local anesthesia complications

Question 1

other complications

Answer 1

1) intravascular injection
2) tissue blanching
3) postoperative discomfort
4) auricular disturbances
5) ocular disturbances
6) excessive spread of analgesia

Question 2

symptoms

Answer 2

1) persistent numbness
- analgesia, dysesthesia, pruritis, hypoesthesia, hyperesthesia
2) causes
- electric shock
- alcohol or sterilizing solution may be toxic to nerve

Question 3

initial response of paresthesia

Answer 3

1) always speak directly doctor to patient
2) sympathy, reassurance, document conversation
3) follow up exam
- determine degree (diagram geography and extent)
- inform patient: solution is waiting it out
- many instances self resolve in a few days, weeks, months
- permanent loss is rate
4) reexamine at 1 month intervals

Question 4

special pencil

Answer 4

1) marking where the paresthesia is

Question 5

when injury does occur

Answer 5

1) you can pass the lingual nerve and possibly amage it?
2) 94% recover in 2-12 weeks
- 5% in 9 months
- up to 10% of remaining injuries will never recover

Question 6

hematoma

Answer 6

1) definition
- effusion of blood into extravascular spaces
2) presentation
- may be apparent during or after treatment as swelling/bruising
3) may be confused with edema, may cause trismus, develop infection, may cause paresthesia

Question 7

hematoma treatment

Answer 7

1) pressure, ice for first several hours
2) follow on treatments
- heat to carry away / absorb trapped blood and byproducts
- APAP first 24 hours
- NSAIDS post 24 hours

Question 8

trismus

Answer 8

1) jaw muscles are sore
2) limited range of motion
3) caused by injection into muscle and hematoma involving muscles of mastication, low grade infection, multiple injections

Question 9

trismus treatment

Answer 9

1) on initial exams, record ROM for later comparison
2) open until it hurts, then go a little further
3) heat, warm saline rinses, analgesics, self-physiotherapy
4 )if no relief in 48 hours, prescribe antibiotics

Question 10

facial nerve paralysis

Answer 10

1) paresis of muscles of facial expression
2) muscle droop, inability to close eyelid, other
3) causes
- anesthetizing the motor component of a facial nerve
- usually associated with infraorbital nerve block, MX cuspid infiltrations, PSA, all mandibular block techniques

Question 11

facial nerve paralysis management

Answer 11

1) tape the eye, and use gauze
2) reassure patient that it is temporary

Question 12

edema

Answer 12

1) swelling and looks like hematomas
2) can occur with or without pain

Question 13

edema management

Answer 13

1) when produced by trauma, it self resolves
2) if edema threatens to compromise airway, treat as an emergency
- ABC
- call 911
- antihistamines, epi pen
3) if edema is infection, treat with antibiotic
- fluctuant is drainable
- cellulitis is not drainable

Question 14

infection

Answer 14

1) post injection pain and swelling, sometimes leading to trismus
2) contaminated needle from oral mucosa contact
3) needle passing through existing infected tissue
4) osteomyelitis from intraosseous injections

Question 15

needle breakage

Answer 15

1) can cause trismus for life
2) use larger gauge
- 25 and 27 gauge
3) never insert to the hub
4) do not bend, force needle
5) be aware of sudden patient movement

Question 16

needle breakage management

Answer 16

1) remain calm
2) instruct patient to hold still and keep mouth open
3) extract with hemostat (no no proceed with incision and probing)
4) keep the fragments

Question 17

comfort matters

Answer 17

1) painless injection and painless visit
- how patients judge you

Question 18

three types of injection pain

Answer 18

1) needle stick
2) needle advancement
3) anesthetic deposition

Question 19

gate theory

Answer 19

1) if a large nerve is stimulated, it closes the gate and inhibits the small nerve sensation
- pressure, movement, vibration
- overrides sensation of pain

Question 20

warming

Answer 20

1) if the anesthetic is cold, they can feel the temperature change

Question 21

injection speed

Answer 21

1) 2 ml over 60 seconds or rapidly over 15 seconds
- significantly more comfortable going slower
- also improve IA block sucess

Question 22

needle size

Answer 22

1) for pain, it doesnt matter
2) matters for deflection
- 30 gauge deflects the most

Question 23

injection pain

Answer 23

1) inject - wait - inject with anesthetic of choice
2) plain - then - vasoconstrictor
—
pros
1) perceived as making 2nd injection more comfortable
2) plain 1st helps address acidity of anesthetic
—
cons
1) both types require two needle sticks vs one
2) inject - wait - inject shallow
3) plain - then- vaso - ???

