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Module 8 > special care > Flashcards

special care Flashcards

1
Q

what is the definition of conscious sedation

A

a technique in which the use of drug produces a state of depression of the central nervous system enabling treatment to be carried out, with verbal communication maintained
loss of consciousness unlikely

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2
Q

what are the 4 types of conscious sedation

A

inhalation
intra venous
oral
intranasal - not widely available

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3
Q

what is assessed pre-conscious sedation

A

thorough MH, SH
airway assessment - neck size/posture/mallampati score
- height, weight, BMI
- heart rate, BP, SpO2

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4
Q

what consent is needed for conscious sedation

A

written

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5
Q

what are the 3 standard techniques of conscious sedation

A

inhalation alone
IV with single drug by single route
oral with single drug by single route

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6
Q

what is used for inhalation sedation

A

nitrous oxide and oxygen

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7
Q

how is inhalation sedation delivered

A

gas via nose piece mask

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8
Q

what anxiety levels is IHS used for

A

mild

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9
Q

what is required by pt for IHS

A

ability to breathe through nose

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10
Q

what effects does IHS have

A

anxiolytic
analgesic

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11
Q

what is the brand name for nitrous oxide

A

entonox

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12
Q

what kind of gas is nitrous oxide

A

sweet smelling
colourless
heavy

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13
Q

what are the properties of nitrous oxide

A

rapid onset of action (3-5 mins)
crosses blood-brain barrier rapid
elimination rapid
no hangover effect

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14
Q

what are signs of IHS overdose

A

headache
nausea
vomiting

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15
Q

what can IHS overdose cause

A

diffusion hypoxia

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16
Q

how do you treat IHS overdose

A

reduce dose
O2 flush

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17
Q

what is diffusion hypoxia

A

when nitrous oxide is discontinued, it leaves the blood more quickly than nitrogen from the air is absorbed
leads to dilution of oxygen in the lungs
causes hypoxia

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18
Q

how is diffusion hypoxia prevented

A

administer 100% oxygen after cessation of nitrous oxide for 5 minutes

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19
Q

what are the indications for IHS

A

mild anxiety
needle phobia
pt not suitable for IV/GA
straightforward dental tx

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20
Q

what should be considered before IHS

A

ability to cooperate:
- age
- learning disability/cognitive impairment
- ability to tolerate mask

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21
Q

what are IHS contraindications

A

copd
recent eye or ear surgery
mask intolerance
pregnancy
vit b12 deficiency
methotrexate intraction
chemo

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22
Q

what equipment is required for IHS

A

RA machine
gas cylinders or piped gas
scavenging

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23
Q

what drug is used for IV sedation

A

midazolam

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24
Q

what anxiety levels would IV sedation be used for

A

mild-moderate

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25
Q

what effect does midazolam have on memory

A

amnesia

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26
Q

what is the reversal drug for midazolam

A

flumazenil

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27
Q

what are the indications for IV sedation

A

dental anxiety/phobia
medically suitable
social history
unpleasant procedures

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28
Q

what are the contraindications for IV sedation

A

needle phobia
medical reasons
social reasons
pregnancy
poor venous access

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29
Q

what equipment is required for IV sedation

A

midazolam
flumazenil
syringes & labels
saline
pulse oximeter
BP cuff and machine
tourniquet

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30
Q

what is the concentartion of midazolam

A

1 mg/ml

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31
Q

what is the concentration of flumazenil

A

500 micrograms in 5 ml

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32
Q

what would stop pulse oximeter from being accurate

A

dark nail polish/gel or acrylic nails
finger tapping/playing with pulse oximeter

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33
Q

what are signs of IV overdose

A

loss of protective reflexes
loss of consciousness
decreased respiration
decreased heart rate

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34
Q

what kind of drugs midazolam and flumazenil

A

benzodiazepine

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35
Q

what is oral sedation

A

midazolam delivered as a drink

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36
Q

what must also be done for oral sedation

A

cannulation - for reversal

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37
Q

what is a premed

A

preliminary administration of a drug preceding a procedure, as an antibiotic or antianxiety agent

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38
Q

give an example of a drug regimen for premed with diazepam

A

5-10mg diazepam
taken last thing at night and on wakening morning of appt
60-90 mins before appt

