Anesthesia Final – Flashcards
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Lecture 1 - History of Pain Control
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One of the first things ever used for pain?
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Coca leaves from the genus ERYTHROXYLUM - Used over 5000 years ago in Ecuador
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Where/when did the development of general and local anesthesia take place?
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In Western Europe from 1750 to 1850
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Who first developed Cocain from the coca leaf?
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Albert Niemann
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Who developed the molecular formula of cocain? In what year?
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1865 - Willhelm Lossen
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What type of molecule is cocain?
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Ester
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Who developed the inferior dental nerve block techniques for dentistry? When?
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William Stewart Halstead in 1884
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Tell me about Horace Wells
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- American dentist - Discovered the pain-killing properties of nitrous oxide - Tried to demonstrate this at the Massechusetts General Hospital but the patient proved to be unresponsive to the gas, Wells was exposed to ridicule - Began extensive experiments with nitrous, ether, and chloroform and his personality ended up being altered because of frequent inhalation - Was put in jail for throwing sulfuric acid at hookers - He then killed himself in prison right as he was being publicly acclaimed as the discoverer of anesthetic gases
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William Morton
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- Gave the first successful public demonstration of ether anesthesia during surgery - Tried to get exclusive rights to the use of ether anesthesia - spent the rest of his life in an expensive contention with his partner Jackson who also claimed rights to it - Died suddenly at the age of 48 from 'congestion of the brain' - probably a cerebral hemorrhage - Jackson outlived Morton but then died in an asylum, insane
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Carl Koller
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- Opthalmic surgeon - Introduced cocain as a surface anesthetic in eye surgery
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William Stewart Halsted
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- American Pioneer of scientific surgery - Developed the first surgical school in the United States - Studied for two years in Europe - Discovered that Blood, once aerated, could be re-infused into a patient's body - INVENTED THE NERVE BLOCK - Developed original operations for many conditions - Introduced the use of thin rubber gloves - Created hospital residencies in training surgeons
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Alfred Einhorn
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- German chemist - Synthesized Procaine (novicaine)
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Henrich Braun
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- Called "The father of local anesthesia" - First to put Procain (novocaine) into clinical application - Added epinephrine to extend duration of the anesthesia
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Nils Lofgren
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- Synthesized lidocaine (1943)
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Lidocain facts
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- Marketed in 1948 as Xylocaine - First Amide
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Lecture 2 - Hilliard
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Mostly just read the notes that I took
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What does bradykinin do?
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Makes nociceptors more sensitive to pain stimuli
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What two things does substance P do?
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- Substance P is released from the nociceptor and causes more bradykinin to be made - this then makes the nerve ending that much more sensitive - Activates mast cells and platelets
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What do histamine and 5HT (serotonin) do?
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Diffuse to other nearby cells and sensitizes them
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When cell damage occurs, what is released into the extracellular space?
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- K, H - Proteolytic enzymes - Prostiglandin E2
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What cleaves Bradykinin?
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Proteolytic enzymes
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What produces Prostiglandin E2?
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Produced by COX activity on arachadonic acid
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Most axons that carry pain are.. Size? Type?
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- Small and myelinated - Type A-delta
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What are the 'slow' pain fibers called?
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C fibers
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Where in the tooth are nociceptors found?
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Along the odontoblasts into the dentinal tubules - However they do NOT extend into the enamel
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Do sodium channels activate fast or slow? Potassium channels?
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Sodium channels activate fast, potassium channels activate more slowly This allows the action potential to rapidly repolarize
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What is the equilibrium potential of Potassium? Sodium?
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K = -90 Na = +60
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Both sodium and potassium channels are similar, both consist of 4 clusters of 6 transmembrane domains. Which channels are one big string of amino acids and which ones are seperate?
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Sodium channels are all one big string Potassium channel clusters are all seperate
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Which domain in each cluster is positively charged?
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The fourth - the rest are negatively charged, this allows the channel to be closed THE PORE IS OPEN WHEN DEPOLARIZED
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What kind of channels do lidocaine and other local anesthetics block?
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Voltage gated sodium channels
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Local anesthetics must cross the nerve membrane, in order to do this the anesthetic must be....