Question 24

topical anesthetic

Answer 24

1) hurricane, EMLA, compounded
2) pros
- perceived as making needly stick more comfy, placebo and sense of care
3) cons
- 1-2 minutes
- analgesia very shallow (1-2 mm)
- tastes awful

Question 25

buffer local anesthetic

Answer 25

1) dental anesthetic is highly acidic
- formulated with HCl
- preservative and vasoconstrictors add to acidity
- acidity extends shelf life
2 )if buffering, you can raise pH to 7.4 and cause H+ to fall off
- create 8000x more active form of anesthetic
- reduce injection pain (CO2 shuts down impulse)
- possibly help anesthetize inflammed tissue

Question 26

iatrogenic damage

Answer 26

1) chewing on self
2) watch me stickers

Question 27

top ten

Answer 27

1) facial nerve paralysis
2) needle breakage
3) injection pain, burning on injection

Question 28

3 principles concerning effects of drugs

Answer 28

1) hepatic dysfunction
2) congestive heart failure
- decrease perfusion
3) renal dysfunction - impairs excretion

Question 29

5 causes of elevated blood levels in LA

Answer 29

1) overdose
2) intravascular injection
3) absorptions rapid
4) slow biotransformation
5) slow removal

Question 30

prepare

Answer 30

1) review med history
2) choice of anesthetic
3) calculate MRD
4) volume of LA administered
5 )LA administered to all four quadrants at one time
6) never get close to MRD

Question 31

overdose of local anesthetic

Answer 31

1) mild - talkative, excited, irritable, sweating, elevation of vitals
2) moderate to severe
- seizure
- shut down CNS depression of BP, HR, RR

Question 32

systemic toxicity treatment

Answer 32

1) GET THEM ON OXYGEN ASAP
2) ABCs
3) call 911

Question 33

vasopressors

Answer 33

1) epinephrine or levonordefrin
2) benefits
- inhibit local vasoconstriction
- limit systemic uptake
- lower toxicity (safer)
- reduce bleeding
- increase depth of numbness

Question 34

epinephrine sensitivity

Answer 34

1) tachycardia, palpitations, sweating, nervousness, all symptoms of anxiety
2) signs of allergy
- skin reactions, sneezing, redness of eyes,
- dyspnea, and anaphylaxis

Question 35

vasopressors require anti-oxidant / preservative in formulation

Answer 35

1) sodium metabisulfite
2) potassium metabisulfite
3) allergic reactions to preservatives (rare)
- respiratory reactions in asthmatics
- individuals with sulfa drug allergies are OK
- individuals with food allergies to sulfites: rash, hives, anaphylaxis, use plain anesthetics

Question 36

at risk groups

Answer 36

1) HTN >200/115
2) pregnancy
3) uncontrolled hyperthyroidism
4) significant cardiac dysrhythmias
5) severe cardiovascular disease
- daily angina

Question 37

recommendations for at risk groups

Answer 37

1) maximum dose with at risk adult 0.04 mg
2) aspirate multiple times
3) use mepivacaine?

Question 38

drug interactions

Answer 38

1) tricyclic antidepressants
2 )cocaine!

Question 39

pregnant and nursing patient

Answer 39

1) 1st trimester
- week 0-12
- avoid LA
- active infection may present higher risk than using LA
2) 2nd trimester
- week 13-24
- optimum time for dental treatment
- most obstetricians recommend no epinephrine