Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

ABPD 2021 > Behavior Guidance > Flashcards

Behavior Guidance Flashcards

1
Q

Pediatric treatment triangle

A

Child
Parent/caregiver
Dentist

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Piaget’s Stages of Cognitive Development

A

Sensorimotor
Preoperational
Concrete Operations
Formal Operations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Sensorimotor stage

A 
0-2 years
Experience is through movement and senses
Object permanentce
Causality
Symbolic play
Perception, recognition of information, categorize, memory
Fear of strangers
Separation anxiety
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Preoperational stage

A 
2-7 years
Children use language and are egocentric
Classification of objects
Reading and writing
Longer attention spans 
Self-control develops 3-6
Develop a conscience
Aggression 
Parallel play to cooperative play 
Gender identity 
Toxic stress
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Concrete Operations

A 
7-11 years
Children think logically but not abstractly 
Literacy
Mental representations of action
Accepting societal norms of behavior
Delayed gratification
Self-directed activities
Body image
Peer relationships
Social acceptance
Positive attitude about school
Meaningful friendships
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Formal Operations

A 
11+ years
Children can think abstractly
Concerned with opinion of others
Information analysis
Rebel, complainer, accuser
Idealism
Introspective and analytic
Egocentric
Opinionated
Argumentative 
Loving relationship 
Sexuality
Popularity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Erikson’s Stages of Psychosocial Development

A

Based on Freud’s psychosexual stages
Psychosocial crisis: failure to move from a stage

Basic trust
Autonomy
Initiative
Industry
Personal Identity
Intimacy
Generativity 
Ego Integrity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Basic rust

A

0-18 months
Bonding between parent and child
Failure = mistrust

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Autonomy

A

18 months - 3 years
Development of individual identity
Failure to develop = shame

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Initiative

A

3-6 years
Increasing autonomy
Curiosity and questioning
Failure = guilt

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Industry

A 
7-11 years
Academic and social skills
Competition, cooperation
Peer influence
Failure = inferiority
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Personal identitiy

A

12-17 years
Feeling of belonging
Failure = role confusion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Intimacy

A

Young adult

Failure = isolation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Common characteristics of 2 year olds

A 
Gross motor skills
Very attached to parents
Plays alone
Rarely shares
Limited vocabulary
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Common characteristics of 3 year olds

A

Less egocentric
Likes to please
Active imagination
Closely attached to parent

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Common characteristics of 4 year olds

A

Tries to impose power
Small social groups
Expansive period - reaches out from parent
Many independent self-help skills

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Common characteristics of 5 year olds

A

Deliberate
Takes pride in possessions
Relinquishes comfort objects
Plays cooperatively with peers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

CDC 6 month old

A

Social/Emotional: familiar faces, plays with others, responds to other’s emotions

Language: responds to sounds, babbles, responds to name

Cognitive: looks at things nearby, brings things to mouth, curious

Movement: rolls in both directions, sit without support, supports weight on legs/bounces

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

CDC 12 months old

A

Social/Emotional: shy with strangers, favorite things/people, shows fear, repeats sounds, plays games

Language: responds to simple requests, gestures, mama/dada

Cognitive: explores, finds hidden things, copies gestures, uses cups, pokes, follows simple directions

Movement: sits up without help, pulls to stand, cruises (walks with furniture), steps, stands

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

CDC 24 months old

A

Social/Emotional: copies others, gets excited, more independent, more defiant

Language: points to things/pictures when named, knows body parts, sentences 2-4 words

Cognitive: finds things when hidden, sorts shapes and colors, simple make-believe games, builds towers of blocks, follows 2-step instructions

Movement: kicks a ball, stands on tiptoe, begins to run, throws ball, copies straight lines and circles

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

CDC 36 months

A

Social/Emotional: copies adults, shows affection, takes turns in games, separates from parents, dresses and undresses self

Language: follows instructions with 2 or 3 steps, can name most familiar things, says first name and age, names a friend, 2-3 sentences

Cognitive: works with toys with buttons, make-believe with dolls, puzzles with 3-4 pieces, copies circle, screws and unscrew lids

Movement: climbs well, runs easily, tricycle, up and down stairs one foot on each step

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

CDC 48 months

A

Social/Emotional: enjoys doing new things, more creative, plays with other children, interested

Language: knows basic rules of grammar, sings song or poem from memory, tells stories

Cognitive: names colors and numbers, understands idea of counting, understands time, draws a person with 2-4 body parts, uses scissors

Movement: hops and stands on one foot, catches ball, pours, cuts with supervision, mashes own food

