Adverse Drug Reactions Flashcards
Drug dosages should be decreased for:
ages under 6 and over 65
If you have lean body weight, you can tolerate ____ dosages of drugs before overdose due to _____. If you are adipose/obese, you can tolerate _____ dosages of drugs before overdose due to _____.
larger
greater blood volume
smaller
lower blood volume
Patients with CHF show blood levels ___ those of healthy patients at the same dosage. Why?
twice
- decreased blood volume
- diminished hepatic blood flow
If you have a pulmonary disease with CO2 retention, what happens?
Inc. CO2 causes respiratory acidosis, and respiratory acidosis lowers seizure levels for LAs.
Effects of atypical pseuodocholinesterase metabolism:
- decreased metabolism of ester anesthetics and succinylocholine
- leads to overdose, prolonged actions
If your patient is stressed, their convulsive threshold is_____.
lowered
An apprehensive patient would perceive ____ as ____, so the dentist would give additional anesthesia leading to a potential ______.
perceive pressure as
pain
overdose
If a LA has a higher level of protein binding, they will have ____absorption into blood leading to ____ activity and ____safety. An example of a LA with these characteristics is _____.
slower absorption
prolonged activity
increased safety
bupivicaine
The greater the degree of vasodilation, the more _______ the absorption.
more rapid
What determines dosage blood level?
mg of drug given, not concentration of the drug.
The larger the dose, the _______ ___ ____ of blood level of the drug.
the larger the dose, the higher the peak
A LA should be injected _______ because a _____ intravascular injection will lead to _______ levels and _____ effects.
should be injected slowly
because a rapid injection will lead to
high blood levels with overdose effects
The ______ the vascularity of an injection site, the more _____ the drug is absorbed into circulation. The mouth is highly vascular which is why we use ______.
greater
rapid
vasoconstrictors
If your liver has decreased function, which LA should you limit?
amides
Give me three options for topicals:
- 5% lidocaine
- dentipatch
- benzocaine- poorly absorbed with lower H2O solubility
If you inject intravascularly, you will see:
- rapid onset of signs/symptoms
- unconsciousness and seizures within minutes
If you overdose an injection, you will see signs and symptoms appear within ______ for LAs without vasoconstrictors, and within _______ for LAs with vasoconstrictors.
5-10 minutes LAs w/out vasoconstrictors and
30 minutes LAs w/ vasoconstrictors
A mild overdose signs and symptoms may not occur for 90 minutes.
Signs of minimal to moderate blood levels:
- Apprehension or excitedness (polar opposites, ok)
- Talkativeness, slurred speech, stutter
- Confusion
- Muscle twitching, tremor
- nystagmus (eye twitching)
- Increase HR, BP, respiratory rate
Symptoms of minimal to moderate blood levels:
- Headache, lightheaded, dizzy
- blurred vision, ringing in ears, numb tongue
- flushed or chilled; drowsy
Three signs/symptoms of moderate to high blood levels:
- Generalized tonic-clonic seizure
- CNS depression after convulsions
- Decreased HR, BP, respiratory rate
An overdose of ______ or ______ may appear initially as _______ and _______ before unconsciousness or seizure activity.
overdose of lidocaine or mepivicaine may appear initially as drowsiness and nystagmus
_____ depression occurs before _____ depression
CNS depression occurs before CVS depression
Your patient has a mild overdose. What four diagnostic cues tell you they have a mild overdose? What steps do you take to manage it?
- talkative
- increased anxiety
- facial muscle twitching
- increased BP, HR, respiratory rate
P: comfortable position and reassure patient (LOL I did this to you.)
CAB: not a concern
D: administer oxygen, monitor vitals
Administer anticonvulsant IV midazolam or diazepam
Activate EMS
If a patient has rapid onset, what is their discharge procedure?
Recovery as needed, but can continue with treatment. Patient can leave unescorted, but evaluate by physician if there are questions.
If a patient has delayed onset, what is their discharge procedure?
Recovery as needed, but patient needs to be escorted to hospital for physician evaluation.
Your patient has a severe overdose with a RAPID onset. What diagnostic cues can tell you they have a severe overdose?
- Symptoms appear during injection or seconds after completion.
- Generalized tonic-clonic seizures
- Loss of consciousness
What are the steps of management for a patient with severe overdose with rapid onset?
P: supine
ACTIVATE EMS with any seizure with LA injection. If unconsciousness continues after supine position, it’s not vasodepressor syncope, med assistance needed.
CAB: as indicated
D:
-administer oxygen- airway maintenance and assisted ventilation are necessary to prevent hypercarbia and hypoxia which lead to lower threshold level.
-protect patient and monitor vitals
-IV anticonvulsant
During postictal periods for a patient with severe overdose with rapid onset, how do you mange the patient?
- close monitoring of vitals, strict attention to CABs
2. Discharge with medical personnel
What are the symptoms and steps of management for a patient with severe overdose with slow onset?
- Overdose progresses from mild to tonic-clonic seizures over a relatively brief period of time (5 mins)
- Same management as severe with rapid onset
(P: supine
Activate EMS
CAB: as indicated
D: O2, protect patient, monitor vitals, give anticonvulsant)
A patient taking __________ cannot eliminate epinephrine at the normal rate and are more susceptible to epinephrine overdose. Patients on __________ may also result in an epi overdose.
MAO inhibitors
noncardioselective B blockers
Two signs of an epinephrine overdose:
Elevated BP and HR
Symptoms of epinephrine overdose:
- fear, anxiety
- restless, dizzy, headache, tremor, weakness
- perspiration, respiratory difficulty, palpitations
What four complications can incur from epinephrine overdose?
