Term
| ALBUTEROL GENERIC NAME/TRADE NAME |
|
Definition
GENERIC: Albuterol
TRADE: Airet, Proventil, Repetabs,Respirol, Ventolin, Volmax, Combivent (with Ipratroprium) |
|
|
Term
| ALBUTEROL CHEMICAL/THERAPEUTIC CLASS |
|
Definition
Sympathomimetic amine; Beta 2 adrenergic agonist.
Antiasthmatic, bronchodilator |
|
|
Term
|
Definition
| Selective Beta 2 adrenergic agonist with minimal number of side effects. Prompt bronchodilation, duration of +/- 5 hours. |
|
|
Term
| ALBUTEROL PHARMACOKINETICS |
|
Definition
Onset 5-15 minutes.
Peak 1 - 1 1/2 hours.
Duration 4-6 hours.
T 1/2 = 2 1/2 - 4 hours |
|
|
Term
|
Definition
1. Bronchial asthma.
2. Reversible bronchospasm associated with chronic bronchitis and emphysema.
3. Anaphylactic respiratory distress. |
|
|
Term
| ALBUTEROL CONTRAINDICATIONS |
|
Definition
1. Hypertension - SBP > 180
2. Tachycardia - HR > 140 adult; >180 peds
3. Severe cardiac disease (chest pain that could be MI
4. Hypersensitivity |
|
|
Term
|
Definition
1. Hyperthyroidism
2. Diabetes mellitus
3. Convulsive disorders |
|
|
Term
|
Definition
CNS - dizziness, headache stimulation, tremors
CV - chest pain, dysrhythmias, hypertension, palpitations, tachycardia
GI - nausea, vomiting |
|
|
Term
|
Definition
Small volume nebulizer with O2 6-10lpm.
Adult - 2.5mg 3.0mL in 0.083% solution by mouthpiece or face mask Q10 min x 4 max
Peds - same by mask or blow-by |
|
|
Term
|
Definition
| Unit dose vials containing 2.5ml in 3mL |
|
|
Term
|
Definition
1. Possibility of side effects increases with other sympathetic agonists.
2. Beta blockers may blunt the effect of albuterol
3. Albuterol also comes in metered-dose inhalers delivering 90mcg per inhalation
4. Overdose can cause bronchial constriction and possibly death. |
|
|
Term
| ASPIRIN GENERIC/TRADE NAME |
|
Definition
Aspirin
Bayer, Bufferin, Ecotrin |
|
|
Term
| ASPIRIN CHEMICAL/THERAPEUTIC CLASS |
|
Definition
Salicylate deriviative
Antiplatelet agent |
|
|
Term
|
Definition
| Aspirin blocks the formation of the substance thromoboxane Alpha2, which causes platelets to aggregate and ateries to constrict. Reduces mortality associated with MI. Reduces rate on nonfatal reinfarction and nonfatal stroke. |
|
|
Term
|
Definition
| Chest pain suggestive of acute MI. |
|
|
Term
| ASPIRIN CONTRAINDICATIONS |
|
Definition
1. Hypersensitivity to aspirin, NSAIDS and tartrazine (FDC yellow dye #5)
2. Bleeding disorders including GI hemorrhage and hemophilia
3. Hemorrhagic states. |
|
|
Term
| ASPIRIN PRECAUTIONS/PREGNANCY CATEGORY |
|
Definition
Children or teenagers with flu-like symptoms, which may be associated with development of Reye's Syndrome.
Pregnancy category C. |
|
|
Term
|
Definition
GI - GI bleeding heartburn, nausea
HEME - prolonged bleeding time |
|
|
Term
|
Definition
When administered together, aspirin and anti-inflammatory agents may cause increased incidence of side effects and increased blood levels of both drugs.
Administration with antacids may reduce drug level from decreased absorption. |
|
|
Term
| ASPIRIN ADMINISTRATION/SUPPLY/NOTES |
|
Definition
Give four 81mg chewable tablets (324mg total dose) PO asap after onset of chest pain.
81mg low dose chewable tablets
Must complete CSEMS local protocols to be authorized to administer |
|
|
Term
| DEXTROSE GENERIC/TRADE NAME |
|
Definition
Dextrose.
Glucose, Glutose, Insta-Glucose |
|
|
Term
| DEXTROSE CHEMICAL/THERAPEUTIC CLASS |
|
Definition
Carbohydrate.
