Anesthesia

Front 1

what do the addition of vasoconstrictors in local anesthetic do to the anesthetic solution

Back 1

1. *** prolong the effect of the local anesthetic, preventing the uptake of the anesthetic in the blood
2. inc. the depth of anesthesia: b/c anesthetic is not taken away via blood allows for it to penetrate into tiss
3. reduces the plasma concentration of the local anesthetic: dec. amt in blood
4. reduces incidence of systemic toxicity
5. reduces bleeding at surgical site

Front 2

these adrenergic receptors are located in smooth muscle throughout the body (eye, lung, blood vessels, uterus GI and urinary tracts). Name this alpha adrenergic receptor and its effect on BP

Back 2

alpha1: shunts blood away from organs and tissues not involved in fight or flight and redistributes to heart lungs, skeletal muscle = inc. BP

Front 3

this adrenergic receptor is found on vascular smooth muscle and prod. vasoconstriction when stimulated

Back 3

alpha-2 POST SYNAPTIC RECEPTOR
* a pre-synaptic receptor results in dec. sympathetic outflow, sedation, vasodilation and dec. BP

Front 4

these adrenergic receptors are mainly found in the heart resulting in inc. heart rate and contractility

Back 4

Beta-1 receptors

Front 5

these adrenergic receptors relaxe smooth muscle resulting in vasodilation (dec. BP) and bronchodilation

Back 5

Beta 2 receptors

Front 6

where will you find beta-3 adrenergic receptors

Back 6

in adipose tissue

Front 7

what localized effects do local anesthetics containing epinephrine have

Back 7

vasoconstriction mediated by alpha receptor activation:
- hemostasis at surgical site
- Ischemia of localized tissue

Front 8

what systemic effects do local anesthetics containing epinephrine produce

Back 8

Heart:
- inc. HR, Inc force and rate of contraction (beta -1)
-inc. CO, O2 demand
-dilation of coronary arteries and dec. in threshold for arrhythmias
Lungs: bronchodilation (beta-2)
skeletal muscle: mostly vasodilate (beta 2)
CNS: min. direct effect due to no crossing of the blood brain barrier

Front 9

what is the most commonly used epinephrine dilution in dentistry

Back 9

1:100,000

Front 10

I am a compound ver similar in structure to epinephrine. I am the ONLY alternate choice of vasoconstrictor to epi. presently available in the US

Back 10

Levonordefrine

Front 11

what kinds of patients should reduced amts of epinephrine be administered to

Back 11

those with:
heart dz (angina, history of MI) and poorly controlled high blood press
** only 2 cartridges with epinephrine limited to .04mg

Front 12

what special consideration must you make for someone taking TCA's (tricyclic antidepressants)

Back 12

problem is elevation in Bp
limit dose to 2-3 cartridges of 1:100000 epi
avoid local anesthetics containing levonordefrin 1:20000 (may result in severe hypertension)

Front 13

what special consideration should you make for someone taking nonselective beta blockers

Back 13

problem: elevation of BP/bradycardia
careful injection of 1 ml of local anesthetic containing vasoconstrictor until profound anesthesia is obtained. After, ea. ml. vitals signs must be obtained before additionvasoconstrictor

Front 14

what special consideration should you make for someone taking cocaine

Back 14

problem elevated bP/HR/arrhythmias
cancel appointment

Front 15

what special consideration should you make for someone who has hyperthyroidism

Back 15

problem: thyroid storm, most extreme form of thyrotoxicosis = fever, tachycardia, neurological abnormalities and hypertension followed by hypotension and shock
EPINEPHRINE ADMIN. IS ABSOLUTELY CONTRAINDICATED

Front 16

if you patient has a BP <180/110 what procedures are appropriate

Back 16

You may proceed with stress reduction protocol this is assuming that pateint has been shown to have BP in range w/in normal limits and elevation is due to stress of appt.

Front 17

if your patient has a BP< 180/110 and a diagnosis of:
coronary artery dz, cerebrovascular dz, angina, and a history of MI/CVA in less than 6 mos. what should you prescribe

Back 17

NO treatment and require a consult with their physician

Front 18

at what BP would you not administer local anesthetic containing vasoconstrictoe

Back 18

>180/110

Front 19

a medical history should be updated how often and what should you ALWAYS ask at this appt.

Back 19

updated every 6 mos.!
always ask:
-has there been any changes in medial hx?
-Are you taking any new meds?

