Local Anesthesia Review – Flashcards
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Absolute MRD: 90 mg (10 carps) Onset: 6-10 mins Pulpal Anesthesia: 90-180 mins Contraindications: children, geriatric, people w/mental or physical disabilities. Indications: long apt, pulpal anesthesia for more than 90 mins, post op pain management. Caution: compromised cardiovascular system.
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0.5% Bupivacaine 1:200,000 epi
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MRD (mg/lb): 3.0 MRD (mg/kg): 6.6 Absolute MRD: 400 mg (7.5 carps) Onset: 1.5-2 mins Pulpal Anesthesia: 20-40 mins Indications: children, geriatric, bisulfate allergy
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3% Mepivacaine plain
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MRD (mg/lb): 3.0 MRD (mg/kg): 6.6 Absolute MRD: 400 mg (11 carps) Onset: 1.5-2 mins Pulpal Anesthesia: 60 mins Contraindications: cardiovascular disease (ASA III-IV), hyperthyroidism, tricyclic antidepressants.
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2% Mepivacaine 1:20,000 levo
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MRD (mg/lb): 3.2 MRD (mg/kg): 7 Absolute MRD: 500 mg (6 carps) Onset: 2-3 mins Pulpal Anesthesia: 60 mins Contraindications: non-selective Beta blockers, cardiovascular disease (ASA III-IV), hyperthyroidism.
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2% Lidocaine 1:50,000 epi
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MRD (mg/lb): 3.2 MRD (mg/kg): 7 Absolute MRD: 500 mg (11 carps) Onset: 2-3 mins Pulpal Anesthesia: 60 mins Contraindications: bisulfite allergy, non-selective beta blockers. Indications: drug of choice for pregnancy.
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2% Lidocaine 1:100,000 epi
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MRD (mg/lb): 3.6 mg MRD (mg/kg): 8 mg Absolute MRD: 600 mg (8 carps) Onset: 2-4 mins Pulpal Anesthesia: Infiltrate: 10-15 mins; Block: 40-60 mins Contraindications: methemoglobinemia, APAP sulfonamides, nitrates, hypoxic cardiac/respiratory failure, anemia. Indications: bisulfate allergy, drug of choice for epi sensitive pts requiring more than 60 mins pulpal anesthesia (rapid bio-transformation- low toxicity). Caution: paresthesia (esp lingual nerve).
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4% Prilocaine plain
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MRD (mg/lb): 3.6 mg MRD (mg/kg): 8 mg Absolute MRD: 600 mg (8 carps) Onset: 2-4 mins Pulpal Anesthesia: 60-90 mins Contraindications: methemoglobinemia, APAP sulfonamides, nitrates, hypoxic cardiac/respiratory failure, anemia. Indications: bisulfate allergy, drug of choice for epi sensitive pts requiring more than 60 mins pulpal anesthesia (rapid bio-transformation- low toxicity), cardiovascular disease, brittle diabetics. Caution: paresthesia (esp lingual nerve).
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4% Prilocaine 1:200,000 epi
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MRD (mg/lb): 3.2 mg MRD (mg/kg): 7 mg Absolute MRD: based on pt weight (11 carps based on epi). Onset: Infiltrate: 1-2 mins; Block: 2-3 mins Pulpal Anesthesia: 75 mins Contraindications: bisulfite and Ester allergies Indications: nursing mothers, liver disease. Caution: paresthesia (esp lingual nerve), liver disease, cardiovascular disease, breastfeeding mothers, children under 4 yrs.
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4% Articaine 1:100,000 epi
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MRD (mg/lb): 3.2 mg MRD (mg/kg): 7 mg Absolute MRD: based on pt weight (22 carps based on epi). Onset: Infiltrate: 1-2 mins; Block: 2-3 mins Pulpal Anesthesia: 45 mins Contraindications: bisulfite and Ester allergies Indications: nursing mothers, liver disease. Cautions: paresthesia (esp lingual nerve), liver disease, cardiovascular disease, breastfeeding mothers, children under 4 yrs.
