WHAT YOU DO PRE-ANESTHESIA???

The preoperative visit usually involves the following actions:

• Review of medical history, family history and social habits
• Physical examination
• Request for additional examinations
• Risk assessment
• Explanation of the GA procedure and risks
• Informed consent form
• GA procedure planning
• Prescription of premedication
• Pre-operative instructions

The first step of the pre-anesthetic evaluation is the review of the patient’s medical history (health conditions and medications), family history, and social history.

Medical History

Reviewing of the past medical history of the patient is an essential part of the preparation for general anesthesia. Your dentist anesthesiologist needs to know about your past and present health conditions.

The existence of diseases such as asthma, diabetes, tuberculosis, seizures or any chronic major organ dysfunction, but particularly diseases of the cardiovascular and respiratory systems, is a significant factor in deciding if a patient is a suitable candidate for general anesthesia, or which anesthetic drugs should be used.

Identification of pregnancy in the first trimester is a contraindication to GA due to the risk of teratogenicity. Pregnant women are generally at a higher risk of regurgitation and aspiration of gastric contents during general anesthesia. It is also generally agreed that the elderly are subject to increased risks of anesthesia.

Previous anesthesia history - Adverse reactions to anesthesia

Your dentist or anesthesiologist must be notified if you (or any other member of your family) have a history of problems or adverse reactions to general anesthesia, such as allergic reactions, intubation problems, anesthesia awareness during GA, or postoperative nausea and vomiting. Several related problems are caused by hereditary disorders which need special attention.

Medications usage

Several common medications may interact with anesthesia drugs either enhancing or reducing their effect. Failure to fully disclose medication usage can increase the risks associated to general anesthesia, because many drug interactions can be potentially dangerous.

Provide the dentist anesthesiologist with a full list of all the medications you take regularly (both prescription and over-the-counter medications), and any other medication you may have taken in the last days. Do not forget to include in the list and any herbal products, natural supplements or alternative medicines you take, because some of them (e.g. valerian, and ginseng) can also interact with certain general anesthesia drugs. Your dentist must also know about any allergic reactions you've had to medicines in the past.

The anesthesiologist will advise you if you have to adjust the dosage or suspend taking certain medications prior or after the general anesthesia procedure.

Family history – Hereditary problems

Some hereditary conditions can cause dangerous complications during general anesthesia, if the anesthesiologist is not made aware of them. Family medical history is useful in identifying possible hereditary conditions such as:

• Malignant hyperthermia. Malignant hyperthermia (MH) is an inherited disorder with a high mortality rate, which may occur during GA causing uncontrolled rise of body temperature.
• Porphyria. A rare hereditary blood disorder in which the hemoglobin is abnormally metabolized, resulting in excessive production of porphyrins. The condition may be triggered by some drugs used in GA such as barbiturates.
• Suxamethonium apnea. It is a rare condition where the patient’s body metabolizes very slowly the drug suxamethonium (succinylcholine) which is used in general anesthesia procedures as a muscle relaxant. As a result the patient may remain paralyzed and unable to breath for longer periods, requiring ventilation support.

Social history and habits (smoking, alcohol, drug usage)

Patients with social habits such as smoking, alcohol or drug usage are more susceptible to complications during or after GA. Any such usage must be disclosed to the dentist anesthesiologist in order to adjust accordingly the anesthesia planning (drug selection and dosage), or suggest another alternative solution.

• Smoking. Smoking has negative effects on the respiratory tract and function, reducing the oxygen-carrying capacity of the blood, and increasing the incidence of respiratory infection and postoperative respiratory morbidity. Patients should stop smoking for at least 12 hours before anesthesia (ideally they should stop smoking for 6 weeks before anesthesia) to reduce this risk.
• Alcohol. Regular consumption of alcohol may have caused liver damage affecting the metabolism and lead to tolerance to anesthetic drugs.
• Drug abuse. Except of the obvious problem due to drug interactions, other issues for general anesthesia in drug abusers include possible inadequate venous access and increased risk for existence of infectious diseases such as HIV or hepatitis. Drug and alcohol abusers are at a much higher risk of anesthesia awareness.

Physical examination

A full physical examination is important to complement the preanesthetic evaluation. The dentist anesthesiologist will particularly focus on the patient's airway, inspecting the mouth and pharynx soft tissues, and neck’s flexibility. The patient will also be checked for loose teeth, dentures, or crowns.

