QUIZ 3: Week 4 Lecture 1: Complications & Legal/Ethical Considerations

Define localized complications

complications that occur in the region of the injection

Define systemic complications

complications that are widespread (throughout the body)

TRUE OR FALSE: Systemic complications occur less frequently than local complications

True

What are systemic complications usually caused by?

Inadvertent intravascular injection

Direct intravascular injection of any local anesthetic will produce a serious overdose occurring almost immediately

What are the 3 types of systemic complications?

Local Anesthetic

Overdose

Vasoconstrictor Overdose

Allergic Reaction

Define overdose

body's response to overly high blood levels of a drug

What are the predisposing factors to an LA overdose reaction?

Age (young and old)

Weight (lighter weight)

Genetics

Disease

Gender/Pregnancy

How does vasoactivity increase the risk for an overdose reaction?

Vasodilation increases risk

Use vasoconstrictors to decreases risk

How does drug dose increase the risk for an overdose reaction?

Higher dose increases risk

How does the route of administration increase the risk for an overdose reaction?

Intravascular injection increases risk

How does the rate of injection increase the risk for an overdose reaction?

Rapid injection increases risk

How does the vascularity of injection site increase the risk for an overdose reaction?

Increased vascularity increases risk

What are the causes of a LA overdose?

1. *Inadvertent intravascular injection*

2. Metabolism of anesthetic is unusually slow

3. Elimination through the kidneys is unusually slow

4. Total dose administered is too large

5. Absorption of anesthetic from the site of injection is unusually rapid

What is the classic expression of a LA overdose?

seizure

How do we manage a mild overdose?

Reassure the patient, terminate procedure

Position in a comfortable position

Administer oxygen

Provide BLS if needed or summon medical

assistance if needed

Monitor vital signs

Allow to recover and discharge

How do we manage a severe LA overdose?

1. Elevate feet, supine position

2. Protect from harm

3. Get emergency help and activate BLS

4. Administer oxygen, monitor vital signs

5. Anticonvulsant if lasts more the 5 minutes

6. Allow to recover, transport to hospital

How can we prevent LA overdoses?

1. ASPIRATE before depositing anesthetic! In areas of increased vascularity, double aspirate

2. Aspirate during injection (if giving ½ cartridge or more)

3. Use a 25 or 27 gauge needle

4. Administer slowly (1 minute per cartridge)

What are the causes of a vasoconstrictor overdose?

High concentration of epinephrine (1:50,000)

Intravascular injection

What are the signs/symptoms of a vasoconstrictor overdose?

Produces an anxiety reaction accompanied by increase in BP and Pulse

Anxiety / Apprehension / Nervousness

Tremors

Tension

Increased heart rate and blood pressure

Throbbing headache

Hyperventilation (don't administer oxygen, have them cup their hands to breathe in the air they're exhaling)

How do you manage a vasoconstrictor overdose?

Terminate procedure

Position patient upright

Reassure patient

How do you manage a prolonged vasoconstrictor overdose?

Provide BLS

Monitor vital signs

Activate EMS if needed

Administer oxygen (unless hyperventilating)

Allow patient to recover and discharge

How do you prevent a vasoconstrictor overdose?

Use lower concentration (1:200,000 vs. 1:50,000)

Aspirate to prevent inadvertent intravascular injection

Administer lowest possible effective dose (especially for patients with CVD)

What are allergic reactions more common with regarding LA?

more common with ESTERS... watch topicals --> Benzocaine

if allergic to AMIDES, likely due to sodium bisulfate

range from rash to anaphylaxis

How do you prevent allergic reactions?

Thorough medical history review

Since most allergic reactions are due to sodium bisulfite, ask about food/wine sensitivity to determine if patient has a sulfite allergy

Ask about previous experiences with Local Anesthesia

If in doubt, have patient allergy tested

What are the types of allergic reactions?

Delayed (roughly 60 minutes)

Immediate

Skin reactions are most common

How do you manage a mild allergic reaction?

Delayed (60 minutes or more) & localized

Administer oral antihistamine (25-50 mg. Diphenhydramine/Benadryl every 6-8 hours)

Medical consult for allergy testing

How do you manage a severe allergic reaction?

Immediate reaction (<60 minutes)

.3 mL of epi (1:1000) subcutaneously

Corticosteroids (60 mg prednisone) should be administered if respiratory distress / bronchospasm / hypotension occurs

What are the symptoms of an anaphylaxis reaction?