Front 20

there is a sm. pop. that have a inc. risk of medical emergency at the dentist what type of workup must you do to ensure that the patient has the physiologic/psychologic reserve to undergo planned treatment w/o complication

Back 20

medical hx: required by law, should be written/electronic, signed by patient and dated, and there should be evidence of Dr. reviewed
2. appropriate physical exam: at min.. HR, resp. rate, BP

Front 21

ASA classification for norm. healthy patient:
-no dyspnea and can do normal activity: climbing stairs, walking 2 blocks

Back 21

ASA I

Front 22

ASA classification for patient with mild systemic dz. Mild dyspnea after normal activity, may rest at top of flight of stairs = dyspnea after norm activity

Back 22

ASA II

Front 23

ASA classification for patient w/ severe systemic dz that is constant threat to life. dyspnea and orthopnea at rest (all the time)

Back 23

ASA IV
symptomatic at rest

Front 24

ASA classification for severe systemic Dz. dyspnea during normal activty but Ok at rest in any position. rests before reaching top of a flight of stairs

Back 24

ASA III

Front 25

what ASA classifications tolerate stress well and there are no treatment modifications necessary

Back 25

ASA i and II

Front 26

what ASA classification don't tolerate psychological/procedural stress well. and how would you change your treatment

Back 26

ASA III: avoid long complex procedures, stress reduction protocol, medical consult is ADVISED

Front 27

what ASA classification can only have emergency care b/c the psychological/procedural stress is too much

Back 27

ASA IV
medical consultation is REQUIRED!

Front 28

what signs and information would cause you to classify your ischemic heart dz/angina patient as unstable angina and at risk for MI

Back 28

if the patient experiences chest pain while doing min exercise or at rest OR if the patient requires multiple doses of nitrates before symptoms resolve

Front 29

T/F: there is no need for antibiotic prophylaxis in the placement of a cardiac pacemaker

Back 29

true

Front 30

how would you manage a ischemic heart dz/angina patient OR a MI patient that has had a consultation with their cardiologist

Back 30

1. stress reduction protocol: gentle tech. profound local anesthesia, short appts.
2. sedation
3. pre-op nitroglycerin sublingually 5 min before start of anesthesia (use patient's tabs)
4. consider admin. O2 during treatment
5. min. vasoconstrictors: 2 cartridges

Front 31

when treating a patient with congestive heart failure when can the patient be treated and what special things will you do to manage their health status

Back 31

-no treatment until patient is optimized medically: min. edema, good exercise tolerance
- stress reduction
-Position patient semi-supine or upright to avoid fluid overload in lungs
-min. vasoconstrictors

Front 32

what are some alterations to treatment you make for an asthmatic patient

Back 32

1. stress red.
2. bronchodilator available
3. avoid local anesthetics containing bisulfite antioxidants
4. use sedation if nec
5. No sings and symptoms on day of treatment

Front 33

In this patient you will avoid nitrous oxide/oxygen sedation and bliateral mandibular blocks and local anesthesia of the soft palate

Back 33

COPD = bronchitis and emphysema

Front 34

besides avoiding nitrous oxide/oxygen sedation and bliateral mandibular blocks and local anesthesia of the soft palate for patients with emphysema. what are some other changes you may make to treatment

Back 34

-position semi-supine or upright
-if supplemental O2 given, flow levels are kept below 4L/min
why? b/c in patients with chronic elevated CO2 the primary stimulus for breathing is dec O2 levels. thus high levels of O2 may depress drive for respiration

Front 35

T/F It is ok to administer routine doses of local anesthetic with vasocon. for all patients with diabetes

Back 35

false only with diabetics that have controlled dz
elective dental treatment is contraindicated in teh poorly controlled diabetic

Front 36

what dz's will you min. the use of vasoconstrictor

Back 36

1. congestive heart failure
2. MI
3. Angina/ischemic heart DZ
4. cerebralvascular accident: stroke

Front 37

coumadin, aspirin, SNSIDS, heparin are all drugs that

Back 37

are anticoagulation meds

Front 38

If your patient is taking coumadin, aspirin, NSAIDS, heparin what are they at risk for during a dental procedure and how should you manage this patient

Back 38

at risk for bleeding during a dental procedure you should
1. consult with physician
2. target INR should be less than 3 before treatment. this will correspond to a PT (prothrombin time of about 1.5-2
3. if physician reduces anticoagulant than period of 3 days required before change in the INR will be seen. An INR sould be done on the day of surgery
4. infiltration PDL and intraosseous injection are suggested for those at risk for bleeding. Avoid block anesthesia due to risk of damaging blood vessels