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Lipophilic
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Once inside the nerve membrane, what then happens to the molecules of the anesthetic?
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Most become protinated
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Is Lidocaine acidic or basic?
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Lidocaine is a weak base
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What two forms is Lidocaine in depending on the pH of the surrounding tissue?
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In acidic media the quaternary amino group accepts a proton and becomes positively charged In more alkaline media the proton dissociates, the molecule has a neutral charge and is more permeable across cell membranes
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Once in the cell, what happens to the lidocaine molecules?
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Since the inside of the cell is acidic, it gets protonated and is then able to stay inside the cell for a longer period of time
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What is wrong with ester type anesthetics?
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High allergy rate and slow onset
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Which anesthetic doesn't have an amino group?
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Benzocaine
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What does a large Ka mean?
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The larger the Ka the more of the anesthetic remains in the charged form (LH+), AND IS LESS PERMEABLE ACROSS THE AXON MEMBRANE AND TAKES LONGER TO TAKE EFFECT
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What does a large pKa mean?
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Very few molecules in free base (RN) form at tissue pH of 7.4, therefore SLOW ONSET So Ka and pKa have the same principle
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Are anesthetics vasoconstrictors or vasodilators?
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The anesthetics themselves are vasodilators
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What does the anesthetics ability to bind protein have an effect on?
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Increased protein binding allows anesthetic cations to be more firmly attached to proteins located at receptor sites; thus duration of action is increased
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What 'action' does the anesthetics lipid solubility effect?
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Anesthetic POTENCY Increased lipid solubility = increased potency
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What 'action' does the anesthetics nonnervous tissue diffusibility effect?
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Onset Increased diffusibility = Decreased time of onset
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What 'action' does the anesthetics Vasodilator activity effect?
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Anesthetic potency and duration
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The more acidic the medium, the less lidocaine is in the ________ state
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Neutral
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What does the pKa of a chemical really mean?
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The pKa is the pH at which half of the molecules are in the charged form and the other half in the uncharged form
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What is the pKa of Lidocaine?
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7.9
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So with a pKa of 7.9, what form is in greater concentration at a physiological pH of 7.4?
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The charged form is 3 times that of the neutral form
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So the lower the pH, the lower the _____form of the anesthetic
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Neutral At a pH of 6.9 there are 10 times more molecules in the charged form than in the neutral form
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Lecture 3: Neurophysiology of Pain
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What type of neurons are sensory neurons?
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Bipolar (nerve cell body in the middle of two axons
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Tell me about Group A nerve fibers
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Myelinated and very fast conduction
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Tell me about Group C nerve fibers
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Non-myelinated and very slow (relatively)
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A-delta fibers: - Diameter? - Conduction velocity
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Diameter = 1-4 microns Speed = 5-25 m/s
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What is the resting potential of the nerve cell membrane?
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-70mV
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Is the interior of the nerve cell membrane at resting potential negative or positive?
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Negative - Once depolarized the inside of the cell then becomes positive with the influx of sodium ions
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When fully depolarized, what is the potential of the nerve cell membrane?
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+40mV
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What is the name of the theory that is currently accepted as to how local anesthetics block nerves?
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The Specific Receptor Theory - States that local anesthetics act by binding to specific receptors on the sodium channel - Direct action of drug, unlike the membrane expansion theory
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How does the membrane expansion theory explain how LA's work?
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They diffuse to hydrophobic regions of excitable membranes thereby disturbing the bulk and expanding critical regions of the membrane (how this causes anesthesia, I dont really know.. this is all the notes say)
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Specific Receptor Theory: Where do the following bind on the sodium channel: Class A Class B Class C Class D
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Class A - External surface of the nerve membrane Class B - Internal surface of the nerve membrane Class C - Receptor-independent physico-chemical mechanism Class D - Combination of receptor and receptor-independent mechanism
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From which direction does the LA enter the Na channel?
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From the Axoplasmic (cytoplasm) side - so from within
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How many nodes of ranvier are needed to stop conduction?
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3
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What are Calcium ions role in the sodium channel?
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They play a regulatory role in the channel - regulate the flow of sodium - Calcium leaving the channel may actually what leads to sodium being able to enter so quickly - Calcium leaving may actually be the first step in nerve membrane depolarization
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What do LA molecules compete with for binding sites?