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39
Q

what are the drug interactions with diazepam

A

antibacterials - rifampicin
antivirals - ritonavir
proton pump inhibitors - omeprazole

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40
Q

what are the indications for diazepam premed

A

very anxious patients
pts when sedation is contraindicated
more complex and prolonged procedures

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41
Q

what are contraindications for diazepam

A

hepatic impairment
renal impairment
pregnancy
breast feeding

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42
Q

what are cautions for diazepam

A

avoid prolonged use
reduce dose in debilitated pts
reduce dose in elderly
respiratory disease

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43
Q

what is an alternative premed to diazepam

A

temazepam

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44
Q

what effects can benzodiazepines have

A

anxiolytic
anticonvulsant
sedation
amnesia
muscle relaxation

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45
Q

why do benzodiazepines cause muscle relaxing

A

central effect:
depression of spinal reflex activity

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46
Q

what are short term side effects of benzodiazepines

A

drowsiness
dizziness
reduced concentration & coordination
hypotension
respiratory depression
sexual fantasy

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47
Q

what are the long term side effects of benzodiazepines

A

tolerance
dependence
withdrawal symptoms

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48
Q

where would you get sedation standards and guidance

A

IACSDS
intercollegiate advisory committee for sedation in dentistry standards
SCDEP - conscious sedation in dentistry

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49
Q

what is the definition of general anaesthesia

A

state of controlled unconciousness with loss of protected reflexes

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50
Q

what are the indications for GA

A

lengthy or complex surgery
very anxious and unable to tolerate concious sedation
profound learning disability
multiple XLA in multiple quadrants
severe trauma or acute infection
when conscious sedation is contraindicated

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51
Q

what are the advantages of GA

A

cooperation not required
pt unaware of procedure taking place
significant amount of tx can be carried out in one visit
may be able to coordinate interventions with other specialities

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52
Q

what are the disadvantages/limitations of GA

A

needs careful tx planning
tx has to be more radical to be done in one visit
open consent needed as tx plan can change
doesnt help pt get over fear #
hospital admission required
pre-op fasting and after care
risk of morbidity and mortality

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53
Q

what is the only place GAs can be administered

A

hospital with intensive care facillites

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54
Q

what is deep sedation

A

nearly unconscious, only has purposeful response to repeated and painful stimulation

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55
Q

what is sedation used to achieve

A

get pt relaxed enough to allow tx to proceed safely and with minimal physiological and psychological stress

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56
Q

what are general indications for sedation

A

anxiety and phobias
prolonged or traumatic procedures
bad gag reflex
medical conditions aggravated by stress
special care

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57
Q

why is conscious sedation safe

A

pt is conscious - communcation maintained
pt spontaneosuly maintains own airway
cario-respiratory fucntion is normal

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58
Q

what happens after IV injection

A

rapid rise in plasma level
drug passes through R side heart, pulmonary circulation and the L side heart
goes to brain via arterial system
effects start once crossed blood-brain barrier

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59
Q

what is the hand-heart-brain circulation time

A

25 seconds

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60
Q

what is a non-barbiturate sedation drug

A

propofol

61
Q

what are the 2 ways a pt recovers from sedation

A
  1. redistribution of the drug from CNS into body fat
  2. uptake and metablosim of drug by liver and elimination by kidneys
62
Q

what is redistribution responsible for after sedation

A

intial recovery, the alpha hald-life, time taken for serum conc to drop by 50%

63
Q

what is elimination responsible for after sedation

A

beta half-life, time taken to remove half the drug from the body

64
Q

what are the differences in benzodiazepines due to

A

affinity for receptors (potency)
half life
active metabolites

65
Q

describe the mechanism of action of benzodiazepines

A

gamma aminobutyric acid
endogenous inhibitory neurotransmitter
GABA controls synaptic flow of chloride ions
activation of the benzodiazepine receptors enhances the flow of chloride ions

66
Q

what happens when chloride ions enter the cell

A

resting membrane potential more negative
more difficult to fire an action potential so reduces:
- polysynaptic transmission
- depressing uptake of sensory information