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4% Articaine 1:200,000 epi
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Trade name for Lidocaine- "the OCTOpus has a long arm SPAN so he can play the XYLOphone"
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Xylocaine
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Trade name for Lidocaine
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Octocaine
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Trade name for Lidocaine- "arm span"
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Lignospan
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Trade name for Mepivacaine- "Mepivacaine is a photographer that takes scandalous POLaroid Pics"
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Polocaine
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Trade name for Mepivacaine- "Mepivacaine is a photographer that takes scandalous polaroid pIcs"
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Isocaine
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Trade name for Mepivacaine- "Mepivacaine is a photographer that takes scandalous polaroid piCs"
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Carbocaine
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Trade name for Mepivacaine- "Mepivacaine is a photographer that takes SCANDalous polaroid picS"
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Scandonest
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Trade name for Prilocaine plain- "I'm going to PRY the NEST out of the big (FORTE) tree"
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Citanest
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Trade name for Prilocaine w/epi- "I'm going to PRY the NEST out of the big (FORTE) tree"
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Citanest Forte
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Trade name for Articaine- "ARTI has a ScEPTer"
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Septocaine
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Bupivacaine- " MARC and Viv like to BUP each other on the nose."
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Marcaine
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Bupivacaine- "Marc and VIV like to BUP each other on the nose."
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Vivacaine
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Trade name for Articaine- "ARTI likes to dress up like ZORO"
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Zorocaine
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Slowly injecting the LA solution
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What is the most important step in preventing a local anesthetic overdose?
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9 mg
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How many milligrams of a local anesthetic is in a full 0.5% solution carpule?
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36 mg
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How many milligrams of a local anesthetic is in a full 2% solution carpule?
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54 mg
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How many milligrams of a local anesthetic is in a full 3% solution carpule?
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72 mg
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How many milligrams of local anesthetic is in a full 4% solution carpule?
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Mepivacaine and Prilocaine (weakest).
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Which local anesthetics are weak vasodilators?
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Procaine. Later named Novocaine when it came out in the US.
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What was the first local anesthetic?
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Pregnancy (1:100,000 epi), methemoglobinemia, and ester allergies.
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What is Lidocaine the drug of choice for?
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The height of the mucobuccal fold, over the distobuccal root/cusp of the maxillary 2nd molar.
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What are the landmarks for administering a PSA nerve block?
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pKa. The higher the pKa, the longer, or slower the onset. The lower the pKa, the faster the onset.
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What affects the onset of the local anesthetic?
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The lipid solubility (how many LA molecules can go through the nerve membrane)
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What affects the potency of the local anesthetic?
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BisulFITE allergy, recent coronary bypass, heart attack or stroke within 6 mos, uncontrolled high BP/diabetes/hyperthyroidism, daily angina.
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Absolute contraindications for vasoconstrictors
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Controlled hyperthyroidism/diabetes/high BP, tricyclics antidepressants (do NOT use levonordefrin), non selective beta blockers, glaucoma, cocaine abuse (do NOT use LA if used cocaine in last 24hrs)
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Relative contraindications for vasoconstrictors. (Use cardiac dose)
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Children, geriatric or mental/physical disorder patients
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Contraindications for Bupivacaine
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Cardiovascular disease (ASA 3-4), hyperthyroidism and tricyclic antidepressants due to Levo.
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Contraindications for 2% Mepivacaine 1:20,000 Levo
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Nonselective beta blockers, bisulfATE allergy, hyperthyroidism (1:50,000 epi), cardiovascular disease (1:50,000 epi)
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Contraindications for Lidocaine
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Methemoglobinemia, APAP sulfonamides, Nitrates, hypoxic cardiac/respiratory failure, hemoglobinopathies. Caution: paresthesia, esp for lingual nerve (IA injection)
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Contraindications for Prilocaine
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Ester allergies, bisulfITE allergy. Caution: paresthesia, esp lingual nerve (IA injection)
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Contraindications for Articaine
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True. Amides rare, esters more common.
