoli ndash Monitoraggio dei segni vitalindash Ossigenondash Midazolam 5 mg im o ivndash Buccolam 10 mg ndash MADper via nasale

httpyoutube7sJMaSOoH88


ipoglicemia

bull Segni e sintomibull Senso di fame

ndash Parola strascicataincoerentendash Comportamento alteratondash Polso rapidondash Apprensioneansiairrequietezzaaggressivitagravendash Disorientamentoperdita di coscienzandash Tremorindash sudorazione

bull Trattamentondash Succo di fruttacaramellazuccherino posndash Se egrave avvenuta perdita di coscienzaglucosio evndash Nel dubbio tra iper e ipoglicemiameglio somministrare glucosio comunque

ndash destrostick

Riconoscere lrsquoictus

bull Sorridio mostra i denti

bull Alza entrambe le braccia e tienile alzate

bull Dicci una frase semplice

ndashAlterazioni improvvise

cefalea

Perdita vistaImprovvisa confusione

ROSIER scale (Recognition of Stroke In the Emergency Room)

bull Appendix G ROSIER scalebull Recognition of Stroke in the Emergency Room (ROSIER)18bull Assessment Date ___________________ Time ___________________bull Symptom onset Date ___________________ Time ___________________bull GCS E=___ M=___ V=___ BP= ____ ____ BG= __________ bull If BG lt 35 mmolL treat urgently and reassess once blood glucose normal

bull Has there been loss of consciousness or syncope Y (-1) N (0) bull Has there been seizure activity Y (-1) N (0) bull Is there a NEW ACUTE onset (or on awakening from sleep)bull I Asymmetric facial weakness Y (+1) N (0) bull II Asymmetric arm weakness Y (+1) N (0) bull III Asymmetric leg weakness Y (+1) N (0) bull IV Speech disturbance Y (+1) N (0) bull V Visual field defect Y (+1) N (0)

bull Total Score ________ (-2 to +5)bull Provisional diagnosisbull Stroke Non-stroke (specify) __________________________bull Note Stroke is unlikely but not completely excluded if total scores are le0bull ROSIER (95 CI) CPSS (95 CI) FAST (95 CI) LAPSS (95 CI)bull Sensitivity 93 (89-97) 85 (80-90) 82 (76-88) 59 (52-66)bull Specificity 83 (77-89) 79 (73-85) 83 (77-89) 85 (80-90)bull Positive Predictive Value 90 (85-95) 88 (83-93) 89 (84-94) 87 (82-92)bull Negative Predictive Value 88 (83-93) 75 (68-82) 73 (66-80) 55 (48-62)

Perdita di coscienza e convulsioniStroke Unit

Interferenza con un pacemaker cardiaco

bull pacing activity of both pacemakers and the dual-chamber ICD was inhibited by

bull 1)a battery-operated composite curing light at between2 and 10 cm from the leads

bull 2)The use of an ultrasonic scaler(ablatore) interferedwith the pacing activity of the dual-chamber pacemaker between 17 and 23 cm from the leads the single-chamber pacemaker at 15 cm from the leads and both ICDs at 7 cm from the leads

bull 3) ultrasonic cleaning system bull Roedig JJ Shah J Elayi CS Miller CS Interference of cardiac pacemaker and

implantable cardioverter-defibrillator activity during electronic dentaldevices use J Am Dent Assoc 2010141521-6

bull It has been estimated that one or two life threatening emergencies will occur in the lifetime practice of a general dentist

bull Obtaining a health history and a set of vital signs is the first step in identifying the patient likely to develop a medical emergency With proper training thorough preparation and regular practice the staff of the dental office will be able to provide appropriate medical care should the need arise

Summary

FONTI DI INFORMAZIONE ED AGGIORNAMENTO

ADA courses

bull DT DENTAL OFFICE EMERGENCIESbull You will receive 2 unit(s) of continuing education credit

upon successful completion of this course The registration fee is only $7600

bull DESCRIPTIONbull This course discusses how the dental office team can

prepare itself to handle medical emergenciesbull AUTHORbull American Dental Association Continuing Education

and the Council on Dental Practice and Product Development and Sales

LEARNING OBJECTIVES

bull Upon completion of this course participants should be able to do the followingndash Describe why itrsquos important to have a dental office emergency planndash Identify what types of emergency training are important for dental

office staffndash Identify ways in which dental office staff can prepare for medical

emergenciesndash Identify the steps involved in taking a good health historyndash Identify some ways to help alleviate patient anxietyndash Identify some of the symptoms that may indicate an impending

emergencyndash Identify some components in a dental office emergency kitndash Discuss the importance of recordkeeping in the event of a dental

office emergencyndash Describe some of the legal aspects of dental office emergencies