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Calcium
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What are four structural characteristics of LA'a?
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- Majority are tertiary amines - Amphipathic - If no hydrophilic part, it is NOT injectible - Intermediate chain is either and ester or amide
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What does Amphipathic mean?
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Has both hydrophilic and lipophilic properties
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What was the first LA synthesized?
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Procaine
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What is pKa?
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A measure of the molecules affinity for hydrogen ions
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Are LA's acidic or basic?
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Weak bases
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What does it mean when pKa = pH?
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RNH = RN + H
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Again, what happens when the pH is low?
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More Cation (protinated form) RNH > RN + H
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Fibers near the surface of the nerve (mantle fibers) tend to innervate...
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More proximal regions (molars for IA block)
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Fibers in the core bundles innervate...
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More distal regions (incisors and canines for IA)
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Do the proximal(mantle) nerves or bundles in the core of the nerve regain feeling first?
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Mantle bundles lose effect sooner than core bundles so proximal regions return to normal faster than distal
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What is the order of sensory loss during anesthesia?
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1. Pain 2. Cold 3. Warmth 4. Touch 5. Deep pressure 6. Motor RECOVERY IS REVERSED FROM THIS..
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Lecture 4 - Pharmacology of Local Anesthetics
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Why don't we give local anesthetics orally?
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- Poor absorption in the GI - Extensive first pass metabolism
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Which mucosa site is the best at absorption?
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Trachea
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Are local anesthetics able to cross the blood-brain barrier?
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Yes.. all of them do All will also cross the placenta
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After 6 half lives, how much of the anesthetic is removed from the body?
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98.5%
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How and where are Esters metabolized?
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Hydrolyzed in Plasma by Pseudocholinesterase
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What is the major metabolite of esters and why is this significant?
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The major metabolite is PABA - this is what causes allergic reactions in people, not necessarily the ester itself
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Amide metabolism is a little more complicated: Where, primarily, are amides metabolized?
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In the liver
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Which anesthetics are fully metabolized in the liver?
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Lidocaine Mepivacaine Bupivacaine
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Where is Prilocaine metabolized?
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Mostly in the liver but with some being metabolized in the Lungs
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Where is Articaine metabolized?
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Metabolized by plasma cholinesterase and in the liver
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How does liver disease affect the metabolism of amides?
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The metabolism of amides is fully dependent on the function of the liver, if the liver isn't functioning properly then the breakdown will take longer - half life goes way up Increased risk of toxicity
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What is the primary excretory organ for getting rid of anesthetics?
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The Kidneys
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Some of the anesthetic is excreted in an unchanged form. What would be the result If there was something wrong with the kidneys?
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Significant renal impairment leads to elevated blood levels which then lead to higher risk of toxicity
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What systemic effects can LA's have if too much is found in the blood stream?
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- Crosses the blood brain barrier, has a depressive effect - Can cause 'tonic-clonic seizures - However, oddly, some anticonvulsive effects at consentrations below therapeutic levels
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What affect does LA have on the heart?
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Myocardial depression: - Decreased excitability - Decreased conduction rate - Decreased force of contraction
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How does LA affect local tissues?
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- Causes skeletal muscle damage - Damage is reversible but takes two weeks for complete regeneration
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How does LA affect the respiratory system?
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- Nonoverdose level = direct relaxant on bronchial smooth muscles - Overdose level = Respiratory arrest possible due to CNS depression - Essentially no effect seen until near toxic levels
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What is the Synthetic version of epinephrine?
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Levonordefrin 1/6th as effective as epinephrine
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What are the three modes of action in which epinephrine-type drugs can act?
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Direct-acting Indirect-acting Mixed-acting
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Which catagory are both epinephrine and levonordefrin in?
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Direct-acting - Acts directly on adrenergic receptors
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What are the two types of adrenergic receptors and what do each do?
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Alpha and Beta Alpha - smooth muscle contraction (vasoconstriction) Beta - Smooth muscle relaxation and cardiac stimulation
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Dilution of Vasoconstrictors: - What is the baseline ratio for the epinephrine dilution?