Nutrient, caloric. |
|
|
Term
|
Definition
| Supplies supplemental glucose in cases of hypoglycemia and restores blood sugar to normal (70-110mg/dL) |
|
|
Term
|
Definition
1. ALOC of unknown etiology (GCS 2. Hypoglycemia (<60mg/dL) by glucometer or clinical judgment
3. Status epilecticus
4. Oral hypoglycemic agent overdose
5. Neonatal resuscitation not responsive to ventilation and chest compressions. |
|
|
Term
| DEXTROSE CONTRAINDICATIONS |
|
Definition
| None for a patient with suspected hypoglycemia. |
|
|
Term
|
Definition
1. Use with caution in pts with increased intracranial pressure because may worsen cerebral edema
2. Localize venous irritaion may occur in smaller veins
3. Infiltration may cause tissue necrosis
4. Dextrose is only administered IV/IO |
|
|
Term
|
Definition
| Tissue necrosis and phlebitis at the injection site. |
|
|
Term
|
Definition
Pt > 2 YO - Dextrose 50% 1g/kg up to 25g IV. Repeat once in 2 min if ALOC persists
Pt < 2 YO - Dextrose 25% 1g/kg up to 25g IV. Repeat once in 2 min if ALOC persists.
Neonate <28 days old - Dextrose 12.5% 1g/kg IV (8mL/kg) |
|
|
Term
|
Definition
| Prefilled syringe containing 25 grams in 50mL (50% solution) |
|
|
Term
|
Definition
| 1. Establish free flowing IV of normal saline in large vein. Aspirate blood before and during administration of dextrose to ensure patency. |
|
|
Term
|
Definition
| Prefilled syringe containing 25 grams in 50mL (50% solution) |
|
|
Term
|
Definition
| Hypoglycemic states require immediate intervention. Prolonged can result in brain damage. |
|
|
Term
|
Definition
| To make Dextrose 25%, dispel 25mL of solution from the pre-filled syringe and draw 25mL of normal saline back into the syringe. Dextrose 25% will contain 12.5g in 50ml. |
|
|
Term
| DIPHENHYDRAMINE GENERIC/TRADE |
|
Definition
|
|
Term
| DIPHENHYDRAMINE CHEMICAL/THERAPEUTIC CLASS |
|
Definition
Ethanolamine derivative
Antihistamine, antianaphylactic agent |
|
|
Term
|
Definition
| Antihistamin with anticholinergic and sedative side effects. Decreases the allergic response by blocking histamine and H1 receptor sites. |
|
|
Term
| DIPHENHYDRAMINE PHARMACOKINETICS |
|
Definition
PO Peak 2 - 4 hours
T1/2 2 - 8 hours
IV = NA |
|
|
Term
| DIPHENHYDRAMINE INDICATIONS |
|
Definition
1. Anaphylaxis, as adjunct to epinephrine
2. Severe vomiting & motion sickness
3. Treat extrapyramidal reactions caused by phenothiazines
4. Adjunct to haloperidol for combative patients secondary to acute psychotic episodes or alcohol intoxication |
|
|
Term
| DIPHENHYDRAMINE CONTRAINDICATIONS |
|
Definition
1. Bronchial asthma
2. Nursing mothers
3. Children < 10kg.
4. Glaucoma
5. Hypersensitivity to drug or other antihistamines |
|
|
Term
| DIPHENHYDRAMINE PRECAUTIONS/PREGNANCY CLASS |
|
Definition
Use with caution in patients with a history of hyperthyroidism, cardiovascular disease and hypertension.