ADA

bull Medical Emergencies in Dentistry Preventionand Preparation

bull Pamela Sparks Stein DMDbull Dr Stein is on the faculty full-time at the

University of Kentucky College of Medicine and College of Dentistry in both the Dept of Anatomyand Neurobiology and the Dept of RestorativeDentistry She authored the award-winningldquoDental Emergency Protocol Manualrdquo and In-Office Emergency Protocol Software Program Contact her at pamsteinukyedu

FINE

Farmaci essenziali

bull Ossigenobombola da 5 ltcome minimo200 atmcon va e vieni mascherina facciale occhialini nasalindash 3 maschere facciali adultipiccolamedia grande

Adrenalinafiale da 1 mg FASTJECT 2 mlsiringapreriempitainiett(77 pound)330 microgr o 165 microgrVideo prodotto dallAllergopharma che illustra come usare ladrenalina auto iniettabile (Fastjekt) in caso di shock anafilattico

bull Nitroglicerinacp sublinguali 03-04 mgCarvasin 5 mg Natispraybull Antistaminicoclorfeniramina(trimeton) fiale 10

mgPrometazina(farganesse 50 mg)bull Albuterolosalbutamolo(Ventolin)bull Aspirinacp 160-325 mg

Farmaci essenziali farmaco indicazioni Dose iniziale(adulti)

ossigeno sempre Inalazione 100 Bombolmaschereambu

adrenalina anafilassi 01 mg ev05 mg im Fialepenna

Asma che non risponde al salbutamolo

01 mg ev02mdash05 mg im

Arresto cardiaco 1 mg ev

Fastjekt anafilassi Siringa preriempita 330 0pp 165 microgr im

Nitroglicerina(Trinitrina 03carvasin 5 mg)

Dolore anginoso 03-04 mgsublinguale Cpfiale

Natispraysublinguale)

ClorfeniraminaTrimeton)

Reazallergica 10 mg evim fiale

Altri farmaci per emergenza

farmaco indicazione Dose iniziale adulto

atropina Bradicardia significativaattacco vaso vagale

05 mg evim

efedrina Ipotensione significativa 5-10 mg iv10-25 mg im

idrocortisone Insuffsurrenalica 100-200 mg iv o im

anafilassi 100-200 mg iv o im

Morfina oprotossido drsquoazoto(N2O)

Buprenorfina

Dolore anginoso che non risponde all NTG

2 mg ev3-5 mg imInalazione al 30-35 con O2015-03 mg subling o im o ev

Lorazepam(Tavor) Crisi epilettica attacchi di panico

4 mg im o ev lentaCp per os 1 mg

Midazolam Crisi epilettica 5 mg im o ev

ranitidina Anafilassiallergia 50 mg ev o 150 mg pos

Ondansetron(zofran) Nauseavomito 4 mgiv o im

Maschera con reservoir

bull httpyoutubenEbsKfLl1n4

bull Acquisti materiale consumabiledoctorshopdoctorpoint

autorizzazione acquisto FU-3doc

SIAD Ozzano Emilia via Libertagrave 17 wwwsiadcom

bull ALLEGATO 3 ndash DICHIARAZIONE SOSTITUTIVA DI CERTIFICAZIONE (ai sensi dellrsquoart 46 del DPR 28122000 n 445)bull

bull

bull Illa sottoscrittoahelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipbull

bull

bull Responsabile dellrsquoEnte di SoccorsoStudio Medicohelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipbull

bull

bull con sede inhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipbull

bull

bull Partita IVACFhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipbull

bull

bull

bull Consapevole delle sanzioni penali nel caso di dichiarazioni non veritiere di formazione o uso di atti falsi richiamate dallrsquoart 76 del DPR n 4452000bull

bull

bull DICHIARAbull

bull di essere soggetto autorizzato al rifornimento allrsquoingrosso di gas medicinali e di impiegare gli stessi sotto la propria sola responsabilitagravebull

bull

bull

bull

bull In fedebull

bull helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipbull

bull Luogo Data helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipbull

bull buongiornobull non possiamo vendere medicinali a studi medici che non abbiano

sottoscritto lrsquoallegato che Le inoltrobull

bull Riesce ad inoltrare ai due medici il modulo facendomelo poi avere via e-mail o via fax allo 051 796026

bull Grazie millebull

bull Massimiliano Lucchinabull Servizio Venditabull

bull SIAD SpA | I-40064 Ozzano dellEmilia (BO) - Via della Libertagrave 17bull Tel +39 051 799399 | Fax +39 051 796026bull massimiliano_lucchinasiadeu | wwwsiadcom