The vital signs of the patient (e.g. blood pressure, heart rate, oxygen saturation) will be checked and recorded. A more extensive physical examination may be required for medically compromised patients.

Request for additional examinations

Although healthy patients under 40 years old may not require further preanesthetic examinations, a blood and urine test, and a chest x-ray are typically recommended. These tests can reveal conditions related to the lung, heart, liver, or kidney function, diabetes or other problems that the patient may be unaware of.

Additional examinations may be asked for patients with a history of health conditions, in order to determine their exact health status.

Continue

ANAESTHETICS

LOCAL COMPLICATIONS OF ANAESTHETICS

A)COMPLICATIONS ARISING FROM DRUGS OR CHEMICAL USED

1.SOFT TISSUE INJURY

2.SLOUGHING OF TISSUES

B)COMPLICATIONS ARISING FROM INJECTION TECHNIQUES

1)NEEDLE BREAKAGE

2)HEMATOMA

3)FAILURE TO OBTAIN LOCAL ANESTHESIA

4)POST-INJECTION HERPETIC LESIONS

C)COMPLICATIONS ARISING FROM BOTH

1)PAIN ON INJECTION

2)BURNING ON INJECTION

3)TRISMUS

4)BLANCHING OF SKIN

5)EDEMA

6)PERSISTENT PARATHESIA OR ANESTHESIA

7)INFECTION

8)PERSISTENT PAIN

9)NEUROLOGICAL SYMPTOMS

               FACIAL N. PARALYSIS

               VISUAL DISTURBANCES

1)SOFT TISSUE INJURY
CAUSES	PREVENTION	MANAGEMENT
-SELF INFLICTED TRAUMA TO LIPS ,TONGUE WHILE STILL NUMB -SEEN IN CHILDREN AND MENTALLY AND PHYSICALLY DISABLED -SOFT TISSUE ANESTHESIA LASTS LONGER THEN PULPAL	-APPROPRIATE DURATION LA -COTTON ROLLS BETWEEN LIPS AND TEETH -WARN THE PATIENT AND GUARDIAN AGAINST EATING,DRINKING HOT FLUIDS AND BITING ON LIPS OR TONGUE TO TEST FOR ANESTHESIA	-ANALGESICS FOR PAIN -ANTIBIOTICS -LUKEWARM SALINE RINSES TO AID IN DECREASE ANY SWELLING THAT MAY BE PRESENT -PETROLEUM JELLY AS LUBRICANT
2)SLOUGHING OF TISSUES
i)EPITHELIAL DEQUAMATION -TOPICAL ANESTHETIC FOR PROLONGED PERIOD -HIGHTENED SENSTIVITY OF TISSUE TO LA REACTION IN AREA OF TOPICAL ANESTHETICS ii)STERILE ABSCESS -PROLONGED --ISCHEMIA DUE TO VASOCONSTRICTOR -DEVELOPS ON HARD PALATE	-DO NOT USE HIGH CONC. LA WITH VASOCONSTRICTOR (NOREPINEPHRINE 1:30,000 NOT PRESCRIBED)	DEPEND ON INJURY -SYMPTOMATIC-ANALGESICS,ORABASE -RESOLVES WITHIN 1-2 WEEKS -AN ESTABLISH LESION MAY REQUIRE INCISION AND DRAINAGE

B)COMPLICATIONS ARISING FROM INJECTION TECHNIQUES

1)NEEDLE BREAKAGE

CAUSES

PRIMARY CAUSE-

              UNEXPECTED MOVEMENT OF PATIENT

SECONDARY CAUSE-

¤  INAAPROPRIATE THICKNESS OF NEEDLE

¤  PREVIOUSLY BENT

¤  REDIRECTION OF NEEDLES ONCE INSERTED INSIDE TISSUE

¤  MANUFACTURE DEFECT(RARE)

¤  FORCING NEEDLE AGAINST RESISTENCE

¤  NEEDLE ENGAING THE PERIOSTEUM

PREVENTION

v  INFORM THE PATIENT

v  USE PROPER GAUZE NEEDLE(FOR N. BLOCK-25 GAUZE,FOR INFILTRATION-27,25,30 GAUZE

v  USE PRESTERLIZED DISPOSABLE NEEDLES

v  ENTIRE LENGTH SHOULD NOT BE INSERTED(FEW MM AWAY FROM HUB)