Front 39

what 3 ?'s should you ask to a patient who has ha a + history for allergy to local anesthetics

Back 39

1. what precipitated the event (where/when)?: during or after injection of local anesthetic. type and vol. administered+ if it contained vasoconstrictor. Was anything else given concurrently
2. describe the allergic event
3. what emergency treatment was given: if they cont. with treatment, patient was discharged home then = unlikely true allergic rxn
If given drugs (epinephrine or benadryl) and transported to a hospital then may have been true rxn

Front 40

your patient has said they have had an allergic reaction to anesthetics. they describe palpitations, headache, sweating, hyperventilation, loss of consciousness. Is this a true allergic event

Back 40

NO psychogenic reaction

Front 41

your patient has said they have had an allergic reaction to anesthetics. they describe: seizure type symptoms

Back 41

No adverse reactions and are no allergic in nature

Front 42

your patient has said they have had an allergic reaction to anesthetics. they describe : itching, rash, watery eyes, wheezing, dyspnea and laryngeal swelling

Back 42

true allergic response

Front 43

when can you treat a pregnant patient

Back 43

-emergency care is often done in all 3 trimester
-but routine denal care is usually accomplished during 2nd trimester
- relative contraindication in first trimester

Front 44

what are the desirable characteristics of local anesthetics

Back 44

1. block axon conduction
2. completely reversible, but sufficient length to allow completion of treatment
3. min. local toxic effects (nerve and muscle damage) + min. systemic toxic effects (organ sys)

Front 45

what does the lipophilic aromatic grp do for the local anesthetic

Back 45

enhances ability of anesthetic to penetrate various anatomical structures

Front 46

what does the lntermediate chain do for the local anesthetic

Back 46

separates hydrophobic and hydrophilic portion, determines the biotransformation (metabolism), way for classification (amides and esters)

Front 47

what does the hydrophilic amino grp do for the local anesthetic

Back 47

imparts water solubility to the molecule ensuring that anesthetic will NOT precipitate

Front 48

I am an aromatic acid and an amino alcohol. I work well as a topical b/c I am NOT water soluable

Back 48

ester we only have one i in our name

Front 49

I am an aromatic amine and an amino acid I have two I's in my name

Back 49

amide

Front 50

true or false:
as you inc your molecular wt. you inc the working time of an anesthetic

Back 50

true

Front 51

what type of molecules are ALL commonly used local anesthetics

Back 51

weak basic tertiary amines (acceptors of hydrogen ion)

Front 52

Wen a local anesthetic is injected what form of the local anesthetic binds to the anionic channel receptors in the sodium channel, thus blocking the influx of sodium ions

Back 52

the ionized (cation) form of the local anesthetic

Front 53

what form of the local anesthetic can penetrate the various barriers (nerve membrane, fibrous tiss) btw the site of injection and the sodium channel (targeted destination)

Back 53

Only the lipid soluble non-ionized (base RN-) form

Front 54

what may lower the pH of tissue so much that the anesthesia will be less effective

Back 54

1. injection of relatively lg. vol. of acidic local anesthetic solution into a sm. area
2. infection
these both reduce the nonionized form of the anesthetic
why? b/c due to the dec. pH = inc. in H+ molecules which bind RN- = RNT+ ionized form

Front 55

nerve fibers exhibit a wide range of sensitivity to nerve bloc. name the sensations that least to most resistant to a block

Back 55

most sensitive
1. pain
2. cold
3. warmth
4. touch
5. pressure
6. proprioception
7. motor = most resistant to block

Front 56

what nerve fibers pain and temperature sensation

Back 56

type: A-delta= myelinated, 10-15 M/sec, 3-4 micrometers
type: C nerve fibers, unmyelinated and are 1-2 micrometers, 1-2 m/sec

Front 57

what are the excitatory effects that a local anesthetic will have on the CNS

Back 57

excitatory: dizziness, visual and auditory distrubances, apprehension, disorientation, muscle twitching
this is more common with ester type agents

Front 58

what are the depression effects that a local anesthetic will have on the CNS

Back 58

depression manifested as slurred speech, drowsiness and unconsciousness
more common with amide type agents

Front 59

If large doses of anesthetic is given what will the effects be on the CNS

Back 59

higher cons: may produces a tonic-colnic convulsions (grand mal)
very lg. doses: respiratory depression which can be fatal

Front 60

local anesthetics have a direct action on the myocardium and peripheral vasculature by closing the sodium channel, what effects may this have on the CVS

Back 60

myocardium: usually depressed both in rate and force of contraction. depression of ectopic pacemakers useful in treating cardiac arrhythmias

Front 61

what are some toxic effects that local anesthetic may have on local tissue

Back 61

1. occasionally focal necrosis in skeletal muscle at injection site, dec. cell motility an delayed wound healing
2. tiss. hypoxia may be prod. by action of excessive vasoconstrictors

Front 62

procaine and lidocain are active vasoconstrictors and dec their own absorption in the blood

Back 62

false! they are active vasodilators. b/c of their hydrophilic and hydrophobic properties they do not remain confined to the injected site for long.