Pregnancy class B. |
|
|
Term
| DIPHENHYDRAMINE SIDE EFFECTS |
|
Definition
CNS: dizziness, drowsiness, sedation, sleeplessness
CV: headache, palpitations
GI: dryness of mouth, nose and throat
RESP: thickening of bronchial secretions, wheezing |
|
|
Term
| DIPHENHYDRAMINE INTERACTIONS |
|
Definition
1. Has additive effects with alcohol and other CNS depressants
2. MAO inhibitors prolong and intensify anticholinergic (drying) effects of antihistamines. |
|
|
Term
| DIPHENHYDRAMINE ADMINISTRATION/SUPPLY |
|
Definition
Adult - give 1mg/kg up to 50mg IM or slow IV push (25mg/min)
Pediatric - give 1mg/kg up to 50mg IM or slow IV push (25 mg/min)
Vial containing 50mg in 1ml. |
|
|
Term
|
Definition
| The IV route is preferred for the patient in severe shock. If an IV cannot be readily established give via IM route, deep into large muscle mass. |
|
|
Term
|
Definition
| The IV route is preferred for the patient in severe shock. If an IV cannot be readily established give via IM route, deep into large muscle mass. |
|
|
Term
| EPINEPHRINE 1:1000 GENERIC/TRADE NAMES |
|
Definition
Epinephrine 1:1000
Adrenalin |
|
|
Term
| EPINEPHRINE 1:1000 CHEMICAL/THERAPEUTIC CLASS |
|
Definition
Catecholamine
Bronchodilator, vasopressor |
|
|
Term
| EPINEPHRINE 1:1000 ACTIONS 1 |
|
Definition
| Naturally occurring catacholamine. Acts directly on alpha and beta andrenergic receptors. It's effect is more profound on beta than alpha receptors. Effects on B1 andrenergic receptors include a positive chronotropic (increased HR) and positive inotropic (contractile force) effect. |
|
|
Term
| EPINEPHRINE 1:1000 ACTIONS 2 |
|
Definition
| The effects of epinephrine on the alpha andrenergic receptor sites include increased systemic vascular resistance. The effects on B and A receptors causes an increased BP. Also causes bronchodilation due to effects on B2 adrenergic receptors. |
|
|
Term
| EPINEPHRINE 1:1000 PHARMACOKINETICS |
|
Definition
|
|
Term
| EPINEPHRINE 1:1000 INDICATIONS |
|
Definition
1. Anaphylaxis
2. Bronchial asthma
3. Respiratory distress due to epiglottitis or croup. |
|
|
Term
| EPINEPHRINE 1:1000 CONTRAINDICATIONS |
|
Definition
Epinephrine should be avoided in the following pts unless signs and symptoms are severe:
1. Hypertension SBP> 180
2. Tachycardia HR >140 adult, 180 child
3. Cardiovascular disease
4. Elderly age >55
5. Angle closure glaucoma |
|
|
Term
| EPINEPHRINE 1:1000 PRECAUTIONS/PREGNANCY CATEGORY |
|
Definition
Precautions:
1. Hyperthyroidism
2. Diabetes mellitus |
|
|
Term
| EPINEPHRINE 1:1000 SIDE EFFECTS |
|
Definition
CNS - anxiety, dizziness, restlessness, tremulousness, headache
CV - anginal pain, dysrhythmias, hypertension, palpitations
GI - nausea, vomiting
SKIN - pallor |
|
|
Term
| EPINEPHRINE 1:1000 INTERACTIONS |
|
Definition
| Cyclic antidepressants and antihistamines may potentiate the effects of epinephrine. |
|
|
Term
| EPINEPHRINE 1:1000 ADMINISTRATION |
|
Definition
Adult - give 0.3mg IM. Repeat in ten minutes if needed
Peds - give 0.01mg/kg up to 0.3mg IM. Repeat in ten minutes PRN. |
|
|
Term
| EPINEPHRINE 1:1000 SUPPLY/NOTES |
|
Definition
Ampule containing 1mg in 1ml.
The IM route is preferred for the patient in severe shock. |
|
|
Term
| GLUCAGON GENERIC/TRADE NAMES |
|
Definition
|
|
Term
| GLUCAGON CHEMICAL/THERAPEUTIC CLASS |
|
Definition
Polypeptide hormone
Antihypoglycemic |
|
|
Term
|
Definition
| Protein secreted by alpha cells of the pancreas. When released, it causes the breakdown of glycogen stored in the liver to glucose. Inhibits synthesis of glycogen from glucose. Both cause in increase in circulating blood glucose. |
|
|
Term
|
Definition
| A return to consciousness following the administration of glucagon take 5-20 minutes. Only effective if there are sufficient stores of glycogen in the liver. |
|
|
Term
| GLUCAGON PHARMACOKINETICS |
|
Definition
Onset withing 15 minutes.