Would occur seconds after administration of LA

Itching

Rash

Wheezing

Respiratory Distress

Swelling

Low blood pressure

May progress to unconsciousness

How do you manage anaphylaxis?

Terminate procedure and immediately activate EMS

Place in a upright position for conscious patient and a supine position for an unconscious patient

Monitor vitals

Administer oxygen as needed

Administer .3 mL of epi (1:1000)

Monitor and provide BLS as needed until help arrives

What is the most common dental emergency?

fainting/syncope

How do you manage fainting?

Supine position --> feet elevated

Loosen binding clothing

Place cool, damp cloth on forehead, reassure

Monitor and record vitals

Administer oxygen

What are the local complications that can occur with LA administration?

Paresthesia

Trismus

Hematoma

Transient Facial Nerve Paralysis

What is paresthesia?

Persistent anesthesia well beyond the expected duration of anesthesia --> pt feels "persistent anesthesia" for days, weeks, years ... rarely permanent

What are most paresthesia reports from?

IALB Nerve Block

What LA will give a less risk for paresthesia?

Less risk of paresthesia with the GG Nerve Block

Whether or not to use 4% Articaine with IA/L/B blocks remains a matter of professional judgment

How do you manage paresthesia?

Reassure the patient that it is most likely temporary and usually resolves in 8 weeks

Seek consultation with oral surgeon

What is trismus?

Reduced opening of the jaws due to trauma to muscles

Minor, common local complication, but can be chronic

Soreness and difficulty opening

What are the causes of trismus?

Trauma to muscles

Multiple needle insertions

Depositing contaminated solution

Using contaminated needles

How can we prevent trismus?

Use sterile equipment

Use correct technique (i.e. Inject solution slowly) and volume

Limit number of penetrations & redirection of the needle

How can we manage trismus?

Apply heat for 20 minutes every hour

Analgesics

Muscle relaxants

Movement therapy for 5 mins every 3-4 hours

Lasts 48-72 hours

Complete recovery 4-20 weeks, typically 6 weeks

What is a hematoma and what causes it?

Bruising (discoloration) and swelling of the tissue noted intra- and extra-orally

Caused by nicking a blood vessel with the needle during injection

Where does a hematoma most commonly occur?

occurs most commonly with injections in highly vascular areas

PSA, IA, and MI

How can we prevent a hematoma?

Know dental anatomy

Review medical histories

Minimize number of needle insertions

Follow injection techniques

Always use a short needle and possibly modify the needle insertion depth using a more conservative technique for the PSA block for children, small adults, and patients with smaller facial characteristics

How do we manage a hematoma?

Immediately apply pressure at the site of bleeding (2 minutes)

Apply cold packs

Do not apply heat the same day, but next day

Inform patient that

swelling and bruising will disappear after 7-14 days

Dismiss patient when bleeding has stopped

Document!

What is Transient Facial Nerve Paralysis?

“Anesthesia of the facial nerve”

Temporary loss of function of muscles of facial expression due to anesthesia of facial nerve

Temporary loss of motor function, unilateral

Unable to close the eye

Mostly a cosmetic problem

Lasts a few hours

What are the causes of Transient Facial Nerve Paralysis?

The needle was directed too far posteriorly (into the parotid gland)

Should contact bone to ensure you're in the right area

Poor IA or GG technique

How do we manage Transient Facial Nerve Paralysis?

Reassure the patient that it is transient

Remove contact lenses

Manually close the eye

Review your technique --> NEED TO CONTACT BONE BEFORE YOU ADMINISTER

What do you need to do when you get needle pricked?

If and when you get pricked REPORT, REPORT, REPORT

Follow your private practice protocol for insuring all the necessary testing for you and the patient is completed

Malpractice Insurance (do not rely on your dentist's/employer's coverage/plan—GET YOUR OWN)

How can you decrease your liability?

Consent forms for local anesthesia

Provide pain control in compliance with state laws and rules

Develop office protocol for authorization

Use accurate technique and good communication

Document the experience

How do you document a needle prick incident?

Identify the problem

Describe the procedure performed

Notation of the level of involvement

Evaluation of outcome

What are the ethical considerations of LA regarding underuse?

Recommend local anesthetic when appropriate

Do not be afraid to use and to offer it to your patients

Use topical anesthetics generously... make your patients comfortable

What are the ethical considerations of LA regarding overuse?

Use the appropriate volume

Do not go over the Maximum Recommended Dose (MRD)