67
Q

is diazepam soluble in water

A

no

68
Q

what is the half life of diazepam

A

30 hours

69
Q

why is diazepam no longer used for IV sedation

A

the organic solvent caused vein damage, pain, thrombophlebitis, skin ulceration

70
Q

what is the issue with diazemuls

A

long half life and possibility of rebound sedation

71
Q

is midazolam water soluble

A

yes

72
Q

what is the pH of midazolam

A

<4

73
Q

describe the administration of midazolam

A

2-2.5mg 5-10 mins before procedure at 2mg/min, increase steps of 1mg if required
usual total dose is 3.5-5mg
maximum 7.5mg per course

74
Q

what is the current limit of midazolam on clinic

A

10mg

75
Q

describe administration of midazolam for elderly ppl

A

initially 0.1-1mg 5-10 mins before procedure at 2mg/min
increase in steps of 0.5-1mg
3.5mg max per course

76
Q

what happens to midazolam when it enters the bloodsteam

A

becomes lipid soluble at physiological pH

77
Q

what is the elimination half-life of midazolam

A

1.9 hours +/- 0.9 hours

78
Q

where is midazolam metabolised

A

rapidly in liver but some in bowel

79
Q

what active metabolite does midazolam produce

A

alpha-hydroxymidazolam

80
Q

what is the half life of alpha-hydroxymidazolam

A

1.25 hours +/- 0.25 hours

81
Q

what can happen shortly after midazolam injection

A

laryngeal reflexes dulled

82
Q

what can rapid injection of midazolam cause

A

respiratory depression and apnoea

83
Q

what happens every time you add an increment of midazolam

A

the half-life starts again with that dose increment and a dangerous accumulation can build up

84
Q

what 4 drugs interact with midazolam

A

antibiotics - cins
antivirals - avirs
antifungals - azoles
anticancer- ibs

85
Q

what are side effects of midazolam

A

vomiting
skin reactions

86
Q

what are 2 precautiosn for midazolam

A

cardiac disease
debilitated patient (children)

87
Q

what are 3 contraindications for midazolam

A

CNS depression
compromised airway
severe respiratory depression

88
Q

what can benzodiazepines cause in pregnancy

A

neonatal withdrawal symptom
late pregnancy - neonatal hypothermia, hypotonia, respiratory depression
small amount present in breast milk, avoid for 24 hours

89
Q

what are the guidelines for use of benzodiazepines in hepatic/renal impairment

A

mild/moderate hepatic - advised caution
severe hepatic - avoid
renal - advised caution due to risk of increased cerebral sensitivity

90
Q

why is caution needed for midazolam in elderly

A

altered drug distribution:
- lower total body water
- increased body fat
- decreased serum albumin
- altered hepatic metabolism
- altered renal excretion

91
Q

what is the half life of flumazenil

A

50 minutes

92
Q

how does flumazenil work

A

has a higher affinity for the benzodiazepine receptor than vitrually all known active drugs

93
Q

how is flumazenil adminitsred (dose)

A

200 ug bolus and wait 1 min
increments of 100 ug every minute until pt fully recovered

94
Q

how much flumazenil can be given in one dose

A

500 ug

95
Q

what is the maximum dose of flumazenil

A

1mg

96
Q

what is propofol

A

aqueous white emulsion with rapid onset, clearance, distrubiton and metabolism

97
Q

what is the half life of propofol

A

distribution 2-4 mins
elimination 30-40 mins

98
Q

what are the problems with propofol

A

pain on injection
expensive
narrow margin of safety
not licensed for dentists to use

99
Q

what does propofol interact with

A

alcohol
LA
anti-hypertensives
anxiolytics
CBD

100
Q

what are contraindications for nitrous oxide

A

1st trimester pregnancy
copd
vit b12 deficiency
history of substance abuse
methylenetetrahydrofolate reductase deficiency
mental health conditions

101
Q

name 2 topical anaesthetics creams

A

EMLA
ametop gel

102
Q

what is emla cream

A

2.5% lidocaine
2.5% prilocaine

103
Q

what is ametop gel

A

4% amethocaine(tetracaine)