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

CDC 60 months

A

Social/emotional: wants to please friends, more likely to agree with rules, aware of gender, more independent

Language: speaks clearly, tells simple stories, uses future tense, says name and address

Cognitive: counts 10 or more things, draws person with 6 or more body parts, prints numbers and letters, copies triangle and other shapes

Movement: sands on one foot for 10s or longer, hops or skips, can do somersault, uses fork/spoon, uses toilet on own, swings and climbs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Frankl Scale

A

1: definitely negative, refusal of treatment
2: negative, reluctant, timid, uncooperative
3: positive, accepts treatment but may be cautious
4: laughs, treatment with ease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Variables influencing child behavior

A 
Parental stress/anxiety 
Toxic Stress 
Medical experiences 
Awareness of dental problem
General behavioral problems 
Dental fear 
Temperament
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Types of Temperament

A

Easy: quick adaptability to chance, tendency to approach new situations, positive mood

Difficult temperament: withdrawal tendencies to new, slow adaptability to change, frequent negative emotional expressions of high intensity

Slow to warm up temperament: withdrawal tendencies to new, slow adaptability to change, frequent negative emotional reactions of low intensity (shy)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Personality traits and poor behavior correlation

A

Negative correlation of child behavior and anger, irritability, fear, reaction, shyness

Impulsivity and negative emotionality associated with behavior problems

Children with behavior problems less likely to have balanced temperament

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Parenting Styles (Baumrind’s Typology)

A

Authoritative: high rule, high warmth

Authoritarian: high rule, low warmth

Permissive/Indulgent: low rule, high warmth

Uninvolved: low rule, low warmth (neglect)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Behavior shaping

A 
State goal or task
Explain necessity
Divide explanation for procedure
Give explanation at child's understanding
Use successive approximation
Reinforce appropriate behavior
Disregard minor inappropriate behavior
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Operant conditioning

A

Response to past behaviors influence future behaviors

Pleasant stimulus introduced + positive reinforcement or reward = probability of response increases

Unpleasant stimulus withdrawn, negative reinforcement or escape = probability of response increases

Unpleasant stimulus introduced, punishment = probability of response decreases

Pleasant stimulus withdrawn, omission or time out = probability of response decreases

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Types of Basic Behavior Guidance Techniques

A 
Positive pre-visit imagery
Direct observation/modeling
Tell-Show-Do
Ask-tell-ask
Voice control
Positive reinforcement
Distraction
Nonverbal
Memory reconstruction
Parental absence/presence
Nitrous oxide
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Types of Advanced Behavior Guidance Techniques

A

Protective stabilization
Sedation
GA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Positive pre-visit imagery

A

Provide children and parents with positive visual imagery about what to expect during dental appointment prior to visit

Indications: all patients

Evidence: good

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Direct observation/modeling

A

Patient observes another patient exhibiting cooperative behavior during treatment

Indications: all patients

Evidence: fair

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Tell-Show-Do

A

Verbal explanation, show, doing procedure

Indications: all patients except hearing impaired

Evidence: weak

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Ask-tell-ask

A

Ask question to assess patient’s feelings, tell information, ask patient understanding

Indications: any patient or parent except upset patient/parent

Evidence: weak

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Voice control

A

Alteration of voice in tone, volume and pace to influence behavior - goal is gaining attention

Indications: any patient except hearing impaired

Evidence: weak

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Positive reinforcement

A

Giving appropriate social feedback to reward desired behaviors

Indications: any patient

Evidence: fair

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Distraction

A

Diverting patient attention from what may be perceived as unpleasant

Indications: any patient

Evidence: excellent

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Nonverbal

A

Reinforcement and guidance through appropriate contact, posture, facial expressio, body language

Indications: any patient

Evidence: fair

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Memory reconstruction

A

Behavior approach to reframe or reshape memories associated with negative experience by suggesting information after event has taken place

Indications: any patient

Evidence: fair

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Parental absence/presence

A

Utilizing presence or absence of parent to gain child’s cooperation

Indication: any patient who has potential to be cooperative
Contraindication: parent unable or unwilling to extent effective support, patient unable to understand

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Protective stabilization

A

Restriction of a patient’s freedom of movement with or without patients’ permission, to decrease risk of injury while allowing treatment

Active: involves another person
Passive: involves device

Contraindicated in patients that are cooperative, patients who cannot be safely immobilized physically or psychologically, or for practitioner convenience

Evidence: weak

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Alternative Communicative Techniques

A

Escape: brief breaks from treatment

Hyponosis

Guided imagery

Humor

Deferred care/active surveillance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Unconstructive behavior guidance techniques

A

Rhetorical questions

Coercing (threats)

Coaxing (begging)

Non-specific praise)

Lengthy explanations

Reassurance (everything is ok)

Punishment, humiliating, belittling

Denying, ignoring

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Parent preference for behavior guidance techniques

A

Parents prefer to be present in dental operatories
Parental acceptance of pharmacological behavior management has increased
Voice control and protective stabilization not as positively perceived

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

How does local anesthetic work?

