Pain and Anxiety Modules 10-14

Systemic complications

- syncope

-local anesthetic overdose

-epinephrine overdose

-allergic reaction

-any potential emergency

Cause of syncope

Drop in BP or emotional response

Syncope prevention

Identify fearful patients and sit patient in supine position

Symptoms of syncope

Sweating, nausea, pallor, Increased HR and RR

Treatment of syncope

-Supine position with legs elevated

-Ammonia/oxygen

-Cool damp cloth on forehead/neck

-Do not let patient stand

Cause of local anesthetic overdose

-Injecting into a vessel (most common)

-Administering too much

-Metabolism/excretion of LA is slow

Prevention of LA overdose

-Aspirate in two planes

-Calculate MRD

-Pre-anesthetic assessment for LA selection

LA overdose symptoms

With LOW overdose: CNS excitation

With HIGH overdose: CNS and CV depression

Treatment of LA overdose

-Mild reactions: no treatment

-Severe reactions: stabilize patient and activate EMS

Cause of epinephrine overdose

-1:50,000 concentration

-intravascular injection

-CV patients

Prevention of epinephrine overdose

-Aspirate in two planes

-Use lowest effective concentration

-Pre-anesthetic assessment to identify CV patients

Symptoms of epinephrine overdose

Fight or flight that lasts 5-10 minutes

Treatment of epinephrine overdose

Healthy patients: reassure them

CV patients: prepare for medical emergency

Cause of allergic reactions

Hypersensitivity to: methylparaben, sodium bisulfite, ester topicals

Prevention of allergic reactions

Pre-anesthetic assessment

Symptoms of allergic reactions

Delayed: rash, itching

Immediate: anaphylaxis

Treatment of allergic reactions

Delayed: antihistamine and document

Anaphylaxis: stabilize patient, activate EMS, document

Local complications

-Needle breakage

-Pain during injection

-Burning during injection

-Hematoma

-Facial paralysis

-Paresthesia

-Trismus

-Infection

-Edema

-Soft tissue injury

-Tissue sloughing

Cause of needle breakage

Sudden unexpected movement or poor technique

Prevention of needle breakage

-Use 25g or 27g

-Use long needle for IA block

-Do not bend needle

-Do not insert to the hub

-Do not force needle

Treatment for needle breakage

-Keep hand in patient's mouth

-Remove if visible

-Refer to oral surgeon

-Document

Cause of pain during injection

Dull/barbed needle or poor technique

Prevention of pain during injection

- inject slowly

- use topical anesthetic

- use sharp needle

- use anesthetic at room temperature

Treatment for pain during injection

Slow down delivery of anesthetic

Cause of burning during injection

- contaminated/expired anesthetic

- poor technique

- heated anesthetic solution

Prevention of burning during injection

- inject slowly

- check cartridge before use

- store anesthetic at room temperature

Treatment of burning during injection

Slow down delivery of anesthetic

Cause of hematoma

- puncture of blood vessel

- poor technique

- multiple needle penetrations

Prevention of hematoma

Use 27 short for PSA and know anatomy

Treatment of hematoma

- apply ice/pressure

- inform patient of swelling/bruising for 7-14 days

- document

Cause of facial paralysis

LA deposited into parotid gland

Prevention of facial paralysis

Contact bone before depositing anesthetic

Treatment of facial paralysis

Reassure patient and document the incident

Cause of paresthesia

-Trauma to nerve sheath

-Edema/hemorrhage near nerve

-Contaminated anesthetic

-ARTICAINE

Prevention of paresthesia

Minimize movement within the tissue and do not soak in disinfectant

Treatment of paresthesia

Reassure patient it can las 3 weeks - 3 months (up to a year eek) and document

Cause of trismus

Muscle trauma from multiple needle insertions or contaminated anesthetic

Prevention of trismus

-Use sharp needle

-Deposit slowly

-Store properly

Treatment of trismus

-Lasts 2-3 days

-Moist heat 20 min on/off

-Document incident

Cause of infection

Contaminated needle/cart or administering through infected area

Prevention of infection

Use sterile needle and do not inject through an infected area

Treatment of infection

Antibiotics after 3 days

Cause of edema

- trauma

- contaminated anesthetic

- allergic reaction to LA/sodium bisulfite

Prevention of edema

identify allergies and store anesthetic properly

Treatment of edema

Resolves by itself in 3-4 days

Cause of soft tissue injury

Self-inflicted (usually kids)