v  DO NOT REDIRECT IF EMBEDDED

v  USE GOOD QUALITY NEEDLE

v  GENTLE MANIPULATION-NO EXCESSIVE FORCE

v  DO NOT PERMIT THE NEEDLE TO ENGAGE THE PERIOSTEUM

v  STABILISATION OF JAW

v  NEEDLE SHOULD ALWAYS BE KEPT DURING INSERTION

v  AVOID MULTIPLE PENETRATIONS

MANAGEMENT

CALM,DO NOT PANIC

INFORM PATIENT

IF VISIBLE-USE HEMOSTAT OR MAC GILLS TUBE

IF NOT-FLOUROSCOPE,FOLLOW UP,SURGERY

2)HEMATOMA

THE EFFUSION OF BLOOD INTO EXTRAVASCULAR SPACES CAN RESULT FROM INADVERTENTLY NICKING A BLOOD VESEL(ARTERY OR VEIN)DURING THE INJECTION OF LA

NICKING OF ARTERY-HEMATOMA INCRESE RAPIDLY IN SIZE

NICKING OF VEIN-MAY OR MAY NOT RESULT IN FORMATION

CAUSE

NICK→BLOOD EFFUSES FROM VESSELS UNTIL EXTRAVASCULAR PRESURRE EXCEEDS INTRAVASCULAR→CLOTTING OCCURS

PREVENTION

³  MODIFY INJECTION TECHNIQUE AS DICTATED BY PATIENT

³  USE SHORT NEEDLE(APPROPRIATE LENGTH)

³  MINIMIZE NO. OF PENETRATION

³  NEVER USE NEEDLE AS A PROBE ON TISSUE

MANAGEMENT

IMMEDIATE-DIRECT PRESSURE AT SITE OF BLEEDING FOR NOT LESS THAN 2 MINS

BLOCK	PRESSURE SITE	CLINICAL MANIFESTATION
IANB	MEDIAL ASPECT OF MANDIBULAR RAMUS	INTRAORAL DISCOLORATION AND PROBABLE TISSUE SWELLING ON MEDIAL ASPECT OF MANDIBULAR RAMUS
INFRAORBITAL	INFRAORBITAL FORAMEN	DISCOLORATION OF SKIN BELOW THE LOWER EYELID
MENTAL N. BLOCK	MENTAL FORAMEN	DISCOLORATION OF SKIN OVER THE MENTAL FORAMEN OR SWELLING IN THE MUCOBUCCAL FOLD IN REGION OF MENTAL FORAMEN
PSA N BLOCK	SOFT TISSUE IN MUCOBUCCAL FOLD AS FAR AS POSSIBLE AS DISTALLY AS CAN BE TOLERATED BY PATIENT	COLORLESS SWELLING APPEAR ON SIDE OF FACE (USUALLY A FEW MINUTES AFTER THE INJEVTION IS COMPLETED)→DAYS INFERIOR AND ANTERIOR TOWARD THE LOWER ANT. REGION OF CHEEK

IN PSA HEMATOMA EARLIER IN PTERYGOID VENOUS PLEXUS

ACCORDING TO SICHER –PSA ARTERY

OF SORENESS DEVELOPS –ADVISE THE PATIENT TO TAKE ANALGESIC

DO ON APPLY HEAT OVER FOR AT LEAST 4-6 HOUR(VASODILATION-INCREASES IN SIZE)

HEAT APPLIED ON NEXT DAY-ACTS AS A)ANALGESIC AND B)    VASODILATORè↑RATE AT WHICH BLOOD ELEMENTS ARE RESORBED

IN FORM OF WARM MOIST TOWELS TO THE AFFECTED AREA FOR 20 MIN EVERY HOUR

RESOLVE S WITHIN 7-14 DAYS.

5)FAILURE TO OBTAIN ANESTHESIA

CAUSES

A)OPERATOR DEPENDENT

i)LA AGENT(TYPE,DOSE)

ii)IMPROPER SURGICAL TECH.

iii)INJ OF WRONG SOLN.

iv)I.V

v_I.M

B)PATIENT DEPENDENT

i)ANATOMICAL-ADDITIONAL INNERVATION

ii)PSYCHOLOGICAL –UNCOOPRATIVE,MOVEMENT

iii)PATHOLOGICAL-INFECTION

ADDITIONAL INNERVATION

‘CUTANEOUS COLLI NERVE’ (CERVICAL CUTANEOUS NERVE)-(A BRANCH OF 3^RD CERVICAL NERVE)-ENTERS A SMALL FORAMEN ON LINGUAL ASPECT OD RAMUS AND SUPPLIES INNERVATION TO MANDIBULAR TEETH.

