Anesthesia Exam 1 – Flashcards
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Failure
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Inability to induce effective conduction blockade
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When local anesthetic failures occur
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experience is painful for the patient and confidence is lost in clinician.
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Difficulty with inferior alveolar nerve blocks
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Due to bifid pattern each branch of the nerve having a seperate foramen
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Various causes of anesthetic failure
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Bony Prominences, atypical facial planes, highly vascular areas, ligamental deflection, circadian influences
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Diurnal Body Rhythm
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used to describe the variable response to drugs during different times of day.
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ANOVA
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Analyses of variances
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VAS
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Visual scales
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ANOVA and VAS
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Used to analyze,quantify, and report on pain or its absence
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Devices used for local anesthetics
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Syringes, cartridges,and needles
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Bevel Adjustments
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places solution closer to nerves
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Vazirani-Akinosi
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technique faces the midline away from mandible
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Anesthetic w/ vasoconstrictors
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must have a minimum of 90% effective vasoconstrictor. Ph no lower than 3.3
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Proper solution storage
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stored in a dark, room-temp location
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The longer the duration of storage
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the higher its acidity
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Highly acidic solutions
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make the administration uncomfortable
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Profound anesthesia
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Adequate volumes of solution must be deposited to block nerve impulses
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Solution Volume Factors
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anatomy of area, individual response, length of anticipated treatment
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Gow-gates technique
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mand. nerve. requires greater initial volumes for sufficient diffusion
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Buccal nerve blocks
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where solution is placed directly over the nerve, requires very little solution.
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Shallow vestibules and bony prominences
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prevents adequate diffusion in infiltrations
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Palatal dilacerations
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increases bony distances through which solutions must diffuse to reach root apices.
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Chemical Barriers
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Existing in tissues prior to injection, and those caused by injury to tissues during injection.
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Techniques to overcome barriers of inflammation
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Use of alternate injections, intraosseous techniques, and intrapulpal anesthesia.
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Causes of Tachyphylaxis
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tissue edema in area of injection, and localized hemorrhage.
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Aberrant innervations
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Unexpected variations
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Accessory innervations
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typical, expected deviations
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Tachyphylaxis
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synonymous with Rapid Drug Tolerance
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Situation that cant be fully explained
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Aberrant innervation
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Accesory innervation
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incomplete anesthesia
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MSA
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Nerves missing in a significant percentage of people
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Two Major sources of inadequate anesthesia in the ASA
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1. Anterior cross-innervation 2. Unusually dense bone
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Inferior Alveolar Nerve Block
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has a relatively high incidence of inadequate anesthesia
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Mylohyoid nerve
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most documented of accessory innervations
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PDL injections
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are invaluable in the mandible and may overcome nearly all innervations. Useful as a supplemental
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Intraosseous injections
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Solution diffuses directly through spongy alveolar bone to dental plexus
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Intravascular injections
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can contribute to failed anesthesia
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Cationic form
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Local anesthetics are packaged primarily
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Inflammation
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Excesses of hydrogen ions prevent formation of base molecules
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Inadequate anesthesia may not typically be caused by
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Poor manufacturing processes
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Infiltration anesthesia over the apex of #9 has failed. Which is not a possibility?
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Unseen inflammation
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The relative acidity of tissues into which anesthetic drugs are injected is related to the efficacy of a drug in the following manner
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A pH driven increase in cationic concentrations decreases rate of success
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Possible successful approaches when an inferior alveolar nerve block fails
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PDL, Mylohyoid, Gow-Gates
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Two injections of 2% lidocaine have failed. What useful supplemental alternative would you NOT use
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Mylohyoid (only useful in mandible)
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Where is the deposition site for the Gow-Gates nerve block relative to inferior alveolar?
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At a higher level in the pterygomandibular space
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Some Nerve blocks require more solution than others
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True
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Adverse Reaction
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Undesired effect
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Complications
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Local, Systemic
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Overdose
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Thresholds
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Primary responsibiltiy of dental clinician
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Recognize and respond to adverse events
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Local Complications
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Tissue injury that occurrs before, during and after the administration of topical and injectable local anesthetic drugs
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Parasthesia
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Lingering pain, numbness resulting from nerve injury
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Hematoma
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Leaking of blood vessels into surrounding tissues
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PSA and maxillary tuberosity approach
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most likely site of a Hematoma
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Inf. alv. nerve blocks
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2nd highest rate of hematoma formation
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Trismus
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Motor disturbance of the trigeminal nerve. Inability to open mouth. Primary cause is hemorrhage and muscle trauma following injection.