A

Blocks sodium channels reversibly

  • prevents depolorization by limiting sodium ions into the cell
  • prevents conduction of action potentials

LA must be fat soluble to enter the nerve (non-ionized)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Order of resistance to conduction block

A 
Pain
Cold
Warm
Touch
Deep Pressure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Composition of local anesthetic

A 
Lipophilic (benzene) ring
Intermediate chain (amide or ester)
Hydrophilic terminus (amino)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

What makes articaine different from other amides?

A

Articaine contains a thiopene ring with an ester group

Not considered an ester local anesthetic but the ester group is on the aromatic ring

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

What buffers the acidic form of local anesthetic so it may enter the nerve?

A

Sodium bicarbonate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

What happens when pH = pKa for local anesthetic?

A

50% of local anesthetic is uncharged, 50% is charged

This leads to more rapid blocking of sodium channels

Lower pKa means that more non-ionized molecules are avilable so the local anesthetic is more effective

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

In a dental cartridge, lidocaine has a pH of 6 and 1% is non-ionized. How does it penetrate the nerve?

A

In tissue solution, pH rises to 7.4 as it is buffered by bicarbonate in blood and 24% is in non-ionized form

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

What decreases local anesthetic effectiveness?

A

Acidic environment, as it shifts to ionized molecules

Injecting too much local anesthetic in a small area can be less effective because large volumes of acidic solution are more difficult to buffer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Buffered local anesthetic

A

In areas where teeth have pulp inflammation, buffered local anesthetic is more likely to achieve successful anesthesia

Buffered LA allows more of the LA to be non-ionized without having to rely on tissues

May allow a few seconds of earlier onset

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

pKas of common LAs

A 
Mepivacaine: 7.7
Articaine: 7.8
Lidocaine 7.8
Prilocaine 7.8
Bupivacaine 8.1
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

IA nerve block technique

A

Palpate deepest part of coronoid notch
Insert needle between pterygomandibular raphe and deep tendon of temporalis
Should be above the lingula

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Mandibular foramen in pediatric patient versus adult patient

A

Below the plane of occlusion
More anterior than adults
Distance from lingula to anterior border is fairly stable with growth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Gow-Gates block

A

Highest block for CNV3
Accesses the nerve before it branches
Done with patient’s mouth open, starting from opposite side of the mouth and aiming for tragus of ear

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Akinosi block

A

Used in patients that cannot open their mouth

Syringe is placed along mucogingival junction of maxillary arch

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

Needle Gage

A 
Larger = less likely to break
Larger = easier to aspirate through
Larger = less likely to deflect
Larger = easier to administer fluid too quickly

No difference in needle gauge and injection pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

Causes of injection pain

A 
Mechanical trauma from needle penetration
Distension of tissue from cartridge contents (administering too fast)
Anesthetic properties (pH, temperature, etc.)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

What determines anesthesia?

A 
LA proximity to nerve
Degree of ionization
Concentration of solution
Volume injected
Time
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

Ester LAs

A 
Novocaine
Tetracaine
Benzocaine
Cocaine
Procaine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

How are esters metabolized?

A

Hydrolyzed in plasma by pseudocholinesterase

PABA is major metabolite, responsible for most allergic reactions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

Amide LAs

A

Lidocaine
Mepivacaine
Bupivacaine
Articane

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

How are amides metabolized?

A

Metabolized by liver in cytochrome p450 system

Articaine is 90% metabolised in plasma, 10% in liver

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

Topical anesthetics

A

20% benzocaine most common

Large doses cause methehmoglobinemia in young children

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

Methemoglobin

A

Alters molecular shape of hemoglobin so it binds water instead of oxygen
Leads to tissue hypoxia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

Treatment for methehmoglobinemia

A

Methylene blue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

Lidocaine

A

Gold standard
pKa = 7.8
2% (20mg/mL)
Duration of pulp anesthesia is 45min, soft tissue 2-3 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
72
Q

Prilocaine

A

4% plain or 3% with epi
pKa = 7.8
Most associated with methemoglobinemia from ortho-toluidine metabolite

Do NOT use in pregnant women (can cause methemoglobinemia in child)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
73
Q