IN CASE OF FAILURE IN OBTAINING OPERATIVE ANESTHESIA AFTER A MANDIBULAR INJ. ,A SUPPLEMENTAL INJ.CAN BE GIVEN TO CERVICAL CUTANEOUS NERVE.THIS IS DONE BY INSERTING THE NEEDLE LINGUALLY BETWEEN 2 BICUSPID TEETH,AT THE REFLECTION OF MUCOUS MEMBRANE AND DIRECTING IT POSTERIORLY,ABOUT HALF OF THE NEEDLE IS INSERTED AND ABOUT 0.5ML OF SOLN. IS INJECTED.

4)POST INJECTION HERPETIC LESIONS

CAUSE

• REACTIVATION OF DORMANT HERPES VIRUS
• H/O RECUURENT HERPES LABIALIS
• IN TERMINAL BRANCHES OF TRIGERMINAL NERVE

PREVENTION-DELAY SURGICAL INTERVENTION IN THE ACTIVE STAGE

MANAGEMENT-ANTIVIRAL DRUGS

C)COMPLICATIONS ARISING FROM BOTH

CAUSES	PREVENTION	MANAGEMENT
1)PAIN ON INSERTION -CARELESS TECH. -BLUNT NEEDLE -RAPID INSERTION OF LA SOLN. CAN CAUSE TISUE DAMAGE -HIGH TEMP. OF SOLN.	-PROPER TECH. -SHARP NEEDLE-INSERT LA SLOWLY -USE STERILE LA SOLN. -USE TOPICAL LA B4 -SOLN. AT ROOM TEMP.	NOT REQUIRED
2)BURNING SENSATION -RAPID INJ. -CONTAMINATED NEEDLE CARTRIDGE -HIGH TEMP. LA SOLN. ALTERED PH OF SOLN. (PH PLAIN-5 APP,WITH VASOCONSTRICTOR-3 APP)	-SLOW INJ. -SOLN. AT ROOM TEMP.	NOT REQUIRED
3)INFECTION -CONTAMINATION OF NEEDLE -IMPROPER PREP. OF SITE -NEEDLE PASSING THROUGH AN AREA OF INFECTION -LA SOLN DEPOSITED UNDER PRESSURE ,AS IN PDL INJ.→TRANSPORT BACTERIA	-PROPER PREP. OF SITE PRIOR TO PENETRATION -CAREFUL HANDLING OF NEEDLES (AVOID TOUCHING NON-STERILE SURFACE)	-ANALGESICS -ANTIBIOTICS -PHYSIOTHERAPY -MUSCLE RELAXANTS
4)EDEMA -TRUAMA -INFECTION -ALLERGY -HEMORRHAGE -INJ OF IRRITATING SOLN.	-PREOP ASSESMENT -CAREFUL HANDLING OF LA ARMAMENTARIUM -ATRAUMATIC TECH.	-FIND OUT CAUSE -ALLERGY-(A,B,C,D)
5)TISSUE BLANCHING -TRAUMA TO BLOOD VESSEL BY NEEDLE -I.V. ADMINISTRATION	-USE ASPIRATION TECH. -AVOID INTRAARTERIAL ADMINISTRATION	-TRANSIENT PHENOMENON -NO T/T REQUIRED

6)TRISMUS

CAUSES

PRIMARY CAUSE-TRAUMA TO MUSCLE ,BLOOD VESSELS IN INFRATEMPORAL FOSSA

SECONDARY CAUSES-

#INJECTION OF LA CONTAINING IRRITATING SOLN.(ALCOHOL,COLD STERILISING SOLN.)

#LA HAVE MILD MYOTOXIC PROPERTIES

(AIDS TO PROGRESSIVE NECROSIS OF EXPOSED MUSCLE FIBRES)

# HEMATOMA –(LEADS TO IRITATION OF MUSCLE FIBRES

# LOW GRADE INFECTION

# EXCESSIVE DEPOSITION OF LA-DISTENSION OF TISSUES-POST INJ TRISMUS

#THE BARB OCCURRED WHEN THE NEEDLE COME INTO CONTACT WITH THE MEDIAL ASPECT OF THR MANDIBULAR RAMUS,WITHDRAWL OF THE NEEDLE FROM TISSUE INCREASED THE LIKELIHOOD OF INVOLVEMENT OF THE LINGUAL OR IANB AND DEVELOPMENT OF TRISMUS

PROBLEMS

AVG. INTERINCISAL OPENING IN ACSES OF TRISMUS IS 13.7MM

IN CHRONIC HYPOMOBILTY-

• IF T/T NOT GIVEN
• SECONDARY TO ORGANISATION OF HEMATOMA WITH SUBSEQUENT FIBROSIS AND SCAR CONTRACTURE
• INFECTION –INCRESED PAIN-INCRASED TISSUE REACTION(IRRITATION AND SCARRING).