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A 1:1 ratio would be 1g/1mL So, 1:1000 = 1 gram in 1000mL
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Practice: 1:10,000 ratio = ? in mg/mL
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.1mg/mL
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1:100,000 = ? in mg/mL What would it be in micrograms/mL
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.01 mg/mL 10 micrograms/mL
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How does epinephrine affect the heart?
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Increases blood pressure, cardiac output, stroke volume, heart rate, strength of contraction and oxygen consumption
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How does epinephrine affect the respiratory system?
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Bronchiole dilator
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How does epinephrine affect the CNS?
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Not a potent CNS stimulant at normal dose but in excess it can be
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How does epinephrine affect the bodies metabolism?
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- It increases oxygen consumption and glycogenollysis in the liver and skeletal muscles - It increases blood sugar levels
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What epinephrine levels in the blood need to be reached in order to have these effects?
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150-200 pg/mL (about 4 cart of 1:100k)
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What is the half-life of Lidocaine?
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1.6 Hours
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Is Articaine's half-life longer or shorter than lidocaine's? Why?
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Shorter - because it is partially metabolized by plasma cholinesterase Half life = .5 hours
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What actually causes the toxicity in the blood?
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The metabolites that result from LA breakdown
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What do effects Lidocaine metabolites cause?
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Sedative effects
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A percentage of a given dose of anesthetic is excreted unchanged. Are more amides or more esters excreted unchanged? What percentage of Lidocaine is excreted unchanged? Mepivicaine?
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Amides Lidocaine - 3% Mepivicaine - 1%
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Lecture 5: Armamentarium and Record Keeping
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Everyone's response to anesthesia is different: What is considered a Normal Responder? Hyper Responder? Hypo Responder?
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Normal - 68.26% of people = Pulpal anesthesia for 60 min Hyper-Responders - 15% of people = anesthesia beyond 60 min Hypo-responders - 15% of people = pulpal anesthesia for less than 60 min
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Does a nerve block or an infiltration last longer?
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Nerve block
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Do larger volumes of anesthetic increase duration?
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No - there is probably an upper limit to where more anesthetic lengthen duration
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How many cartridges of LA can a patient with cardiovascular disease have based on the epinephrine concentration? - 1:50,000 - 1:100,000 - 1:200,000
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- 1:50,000 = 1 = 5.5 if healthy - 1:100,000 = 2 = 11 if healthy - 1:200,000 = 4 = 22 if healthy
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Why would people not want to use articaine?
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Some say it is more likely to cause paraethesia/anesthesia for nerve blocks
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Needle color code: What gauge corresponds to which color? Blue Yellow Red
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Blue - 30 Yellow - 27 Red - 25
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What are the lengths of a long and a short needle?
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Long = 32 mm Short = 20mm
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How long does a 'short duration' LA last? Intermediat? Long?
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Short - less than 30 min Intermediate - 60 min Long - Greater than 90 min
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What 'duration' is Lidocaine with 1:100,000 epi?
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Intermediate
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Lecture 6: Physical and Psychological Evaluation
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ASA I
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Healthy - Can walk up one flight of stairs or two city blocks without distress - Green flag for treatment
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ASA II
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Mild systemic disease without significant systemic effects: - Controlled hypertension - Controlled diabetes without systemic effects - Pregnant - Smokes - Can walk up a flight of stairs but will have to rest after - Yellow flag
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ASA III
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Severe systemic disease with significant systemic effects: - Poorly controlled hypertension - Morbidly obese - Chronic renal failure - Stable Angina - Can walk up a flight of stairs but will have to stop in the middle and rest - Yellow flag
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ASA IV
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Severe systemic disease that is a constant threat to life - Unstable angina - Hepatorenal failure - Symptomatic COPD - Unable to walk up one flight of stairs - Out of breath even at rest - Red flag for treatment
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ASA V
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A patient who is not expected to survive without surgical proceedures - Multiorgan failure -Dental treatment is not indicated
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How long after a MI (heart attack) do you have to wait before treating a patient?
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6 months - ASA IV until 6 months, after 6 months patient is ASA III
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What is the range for Pre-hypertension?
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120-139/80-89 -All procedures okay
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What is the range for stage hypertension?
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140-159/90-99 - ASA II - Most proceedures okay - Need a medical consult before extensive restorative, surgery or before using >.04 mg epinephrine
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What's the lower range for Stage 2 hypertension?