Implications of glucose 6 phosphate dehydrogenase deficiency on local anesthetic use

A

Deficiency in enzyme can result in hemolytic attack (jaundice, cyanosis, headache, fatigue, hemoglobinuria)

Greater tendency to develop methemoglobinemia and methylene blue is not as effective

Best to use mepivacaine for these patients

Side note: these patients cannot eat fava beans, also need to avoid antimalarial drugs and sulfonamide antibiotics

74
Q

Mepivacaine

A

3% plain or 2% with 1:20k levonordefrin

pka = 7.7

75
Q

Articaine

A

4% with 1:100 epi
pKa = 7.8

High tissue diffusion (liposolubility) due to thiopene substitution for benzene ring

Only amide to contain ester group

More rapidly metabolized than other LA due to 90% metabolism in plasma

76
Q

Patients younger than what age should not be administered articaine?

A

4 years

77
Q

Purpose of vasoconstrictors in local anesthetics

A 
Longer duration, requires less volume 
Local anesthetic stays local 
Counteracts vasodilation of amide 
Less bleeding during procedures 
Decreases systemic toxicity due to slower release of drug into bloodstream
78
Q

Most common vasoconstrictor in local anesthetic?

A

1:100,000 epinephrine = 10 ug/mL

79
Q

What is the maximum dose of epinephrine?

A

200ug

Approximately 11 cartridges of 2% lidocaine 1:100k epi

80
Q

Effects of epinephrine from local anesthetic

A 
Increases systolic and diastolic pressure
Increases cardiac output
Increases stroke volume
Increases heart rate
Increases contraction strength
Increases myocardial oxygen consumption
81
Q

Epinephrine in cardiac patients?

A

Not generally associated with any significant cardiovascular effects in healthy patients or those with mild/moderate heart disease

Reduced dosages or local anesthetics without vasoconstrictors are indicated for patients with more significant disease

Epinephrine impregnated retraction cord should be used cautiously or avoided in certain situations

If LA wears off, the pain reaction can cause more cardiac problems than the epinephrine itself

82
Q

Does LA make a difference during GA?

A

Majority of providers prefer use of LA during GA cases

Rationale is improved patien recovery

Most commonly used for extractions

Some studies showed there is no statistically significant difference in pain between any subgroups of patients with or without local anesthetic

Caution for soft tissue trauma - especially in patients with developmental/intellectual disability

83
Q

Max dose of articaine

A

7mg/kg

84
Q

Max dose of lidocaine

A

4.4 mg/kg

85
Q

Max dose of mepivacaine

A

4.4mg/kg

86
Q

Max dose of prilocaine

A

6.0mg/kg

87
Q

Symptoms of LA overdose

A 
Tonic-clonic seizures
CNS depression
Hypotension
Bradycardia
Respiratory depression
88
Q

Management of LA overdose

A

Place in supine position
Administer oxygen
CPR as necessary
Seizure management: benzodiazepines
20% lipid emulsion (1.5mL/kg over 1 minute) - traps unbound amide LA
Fluid bolus of 10-20mL/kg balacned salt solution and phenylephrine (0.1ug/kg/min)

89
Q

LA reversal

A

Phentolamine mesylate
Acts by vasodilation - allows effects to go away more rapidly

Not for use in LA overdose!

Not recommended for children under 6 years or less than 15kg

90
Q

Allergy to LA

A

Dental cartridge with vasoconstrictor contains sodium metabisulfite as an antioxidant

Local anesthetics without vasoconstrictor are less likely to cause reactions in patients with metabisulfite allergies

Sulfites are found in wines and added to foods as preservatives

Sulfa medications are clinically unrelated - no cross-allergenicity

91
Q

LA and pregnancy

A

Category B: lidocaine and prilocaine (? - not really)

Category C: articaine, mepivacaine, bupivacaine

92
Q

Physical properties of nitrous oxide

A

MAC > 100%
Colorless
Mild odor/taste
Poorly soluble in blood
Not flammable but supports combustion in presence of O2
Found in liquid and gas equilibrium in pressurized cylinders

93
Q

What is the cylinder pressure of nitrous oxide tank?