PREVENTION

Ø  USE SHARP,STERILE,DISPOSABLE NEEDLE

Ø  USE ASEPTIC TECH.

Ø  ATRAUMATIC TECH.

Ø  AVOID MULTIPLE PENETRATION

Ø  USE MINM EFFECTIVE VOL. OF LA

MANAGEMENT

1)HEAT THERAPY-HOT MOIST TOWELS TO AFFECTED AREA FOR 20 MINS EVERY HOUR

2)WARM SALINE RINSE-HELD IN THE MOUTH ON THE INVOLVED SITE AND SPIT OUT

3)ANALGESICS ASPIRIN(325MG)

4)MUSCLE RELAXANTS-

CHLOROXAZONE (250 mg IN 2 TO 3 DIVIDED DOSE)

OR DIAZEPAM (5-10 mg BID)

OR MEMEPROBAMATE(1.2g IN 3-4 DIVIDED DOSES)

5)PHYSIOTHERAPY-OPENING AND CLOSING THE MOUTH ,AS WELL AS LATERAL EXCURSIONS OF THE MANDIBLE FOR 5 MINS EVERY 3 TO 4  HOURS.

6)CHEWING GUMS (SUGARLESS)-TO PROVIDE LATERAL MOVEMENT OF TMJ

7)ANTIBIOTICS

AVOID FURTHER DENTAL T/T IN INVOLVED REGION UNTIL SYMPTOMS RESOLVE AND PATIENT IS COMFORTABLE.

IF DENTAL CARE HAS TO BE CONTINUED –THAN ALTERNATE METHOD OR TECH. FOR ACHIEVING LA MAY BE EMPLOYED.

THE AKINSI MANDIBULAR N. BLOCK PROVIDES RELIEF FORM THA MOLAR DYSFUNCTION AND ALLOWS THE PATIENT TO OPNE THE MOUTH AND PERMITS ADMINSTARTION OF APPROPRIATE ADDITIONAL INJ. IF REQUIRED.

COMPELTE RESOLUTION OD POST INJ. TRISMUS TAKES APPROXIMATELT 6 WEKS ,WITH A RANGE OF 4 TO 20 WEEKS.

7)NEUROLOGICAL SYMPTOMS

A)VISUAL DISTURBANCES

i)SQUINT

ii)DIPLOPIA

iii)TRANSIENT AMAUROSIS

iv)PERAMNENT BLINDNESS

i)DIPOPIA OR DOUBLE VISION

v  LA SOLN. INFILTRATING INTO THE ORBIT TO ANESTHETIC THE EXTRINSIC OCULAR MUSLCES OF THE YES.

v  INTAARTERIAL INJ.-UNCOMMON VASCULAR PATTERNS-(ORBIT IS SUPPLIED EITHER WHOLLY OR PARTLY BY MIDDLE MENINGEAL ARTERY.)

v  NO MANAGEMENT REQUIRED (RESOLVES WITHIN 3 HOURS,OR WHEN EFECT ENDS)

ii)TRANSIENT SQUINT AND DOUBLE VISION

v  PARALYSIS OF EXTRINSIC MUSCLES

LA DIFFUSED INTO ORBIT FROM PTERYPALATINE GANGLION AND INFRATEMPORAL FOSSA VIA INFRAORBTAL FISSURE,EFFECTING OCCULOMOTOR,TROCHLEAR,ABDUCENS NERVE.