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160-169/100-109 - ASA II - Some minor procedures okay - Medical consult before treatment - Do not use >.04 mg epinephrine (basically 2 cartridges)
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What is the upper range for Stage 2 hypertension?
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170-179/100-109 - ASA III - Only diagnostic procedures okay -
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What is the range for Stage 3 hypertension?
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>180/>110 - ASA III - Stop exam, no treatment, refer for medical consult immediately
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As far as anesthetic goes, what do you give someone with hyperthyroidism?
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An anesthetic with no vasoconstrictor
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Pregnancy category A
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Generally considered safe
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Pregnancy category B
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Caution advised - Animal studies show no risk or adverse fetal effects but no human trials have been done
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Pregnancy category C
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Weigh the risks and benefits - Animal studies show adverse fetal affects but no human trials done
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Pregnancy category C/D/D
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Weigh the risks and benefits - Category C in first trimester but positive evidence of human fetal risk in second and third trimester
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Pregnancy category D
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Weigh the risks and benefits - Positive evidence of human fetal risk
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Pregnancy category X
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Contraindicated
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What are the six vital signs?
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Blood pressure Heart rate Respiratory rate Temperature Height Weight
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What is the range for normal heart rate?
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60-110
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Normal respiratory rate?
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~12/min
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What are your major concerns with people who use meth or cocaine?
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Tachychardia, Hypertension, cardiac arrest - Postpone dental proceedures when the use of cocaine is confirmed or suspected within 24 hours
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Lecture 7: Maxillary Anatomy and Injection Techniques
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What is an injection called that is given above the apex of the tooth that is to be treated?
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The proper term is Field Block but common usage identifies them as infiltration or supraperiosteal
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What kind of injection would a Nasopalatine injection be?
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Nerve block
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Is V2 motor or sensory or both?
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Fully sensory
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What does V2 innervate?
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Maxillary teeth and periodontal tissues
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Tell me about the PSA nerve
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Usually two branches - One stays on the outside of the bone to innervate the buccal gingiva - The other goes inside the bone and innervates the maxillary sinus - It then travels down and innervates the pdl and pulpal tissues of the third, second, and first molars. However, in 28% of patients, the mesiobuccal root of the first molar is not innervated by the PSA.
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Where does the MSA nerve originate from?
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The Infraorbital nerve
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What does the MSA innervate?
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The two maxillary premolars and possibly the mesiobuccal root of the first molar
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Does the anterior superior alveolar nerve descend inside the bone or after it exits the infraorbital foramen?
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Descends within the anterior wall of the maxillary sinus
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What does the ASA innervate?
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Incisors and canines -Also the anterior part of the nasal cavity - In persons without an MSA nerve, the ASA will also provide innervation to the premolars and the mesiobuccal root of the first molar
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What foramen does the greater palatine descend through?
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Pterygopalatine canal
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How far anteriorly does the greater palatine nerve innervate?
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As far as the first premolars
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What foramen does the nasopalatine nerve travel through?
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Incisive canal
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What is the main contraindication of the PSA injection?
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Patient at high risk of hemorrhage
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Main complication of PSA
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Hematoma
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What areas of the gingiva does the PSA innervate?
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Buccal only up to the first molar
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What is the main contraindication for MSA?
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Acute infection/inflammation
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What gingiva does the MSA innervate?
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Buccal only up to the first premolar - Includes buccal gingiva over the mesiobuccal of first molar
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When is the ASA contraindicated?
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When only one/two tooth anesthesia is required
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Lecture 8: Mandibular Anatomy and Injection Techniques
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Where does the motor portion of V3 originate?
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In the motor cells located in the pons and medulla oblongata
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Where does the sensory portion of V3 originate?
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At the inferior angleof the trigeminal ganglion
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What areas of the skin does V3 innervate?
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Temporal Auricula External auditory meatus Cheek Lower lip Lower part of the face (chin region)
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What part of the mucous membrane does V3 innervate?
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Cheek Tongue - anterior two thirds Mastoid cells
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Tell me everything that gets numb with the IA injection
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- All teeth in the lower arch (half) - All lingual gingiva - Buccal gingiva from the second premolar to the midline - The lip and cheek from the second premolar to the midline - Half of the tongue (anterior 2/3)
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What is the foramen called where the IA enters the ramus?