T1/2 = 3 to 6 minutes. |
|
|
Term
|
Definition
When unable to obtain IV access and give dextrose AND:
1. ALOC of unknown etiology (GCS 2. Hypoglycemia based on glucometer or clinical judgment.
3. Status epilepticus
4. Oral hypoglycemic agent overdose. |
|
|
Term
| GLUCAGON PRECAUTTIONS/PREGNANCY CATEGORY |
|
Definition
Glucagon in only effective if there are sufficient stores of glycogen in the liver. IV dextrose is the agent of choice.
Pregnancy category C |
|
|
Term
|
Definition
CNS - dizziness, headache
CV - hypotension
GI - nausea, vomiting |
|
|
Term
|
Definition
Adult - 1mg IM
Pediatric - 1mg IM |
|
|
Term
|
Definition
| Must be reconstituted before administration. Supplied in rubber stoppered vials containing 1mg powder and 1ml of diluting solution. |
|
|
Term
|
Definition
| Must complete local protocols class to use. May be given to reverse effects of beta blocker overdoses, usually 3 to 10 mg IV bolus followed by a 2 - 5 mg/h infusion. |
|
|
Term
| IPRATROPIUM GENTERIC/TRADE NAMES |
|
Definition
|
|
Term
| IPRATROPIUM CHEMICAL/THERAPEUTIC CLASS |
|
Definition
Quarternary ammonium compound.
Bronchodilator |
|
|
Term
|
Definition
| Anticholinergic bronchodilator related to atropine. Inhibits action of acetylcholine at receptor sites on bronchial smooth muscle, thus inhibiting parasympathetic stimulation and causing bronchodilation. Antisecretory properties locally. |
|
|
Term
| IPRATROPIUM PHARMACOKINETICS |
|
Definition
Onset 5 to 15 minutes.
Peak 1 to 2 hours.
Duration 3 to 6 hours. |
|
|
Term
|
Definition
1. Bronnchoconstriction in COPD, including chronic bronchitis and emphysema as an adjunct to albuterol.
2. Bronchial asthma as an adjunct to albuterol. |
|
|
Term
| IPRATROPIUM CONTRAINDICATIONS |
|
Definition
| Hypersensitivity to the drug, or to atropine and its derivatives. |
|
|
Term
| IPRATROPIUM PRECAUTIONS/PREGNANCY CATEGORY |
|
Definition
Use with caution in patients with narrow-angle glaucoma, prostatic hypertrophy or bladder-neck obstruction.
Pregnancy category B |
|
|
Term
|
Definition
CNS - anxiety, dizziness, headache, nervousness
CV - palpitations GI - nausea, vomiting
EENT - blurred vision, dry mouth
RESP - bronchospasm, cough |
|
|
Term
| IPRATROOPIUM ADMINISTRATION |
|
Definition
| Using small volume nebulizer, O2 6-10L/min. Adults and children 500mcg in 2.5mL mouthpiece, face mask or blow by. Do not repeat. |
|
|
Term
|
Definition
Unit dose vials containing 500mcg in 2.5ml.
Give only one dose with the initial albuterol treatment. Do not use as stand alone drug. Not used for anaphylactic respiratory distress. |
|
|
Term
| NALOXONE GENERIC/TRADE NAME |
|
Definition
|
|
Term
| NALOXONE CHEMICAL/THERAPEUTIC CLASS |
|
Definition
Thebaine derivative
Antidote, opiate |
|
|
Term
|
Definition
| Chemically similar to opiates, but only antagonistic properties. Competes for opiate receptors in the brain. Displaces narcotic molecules from opiate receptors. Reverses respiratory depression from narcotic overdose. |
|
|
Term
| NALOXONE PHARMACOKINETICS |
|
Definition
IV - Onset 2 minutes
T1/2 4 minutes |
|
|
Term
| NALOXONE INDICATIONS/CONTRAINDICATIONS |
|
Definition
1. Respiratory depression caused by narcotics.
2. Coma unknown etiology.
Contra - hypersensitivity. |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Administer cautiously to pts who are know or suspected to be physically dependent on narcotics. Abrupt reversal can cause withdrawal-type effects. This includes newborns of dependent mothers. |
|
|
Term
| NALOXONE PREGNANCY CATEGORY |
|
Definition
|
|
Term
|
Definition
CNS - seizures, tremulousness, withdrawal symptoms.