Prevention of soft tissue injury

Select LA with appropriate duration

Treatment of soft tissue injury

-Analgesics

-Antibiotics if severe

-Warm saltwater rinses

-Vaseline for lips

Trigeminal nerve is considered a ____ nerve

Mixed

Vi and V2 are

Sensory

V3 is

Sensory and motor

CN V1

Ophthalmic division

3 branches of CN V1

nasociliary, frontal, lacrimal (NFL)

Where does CN V1 pass

Superior orbital fissure

CN V2

Maxillary division

Where does CN V2 pass through

Foramen rotundum

Where does CN V2 enter?

pterygopalatine fossa

What are the 5 major branches of CN V

-nasopalatine n

-greater palatine n

-PSA n

-infraorbital n (ASA + MSA)

-zygomatic n

Which nerves branch from the pterygopalatine ganglion to travel through the pterygopalatine canal and reach the soft palate?

lesser palatine and greater palatine nerves

CN V3

Mandibular division

What does CN V3 pass through?

Foramen ovale

3 sections of CN V3

-undivided trunk

-anterior trunk

-posterior trunk

What the undivided trunk of CN V3 give rise to?

muscular branches

What does the anterior trunk of CN V3 give rise to?

long buccal nerve and muscular branches

What does the posterior trunk of CN V3 give rise to?

IA nerve, lingual nerve, and auriculotemporal nerve

5 major branches of CN V3

-long buccal nerve

-muscular branches

-auriculotemporal nerve

-lingual nerve

-IAN (mylohyoid, mental, incisive nn)

T/F: facial nerve is a mixed nerve

True

Motor component of CN VII

muscles of facial EXPRESSION

Sensory component of CN VII

sensory to anterior 2/3 tongue

What does CN VII pass through?

internal acoustic meatus

What branches does CN VII give off after passing through internal acoustic meatus?

chorda tympani and greater petrosal nerves

Where does CN VII exit the skull?

Stylomastoid foramen

What branches does CN VII give off after entering the parotid gland?

- temporal nerve

- zygomatic nerve

- buccal nerve

- nerve

- cervical nerve

(ten zebras bit my coochie)

External carotid artery terminates as

maxillary and superficial temporal aa

Where does maxillary artery begin?

Parotid gland

What 4 branches does maxillary artery give rise to in the infratemporal fossa?

-middle meningeal a

-inferior alveolara

-branches to muscles of mast

-buccal a

What branches does maxillary artery give rise to in the pterygopalatine fossa?

-PSA

-Infraorbital a

-greater palatine a

-sphenopalatine a

What is associated with hematoma and spread of infection if a PSA is administered incorrectly?

pterygoid plexus

Protective function of pterygoid plexus

Protects the maxillary artery from being compressed during mandibular movement

What is innervated by posterior superior alveolar nerve?

Maxillary molars and buccal gingiva

What is innervated by middle superior alveolar nerve?

Maxillary premolars, MB cusp of 1st molar, and buccal gingiva

What is innervated by anterior superior alveolar nerve?

Maxillary canines, laterals, centrals, and labial mucosa/inner aspect of the lip to midline

How much LA is used for a PSA block?

0.9-1.8 cc

How much LA is used for MSA block?

0.9-1.2 cc

How much LA was used for an ASA block?

0.9-1.2 cc

How much LA is used for a GP block?

0.25cc

How much LA is used for a NP block?

0.25 cc

How much LA is used for an infraorbital nerve block?

1.2 cc

How much LA is used for a supraperiosteal infiltration?

0.9-1.0 cc

Target area of the MSA block

Slightly apical to the premolars

What needle is used for a MSA block?

27 short

Insertion length for a MSA block

1/3 - 1/2 needle length

Target area of the PSA block

Apical to the root of the 3rd molar

What angulation should a PSA block penetration have

45 angle to the long axis of the tooth and 45 degree angle medially

What needle is used for a PSA block?

27 short

Insertion length for a PSA block

half the needle length

Target of the ASA block

Apical and slightly distal to the canine

What needle is used for an ASA block?

27 short

Insertion length for ASA block?

1/3 - 1/2 needle length

What does the greater palatine nerve innervate?

Palatal soft tissue from the distal of the canine to the junction of hard and soft palate