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The mandibular foramen
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Is anesthesia of the tongue a good indicator of success?
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No - It is possible for the lingual nerve to get anesthetized without the IA getting anesthetized
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What muscle does the long buccal nerve pass through?
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It passes through the two heads of the lateral pterygoid muscle
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Does the buccal nerve innervate the buccinator muscle?
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NO - The facial nerve does
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According to the power point, should you wait to give the buccal nerve injection until after the IA injection has kicked in?
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No - do it right after - The corner of the mouth and the lip are not innervated by the buccal nerve so there is no need to wait
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What does the Buccal nerve innervate?
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The buccal gingiva around the molars
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Once the IA nerve reaches the mental foramen, the nerve splits into two branches, what are their names?
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Incisive nerve Mental nerve
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What does the incisive nerve innervate?
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The mandibular incisors, canine, first and second premolars
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What does the mental nerve innervate?
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- Skin of the chin - Buccal gingiva of the Second premolar forward - Oral mucosa from teh second premolar forward
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What's a main advantage in doing an incisive nerve block instead of the whole IA?
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You don't get lingual anesthesia which is uncomfortable and unnecessary for many patients
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What does the incisive nerve block injection anesthetize?
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Teeth, buccal gingiva, and lip/cheek from the second premolar forward
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What nerves does the Gow-Gates anesthetize?
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Virtually the entire branch of V3 - IA - Lingual nerve - Mylohyoid - Mental - Incisive - Auriculotemporal - Buccal
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What areas in the mouth does the Gow-Gates anesthetize?
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- Tongue - All teeth (half) - All buccal and lingual gingiva - Cheek/Lip from the second premolars forward
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Where should the needle end up when doing a gow gates?
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On the lateral side of the anterior surface of the condyle - If bone is not contacted then anesthetic solution should not be administerd
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When do you primarily use the Vazirani-Akinosi Injection?
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When a patient has limited mandibular opening (Trismus)
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Which nerves are anesthetized with the Vazirani-Akinosi Injection?
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- Inferior alveolar - Incisive - Mental - Lingual - Mylohyoid
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Which areas of the mouth are anesthetizes with the Vazirani-Akinosi Injection?
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Same as the Gow-Gates - Half of tongue - Entire arch (half) - All Buccal and lingual mucosa - Cheek/Lip from the second premolar forward
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What can be a complication of the Vazirani-Ankinosi injection?
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Transient facial nerve paralysis - Caused by overinsertion and injection of the local anesthetic solution into the body of the parotid gland - Should inject about 25mm
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What volume of anesthetic fluid would you use in an IA? Buccal?
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1.5ml - IA .3ml - Buccal
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Lecture 9: Clinical Day #1 - PSA, MSA, ASA
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What gauge needle should you use for the PSA?
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27 gauge long
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Where do you inject when doing a PSA?
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Into the height of the mucobuccal fold over the second molar
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Lecture 10: Clinical Day #2 - Greater Palatine, Nasopalatine, Left IA
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No Cards - Everything in this lecture had already been covered in other lectures
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Lecture 11: Complications with Local Anesthesia
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What gauge/type needle is primarily involved in needle breakage?
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30 gauge short needle - Usually inserted to the hub in IA or PSA
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What is Parasthesia?
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Defined as persistent anesthesia (anesthesia well beyond the expected duration) or altered sensation well beyond the expected duration of anesthesia - The definition of parasthesia should also include hyperesthesia and dysesthesia, in which the patient experiences both PAIN and NUMBNESS
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What types of things tend to cause parasthesia?
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- Any sort of trauma - Trauma to nerve sheath during injection - electric shock - Hemorrhage around the nerve sheath causing pressure - LA itself can do it - mainly occurs with the 4% solutions
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What kinds of things can cause Trismus?
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- Intramuscular injection or supramuscular - Hemorrhage - Low grade infection - Usually IA or PSA
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How do you treat Trismus?
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- Heat therapy - Warm salt water rinse - After 48 hours consider infection
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What causes a hematoma?
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Due to nicking of vessel during injection -IA - Visible INTRAORALLY - PSA - Visible EXTRAORALLY
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Why is hematoma a problem?
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- Because it can lead to trismus - Prone to infection
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What do you do if you see a hematoma start to form?
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- Direct pressure immediately - PSA is hard to access
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What is a major cause of Sloughing of Tissues?
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Prolonged topical -Usually occurs on the hard palate
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What are the two most common postanesthetic intraoral lesions?
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- Recurrent aphthous stomatitis - Herpes simplex
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What are the most frequently observed complications of Local Anesthetic?
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Anxiety-Induced events Dizziness Tachycardia Agitation Nausea Tremor
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What are some more severe complications?
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Seizure Bronchospasm
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What is the most common cause of adverse reactions to LA?
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Rapic Inravascular injection
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If a patient has a sodium bisulfite allergy what must the patient not have?
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LA with a vasoconstrictor
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Which immune cell or antibody is active in the following reactions? - Type I reaction - Anaphylactic - Types II reaction - Cytotoxic - Type III reaction - Immune complex - Type IV reaction - Cell-mediated
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Type I - IgE Type II - IgG and IgM Type III - IgG Type IV - ?
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Tell me about generalized Anaphylaxis.. How serious is it? What are the clinical signs?
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- Acute life-threatening allergic reaction - Can lead to death in a few minutes Clinical Signs: - Skin reaction - Smooth muscle spasms of the GI tract - Respiratory distress - Cardiovascular collapse
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What is the treatment for anaphylaxis?
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Epinephrine - CPR and basic life support if needed
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What is Vasovagal Syncope and what do you do when it happens?
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- Fainting - Put the patient in a supine position so that blood flow can be restored to the brain - If the flow patterns to the brain are not restored, life threatening cardiovascular and pulmonary effects can occur
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What are the early symptoms of Syncope?
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- Loss of color - Perspiration - Nausea - Increased heart rate - Feeling of warmth
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What are the late symptoms of Syncope?
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- Yawning - Dilated pupils - Cold extremities - Hypotension - Dizziness - Loss of consciousness
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Is a sulfa allergy a contraindication to using Articain?
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NO
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Lecture 12: Anesthesia in the Dental Specialties
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.
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What is a possible complication of the PDL injection?
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-Enamel hypoplasia to the developing tooth bud if used on primary teeth - Ischemia (lack of blood flow) to the surrounding tissues and pulp
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What all gets numb when doing a PDL injection?
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Buccal and lingual gingiva as well as the pulp of the tooth
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What are the name brand methods of the Intraosseous injections?
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- Stabident - X-tip - Intraflow
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What is a complication of the Intraosseous injection?
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- Quick systemic uptake
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What gets numb with the intraosseous injection?
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Buccal and lingual gingiva as well as the pulp of the tooth
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What teeth is the intrapulpal injection mostly used on?
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Mandibular molars
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What does the intrapulpul injection get numb?
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Just the tooth - not the surrounding tissues
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What are two tooth morphology issues that you have to deal with in Endo?
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Mandibular molars with accessory innervation my mylohyoid Maxillary molars with very flared palatal roots
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If the patient is really infected, what may you have to do?
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Rely more on nerve blocks (away from the infection) rather than infiltration
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What is the Authors MRD for the following anesthetics? (mg/lb) - Articaine - Lidocaine - Mepivacaine - Prilocaine - Bupivacaine
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Articaine - 3.2 Lidocaine - 2.0 Mepivacaine - 2.0 Prilocaine - 2.7 Bupivacaine - 0.6
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What are the anatomical differences you have to be aware of with pediatric patients?
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- The cortical bone is much less dense which means you don't need to do a nerve block on the maxillary (infiltration for all teeth) - Infiltration also works most of the time on the mandible as well. - This way you keep kids from chewing on their cheeks - Also, the ramus is much shorter, the mandibular foramen is AT the mandibular occlusal plane
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What is the cross arch landmark in kids when doing an IA?
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The Primary molars
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What are the two anesthetics used in the perio sulcus anesthetic gel (oraqix)?
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Lidocaine and Prilocaine (2.5% of each)
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What is the main anesthetic concern for oral surgery?
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The volume of anesthetic used. If doing multiple extractions you could easily be giving upward of 5 or 6 cartidges.. that's a lot
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What is the anesthetic reversal tool called?
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OraVerse
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What is the chemical used in the anesthetic reversal tool and how does it work?
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Phentolamine Mesylate - It is a competitive alpha-adrenergic antagonist - It works by accelerating the rate of redistribution of local anesthetic from the submucosa into the CV system - REVERSES THE EFFECTS OF THE VASOCONSTRICTOR
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Lecture 13: Medical Emergencies in the Dental Office
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.
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What do anaphylactic reactions in the dental office usually result from?
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Drug administration or reaction to an allergen in impression material or other materials used - Drug administration is the most common
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Are reactions to anesthesia always immediate?
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No, they can occur as quickly as 30-60 seconds or as slowly as 1 hour after the injection
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What are some signs that someone is having an adverse reaction to the anesthetic?
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Light headed Dizzy Drowsy Slurred speech Nausea
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What are the main signs of someone who is having a bad reaction to the Vasoconstrictor?
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These are more about rapid heartbeat and the chest: - Restlessness - Chest pain - Dysrhythmias - Cardiac arrest
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Is hypo or hyperglycemia more critical in an emergency situation?
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HYPOglycemia
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What do you do if you suspect someone is hypoglycemic?
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- Give them glucose regardless - If its not hypoglycemia then no harm done - Hypoglycemia has to be treated very rapidly
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What are the signs that someone is hypoglycemic?
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- Hunger - Nausea - Cool, moist skin - Shallow respirations - Irritation - Confusion - Bizarre behavior
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What is angina pectoris?
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Chest pain caused by temporary myocardial ishemia without any heart damage
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What causes angina pectoris?
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Caused by the narrowed coronary arteries' inability to supply the myocardium with sufficient blood to meet the heart's demand for oxygen during times of stress
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How do you treat Angina Pectoris?
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- Place the patient in a semireclined position - Provide supplemental oxygen - Administer aspirin, 650mg - Administer sublingual nitroglycerin (0.4 mg) every 5 minutes for three doses - If symptoms don't go away, assume the patient is having a heart attach and get them to a hospital
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What is happening during a heart attach (Myocardial infarction)?
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Myocardial oxygen demand exceeds available oxygen supplied by the blood for an extended period of time - This occurs due to clogged coronary arteries (ATHEROSCLEROTIC CORONARY ARTERY DISEASE)
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What is a cerebrovascular accident (stroke)?
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Any process that acutely interferes with blood flow to the brain
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What are the three major causes of stroke?
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- Arterial thrombosis (blood clot) - Embolism (embole = something that clogs something else) - Hemorrhage of the vasculature
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How do you position the patient if you suspect a stroke?
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Place the patient in a supine position with the head slightly elevated
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How do you position the patient if you suspect a heart problem?
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Semireclined position
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What happens during cardiac arrest and how is it different than a heart attack?
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Cardiac arrest is where your heart stops suddenly due to ventricular fibrillation (electrical problems) - THE PATIENT WILL ALWAYS LOSE CONSCIOUSNESS In a heart attack the blood doesn't get enough oxygen - THE PATIENT WILL NORMALLY MAINTAIN CONSCIOUSNESS
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What percentage of people live through cardiac arrest?
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7% - national average
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Why is early defibrillation so important?
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Chances of success decrease 7% to 10% each minute
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Who do you give oxygen to?
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Indicated for all patient undergoing a medical emergency with a free airway
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What is the normal flow of oxygen set to?
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12 liters per minute
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Physiologically, what does an albuterol inhaler do?
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Stimulates beta-2 receptors - expands airways by releasing the surrounding muscles
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What does nitroglycerin do?
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Expands blood vessels for patients with angina
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How much epinephrine do you give someone that is undergoing anaphylactic shock?
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.5ml for adults - the younger the patient the less they need
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When do you use Diphenhydramine antihistamine?
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That's just a big word for Benadryl - Use for Acute hay fever and other types of allergy including anaphylactic shock (after epi)
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What does the ABCD Algorithm stand for?
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Airway - Open airway Breathing - check breathing Circulation - look for breathing and pulse Defibrillation - Follow directions on AED