- increased BP could produce CVA
- Cardiac dysrhythmias
- Anginal pain
- MI
How do you manage an Epinephrine overdose?
P: comfortable position but AVOID supine CAB D: -Reassure patient -Monitor vitals -Activate EMS (markedly elevated BP) -O2 -Administer vasodilator if BP doesn't return to baseline -if patient's symptoms persist, take to hospital
Name four diagnostic cues of a sedative hypnotic overdose:
- Decreased consciousness
- Respiratory depression
- Slurred speech
- Loss of motor coordination
Management of sedative hypnotic overdose:
P: supine
CAB: Make sure adequate oxygenation
-assisted ventilation if necessary: Adult 1br/5sec or child 1br/3sec
D: Activate EMS
-Oxygen
-Vitals
-BLS until cerebral blood level of drug decreases
-Start IV line after opening airway
-Give antagonist (Flumazenil: reversal agenet for benzodiazepines
Diagnostic cues of an opioid overdose:
- Altered loss of consciousness
- Respiratory depression
- Miosis
Management of sedative opioids or narcotics overdose:
P: supine CAB: Make sure adequate oxygenation D: Activate EMS -O2 -Vitals -IV after opening airway -Give antagonist (Naloxone IV or IM): .1mg per minute IV until respiratory rate increases or .4mg IM
What is chief manifestation of aspirin allergy?
bronchospasm
Patients with a history of these three things have a greater risk for anaphylactic reactions with aspirin:
nasal polyps
pansinusitis
asthma
What two components of a local anesthetic cartridge could a patient have an allergy to?
methylparaben and sodium bisulfite
If a patient has an allergy to local anesthetics, what are two viable options?
- general anesthesia
- histamine blocker like benadryl with 1:100,000 epi (pulpal anesthesia up to 30 mins, burns on injection, tissue swelling and soreness)
If a patient has an ester allergy, it is safe to use_____.
amides
If a patient has a paraben allergy, there is ______ when using dental cartridges.
no concern
If a patient has a sulfite allergy, use local anesthetics __________.
without a vasoconstrictor
If a patient has an amide (what UNMC uses) allergy, the patient should ___________.
go under with general anesthesia.
Type I, II, III allergic reactions are _______ onset within _______. The more _______ the signs and symptoms the more _____ the ultimate reactions.
- immediate onset
- within minutes to hours
- the more rapid the more intense the reaction
Type IV allergic reactions are _____ onset within ____ with a ______ intense reaction.
- delayed
- hours to days
- less
A person is considered to be in anaphylactic shock if they are ______ and ________.
hypotensive and unconscious
__________ anaphylaxis involved reactions in one organ system.
Localized
Three common types of sensitization reactions:
Urticaria
Erythema
Angioedema
Two types of urticaria and descriptions:
pruritis (itching)
wheals ( smooth, slightly elevated)
Three types of localized swelling involved in angioedema:
periorbital
perioral
intraoral
Common signs and symptoms of respiratory reactions (identical to non allergic asthma)
Respiratory distress Dyspnea Wheezing Flushing Perspiration Tachycardia Anxiety Accessory muscles of respiration
When is generalized anaphylaxis most likely to occur and when do most fatalities occur after generalized anaphylaxis?
- occur after parenteral administration
- fatalities occur within first 30 mins
Look over top of page 13 for common system progressions
–
How to manage delayed skin reaction (appear after 60 mins):
P: comfortable
CAB: not a problem
D: if localization reaction, use oral histamine blocker
-chlorpheniramine: Adult: 4 mg Child: 2 mg
-diphenhydramine: A: 50 mg C: 25 mg
3 to 4 doses for three days
Do not discharge until symptoms go away
Diagnostic clues of delayed onset skin reaction:
Hives, itching
Edema
Flushed skin
Diagnostic clues of rapid onset skin reaction:
Hives, itching
Edema
Flushed skin
Conjunctivitis and rhinitis (these two diff. it from delayed onset)
How to manage rapid onset skin reaction:
P: comfortable
CAB: not a problem
D: in absence of CV and respiratory involvement, administer a histamine blocker IM or IV with oral prescription for 3 days
Activate EMS
How to manage rapid onset skin reaction in presence of CV and respiratory involvement:
P: supine with feet elevated if hypotensive
CAB: not a problem
D: administer oxygen
-start IV
-administer epinephrine: 1ml of 1:10,000 IV slowly over 3 minutes repeated if necessary over next 15 to 30 minutes up to a total of 5 ml (.3ml of 1:1,000 IM or SC in adult up to 3 doses, .15mg for child)
Activate EMS
When would you likely see a bronchospasm?
Asthmatic patient allergic to bisulfites and aspirin allergies
Steps in managing bronchospasm:
P: comfortable, usually upright
CAB
D: Calm patient
-EMS
-Administer bronchodilator (EPI or albuterol)
-Administer epi IM or IV repeat every 3 mins
-Discharge with EMS
Diagnostic cues in laryngeal edema:
respiratory distress, exaggerated chest movements, high pitched crowing or no sound, cyanosis, loss of consciousness
Steps in managing laryngeal edema:
P: comfortable or supine if loss of consciousness
CAB: head tilt, chin lift
D: EMS
-EPI IM or IV repeat every 3 to 5 minutes
-maintain airway
-if resolution with epi, administer histamine blocker and corticosteroid to help provent recurrence
- if loss of airway, CRICK ‘EM.
Management of generalized anaphylaxis:
P: Supine with legs elevated
CAB
D: EMS
-EPI (.3mg intralingual or sublingual, repeat within 5 minutes if no improvement)
-O2
-Monitor vitals
-If initial resolution, administer histamine blocker and corticosteroid