Bombola di ossigeno

bull 5 litri200 atm=1000 litri

bull Se usate 6 ltmin ce nrsquoegrave per 166 min

bull Guardate la pressionequando egrave per es a 80 atmsignifica che ci sono ancora 400 lt

bull A 20-30 atm egrave meglio sostituire con una altra piena

La valigetta degli orrori set di rianimazione completo di bombola ricaricabile di ossigeno da 05 LT in acciaio riduttore con manometro ed erogatore pallone rianimatore maschera rianimazione 2 cannule di Guedel pinza tiralingua apribocca elicoidale tubo atossico in contenitore plastico antiurto

Shocking News about Florida Dentists Dentists and Dental Hygienists May Lack Proper Training

Keith W Murray

bull FLORIDA - CHAPTER 64B5-17 DENTAL PRACTICE AND PRINCIPLES 64B5-17015 Office Safety Requirement As part of the minimum standard of care every dental office location shall be required to have an automatic external defibrillator by February 28 2006 Any dentist practicing after February 28 2006 without an automatic external defibrillator on site shall be considered to be practicing below the minimum standard of care Specific Authority 466004(4) 466017(3)(c) FS Law Implemented 466017(4) 466028(1)(x) FS HistoryndashNew 5-31-04

August 18 2009

Girdler NMWilkson KEBooth EJA prospective study of complications and outcomes associated with conscious sedation for

the anxious dental patientJ Disabil Oral health 2005624-30

bull Vedere poca roba 2 gruppi uno sedato col mida z vs uno sedato conN2O

bull

bull

Essere preparati per le emergenze

bull Storia clinica del pazienteanamnesi con aggiornamento ad ogni visita

bull Identificazione del paziente a ldquorischiordquo presenza dellrsquoanestesista o spostamento in altra sedecasa di curadaysurgHosp

bull Quando si conferma un appuntamento ricordare ai paz di prendere le loro medicine

Essere preparati




ad ogni postazione































PREOP ASSESSMENT











Contraindications



ndash Hypotension


ndash OSA




ndash Short neck






ndash Receding chin

ndash Large tongue


Pregnancy
















apnea

OSA screening






















gasate)

2 ore
















FIRMA



CM 1312009

DottClaudio Melloni


Via Fossolo 28

40138 Bologna

tel051390048



professionaleGrazie










Ha tosse SI NO

















SI NO





SI NO



SI NO Fuma SI NO


SI NO




Raccolta dati

cM 1195


COGNOME E NOME



INTERVENTO

ANESTESISTACHIRURGO





Premedicazioneora


mantenimento


Via

venosa


AG


5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

160

165

170

175

180


altri stopanalgesia







Via Murri 164

Bologna



il


















DATA


























































































Segni vitali


Inserire fot Omron

IMG_6728JPG


(CMS5000)




ndash Cute pallida

ndash Sudorazione









bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

Essere preparati




ad ogni postazione































PREOP ASSESSMENT











Contraindications



ndash Hypotension


ndash OSA




ndash Short neck






ndash Receding chin

ndash Large tongue


Pregnancy
















apnea

OSA screening






















gasate)

2 ore
















FIRMA



CM 1312009

DottClaudio Melloni


Via Fossolo 28

40138 Bologna

tel051390048



professionaleGrazie










Ha tosse SI NO

















SI NO





SI NO



SI NO Fuma SI NO


SI NO




Raccolta dati

cM 1195


COGNOME E NOME



INTERVENTO

ANESTESISTACHIRURGO





Premedicazioneora


mantenimento


Via

venosa


AG


5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

160

165

170

175

180


altri stopanalgesia







Via Murri 164

Bologna



il


















DATA


























































































Segni vitali


Inserire fot Omron

IMG_6728JPG


(CMS5000)




ndash Cute pallida

ndash Sudorazione









bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull



























PREOP ASSESSMENT











Contraindications



ndash Hypotension


ndash OSA




ndash Short neck






ndash Receding chin

ndash Large tongue


Pregnancy
















apnea

OSA screening






















gasate)

2 ore
















FIRMA



CM 1312009

DottClaudio Melloni


Via Fossolo 28

40138 Bologna

tel051390048



professionaleGrazie










Ha tosse SI NO

















SI NO





SI NO



SI NO Fuma SI NO


SI NO




Raccolta dati

cM 1195


COGNOME E NOME



INTERVENTO

ANESTESISTACHIRURGO





Premedicazioneora


mantenimento


Via

venosa


AG


5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

160

165

170

175

180


altri stopanalgesia







Via Murri 164

Bologna



il


















DATA


























































































Segni vitali


Inserire fot Omron

IMG_6728JPG


(CMS5000)




ndash Cute pallida

ndash Sudorazione









bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull











Contraindications



ndash Hypotension


ndash OSA




ndash Short neck






ndash Receding chin

ndash Large tongue


Pregnancy
















apnea

OSA screening






















gasate)