v  NO TREATMENT REQUIRED

CAUSES	PREVENTION	MANAGEMENT
FACIAL NERVE PARALYSIS DIRECTLY LA DEPOSITION IN VICINITY OF 7TH CRANIAL NERVE 1)INFRAORBITAL N. BLOCK 2)PARAPERIOSTEAL OF MAXILLARY CANINE INDIRECTLY-INTO DEEP LOBE OF PAROTID GLAND IN IANB	FOLLOW STANDARD PROTOCOL	EXPLAIN, REASSURE PATIENT -UNILATERAL LOSS OF MOTOR FUNCTION-TRANSIENT -EYE DRESSING GIVEN -CONTACT LENSES SHOULD BE REMOVED
8)PERSISTENT PARATHESIA OR ANAESTHESIA -INJECTING CONTAMINATED LA SOLUNTION -TRAUMA TO N. SHEATH -HEMORRAHGE AROUND N.	-FOLLOW STANDARD PROTOCAL -CAREFUL SURGICAL TECH. -PROPER HANDLING OF CARTRIDGE	-REASSURE THE PATIENT - VIT B1,B6,B12 -IF DOES NOT RESOLVE THAN REFER FOR SURGERY
9)PERSISTENT PROLONGED PAIN -POOR SURGICAL TECH.(IN SUPRAPERIOSTEAL TEARING VOL.) -NEEDLE TIP BARBS -ISCHEMIC NECROSIS -MULTIPLE PENETRATIONS	-GOOD SURGICAL TECH. -AVOID NEEDLE WITH BARBS -USE VASOCONSTRICTORS WITH MAXIMUN DILUTION -AVOID MULTIPLE PENETRATION	-SYMPTOMATIC

SYSTEMIC COMPLICATIONS OF LA

CAUSES OF ADVERS EDRUG REACTION

TOXICITY CAUSED BY DIRECT EXTENSION OF THE USUAL PHARMACOLOGICAL EFFECTS OF DRUGS-

1.SIDE EFFECTS

2.OVERDOSE

3.LOCAL TOXIC EFFECTS

TOXICITY CAUSED BY ALTERATION IN RECIPIENT OF THE DRUG

1.A DISEASE PROCESS(HEPATIC DYSFUNCTION,CHF,RENAL DYSFUNCTION)

2.EMOTIONAL DISTURBANCES

3.GENETIC ABBERATIONS(ATYPICAL PLASMA CHOLINESTERASE,MALIGNANT HYPERTHERMIA)

TOXICITY CAUSED BY ALLERGIC RESPONSES TO THE DRUGS

OVERDOSE

A DRUG OVERDOSE REACTIONS HAS BEEN DEFINED AS THOSE CLINICAL SIGNS AND SYMPTOMS THAT RESULT FROM AN OVERLY HIGH BLOOD LEVEL OF A DRUG IN VARIOUS TARGET ORGANS AND TISSUES

PREDISPOSING FACTOR

PATIENT FACTORS,DRUG FACTORS

PATIENT FACTOR	DRUG FACTOR
AGE WEIGHT OTHER DRUGS SEX PRESENCE OF DISEASE GENETICS MENTAL ATTITUDE AND ENVIRONMENT	VASOACTIVITY CONC. DOSE ROUTE OF ADMINISTRATION RATE OF INJ. VASCULARITY OF INJ SITE PRESENCE OF VASOCONSTRICTOR

CLINICAL  MANIFESTAIOTNS OF OVERDOSE

MINIMAL TO MODERATE OVERDOSE LEVELS

SIGNS	SYMPTOMS
q  TALKATIVENESS q  APPREHENSION q  EXCITABILITY q  SLURRRED SPEECH q  EUPHORIA q  DYSARTHIA q  NYSTAGMUS q  VOMITTING q  DISORIENTATION q  LOSS OF RESPONSE TO PAINFUL STIMULI q  ↑BP q  ↑HR q  ↑RR	q  LIGHTHEADENESS AND DIZZINESS q  RESTLESSNESS q  NERVOUSNESS q  NUMBNESS q  SENSATION q  METALLIC TASTE q  VISUAL DISTURBANCES q  AUDITORY DISTURBANCES q  LOSS OF CONSCIOUNESS q  DROWSINESS AND DISORIENTATION

MODERATE TO HIGH OVERDOSE LEVELS

L  SEIZURE

L  CNS DEPRESSION

L  ↓BP

L  ↓HR

L  ↓RR

LIDOCAINE LEVEL	CVS
1.8-5.0 ug/ML	ANTIDYSRRTHMIC ACTIONS
5.0-10.0	MYOCARDIAL DEPRESSION
10.0PLUS	MASSIVE PERIPHERAL VASODILATION,MYOCARDIAL DEPRESSION CARDIAC ARREST
	CNS
0.5-4	ANTICONVULSANT ACTION
4.5-7	CNS DEPRESSION,EXCITATION
7.5-10.0	CNS DEPRESSION ,SEIZURE
10.0 PLUS	GENERALIZED CNS DEPRESSION

CVS EFFECTS

LA (VASODILATOR)

↓

PERIPHERAL RESISTANCE

↓

↓BP(BP=PR*CO)

FURTHER IN LA CONC.