104
Q

can you use ametop gel in pregnancy

A

no

105
Q

how many problem drug users in scotland

A

72000

106
Q

how much does drug users cuase per year

A

2.6bn

107
Q

5 most common drugs in scotland

A

cannabis
cocaine
ecstasy
amphetamines
heroin

108
Q

what % scottish adults use cocaine

A

3.8

109
Q

what does cocaine + alcohol cause

A

cocaethylene

110
Q

what does cocaetheylene do to the body

A

makes u 24x more likely to have heart attack

111
Q

name 5 stimulants

A

caffeine
nicotine
cocaine
amphetamines
ecstasy

112
Q

name 5 depressants

A

alcohol
solvents
heroin
morphine
benzodiazepines

113
Q

name 3 hallucinogens

A

LSD
magic mushrooms
cannabis

114
Q

how many deaths per year from drug abuse

A

500

115
Q

how many deaths per year from alcohol

A

5-250000

116
Q

how many deaths per year from smoking

A

100,000

117
Q

what are the 2 main statures relating to drugs in the UK

A

the medicines act 1968
misuse of drugs act 1971

118
Q

what are 5 class A drugs

A

heroin
cocaine
methamphetamine
ecstasy
methadone

119
Q

name 2 class B drugs

A

amphetamines
cannabis

120
Q

name 3 class 3 drugs

A

benzodiazepines
ketamine
anabolic steroids

121
Q

what is heroin a derivative of

A

morphine

122
Q

how much more potent is heroin than morphine

A

4x

123
Q

what are the positive effects of opiates

A

initial euphoria
removal of tension
tranquility
sense of control
detachment from worries & fears
analgesia

124
Q

what are the negative effects of opiates

A

itching
flushing
myosis
appetite suppression
slurred speech
slow gait
depression
constipation

125
Q

what health problems come with risky behaviour

A

unwanted pregnancy
death
STDs
assault
BBV’s

126
Q

what health problems are associated with injecting

A

BBVs
DVT
collapased veins
amputation
abscesses

127
Q

what mental health problems are associated with drug use

A

paranoia
schizophrenia
depression
bulimia/anorexia
bipolar

128
Q

what is the ffoulds classifications

A

organic
psychosis
neurosis
personality disorder
eating disorder

129
Q

what is neurosis

A

contact retained with reality

130
Q

what is psychosis

A

contact lost with reality

131
Q

give 5 examples of neuroses

A

anxiety
phobic
obsessional
hypochondrial
depressive

132
Q

name 2 funtional psychoses

A

bipolar
schizoprenia

133
Q

what is schizophrenia

A

though and emotion disorder

134
Q

name 3 eating disorders

A

anorexia nervosa
bulimia nervosa
pica

135
Q

what are the oral effects of anorexia

A

ulcers
dry mouth
infections
bleeding

136
Q

what are oral effects of bulimia

A

dental erosion
oesophageal stricture

137
Q

what are oral signs of pica

A

fractured teeth
dentures
braces

138
Q

what are 3 ways of breaking the cycle

A

harm reduction
substitution
prison

139
Q

what are 3 reasons for homelessness

A

relationship breakdown
prison
loss of employment

140
Q

what is methadone

A

methadone hydrochloride
synthetic opiate analgesic

141
Q

how does methadone work

A

action on CNS
continuous occupancy of Mu opioid receptors
stabilizes neurochemistry

142
Q

where is methadone absorbed

A

buccal mucosa
stomach

143
Q

what is the sugar content in normal methadone

A

50%
70ml = 35g sugar

144
Q

why do drug misusers have poor oral health

A

dry mouth
bruxism
sugar craving
sugar in medication
non-attendance
poor knowledge
smoking and alcohol

145
Q

what is found orally with amphetamines

A

xerostomia - caries and perio
bruxism - TMD
attrition/erosion

146
Q

what does ecstasy cause OH wise

A

bruxism - TMD
occlusal wear on posterior teeth
xerostomia
attrition and erosion
mucosal burns

147
Q

what does cocaine cause OH wise

A

xerostomia
caries in unusual surfaces
bruxism TMD
erosion
gingival and tongue erosions
ulceration of palate
cluster headaches

148
Q

what is the risk of LA after cannabis use

A

increased risk of tachycardia with adrenaline

149
Q

what is some methadone specific advice for users

A

drink with a straw
take near mealtime
swallow immediately
rinse with water after
chew sugar free gum to increase saliva

Module 8 (7 decks)

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