A

750psi

Unaltered until >3/4 missing

94
Q

Anesthetic properties of nitrous oxide

A

Low blood solubility results in rapid induction and awakening

MAC 104% means that it is incapable of full anesthesia by itself

Used in anesthesia to achieve more rapid induction/reovery because MAC is additive with other, slower-active anesthetics

95
Q

Physiological effects of nitrous oxide (cardiac)

A

Minor depression in cardiac output
Slight increase in peripheral resistance

Results in little change in BP

96
Q

Guedel’s Stages of Anesthesia

A

Stage I: patient relaxed, able to follow instructions, some pain reduction, 4 planes

Stage II: deepened CNS depression, excitement/delierium/jerky movements, laryngospasm may occur

Stage III: patient unconscious, laryngeal and pharyngeal reflexes are inactive, used for major surgical procedures, 4 planes

Stage IV: medullary paralysis, death

97
Q

Concentration effect

A

The higher the concentration of nitrous oxide, the more rapidly the alveolar concentration approaches te inspired concentration

Higher concentrations effectively increase alveolar ventilation

98
Q

Second Gas Effect

A

Other anesthetic gases administered with high concentrations of N2O rush inward to replace nitrous oxide that is absorbed by the pulmonary blood

Oxygen delivery is enhanced

99
Q

Room oxygen

A

21% oxygen, 78% nitrogen

Machines cannot administer less than 25% oxygen so the patient is always getting more than room air

100
Q

Elimination of nitrous oxide

A

Essentially all is exhaled

Some is metabolized in GI tract

101
Q

Effects of nitrous oxide

A 
Body warmth
Tingling hands and feet
Circumoral numbness
Auditory effects
Euphoria
102
Q

Mechanism of action of nitrous oxide

A

Inhibits NMDA of excitatory glutamate receptor

Stimulates GABA and alpha-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate receptors

May promote release of endogenous opioid neurotransmitters (endorphins)

103
Q

Adverse effects of nitrous oxide

A

Increases volume of any closed air pocket in body (why otitis media is contraindication)

Nausea and vomiting - usually result of long duration, fluctuation in concentration, lack of titration, or increased concentrations

104
Q

Indications for nitrous oxide

A 
Anxious patients
Long procedures
Painful procedures
Patients with simple restorative needs unlikely to tolerate LA
Gag reflex
Difficulty obtaining local anesthesia
105
Q

Contraindications for nitrous oxide

A 
Moderate to severe asthma 
Current respiratory infection
Acute otitis media or recent middle ear surgery
COPD
Severe emotional disturbances
1st trimester of pregnancy
Methylenetetrahydrofolate reductase deficiency (MTHFR)
Severe psychiatric imbalance
Precooperative patients
Mouth breathers
Treatment with bleomycin sulfate
Cobalamin (B12) deficiency
106
Q

Medical consultation is indicated for use of nitrous oxide for some patients

A 
Severe COPD
Congestive heart failure
Sickle cell disease
Acute otitis media 
Acute severe head injury 
MTHFR deficiency
107
Q

MTHFR deficiency

A

Inactivates methionine synthetase
Autosomal recessive disorder
MTHFR is responsible for folate metabolism and homocysteine regulation

Nitrous oxide inhibits transformation of homocysteine to methionine and subsequently leads to accumulation of homocysteine in affected children

Can lead to cardiac problems, neurologic death

108
Q

Oxygen tanks

A

2000 psi tanks

Read levels as it decreases

109
Q

Nitrous oxide tank safety

A

Fail-safe mechanism provides automatic shutdown if O2 is less than 25%
Pin-indexed yoke system prevents crossover of cylinders

110
Q

Diffusion hypoxia

A

When N2O administration is stopped, large quantities of N2O may diffuse from blood into alveoli and dilute oxygen

Results in less oxygen available for uptake, so patient can desaturate

Can be eliminated by 100% O2 following N2O administration

Importance is in scavenging expired N2O and reducing N2O pollution

111
Q

Emergency Oxygen Requirements

A

Positive pressure O2 delivery system
15L/min is recommended when using bag valve mask
Capable of administering >90% O2 at 10 L/min for at least 60 min (650L, “E” cylinder)

112
Q

If a 100% solution of local anesthetic contains 1g of drug/mL, how much does 10% contain? 4%?

A

100% would be 1g = 1000mg/mL
10% would be 0.1g = 100mg/mL
4% would be 0.04g = 40mg/mL

113
Q

A cartridge that contains 1.7mL of solution at 2% concentration would contain how much drug?

A

2% = 0.02g = 20mg/mL

1.7mL X 20mg/mL = 34mg

114
Q

If a 25kg patient has already received 2.5 cartridges of 1.7mL 2% lidocaine, how much articaine can you administer?