2 ore
















FIRMA



CM 1312009

DottClaudio Melloni


Via Fossolo 28

40138 Bologna

tel051390048



professionaleGrazie










Ha tosse SI NO

















SI NO





SI NO



SI NO Fuma SI NO


SI NO




Raccolta dati

cM 1195


COGNOME E NOME



INTERVENTO

ANESTESISTACHIRURGO





Premedicazioneora


mantenimento


Via

venosa


AG


5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

160

165

170

175

180


altri stopanalgesia







Via Murri 164

Bologna



il


















DATA


























































































Segni vitali


Inserire fot Omron

IMG_6728JPG


(CMS5000)




ndash Cute pallida

ndash Sudorazione









bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull




ndash Short neck






ndash Receding chin

ndash Large tongue


Pregnancy
















apnea

OSA screening






















gasate)

2 ore
















FIRMA



CM 1312009

DottClaudio Melloni


Via Fossolo 28

40138 Bologna

tel051390048



professionaleGrazie










Ha tosse SI NO

















SI NO





SI NO



SI NO Fuma SI NO


SI NO




Raccolta dati

cM 1195


COGNOME E NOME



INTERVENTO

ANESTESISTACHIRURGO





Premedicazioneora


mantenimento


Via

venosa


AG


5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

160

165

170

175

180


altri stopanalgesia







Via Murri 164

Bologna



il


















DATA


























































































Segni vitali


Inserire fot Omron

IMG_6728JPG


(CMS5000)




ndash Cute pallida

ndash Sudorazione









bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull




ndash Receding chin

ndash Large tongue


Pregnancy
















apnea

OSA screening






















gasate)

2 ore
















FIRMA



CM 1312009

DottClaudio Melloni


Via Fossolo 28

40138 Bologna

tel051390048



professionaleGrazie










Ha tosse SI NO

















SI NO





SI NO



SI NO Fuma SI NO


SI NO




Raccolta dati

cM 1195


COGNOME E NOME



INTERVENTO

ANESTESISTACHIRURGO





Premedicazioneora


mantenimento


Via

venosa


AG


5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

160

165

170

175

180


altri stopanalgesia







Via Murri 164

Bologna



il


















DATA


























































































Segni vitali


Inserire fot Omron

IMG_6728JPG


(CMS5000)




ndash Cute pallida

ndash Sudorazione









bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

Pregnancy
















apnea

OSA screening






















gasate)

2 ore
















FIRMA



CM 1312009

DottClaudio Melloni


Via Fossolo 28

40138 Bologna

tel051390048



professionaleGrazie










Ha tosse SI NO

















SI NO





SI NO



SI NO Fuma SI NO


SI NO




Raccolta dati

cM 1195


COGNOME E NOME



INTERVENTO

ANESTESISTACHIRURGO





Premedicazioneora


mantenimento


Via

venosa


AG


5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

160

165

170

175

180


altri stopanalgesia







Via Murri 164

Bologna



il


















DATA


























































































Segni vitali


Inserire fot Omron

IMG_6728JPG


(CMS5000)




ndash Cute pallida

ndash Sudorazione









bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull















apnea

OSA screening






















gasate)

2 ore
















FIRMA



CM 1312009

DottClaudio Melloni


Via Fossolo 28

40138 Bologna

tel051390048



professionaleGrazie










Ha tosse SI NO

















SI NO





SI NO



SI NO Fuma SI NO


SI NO




Raccolta dati

cM 1195


COGNOME E NOME



INTERVENTO

ANESTESISTACHIRURGO





Premedicazioneora


mantenimento


Via

venosa


AG


5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

160

165

170

175

180


altri stopanalgesia







Via Murri 164

Bologna



il


















DATA


























































































Segni vitali


Inserire fot Omron

IMG_6728JPG


(CMS5000)




ndash Cute pallida

ndash Sudorazione









bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

OSA screening






















gasate)

2 ore
















FIRMA



CM 1312009

DottClaudio Melloni


Via Fossolo 28

40138 Bologna

tel051390048



professionaleGrazie










Ha tosse SI NO

















SI NO





SI NO



SI NO Fuma SI NO


SI NO




Raccolta dati

cM 1195


COGNOME E NOME



INTERVENTO

ANESTESISTACHIRURGO





Premedicazioneora


mantenimento


Via

venosa


AG


5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

160

165

170

175

180


altri stopanalgesia







Via Murri 164

Bologna



il


















DATA


























































































Segni vitali


Inserire fot Omron

IMG_6728JPG


(CMS5000)




ndash Cute pallida

ndash Sudorazione









bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull






















gasate)