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Muscles involved in trismus
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Muscles of mastication medial pterygoid muscle blood vessels of infratemporal fossa
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Possible causes of trismus
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Bleeding toxicity of anesthetic solutions direct physical injury
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Possible causes of pain on injection
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penetration of well innervated anatomic structures Rapid deposition Solution temperature
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Oraverse
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only pharmaceutical agent capable of reversal of numbness of soft tissue
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Parathesia
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persistant partial or complete numbness
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Lingual Nerve
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Most frequently involved in parathesias that follow dental injections
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Over insertion of the IA nerve block
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Causes penetration of the capsule surrounding the deep lobe of the parotid gland
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If anesthetic is deposited into Parotid gland
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the facial nerve is anesthetized
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Postanesthetic lesions
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Resulting from infectious or a suspected autoimmune etiology
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Necrosis prevention
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Avoid epinephrine concentrations of 1:50,000 Avoid excessive use of topical avoid excessive blanching Avoid excessive distension of tissues
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Most frequent systemic complication
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Overdose
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Hypo-responders
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Individuals who do not respnd with adverse systemic signs and symptoms to local anesthetic drugs until much higher than recommended dose is administered.
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Hyper-responders
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Individuals who respond who respond adversely when less than maximum dose is used.
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Signs and symptoms of local anesthetic overdose
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Ringing in ears metallic taste in mouth increased anxiety circumoral tingling/numbness
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Later signs of overdose
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Twitching/tremors slurred speech fatigue seizures
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Prevention of local Anes. OD
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Assess Max dose administer dose slowly Aspirate Re-aspirate
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Hypersensitivity in local anesthetic
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classified as Immediate (type I) and delayed (type IV)
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A clinician is administering an IA nerve block prior to therapy when the patient suddenly jerks and the needle breaks. Embedded portion is not visible. What should clinician do?
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Refer for evaluation
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A second cartridge of 2% lidocaine has been administered for an IA nerve block when the 160lb patient becomes anxious and states she doesnt feel well, even nauseous. she becomes less anxious. gets slurred speech. what is wrong with her.
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The patient is suffering from overdose due to intravascular administration
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Allergies to topical anesthetic drugs that cause mucosal signs and symptoms hours to days afer exposure are explained best by?
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Delayed hypersensitivity
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A patient calls several days after an IA block and reports numbness is still present along with some annoying sharp pains
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Paraesthesia;dysesthesia
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Rapid tissue swelling is noticed after a PSA block
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Place pressure on area while someone else looks for ice. terminate procedure
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Of the following possible adverse reactions which one occurs most frequently?
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Overdose
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Considering all of the following measure for preventing overdose which one is most importnat
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Slow administration
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Three basic types of injections
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Infiltrations Field blocks Nerve Blocks
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Local infiltration
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Deposition directly at or near small terminal nerve endings in immediate area of treatment
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Field block injection (supraperiosteal)
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Deposition near larger terminal nerve branches
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Nerve block
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involve deposition near major nerve trunks at greater distances from areas of treatment.
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Needle pathway
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route a needle travels as it advances to target site.
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Deposition site
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anatomical location where the drug is deposited
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10 Standard Operating Procedures
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Pre-injection Patient assessment Informed consent Assemble Armentarium Pre-injection Prep Supportive communication and PREP Prepare injection site Aspiration Deposition completion Documentation
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Most important step in the administration of a safe injection is
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Rate of delivery
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Onset of anesthesia
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usually occurs in 3-10 minutes
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The first step in the administration of local anesthetic solution is to?
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Assess the patient
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A primary benefit of orienting the needle bevel toward bone during injection is?
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Reduces trauma to the periosteum when bone is contacted
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What is the most appropriate local anesthesia chart entry?
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Date, drugs, total drug volume, injection sites, results of aspiration test, notation on adverse events, clinicians signature
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Structures affected by infiltrations include
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Dental Plexus (pulp, facial gingiva, pdl, and alveolus)
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optimum site of penetration for infiltration
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The height of the mucobuccal fold closest to the apex of the tooth being anesthetized.
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Needle pathway for Infiltration
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Needle passes through thin mucosal tissues to superficial fascia
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Minimum volume of anesthetic for maxillary infiltration
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0.6ml (1/3 of the cartridge)
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Signs of numbness in infiltration
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numbing of gingival and labial tissues at site of injection
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Most common cause of failure in infiltration
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Deposition of solution too far from apex of a tooth.
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ASA Nerve Block
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numbs pulps of C.I to canines of injected side and their facial periodontium. All or a portion of of upper lip, cheek, lower nose
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ASA Nerve
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Terminal branch of the maxillary division of the trigeminal nerve Descends through anterior wall of max. sinus to supply dental plexus of the canine, lateral, and central incisors.