A

4.4mg/kg x 25kg = 110mg
110mg/34mg = 2.3 cartridges lidocaine
7mg/kg x 25kg = 175mg
175mg/68mg = 2.5 cartridges articaine

Can give some additional lidocaine, but cannot give more articaine beecause the max total is more based on the more potent local anesthetic and based on volume

115
Q

Factors less likely to have successful sedation

A 
Inflexibility
Emotionality
Shy
Inadaptability
Withdrawal
116
Q

Factors likely to have a successful sedation

A

Older age
Persistence/will power/effortful control
Desire to help

117
Q

Minimal sedation (anxiolysis)

A

Responds normally to verbal stimulation
Cognitive function and coordination may be impaired
Ventilatory and cardiovascular functions unaffected

Typical of patients with nitrous oxide

118
Q

Moderate sedation

A

Responds purposefully to verbal commands, alone or accompanied by light tactile stimulus
No interventions required to maintain airway and spontaneous ventilation
Cardiovascular function maintained

Intended level for most dental oral sedation

119
Q

Deep sedation

A

Patient cannot easily be aroused but responds purposefully following repeated or painful stimulation
Ability to independently maintain ventilatory function may be impaired and require assistance and spontaneous ventilation may be inadequate
Cardiovascular function is maintained

Typical of patients that are over-sedated

120
Q

General anesthesia

A

Drug-induced loss of consciousness which patients are not arousable even by painful stimulation
Ability to independently maintain ventilatory function is impaired and requires assistance
Cardiovascular function may be impaired

121
Q

Pre-sedation assessment

A

Medical history: ROS, medications, allergies, surgical history

Physical evaluation: review of airway, weight

Last food/drink intake

122
Q

ASA Status

A

I: normal, healthy
II: mild systemic disease
III: severe systemic disease
IV: severe systemic disease that is constant threat to life
V: moribund and not expected to survive without procedure
VI: dead

123
Q

What ASA status is appropriate for in-office sedation?

A

I and II

124
Q

How does birth history play into sedation case selection?

A

Premature birth (<37 weeks) can lead to delayed airway development

Early life intubation - possible pulmonary barotrauma, increased incidence of laryngeal stenosis

125
Q

Obesity and Sedation

A

Physiologic differences in volume of distribution, metabolism, and clearance of drugs

Increase in fat mass can increase volume of distribution of lipophilic medication

Increase in lean body mass may increase drug clearance due to enhanced liver/kidney function

Total body weight is reasonable for children at normal weight

For overweight/obese patients, TBW may increase likelihood of administering supratherapeutic doses

126
Q

Obesity impact on breathing

A

Added weight puts pressure on diaphragm

Decreases functional reserve capacity, ERV, VC and TLC

Decrease in FRC increases incidence of atelectasis (lung collapse)

127
Q

Obesity and reflux

A

Fasting obese patients have greater gastric fluid volume and lower pH

Risk of gastric regurgitation is higher in obese patients

Increases risk for gastric aspiration pneumonitis

128
Q

How should drug doses be adjusted for obese patients?

A

Most drug doses should likely be adjusted lower to ideal body weight rather than actual weight

129
Q

ENT concerns for sedation

A 
OSA
Snoring
Known airway problems
Difficulty swallowing
History of difficult intubation

Sedation medications make all of these problems worse

130
Q

Cardiac concerns for sedation

A 
Cardiac surgery
Heart defect/murmur
Congestive heart failure
Irregular heartbeat
High BP

Cardiac patients are generally not appropriate candidates for outpatient procedural sedation or GA

131
Q

Respiratory concerns for sedation

A

Asthma (poorly controlled)
Recent pneumonia or URI
Chronic lung disease (CF, COPD)
Home oxygen requirement

132
Q

GI concerns for sedation

A 
Symptomatic GERD (aspiration risk)
Liver disease (may not process medication as well) 
Parenteral nutrition (G-tube, J-tube)
133
Q

Renal concerns for sedation

A

Acute or chronic renal failure

Affects medication metabolism

134
Q

Neurologic concerns for sedation

A

Epilepsy/seizures with poor control

Not an absolute contraindication - sometimes benzodiazepine may be beneficial as it increases seizure threshold

135
Q

Musculoskeletal concerns for sedation

A 
Scoliosis affecting mobility and/or lung function
Muscular dystrophy (risk for malignant hyperthermia)
136
Q

Hematologic concerns for sedation

A

Anemia
Sickle cell
Bleeding disorder
History of cancer

Type of procedure planned matters (ex: intubation may be impossible due to bleeding risk)

137
Q

Endocrine concerns for sedation

A

Diabetes - treat in consultation with patient’s physician

  • oral hypoglycemic agents usually discontinued on day of surgery
  • may need intra and post operative assessment of blood glucose