AFFECT N. CONDUCTION OF HEART

↓

MYOCARDIAL CONTRACTILITY

↓

C.O.(CO=HR*SV)

HEART’S NEURONAL CONDUCTION SYS. IS INHIBITED OR COMPLETELY BLOCKED BY LA.

AT TOXIC LEVELS,DEPRESSION OF INTRACARDIAC N. CONDUCTION CAN RESULT IN ATRIOVENTRCULAR DISSOCIATION,VENTRICULAR RHYTHM ,VENTRICULAR FIBRILLATION AND ULTIMATELY CARDIAC ARREST.

CNS EFFECTS

THE CONDUCTION OF INHIBITORY NEURONS ID USUALLY BLOCKED BY LA AGENTS AS THEY REACH TOXIC LEVELS-RESULTING IN UNMODIFIED ACTION OF FACILITATORY NEURONS(IE,CONVULSIVE-LIKE MOVT.)AS THE DOSE INCREASES,FACILITATORY NEURONS ARE ALSO BLOCKED RESULTING IN CESSATION OF FUNCTION.

CERTAIN AMIDE TYPE AGENTS(IE LIDOCAINE)-EFFECT PRIMARILY FACILATORY NEURONS,HENCE DEPRESSION IS SEEN RATHER THAN EXCITATION.

MANAGEMENT

1)MILD OVERDOSE

RETENTION OF CONCIOUSNESS,TALKATIVENESS,AGITATION,

↑HR,↑BP. ↑RR(5-10 MIN)→←

P→A→B→C→D

DEFINITIVE CARE

i)REASSURE THE PATIENT

ii)ADMINISTER OXYGEN VIA NASAL CANULA TO PREVENT ACIDOSIS

iii)MONITOR AND RECORD VITAL SIGNS

iv)ESTABLISH i.v. INFUSION

v)USE OF ANTICONVULSANTS –NOT USUALLY INDICATED

       DIAZEPAM-5mg.MIN i.v.

        MIDAZOLAM-1mg/MIN

2)SEVERE OVERDOSE

UNCONSCIOUSNESS WITH OR W/O CONVULSIONS

RAPID ONSET(WITHIN 1 MINUTE)

i)PROTECT PATIENTS ARMS,LEGS AND HEAD

LOOSEN TIGHT CLOTHES

ii)IMMEDIATELY SUMMON EMERGENCY MEDICAL ASSISTENCE.

iii)CONTINUE BLS

iv)ADMINISTER ANTICONVULSANT

    DIAZEPAM –i.v -5mg/min

IF VENEPUNCTURE NOT FEASIBLE

     MIDAZOLAM-im -1mg

IF HYPOTENSION PERSISTS(30 MINS)-VASOPRESSOR

     (PHENYNEPHRINE OR METHAOXAMINE)IM

EPINEPHRINE OVERDOSE

CLINICAL MANIFESTATIONS

SIGNS-↑BP. ↑HR,CARDIAC DYSRTHYMIAS

SYMPTOMS-FEAR,ANXIETY,THROBBING HEADACHE,PERSPIRATION,WEAKNESS,PALLOR,RESP. DIFFICULTY,PALPITATION

EPINEPHRINE	mg/ml	Mg/CARTRIDGE	MAX NO. OF CARTRIDGES
1:50,000	0.02	0.036	5(H),1(C)
1:100,000	0.01	0.018	10(H),2©
1:200,000	0.005	0.009	20(H),4©

MANAGEMENT

P→A→B→C→D

P-SEMISITIING OR ERECT POSITION( ↓CEREBRAL BP)

i)REAASURE THE PATIENT

ii)MONITOR VITAL SIGNS

iii)OXYGEN ADMINISTERE IF NECESSARY( C/I IN HYPERVENTILATION)

iv)RECOVERY

ALLERGY

ALLERGY IS A HYPERSINSITIVE STATE,ACQUIRED THROUGH EXPOSURE TO A PARTICULAR ALLERGEN,REEXPOSURE TO WHICH PRODUCE HEIGHTENED CAPACITY OT REACTION.