CV - hypertension, hypotension, tachycardia, ventricular dsyrhythmia
GI - nausea, vomiting |
|
|
Term
| NALOXONE ADMINISTRATION - ADULT/SUPPLY |
|
Definition
Adult - 2mg IV at 0.4mg/min (5 in to push)
IM - give two 0.8mg injections (1.6mg) in different muscles.
If no response, contact medical control.
Vial containing 4mg in 10mL. |
|
|
Term
|
Definition
Pediatric - IV - five 0.1mg/kg up to 2mg IV at 0.4mg/min
IM - give 0.1mg/kg up to 1.6mg IM.
If no response, call medical control. |
|
|
Term
|
Definition
| 1. Unless necessary, avoid insertion of advanced airway prior to administration of naloxone. 2. Administer by slow IV push (0.4mg/min.) 3. Reversal effects may be temporary, titrate to respiratory rate. 4. Common narcotics include codeine, Darvon, Demerol, Dilaudid, fentanyl, heroin, morphine, Nubain, paregoric, Percodan, Stadol, Talwin. |
|
|
Term
| NITROGLYCERIN GENERIC/TRADE NAMES |
|
Definition
Nitroglycerin.
Nitrolingual, Nitroquick Nitrostat, Nitr-bid, Nitrol |
|
|
Term
| NITROGLYCERIN CHEMICAL/THERAPEUTIC CLASS |
|
Definition
Nitrate, organic.
Antianginal, vasodilator |
|
|
Term
|
Definition
| Rapid smooth muscle relaxant that causes vasodilation and to a lesser degree dilates the coronary arteries. This results in increased coronary blood flow and improved perfusion of the ischemic myocardium. |
|
|
Term
|
Definition
| Vasodilation decreases preload and leads to decreased cardiac work, helping to reverse the effects of angina pectoris. |
|
|
Term
|
Definition
| Decreased preload results in decreased pulmonary capillary hydrostatic pressure and reduction of fluid passing into the pulmonary interstitium and alveoli cardiogenic pulmonary edema. |
|
|
Term
| NITROGLYCERIN PHARMACOKINETICS |
|
Definition
SL - Onset 1 to 3 minutes. Peak 5 minutes. Duratin at least 25 min. T1/2 2-3 min.
TOP - Onset 15 to 60 min. Peak 30 to 120 min. Duration 2 to 12 hours. |
|
|
Term
| NITROGLYCERIN CONTRAINDICATIONS |
|
Definition
| 1. Hypotension SBP < 100. 2. Bradycardia HR < 60. 3. Increased intracranial pressure (CVA, head injury). 4. Hypersensitivity. 5. Patient on Viagara or other anti-impotence agent. |
|
|
Term
| NITROGLYCERIN PRECAUTIONS 1 |
|
Definition
| 1. Administer with extreme caution if at all to pts. with suspects inferior wall MI with possible right ventricular involvement because these patients require adequate RV preload. |
|
|
Term
| NITROGLYCERIN PRECAUTIONS 2 AND 3 |
|
Definition
Pts taking routinely may develop tolerance and require an increased dose.
Postural syncope sometimes occurs following administration and should be anticipated. Keep pt. supine. |
|
|
Term
| NITROGLYCERIN PRECAUTIONS 4 AND PREGNANCY CATEGORY |
|
Definition
Careful clinical or hemodynamic monitoring must be used because of the possibility of hypotension and tachycardia.
Pregnancy category C. |
|
|
Term
| NITROGLYCERIN SIDE EFFECTS |
|
Definition
CNS: dizziness, headache, weakness
CV: dysrhythmias, palpitations, postural hypotension, tachycardia
GI: nausea, vomiting
SKIN: diaphoresis, flushing, pallor, rash |
|
|
Term
| NITROGLYCERIN INTERACTIONS 1 AND 2 |
|
Definition
1. Severe hypotension is possible in pts who have recently ingested alcohol.
2. Orthostatic hypotension is possible when used in conjunction with beta andrenergic antagonists. |
|
|
Term
| NITROGLYCERIN INTERACTIONS 3 |
|
Definition
| Administration contraindicated in pts who are using anti-impotence agents such as sildenafil since they have been known to hypotensive effects of organic nitrates. |
|
|
Term
| NITROGLYCERIN ADMINISTRATION |
|
Definition
| An IV or INT must be established prior to administering unless the patient has taken before without complications. |
|
|
Term
| NITROGLYCERIN SUBLINGUAL ADMINISTRATION |
|
Definition
Chest pain - give 0.4mg SL. Repeat q 5 min up to 3 doses. Pulmonary edema (SBP>180) give 2 tablets 0.4mg SL. Repeat 2 tablets q 3 min PRN. Pulmonary edema (SBP 100-180) five 1 tablets 0.4mg SL. Repeat 1 tablet q 5 min PRN.
Pediatric - not indicated. |
|
|
Term
|
Definition
1. Alternate the SL site when repeating dose.
2. May produce burning or tinging sensation when administered SL. This is not a reliable method to determine potency. |
|
|
Term
| NITROGLYCERIN TOPICAL DOSE |
|
Definition
| Chest pain - if pain persists after SL, apply 1 inch of paste. Pulmonary edema SBP > 180, apply 2 inches of paste. Pulmonary edema SBP 100-180 apply 1 inch of paste. Pediatric not indicated. |
|
|
Term
| NITROGLYCERIN TOPICAL NOTES |
|
Definition
1. Apply paste to chest or upper arm.
2. Do not rub into skin.
3. If contraindications develop when paste is applied, remove the paste.
4. Wear gloves for application and removal of paste. |
|
|
Term
| NITROGLYCERIN SUPPLY AND NOTES |
|
Definition
Tablet: Bottle containing 0.4mg (1/150 grain) tablets
Paste: Packets containing 1 gr (1 inch) or tubes containing 30 to 60 grams.
Keep in original container, tightly capped. |
|
|
Term
| ONDANSETRON GENERIC AND TRADE NAMES |
|
Definition
|
|
Term
| ONDANSETRON CHEMICAL AND THERAPEUTIC CLASS |
|
Definition
Carbazole derivative
Antiemetic |
|
|
Term
|
Definition
| Selective 5-HT3 antagonist which is an effective anti-nausea and anti-emetic with minimal side effects. Nausea and vomiting are strongly associated with serotonin receptors of the 5-HT3 type. Present peripherally on vagal nerve terminus and centrally in the chemoreceptor trigger zone of the area postrema. |
|
|
Term
| ONDANSETRON PHARMACOKINETICS/INDICATIONS |
|
Definition
IV: peak immediate. IM: n/a
1. Severe vomiting or nausea
2. Vertigo |
|
|
Term
| ONDANSETRON CONTRAINDICATIONS/PRECAUTIONS/PREGNANCY CATEGORY |
|
Definition
| Contra: hypersensitivity. Pre: rarely, transient ECG changes including QT interval prolongation. Pregnancy cat B. |
|
|
Term
| NITROGLYCERIN SIDE EFFECTS |
|
Definition
CNS: headache, lightheadedness, seizures
CV: angina, bradycardia, syncope, tachycardia. EENT: blurred vision. GI; constipation, diarrhea. RESP: bronchospasm. SKIN: rash |
|
|
Term
| NITROGLYCERIN ADMINISTRATION/SUPPLY |
|
Definition
IV: give 0.1 mg/kg up to 4.0 over 2 to 5 min. May repeat once in 5 min if needed.
IM: give 0.1 mg/kg up to 4 mg IM. Do not repeat.
Vial containing 4mg in 2mL. |
|
|
Term
|
Definition
| Dextrose, Glutose, Insta-Glucose |
|
|
Term
|
Definition
| Used to treat pts. with history of diabetess with ALOC and ability to swallow. Can reverse hypoglycemic condition. Time makes a critical difference. Comes in a tube of gel. |
|
|
Term
| ORAL GLUCOSE INDICATIONS/CONTRAINDICATIONS |
|
Definition
Pt. with ALOC ad known history of diabetes controlled with medication.
1. Unresponsive.
2. Unable to swallow. |
|
|
Term
| ORAL GLUCOSE SIDE EFFECTS AND SUPPLY |
|
Definition
None when given properly. May be aspirated without a gag reflex.
Tube contains 15 grams. |
|
|
Term
|
Definition
1. Assure signs and symptoms of AL with known history.
2. Assure pt. is conscious and can swallow and protect airway.
3. Administer between cheek and gum. Place on tongue depressor between cheek and gum. |
|
|