Hypo/hyperthyroidism - hyperthyroidism at increased risk for oversedation

Adrenal disorder

Inborn errors in metabolism

138
Q

Diabetes lab values

A

Fasting blood glucose > 126 mg/kL
Glycosylated hemoglobin (HbA1C): >6.5%
Glucose tolerance test (GTT): at 2 hours of 200 mg/dL

139
Q

Genetic disorder concerns for sedation

A

Any syndrome should be investigated thoroughly

140
Q

Behavioral problems concerns for sedation

A

Autism: unpredictability of sedation, behavioral meds may cause sedation

ADHD: stimulant medications can be taken with sip of water

ODD: probably not a great candidate

141
Q

Other concerns for sedation

A 
Abnormal labs or studies
Multiple allergies (especially a recent allergic reaction)
142
Q

Greatest risk factors for adverse sedation events

A 
Less than 5
Premature birth
ASA III+
Chronic reactive airway disease
Current URI with opaque/yellow secretions 
Obesity
OSA
Dev delay/intellectual disability
143
Q

How is a child’s airway different than adults?

A

Increased airway resistance (16x greater than adults)

Relatively larger head, tongue and epiglottis

Less developed mandible

Airway narrowest at cricoid cartilage until 8 years (vs epiglottis in adults)

Larynx is higher

Vocal cords angled upward and more anterior

Short trachea

More reactive airway - higher chance of developing laryngospasm

144
Q

Cardiac evaluation prior to sedation

A

Children have higher heart rate

Cardiac output = stroke volume x heart rate

Increased respiratory rate, cardiac index, and greater proportional distribution of cardiac output to organs allows for more rapid uptake of inhalation anesthetics

145
Q

Mallampati scale

A

Provides measure of available air space and relative soft tissue obstruction

146
Q

Brodsky scale

A

Commonly used by ENT physicians to assess tonsils prior to removal

Considered a risk factor for OSA

147
Q

Features of of NPO guidelines

A

Minimizes chance for emesis and subsequent aspiration
Maximizes absorption of the drug
Leaves patients with greater chance of post-op dehydration and hypoglycemia

148
Q

Medications and NPO

A

It is permissible for patient to take routine medications with a sip of clear liquid or water on day of procedure

149
Q

NPO guidelines

A

Clear liquids: 2 hours
Breast milk: 4 hours
Infant formula/nonhuman milk/light meal: 6 hours
Heavy meal: 8 hours

150
Q

Pre-sedation guidelines

A 
Discuss medication regimen
Time to arrive
Expected latent period
Two adults 
Call office if child is ill
Discussion of NPO 
Must rest with immediate adult supervision for rest of day
151
Q

Monitoring in sedation

A

Human: head position, breath sounds, chest movement, patient color

Capnography or precordial stethoscope strongly recommended

Documentation: level of consciousness, responsiveness, HR, BP, oxygen, CO2, etc.

BP: minimum before sedation and prior to discharge, but at least 10min intervals recommended

152
Q

Sensors for ventillation

A

Hpercapnia drive: medulla chemoreceptors sense acidity generated by carbonic acid from O2 entering the brain

Hypoxemic drive: carotid arch bodies sense low O2 tension

153
Q

Hypoxia

A

Diminished oxygen in any tissue

May result from airway obstruction and hypoventilation

154
Q

Hypoexmia

A

Diminished oxygen in blood

May result from inadequate pulmonary perfusion

155
Q

Hemoglobin

A

2 alpha and 2 beta chains
98-99% of oxygen in arterial red blood bound to hemoglobin, with 1-2% in plasma

Saturation of hemoglobin and arterial oxygen tension (PaO2) are related

156
Q

Oxyhemoglobin dissociation curve

A

Becomes steep at 90% SaO2 with implications for cellular function (edge of clicc)

Cyanosis not detectable until hemoglobin saturation well below 80%

Oxyhemoglobin curve describes non-linear tendency for oxygen to bind to hemoglobin

157
Q

Right and left shifts of oxyhemoglobin curve

A

Right shift: during stress/exercise, requires larger partial pressure to maintain saturation
-decreased hemoglobin affinity for oxygen so that oxygen is offloaded to working tissues

Left shift: increasing affinity for oxygen
-blood returning to lungs

158
Q

Pulse Oximeter

A

Provides measure of arterial hemoglobin oxygen saturation

Deoxygenated hemoglobin absorbs more red light at 660nm

Oxygenated hemoglobin absorbs more infrared light at 910nm

Readings are dependent on pulsatile blood flow, taken at maximum intensity of waveform