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Penetration site of ASA
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Height of mucobuccal fold anterior to the canine eminence (canine fossa)
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Common causes of injection failure
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deposition too far from target inflamm or infection
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Cross innervation
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overlap of terminal fibers
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MSA Nerve Block
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numbs the Pulps of max. 1st and 2nd premolars innervates mesiobuccal root of 1st molar
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Absence of MSA
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between 50 to 72 % people
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An anatomical variation that can complicate MSA
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a large zygomaticoalveolar crest
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Penetration site for MSA
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The height of mucobuccal fold over the maxillary second premolar
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Infraorbital Nerve Block
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numbs Max. Central thru Canines and premolars
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PSA
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Numbs Max. 1st, 2nd, and 3rd molars
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PSA Nerve
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branches from maxillary nerve to pterygopalatine fossa
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Penetration site for PSA
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Height of mucobuccal fold to the zygomatic process of the maxilla
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PSA injection
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Has the highest risk of hematoma due to it close proximity to pterygoid plexus
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Nasopalatine Nerve Block
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Indicated for pain management of palatal soft and osseous tissue in anterior third of palate
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Nasopalatine nerve
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longest branch of posterior superior nasal branch of maxillary nerve
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Penetration site of Nasopalatine nerve block
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Palatal mucosa lateral to the widest anterposterior dimension of incisive papilla
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Pressure anesthesia
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applying constant pressure to the site for a full minute in order to achieve profound pressure anesthesia of deep tissues
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Gate Control theory
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Certain gates in spinal nervous system, when flooded with impulses from less painful stimuli impulses generated from more painful stimuli can be blocked.
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Deposition rate of Nasopalatine
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0.4ml over 40 seconds palatal rate 3 minutes per cartridge
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Complications of Nasopalatine
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Increased risk of necrosis
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Palatal Anterior Superior Alveolar Nerve Block deposition rate
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0.5ml over 60 seconds 1.8ml over 3 minutes
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Anterior Middle Superior Alveolar Nerve Block
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Does not provide labial anesthesia Optimal injection site is located between premolars along line of median palatine raphe
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Greater Palatine
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Nerve branches from Max. nerve to pterygopalatine fossa to pterygopalatine canal through greater palatine foramen. Numbs Palatal tissues of posterior teeth.
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What best describes the deposition site of Nasopalatine?
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Deposition site is near the wall of the incisive canal
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What statement is true of NP Nerve Block
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They provide bilateral anesthesia
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What is an important consideration in all palatal procedures
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Always administer solution slowly
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IANB
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Numbs all teeth in Quadrant All periodontium, buccal mucosa, premolars to midline, floor of mouth, and 1/2 tongue in quadrant.
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Inf. Alveolar nerve
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Largest branch of mandibular division of trigeminal nerve
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3 key landmarks for successul IA injections
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Pterygomandibular raphe coronoid notch internal oblique ridge
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Pterygomandibular raphe
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Represents the medial extent of the area of injection
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Coronoid notch
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Defines the height of injection' Greatest concavity found 6-10mm superior to mandibular occlusal plane.
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Internal oblique ridge
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REpresents lateral extent of injection
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Mylohyoid Nerve block
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Can be used as a supplement for an IA
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IA injection positive aspiration rate
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10-15%, highest rate of all injections
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Lingual Nerve Blocks
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Numbs lingual soft tissue, floor of mouth, anterior 2/3s of tongue Most frequently injured nerve "electric shocks"
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Buccal Nerve Block
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Numbs buccal to molar
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Mental Nerve Block
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Numbs buccal soft tissues
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Incisive Nerve Block
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Numbs Premolars to midline (teeth and soft tissue)
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Gow Gates Mand. Nerve block
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Numbs all teeth in quadrant Injury can occur from injections into tempormandibular joint capsule and otic ganglion
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Vazirani akinosi Nerve block
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"Closed Mouth"technique
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Which is an alternative to nearly all mandibular anesthetic techniques?
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PDL
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When administering a Gow gates mand. nerve block all are important except?
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Having a client remove all ear jewelry
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Palpating anatomy prior to all mand. injections is
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helpful in some techniques and useless in others
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What is the correct order from inferior to superior location of mand. techniques listed in relation to the pterygomandibular space?
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IA, Akinosi, Gow-Gates
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PDL injection
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primary method of anesthesia for single teeth Also referred to as intraligamentary or peridental technique
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The rate of deposition of local anesthetic drugs in inraosseous, intrapulpal, and PDL injections is represented by?
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0.2ml over 20 seconds
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Which technique does not typically provide reliable pulpal anesthesia
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Intraseptal
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Which one is not recommended as an anesthetic approach in irreversible pulpitis?
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Higher concentrations of Lidocaine
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True statement of PDL
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Solution diffuses thru alveolar bone to dental plexus