PREDISPOSING FACTORS

z  METHLYPARABEN

z  SODIUM BISULPHITE ALLERGY

z  EPINEHRINE

z  LATEX ALLERGY

z  TOPICAL ANESTHETIC ALLERGY

PREVENTION-PROPER HISTORY

ALLERGY TESTING

0.1ML OF EACH(INTRAVENOUS)

¶  0.9%NACL

¶  1% OR 2% LIODCAINE,

¶  3%MEPIVACAINE

¶  4%PRILOCAINE(W/O METHYL PARABEN,BISULPHITE,VASOPRESSORS.

INTRAORAL CHALLENGE TEST

0.9 ML OF LA SOLN. SUPRAPERIOSTEAL INFILTRATION ATRAUMATIC(BUT W/O TOPICAL LA)ABOVE A MAXILLARY RIGHT OR LEFT PREMOLAR OR ANT. TOOTH.

DENTAL MANAGEMENT IN CASE OF PRESENCE OF LA ALLERGY:

Í NO T/T OF AN INVASIVE NATURE CARRIED OUT

Í IF EMERGENCY –THEN UNDER GENERAL ANESTHESIA

Í IF GA NOT AVAILABLE –HISTAMINE BLOCKER

DIPPHENHYDRAMINE HCL IN 1 % SOLN. WITH 1:100,000 EPINEPHRINE(30 MIN OF PULPAL ANESTHESIA)

Í NITORUS OXIDE

Í ALTERNATIVES-ELECRONIC DENTAL ANESTHESIA

CLINICAL MANIFESTATIONS OF ALLERGY

DERMATOLOGICAL REACTIONS-

URTICARIA-WHEAL

ANGIOEDEMA-LOCALISED SWELLING INVOLVING FACE,HANDS,FEET,GENITILIA,LIPS,TONGUE.

RESPIRATORY REACTIONS-

BRONNCHOSPASM

RESP. DISTRESS

DYSPNOEA,WHEEZING,FLUSHING,CYANOSIS,PERSPIRATION,TACHYCARDIA,INCREASED ANXIETY,LARYNGEAL EDEMA

GENERALISED ANAPHYLAXIS

SKIN REACTION-PRURITIS,ERYTHEMA,URTICARIA,CONJUCTIVITIS,RHINITIS

GIT DISTURBANCE

RESP STMPTOMS-WHEEZING,DYSPNOEA

CVS-PALLOR,TACHYCARDIA,HYPOTENSION,CARDIAC DYSARRTHYMIA,UNCONCIOUSNESS,CARDIAC ARREST

MANAGEMENT

P→A→B→C→D

i)ADMINISTER EPINEPHRINE 0.3mg IM/SC OR

 HISTAMINE BLOCKER-50mg DIPHENHYDRAMINE OR

10 mg CHLORPHENIRAMINE

ii)MEDICAL CONSULTATION FROM PHYSICIAN

iii)OBSERVE THE PATIENT (60MIN)

iv)PRESCRIBE ORAL HISTAMINE BLOCKER

    50 mg CAP-TDS FOR 3-4 DAYS

BRONCHSPASM

P→A→B→C→D

i)TERMINATE T/T

ii)ADMINISTER OXYGEN (5-6 L/MIN)

iii)ADMINISTER EPINEPHRINE 0.3 mg IM/SC

iv)ADMINISTER HISTAMINE BLOCKER TO MINIMIZE RELAPSE

HISTAMINE BLOCKER-50mg DIPHENHYDRAMINE OR

10 mg CHLORPHENIRAMINE

 v)MEDICAL CONSULTATION

LARYNGEAL ODEMA

P→A→B→C→D

i)ADMINISTER EPINEPHRINE 0.3 mg IM/SC

ii)EMERGENCY MEDICAL SERVICE

iii)MAINTAIN AIRWAY

iv)ADDITIONAL DRUGS

HISTAMINE BLOCKER

-50mg DIPHENHYDRAMINE OR

10 mg CHLORPHENIRAMINE

CORTICOSTEROID-

  100mg HYDROCORTICOSONE IM/IV

GENERALIZED ANAPHYLAXIS

P→A→B→C→D

i)                    EMERGENCY MEDICAL SERVICE

ii)                  EPINEPHRINE (0.3ML OF 1:1000) IM/IV

iii)                OXYGEN AND VITAL SIGNS

iv)                IF DOES NOT IMPROVE SECOND DOSE OF EPINEPHRINE IN 10 MIN

v)               ADDITIONAL DRUGS

                 HISTAMINE BLOCKER

                       -50mg DIPHENHYDRAMINE OR

                          10 mg CHLORPHENIRAMINE

                CORTICOSTEROID-

                        100mg HYDROCORTICOSONE IM/IV

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