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True or false? Allergies to amides are rare.
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Esters. (pseudo-cholinESTERase) administer with caution.
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What is a relative contraindication for atypical pseudo-cholinesterase?
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It is NOT dose dependent (can have reaction no matter how much local anesthetic given). Develop rash/hives (aka wheals), localized swelling, wheezing, dyspnea (difficulty breathing)
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Allergic reactions to local anesthesias
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Administer antihistamine, sit upright. If anaphylactic Pt will have respiratory distress and will need to administer epinephrine and oxygen.
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Treatment for allergic reaction to local anesthesia
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Talkative, apprehension, excitable, slurred speech, nystagmus, sweating, vomiting, increased BP/heart rate/respiration, metallic taste, bilateral numbness of tongue.
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Symptoms of minimal-moderate LA overdose
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Tonic clinic seizure followed by CNS depression, decreased BP/heart rate/respiration.
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Moderate-high LA overdose symptoms
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Pallor, dizziness, weakness, nausea, THROBBING headache, anxiety, tremor, heart palpitations, increased heart rate/BP (sharp rise in systolic BP)
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Symptoms of vasoconstrictor overdose
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Stop injection, keep in supine position, loosen clothing, reassure patient, monitor vitals, administer oxygen, 911 if patient goes into seizure, CPR if needed, if seizure lasts more than 5 mins administer IV diazepam.
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Treatment of LA overdose
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Terminate procedure, sit patient erect, reassure patient, monitor vitals, administer oxygen, CPR, call 911 if symptoms last more than 5 mins.
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Treatment of vasoconstrictor overdose
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Limited opening of the jaw
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What is Trismus?
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Muscle trauma on injection (happens most to medial pterygoid), low grade infection in injection area, multiple needle penetrations in area, hemorrhage (happens with hematoma)
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What causes Trismus?
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Injecting into the parotid gland and hitting the facial nerve (cranial nerve VII)
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What causes facial paralysis?
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Rapid injection of solution, low pH of LA (contains vasoconstrictor), contaminated solution.
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What causes a burning sensation upon injection?
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Rapid transmission of nerve impulses along a myelinated nerve fiber that jumps along the nodes of ranvier.
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What is saltatory conduction?
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Anterior and medial to IA
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Where is the lingual nerve in relation to the IA nerve?
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Medial to the lateral pterygoid muscle,
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Where is the IA nerve
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Milligrams: 0.9-1.8, Carpules: 1/2 to 1
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Recommended amount of LA given for a posterior superior alveolar (PSA) injection
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Milligrams: 0.9-1.2, Carpule: 1/2-3/4
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Recommended amount of LA given for a middle superior alveolar (MSA) injection
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Milligrams: 0.9-1.2, Carpule: 1/2-3/4
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Recommended amount of LA given for an anterior superior alveolar (ASA) injection
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Milligrams: 0.45-0.6, Carpule: 1/4-1/3
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Recommended amount of LA given for a greater palatine (GP) injection
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Milligrams: 0.45, Carpule: 1/4
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Recommended amount of LA given for a nasopalatine (NP) injection
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Milligrams: 0.6, Carpule: 1/3
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Recommended amount of LA given for a supraperiosteal/infiltration injection
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Milligrams: 1.5, Carpule: 5/6
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Recommended amount of LA given for an inferior alveolar (IA) injection
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Milligrams: 0.3, Carpule: 1/6
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Recommended amount of LA given for a long buccal (LB) injection
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Milligrams: 0.6, Carpule: 1/3
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Recommended amount of LA given for a mental (M) injection
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Milligrams: 0.6-0.9, Carpule: 1/3-1/2
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Recommended amount of LA given for an incisive (IN) injection
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Superior to mandibular foramen (most common cause of LA failure is being too inferior to the nerve, so must be superior.)
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Where is the target site for the needle in an inferior alveolar nerve block?
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The medial pterygoid.
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What muscle is penetrated during the inferior alveolar nerve block?
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Immediately after a stimulus has initiated an action potential, a nerve is unable to respond to another stimulus regardless of its strength.
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Absolute refractory period
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1-2 mins
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What is the minimum length of time it should take to administer one cartridge of a local anesthetic solution?
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1-Remain calm, do not panic 2- Have patient remain open 3- If needle is visible, remove with hemostats/cotton pliers. 3a- If not, DO NOT probe for fragment or make an incision to find it. b- Calmly inform patient and attempt to allay fear and apprehension. c- Refer patient to an oral surgeon. d- Note incident in patient's records, keep remaining needle fragment and inform your insurance carrier (prepare for litigation).
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What should you do if a needle breaks while giving an injection?
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Depolarization phase (this is the phase before an impulse is fired)
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What stage of a nerve impulse conduction does a local anesthetic take effect?
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Sodium bisulFITE (commonly causes allergic reactions- esp in asthma patients)
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Preservative added to vasoconstrictors
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0.09 mg (1.8 x 0.05 mg/ml)
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Milligrams of epinephrine in a full 1:20,000 solution cartridge
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0.036 mg (1.8 x 0.02 mg/ml)
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Milligrams of epinephrine in a full 1:50,000 solution cartridge
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0.018 mg (1.8 x 0.01 mg/ml)
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Milligrams of epinephrine in a full 1:100,000 solution cartridge
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0.009 mg (1.8 x 0.005 mg/ml)
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Milligrams of epinephrine in a full 1:200,00 solution cartridge
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Decreases the possibility of a toxic adverse reaction by decreasing systemic uptake. Lowers PH.
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The effect vasoconstrictors have on local anesthetics
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Lateral to the pterygomandibular raphe, medial to the internal oblique ridge, at the height of the coronoid notch.
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Site of injection for an IA nerve block
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Atypical plasma cholinesterase
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Contraindication for esters
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The cartridge was frozen. (small bubbles normal from manufacture, large bubbles mean LA contaminated and if stopper is extruded it means LA was frozen).
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A large bubble (>2mm) and an extruded stopper on a local anesthetic cartridge most likely means
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3 cartridges. (4 will elicit the response. Give 3 as to not actually elicit response).
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Epinephrine produces an elevation in blood sugar levels. How many cartridges can be safely given before this response is elicited?
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Maxillary canines to the centrals on injected side, and facial tissue in that area. (May innervate the maxillary premolars and the mesiobuccal root of the 1st molar if MSA not present).
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The ASA nerve innervates
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Maxillary premolars, and sometimes the mesiobuccal root of the 1st molar. Also buccal tissue in that area.
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The MSA nerve (when present- 50-72% missing) innervates
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Maxillary molars and the buccal tissue in that area. (Mesiobuccal root of 1st molar may not be innervated due to innervation of MSA nerve).
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The PSA nerve innervates
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All mandibular teeth in quadrant, buccal mucosa from the premolars to the midline, floor of mouth and 1/2 of tongue on quadrant side.
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The IA nerve innervates
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Buccal mucosa of mandibular molars.
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The long buccal nerve innervates
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The buccal tissue of the mandibular premolars to the midline on side of injection.
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The mental nerve innervates
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Mandibular premolars to the midline on side of injection and skin of the lower lip and chin from the mandibular premolars to the midline.
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The incisive nerve innervates
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High pH, high protein binding , lower concentration of anesthetic agent.
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Articaine may be more effective than other anesthetics due to what characteristics?
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0.04mg (1/5 healthy dose)
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Cardiac dose for epinephrine
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0.2 mg
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MRD of epinephrine for healthy patient
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1.0 mg (11 carps)
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MRD of Levonordefrin for healthy patient
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0.2 mg (2 carps)
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Cardiac dose for Levonordefrin
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Upper respiratory infection
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Absolute contraindications for nitrous oxide
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A myocardial depression
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The direct action of local anesthetics on the myocardium is:
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60 mins
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Pulpal anesthesia for 2% Mepivacaine 1:200,000 Levo
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Infiltration: 5-10 mins Block: 20-40 mins
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Pulpal anesthesia for 3% Mepivacaine plain
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60 mins
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Pulpal anesthesia for 2% Lidocaine 1:50,000 epi
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60 mins
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Pulpal anesthesia for 2% Lidocaine 1:100,000 epi
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Infiltration: 10-15 mins Block: 40-60 mins
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Pulpal anesthesia for 4% Prilocaine plain
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60-90 mins
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Pulpal anesthesia for 4% Prilocaine 1:200,000 epi
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75 mins
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Pulpal anesthesia for 4% Articaine 1:100,000 epi
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45 mins
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Pulpal anesthesia for 4% Articaine 1:200,000 epi
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90-180 mins
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Pulpal anesthesia for 0.5% Bupivacaine 1:200,000 epi
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A-delta and C
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Nerve fibers involved in dentistry
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A higher concentration means more base molecules, and more base molecules are needed to diffuse through mucous membranes (ex. 20% Benzocaine vs 4% anesthetic solution)
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Why are topical anesthetics manufactured in higher concentrations than local anesthetics?
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1.8 ml
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Milliliters in 1 full cartridge of a LA
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0.9 ml
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Milliliters in 1/2 a cartridge of a LA
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0.45 ml
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Milliliters in 1/4 cartridge of a LA
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0.6 ml
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Milliliters in 1/3 cartridge of a LA
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1.2 ml
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Milliliters in 2/3 cartridge of a LA
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1.4 ml (1.35 ml to be exact)
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Milliliters in 3/4 cartridge of a LA
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0.2 ml
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Milliliters in 1 "stopper full" (1/9) of a cartridge of a LA
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Palatal tissue from canine of one side, to the canine of the other, and the anterior 1/3 of the hard palate.
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The Nasopalatine nerve innervates
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1:50,000 epi 4% LA solution- reduce dose to half.
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What anesthetic and vasoconstrictor concentrations should be avoided with palatal injections?
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Bilateral maxillary centrals, laterals and canines- to a lesser degree, facial and palatal tissues in area but NOT lip (Good for cosmetics).
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Palatal ASA (P-ASA) nerve block anesthetizes:
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Maxillary premolars to incisors, and buccal and palatal tissues in area. Facial and lip tissue NOT anesthetizes- good for cosmetics.
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Anterior MSA (A-MSA) nerve block anesthetizes:
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Medial to canine eminence, at height of mucobuccal fold. Insert needle 6mm. Deposit 1/2-3/4 carp over 30-40 secs.
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Injection technique for ASA
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Between roots of premolars at height of mucobuccal fold. Insert needle 6mm towards apex of 2nd premolar. Deposit 1/2-3/4 carp over 30-40 secs.
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Injection technique for MSA (absent in 50-72% of population)
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Distobuccal root of 2nd molar at height of mucobuccal fold. Insert needle 16mm in 45•, 45•, 45• direction (Barrel of syringe in corner of mouth, aligned with ala of the nose and pointing towards opposite corner of head- think of head as a cube). Deposit 1/2-1 carp over 30-60 mins.
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Injection technique for PSA
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(Child's weight/150) x MRD
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Clark's rule
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(MRD x child's age)/12+child's age
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Young's rule
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The lipophilic portion allows the solution to diffuse through the nerve membrane. The hydrophilic portion allows the solution to diffuse through the interstitial tissue.
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Hydrophilic and lipophilic portions of local anesthetics
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Absence of pain sensation only
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Analgesia
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Loss of pain, touch, temperature and pressure.
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Anesthesia
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1800-2100 psi
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What is the pressure in a full tank of oxygen?
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650-900 psi
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What is the pressure in a full tank of nitrous oxide?
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900-1100 psi
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What is the pressure in half a tank of oxygen?
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650-900 psi (nitrous gauge does not accurately show level of nitrous in tank, but does in oxygen)
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What is the pressure in half a tank of nitrous oxide?