30-40s delayed

159
Q

Precordial stethoscope

A

stethoscope with microphone affixed to patient’s suprasternal notch helps detect respiratory alteration or block

160
Q

Capnography

A

Now standard of care

CO2 tension provides purset measure of adequate ventilation

Respiratory depression = fewer waveforms

Respiratory obstruction = reduced height and altered shape

Capnography can diagnose airway obstruction, bronchospasm, malignant hyperthermia, confirm endotracheal tube placement, determine adequacy of chest compressions during BLS

161
Q

Onset of hypoxemia

A

Time from apnea to hypoxemia is a function of the amount of O2 in the functional residual capacity

Basis of oxygenating patient prior to GA intubation

Obese adults and children have reduced functional residual capacity and despite preoxygenation will experience significant desaturation within 3-4 minutes

162
Q

Signs of airway obstruction

A 
Increased sonorous breath sounds
Nasal flaring
Discordant chest wall motion
Retraction at suprarenal area
Cyanosis
Tripping (bent over, chest parallel to ground)
163
Q

Pharmacokinetics

A

How drugs are absorbed and distributed in the body

Oral absorption: 30-60 minutes

Lipophobic drugs are less absorbed than lipophilic drugs

164
Q

Pharmacodynamics

A

How drugs affect the brain

Interaction of drug and recptors at site of action

165
Q

Pharmacotherapeutics

A

Principles guiding the choice of drug

Efficacy, onset, toxicity, duration of action

166
Q

Diazepam

A 
Anterograde amnesia
Paradoxical reaction possible 
Non-analgesic
Reversible binding to CNS GABA receptors
Treatment of skeletal muscle spasms
Long half life
167
Q

Midazolam

A

Anterograde amnesia
Paradoxical reaction possible
Hiccups
Non-analgesic
Reversible binding to CNS GABA receptors
Treatment of skeletal muscle spasms
Metabolized by liver, excreted by kidneys

168
Q

What warrants caution with benzodiazepines?

A

Substances: Grapefruit juice, erythromycin, clarithromycin, antifungals, antivirals, some antidepressants, valproic acid

Conditions: narrow angle glaucoma

Calcium channel blockers inhibit the CYP3A enzymes required for metabolism, so increase in bioavailability

169
Q

Hydroxyzine

A

H1 antihistamine (anticholinergic, antihistaminic, antiemetic)

Drowsiness

Decreases secretions

Bronchodilation

Extra-pyramidal activity (jerky movements)

Non-reversible

Metabolized by liver, excreted by kidney

170
Q

Other antiemetic/antihistamine

A

Promethazine

Diphenhydramine

171
Q

Chloral hydrate

A

Barbiturate/hypnotic

Non-analgesic

Mucosal irritant (increased laryngospasm)

Metabolized by liver to chlortriethanol (an aolchol)

Adverse reaction with warfarin and furosemide

Excreted by kidney

Non-reversible

172
Q

Meperidine

A

Synthetic opioid analgesic
Sedative, antispasmodic

Reversible (naloxone)

Produces histamine release from mast cells (caution in asthma)

Can cause emesis

Lowers seizure threshold

Metabolized by liver, excreted by kidney

173
Q

Contraindications for meperidine

A 
MAO inhibitors
SSRI
Tricyclic antidepressants 
Seizure disorders
Severe asthma
174
Q

Morphine

A

Restricted use in most institutions

80% success rate found for oral morphine, midazolam

175
Q

Herbal medication and sedation concerns

A

Herbal medicines may alter sedation drug pharmacokinetics through inhibition of cytochrome P450

St John’s wort, ginko, ginger, ginseng, garlic = increased or decreased medication

Kava may increase sedation through GABA

Valerian may produce sedation through GABA

176
Q

Promethazine in children (Phenergan)

A

Black box warning for fatal respiratory depression in children under 2

177
Q

Codeine in children

A

Children with duplicated cytochromes have greater prodrug conversion and potential overdose

178
Q

Metabolism of sedation drugs

A

First pass: drugs absorbed in enteric routes go to liver via portal circulation

Midazolam potentiates GABA receptor

179
Q

Discharge Criteria - University of Michigan

A

0: awake and alert
1: minimally sedated, tired or sleepy, appropriate response to verbal conversation and/or sound
2: moderately sedated, somnolent/sleeping, easily aroused with light tactile stimulation or verbal command
3: deeply sedated, arousable with significant physical stimulation
4: unarousable

180
Q

Discharge Criteria - modified wakefulness test

A

Child remains awake in darkened calm environment for 20 minutes

ABPD 2021 (14 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions