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D2 Summer > Pain and Anxiety Week 3 > Flashcards

Pain and Anxiety Week 3 Flashcards

1
Q

What is the mechanism of action for topical anesthetics?

A
  1. Blocks nerve conduction at mucous membrane surfaces
  2. Decreases Na+ permeability = decreases depolarization = blocks nerve impulse

(MOA is similar to injectable LAs)

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2
Q

What are the different forms of topical anesthetics?

A

Gel
Ointment
Metered and unmetered sprays
Cream
Liquid
Lozenges

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3
Q

What is the range of effective concentrations for topical anesthetics? What does this depend on?

A

0.2% - 20%, depends on form

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4
Q

What is the choice of method of delivery for topical anesthetic based on?

A

Each individual patient

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5
Q

Which topical anesthetic is associated with methemoglobinemia?

A

Benzocaine sprays

(recall that injectable procaine has the same issue)

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6
Q

Why do we need the site to be dried with gauze or sponge before we apply the topical anesthetic?

A

dryer site = will absorb the anesthetic better

(won’t get washed away by saliva)

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7
Q

How long should topical anesthetic be placed at site?

A

1-2 mins

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8
Q

What is the tissue depth of topical anesthetic?

A

2-3 mm

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9
Q

What are 3 common topical anesthetics used in dentistry?

A

Benzocaine
Lidocaine
Combination of Benzocaine + Butamben + Tetracaine = Cetacaine

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10
Q

Is Benzocaine (topical) an ester or amide?

A

Ester

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11
Q

Which topical has a very low toxicity due to the fact that it has SLOW absorption?

A

Benzocaine

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12
Q

What is the onset of Benzocaine (topical)?

A

30 seconds - 2 mins

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13
Q

What is the duration of Benzocaine (topical)?

A

5-15 mins

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14
Q

Which topical has a 20% concentration?

A

Benzocaine

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15
Q

Where is Benzocaine (topical) metabolized?

A

Plasma + some liver

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16
Q

What is the MRD of Benzocaine (topical)?

A

None

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17
Q

What is the pregnancy category for Benzocaine (topical)?

A

pregnancy = category C; lactation unknown safety

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18
Q

What is Benzocaine (topical) spray associated with?

A

Methemoglobinemia

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19
Q

Which topical has a very low toxicity due to the fact that it has POOR absorption?

A

Lidocaine

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20
Q

Which topical is good for those with an ester allergy?

A

Lidocaine

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21
Q

Is Lidocaine (topical) an ester or amide?

A

Amide

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22
Q

What is the onset of Lidocaine (topical)

A

2-10 mins

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23
Q

What is the duration of Lidocaine (topical)

A

15-45 mins

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24
Q

Which topical has a concentration of 2%-5%?

A

Lidocaine

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25
Q

Where is Lidocaine (topical) metabolized?

A

Liver

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26
Q

What is the MRD for Lidocaine (topical)?

A

MRD = 300 mg, but we use 200 mg safely

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27
Q

What is the pregnancy category for Lidocaine (topical)?

A

pregnancy = category B; small amount enters breast milk

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28
Q

What is Cetacaine (topical) a combination of?

A

Benzocaine + Butamben + Tetracaine

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29
Q

Is Cetacaine (topical) an ester or amide?

A

Ester

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30
Q

T/F: Benzocaine, Lidocaine, and Cetacaine are all topicals that have a very LOW toxicity

A

True

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31
Q

What is the onset of Cetacaine (topical)?

A

30 seconds

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32
Q

What is the duration of Cetacaine (topical)?

A

30-60 mins

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33
Q

What is the concentration of Cetacaine (topical)?

A

14% benzocaine + 2% butamben + 2% tetracaine

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34
Q

Where is Cetacaine (topical) metabolized?

A

Plasma + some liver

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35
Q

What is the MRD for Cetacaine (topical)?

A

MRD = 200 mg

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36
Q

What is the pregnancy category for Cetacaine (topical)?

A

pregnancy = category C; lactation - use caution

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37
Q

Topical anesthetics increase ________ __________, which increases ___________

A

blood levels; toxicity

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38
Q

T/F: The concentration of topicals are lower than injectable LA’s.

A

False!! They’re higher

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39
Q

Why do we need a higher concentration in topical anesthetics?

A

Must diffuse thru mucous membranes

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40
Q

T/F: There are NO vasoconstrictors in topicals

A

True

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41
Q

Because there are NO vasoconstrictors in topicals, there is an increased __________ __________ and therefore an increased _____________

A

absorption rate; toxicity

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42
Q

Which groups of people have an increased risk of toxicity and adverse reactions to topical?

A

Elderly
Children
Medically compromised

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43
Q

What are the toxicity and adverse reactions of topical anesthetic?

A

Irritation @ site
Sloughing
Taste alteration
CNS effects (excitation -> depression)
CV effects (decreased HR/BP; cardiac arrest)

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44
Q

T/F: The CNS and CV effects of toxicity/adverse reactions in topical anesthetic have the same signs and symptoms as in injectable LAs

A

True!

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45
Q

What are the 7 ways to avoid toxic rxns from topicals?

A
  1. Know relative toxicity of drug
  2. Know concentration of drug
  3. Use smallest volume
  4. Use lowest concentration
  5. Use least toxic drug
  6. Limit area of application
  7. Avoid sprays
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46
Q

What does a (+) and (-) result for the aspiration test mean?

A

(+) aspiration = blood entered carpule
(-) aspiration = no blood; small bubble may have entered carpule

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47
Q

What is aspiration test and what does it determine?

A

Negative pressure within a cartridge prior to injecting to determine if needle is within a blood vessel

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48
Q

Angled surface of the needle tip

A

Bevel

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49
Q

Diameter of a needle

A

Gauge

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50
Q

The larger the gauge, the __________ the diameter

A

smaller

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51
Q

What is the weakest part of the needle?

A

Hub

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52
Q

What does the hub + needle adaptor attach?

A

Attaches needle to syringe adaptor

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53
Q

What materials can the hub + needle adaptor be?

A

Plastic or aluminum

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54
Q

What does a plastic hub + needle adaptor allow for?

A

Movement to align bevel

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55
Q

Why is the hub + needle adaptor usually marked with ink?

A

For bevel location

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56
Q

What is the end of the needle shaft that penetrates the diaphragm of the carpule?

A

Carpule-penetrating end

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57
Q

When should the carpule-penetrating end be placed?

A

After carpule is loaded and the harpoon is engaged

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58
Q

What must remain covered until ready for use?

A

Needle shaft

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59
Q

What are the 2 needle lengths commonly used in dentistry?

A

Long = 32 mm
Short = 20 mm

60
Q

What is needle length selection based on?

A

Amount of tissue that must be penetrated to reach target location

61
Q

Where should the needle NEVER be inserted to?

A

The hub

62
Q

What needle length is ALWAYS required for a mandibular block?

A

Long

63
Q

Each needle is used on _____ pt

A

one

64
Q

________ _______ remains over needle until ready to inject

A

Plastic shield

65
Q

When should the needle be replaced?

A

After 3-4 penetrations (dulls the tip)

66
Q

What should you do immediately after done injecting?

A

Cover needle with plastic shield, using the 1-handed scoop technique

67
Q

You should know where an _________ _________ is at all times

A

uncovered needle

68
Q

What should you do if a needle becomes contaminated?

A

Recap and dispose; replace needle

69
Q

Where should you put all contaminated needles?

A

Approved sharps container

70
Q

How many mL of LA are in each carp? How many mL does the stopper remove?

A

1.8 mL
Stopper removes 0.2 mL

71
Q

What are 5 systemic complications of LA?

A
  1. Syncope
  2. LA overdose
  3. Epi overdose
  4. Allergic rxn
  5. Any potential medical emergency
72
Q

Causes of syncope

A

Drastic drop in BP
Emotional response to injection

73
Q

Prevention of syncope

A

Identify fearful pt in pre-anesthetic assessment
Hide needle
Supine position

74
Q

Symptoms of syncope

A

Sweating, nausea, pallor
Increased HR and RR

75
Q

Treatment for syncope

A

Supine position w/ legs higher than head
Ammonia capsule or O2
Cool damp cloth on forehead/neck
Monitor vitals
Reassure pt (don’t let them sit up or stand)

76
Q

Causes of LA overdose

A

Injecting into vessel (MOST COMMON)
Administering too large of dose
Metabolism/excretion of LA is slow

77
Q

Prevention of LA overdose

A

Aspirate in 2 planes
Calculate MRD
Pre-anesthetic assessment for LA selection

78
Q

Symptoms of LA overdose

A

CNS excitation (low overdose)
CNS/CV depression (higher overdose)

79
Q

What is treatment of LA overdose determined by?

A

Onset and severity

80
Q

How do you treat mild LA overdoses?

A

No treatment

81
Q

How do you treat moderate/severe LA overdoses?

A

Stabilize pt
Activate EMS

82
Q

Rapid onset = ?

A

More severe reaction

83
Q

Causes of epinephrine overdose

A

1:50,000 conc
Intravascular injection
CV pts

84
Q

Prevention of epinephrine overdose

A

Aspirate in 2 planes
Use lowest effective conc.
Pre-anesthetic assessment to identify CV pts

85
Q

Symptoms of epinephrine overdose

A

Fight or flight response

(lasts 5-10 mins)

86
Q

Treatment of epinephrine overdose

A

Healthy pts -> reassure
CV pts -> prepare for medical emergency

87
Q

Allergic reactions to LA can be __________ or ___________

A

delayed; immediate

88
Q

Causes of allergic reactions

A

Methyparaben (preservative used until 80s)
Sodium bisulfite (in vasoconstrictors)
Ester topicals

89
Q

How to prevent allergic reactions

A

Pre-anesthetic assessment

90
Q

Symptoms of allergic reactions

A

Delayed: rash, itching
Immediate: anaphylaxis

91
Q

Treatment of allergic reactions

A

Delayed: antihistamine, document
Immediate: stabilize pt, activate EMS, document

92
Q

Examples of local complications of LA

A

Needle breakage
Pain/burning during injection
Hematoma
Facial paralysis
Paresthesia
Trismus
Infection
Edema
Soft tissue injury
Sloughing

93
Q

Causes of needle breakage

A

Sudden unexpected movement
Poor technique

94
Q

Prevention of needle breakage

A

Use 25g or 27g needles
Use long needle for IA block
Do not bend needle, insert needle to hub, or force needle

95
Q

Treatment of needle breakage

A

Keep hands in pts mouth
Remove needle if visible
Refer to OS
Document

96
Q

Causes of pain during injection

A

Dull/barbed needle

97
Q

Prevention of pain during injection

A

Inject slowly
Use topical
Use sharp needle
Use anesthetic at room temp

98
Q

Treatment of pain or burning during injection

A

Reassure pt
Slow down delivery of anesthetic

99
Q

Causes of burning during injection

A

Contaminated/expired anesthetic
Heated anesthetic

100
Q

Prevention of burning during injection

A

Inject slowly
Check carp before use
Store anesthetic at room temp

101
Q

Causes of hematoma

A

Puncturing blood vessel
Multiple needle penetrations

102
Q

Prevention of hematoma

A

Use 27 short for PSA
Know anatomy

103
Q

Treatment of hematoma

A

Apply ice and pressure ASAP
Inform pt of swelling/discoloration (7-14 days)
Document

104
Q

Causes of facial paralysis

A

LA deposited in parotid gland
Bone not contacted during mandibular block

105
Q

Prevention of facial paralysis

A

Contact bone before depositing LA

106
Q

Treatment of facial paralysis

A

Reassure pt
Document

107
Q

Causes of parasthesia

A

Trauma to nerve sheath (pt feels a shock)
Edema/hemorrhage near nerve
Contaminated anesthetic (soaked in disinfectant)
Possible association w/ Articaine

108
Q

Prevention of parasthesia

A

Minimize needle within tissue
Do NOT soak carps in disinfectant

109
Q

Treatment of parasthesia

A

Reassure pt (3 weeks - 3 months; possibly 1 year)
Document

110
Q

Causes of trismus

A

Muscle trauma from multiple needle insertions
Contaminated anesthetic

111
Q

Prevention of trismus

A

Use sharp needle
Inject slowly
Store anesthetic properly

112
Q

Treatment of trismus

A

Reassure pt (2-3 days)
Moist heat (20 mins on/20 mins off)
Document

113
Q

Causes of infection

A

Contaminated needle/cartridge
Administer anesthetic thru infected area

114
Q

Prevention of infection

A

Sterile needle -> replace if contaminated
Store anesthetic properly
Do not inject infected area

115
Q

Treatment of infection

A

Antibiotics after 3 days

116
Q

Causes of edema

A

Trauma
Contaminated needle
Allergic rxn

117
Q

Prevention of edema

A

Good technique
Pre-anesthetic assessment to identify allergies
Store anesthetic properly

118
Q

Treatment of edema

A

NONE (goes away 3-4 days)

119
Q

Causes of soft tissue injury

A

Self-inflicted (usually kids)

120
Q

Prevention of soft tissue injury

A

Select LA w/ appropriate duration
Warn pts/parents

121
Q

Treatment of soft tissue injury

A

OTC analgesics
Antibiotics if severe
Warm salt water rinse
Vaseline for lips

122
Q

Which branches of CN V have sensory only?

A

CN V1 + CN V2

123
Q

Which branch of CN V has sensory + motor?

A

CN V3

124
Q

CN V1 opening

A

Superior orbital fissure (sphenoid bone)

125
Q

3 major branches of CN V1

A

Nasociliary
Frontal
Lacrimal

(NFL)

126
Q

CN V2 opening

A

Formen rotundum (sphenoid bone)

127
Q

CN V2 enters the…

A

Pterygopalatine fossa

128
Q

5 major branches of CN V2

A

Nasopalatine
Greater palatine
PSA
Infraorbital -> ASA + MSA
Zygomatic

129
Q

CN V3 opening

A

Foramen ovale (sphenoid bone)

130
Q

3 trunks of CN V3 and their contents

A

Undivided: muscular branches
Anterior: long buccal nerve + muscular branches
Posterior: IA, lingual, auriculotemporal nerves

131
Q

5 branches of CN V3

A

Long buccal
Muscular branches (to mm of mastication)
Auriculotemporal
Lingual
IA -> mylohyoid, mental, incisive

132
Q

What does CN VII do?

A

Motor to mm of facial expression
Sensory to ant 2/3 tongue (taste)

133
Q

Path of CN VII

A
  1. Internal acoustic meatus
  2. Stylomastoid foramen
  3. Parotid gland (no innervation)
134
Q

What branches of CN VII are in the internal acoustic meatus?

A

Chorda tympani (submandibular/sublingual glands)

Greater petrosal (lacrimal gland)

135
Q

What branches of CN VII are in the parotid gland?

A

Temporal
Zygomatic
Buccal
Mandibular
Cervical

136
Q

What cranial nerve wraps around the parotid gland?

A

CN VII

(be careful when doing mandibular block!)

137
Q

What does the external carotid artery terminate as?

A

Maxillary artery
Superficial temporal artery

138
Q

Where does the maxillary artery begin within?

A

Parotid gland (at neck of mandibular condyle)

139
Q

The maxillary artery runs between ___________ and ___________ ____________ (lingula)

A

mandible; sphenomandibular ligament

140
Q

The maxillary artery enters the __________ fossa and then the ___________ fossa, giving off 4 branches at each

A

infratemporal; pterygopalatine

141
Q

4 branches of maxillary artery within infratemporal fossa

A
  1. Middle meningeal
  2. Inferior alveolar -> mental + incisive + mylohyoid
  3. Branches to mm of mastication
  4. Buccal
142
Q

4 branches of maxillary artery within pterygopalatine fossa

A
  1. PSA
  2. Infraorbital -> ASA
  3. Greater palatine
  4. Sphenopalatine -> nasopalatine
143
Q

What protects the maxillary A from being compressed during mandibular movement?

A

Pterygoid plexus

144
Q

What is associated with hematoma and spread of infection during incorrectly administered PSA injections?

A

Pterygoid plexus

145
Q

What is a venous plexus of small anastomosing vessels?

A

Pterygoid plexus

146
Q

Where is the pterygoid plexus located?

A

Around pterygoid muscles; surrounds maxillary artery in infratemporal fossa

D2 Summer (37 decks)

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