2 ore
















FIRMA



CM 1312009

DottClaudio Melloni


Via Fossolo 28

40138 Bologna

tel051390048



professionaleGrazie










Ha tosse SI NO

















SI NO





SI NO



SI NO Fuma SI NO


SI NO




Raccolta dati

cM 1195


COGNOME E NOME



INTERVENTO

ANESTESISTACHIRURGO





Premedicazioneora


mantenimento


Via

venosa


AG


5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

160

165

170

175

180


altri stopanalgesia







Via Murri 164

Bologna



il


















DATA


























































































Segni vitali


Inserire fot Omron

IMG_6728JPG


(CMS5000)




ndash Cute pallida

ndash Sudorazione









bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull


CM 1312009

DottClaudio Melloni


Via Fossolo 28

40138 Bologna

tel051390048



professionaleGrazie










Ha tosse SI NO

















SI NO





SI NO



SI NO Fuma SI NO


SI NO




Raccolta dati

cM 1195


COGNOME E NOME



INTERVENTO

ANESTESISTACHIRURGO





Premedicazioneora


mantenimento


Via

venosa


AG


5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

160

165

170

175

180


altri stopanalgesia







Via Murri 164

Bologna



il


















DATA


























































































Segni vitali


Inserire fot Omron

IMG_6728JPG


(CMS5000)




ndash Cute pallida

ndash Sudorazione









bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

Raccolta dati

cM 1195


COGNOME E NOME



INTERVENTO

ANESTESISTACHIRURGO





Premedicazioneora


mantenimento


Via

venosa


AG


5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

160

165

170

175

180


altri stopanalgesia







Via Murri 164

Bologna



il


















DATA


























































































Segni vitali


Inserire fot Omron

IMG_6728JPG


(CMS5000)




ndash Cute pallida

ndash Sudorazione









bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull


Via Murri 164

Bologna



il


















DATA


























































































Segni vitali


Inserire fot Omron

IMG_6728JPG


(CMS5000)




ndash Cute pallida

ndash Sudorazione









bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull























































































Segni vitali


Inserire fot Omron

IMG_6728JPG


(CMS5000)




ndash Cute pallida

ndash Sudorazione









bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

Inserire fot Omron

IMG_6728JPG


(CMS5000)




ndash Cute pallida

ndash Sudorazione









bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull


(CMS5000)




ndash Cute pallida

ndash Sudorazione









bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull




ndash Cute pallida

ndash Sudorazione









bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull





bull Chiamare aiuto




Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

Algoritmo di base


bull A airway

bull B breathing

bull Ccirculation




vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull



vigile

soporoso

coma


stimolo doloroso


apertura occhi

risposta motoria








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull








Distress



















bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull











bull Googlewikihow


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull


Asmabroncospasmo






Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull




Arresto cardiaco







bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull




bull Source



bull OBJECTIVE







bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull






bull CONCLUSION


Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

Angina





Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull


Sharplocalized


teeth






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull






Infarto miocardico









bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull





bull Sforzo fisico


bull Digestione




ndash dolore










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull










bull empatia


Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

Fin qui nov 10



Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

Puntata ipertensiva



Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

Aritmie

bull Senza ECG


Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

Allergia




anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

anafilassi


bull Ossigenazione



ndash Cortisone

bull Chiamare aiuto


Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

Cause di allergia









Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull






Pathophysiology

Stress



darr venous return











Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull






Administer O2

Monitor vital signs




Do not panic










bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull







bull Advanced age
















DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull











DBP also drops









Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull




Administer O2

Monitor vital signs




iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

iperventilazione



ndash Svenimento


ndash Palpitazioni









ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull






ipoglicemia




ndash destrostick






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull






cefalea















Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull














Summary


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull


ADA courses






LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

LEARNING OBJECTIVES






ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

ADA




FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

FINE

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull

Farmaci essenziali




















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull
















05 mg evim





Buprenorfina














bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull







bull


bull


bull


bull


bull

bull


bull

bull DICHIARAbull


bull

bull

bull

bull In fedebull









Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull







Bombola di ossigeno







Keith W Murray


August 18 2009




bull

bull



Keith W Murray


August 18 2009




bull

bull




bull

bull

Emerg in odonto clinica first

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Transcript of Emerg in odonto clinica first