Front 63

why must you use caution when administering local anesthesia to a patient with severe liver dz

Back 63

amides are metabolized by oxidation and hydrolysis by the liver amidase. Severe hepatic dz may reduce metabolism and lead to toxic reactions

Front 64

this type of anesthetic is the most widely used and versatile

Back 64

lidocaine

Front 65

this type of local anesthetic has a rapid onset and a very long duration of action even without vasoconstrictor

Back 65

bupivacaine

Front 66

I am the ONLY amide type local anesthetic that contains an ester grp therefore I am metabolized both in the liver and plasma

Back 66

articaine

Front 67

this topical anesthetic is a derivative of procaine and is poorly soluble in water thus is ONLY available as a topical anesthetic. It is also poorly absorbed into the blood so overdosing is unlikely

Back 67

benzocaine

Front 68

this topical anesthetic is available as an injectable and topical. It is also a potent agent that should be used with great caution to avoid systemic toxicity

Back 68

tetracaine

Front 69

this anesthetic is exclusively used as a topical agent. It has a vasoconstrictive as well as anesthetic prop.

Back 69

cocaine

Front 70

how is the metabolism of esters different from amides

Back 70

esters: hydrolysis by plasma and liver esterase's = don't use if patient is deficient in plasma cholinesterase
remember that articaine is the only amide with an ester grp = metabolized both in plasma and liver
amides are oxidized by liver enzymes

Front 71

why do we aspirate

Back 71

to prevent intravascualr infection which inc. toxicity by 16x

Front 72

I am credited with the discovery of gen. anesthesia. I inhaled N2O to extract my own wisdom tooth

Back 72

1844, Horace Wells DDS

Front 73

What did WTG morton DDS do in 1846

Back 73

administered ether for a patient in Mass. gen. hospital

Front 74

who blocked the inferior alveolar nerve with cocaine.Showing that the infection of a nerve trunk in any part of its course is followed by local anesthesia in its entire peripheral distribution

Back 74

Halstead 1884

Front 75

needles used for local anesthesia are sterile, disposable, and manufactured out of stainless steel. what do these characteristics reduce the risk of

Back 75

1. cross contamination
2. needle breakage
3. tiss. trauma

Front 76

what 3 diameter needles are commonly used in dental intraoral injections

Back 76

1. 25 gauge
2. 27 gauge
3. 30 gauge
smaller gauge number rep. larger diameter needle

Front 77

how long is a long needle, snort needle and ultrashort needle

Back 77

long = 3-=35
short = 20-25
ultrashort = 10 mm
the length must be sufficient to reach the target area and allow for adequate exposure of nedle if needle broke

Front 78

what injections ALWAYS require selection of a long needle

Back 78

infraorbital, gow gates and akinosi

Front 79

what are the advantages of a 25 gauge needle

Back 79

1. rigid: can be directed to target w/o deviation
2. less likely to penetrate smaller vessels
3. aspiration is easier
4. safety: less likely to break

Front 80

when doing multiple injection on the same patient how do ensure that the needle is not barbed

Back 80

pull needle through sterile 2x2 gauze pad
if barbed throw needle away

Front 81

what are the 2 types of syringes

Back 81

1. cartridge type:
-breech-loading
-self aspirating
-peripress or ligmaject
-needleless (srjet
-CCLAD
2. luer-lok: used in medicine and for IV sedation

Front 82

what parts does a typical dental syringe consist of

Back 82

1. barrel: holds cartridge
2. hub: attaches needle to syringe
3. piston: engages plunger of aesthetic cartridge

Front 83

why must cartridges be stored at room tep and in the dark

Back 83

exposre of cartridge to heat and light result in degradation of vasoconstricto

Front 84

what is the vol. of a dental cartridge

Back 84

1.8 ml

Front 85

what are teh advantages of dental anesthetic cartridges compared to a multi dose vials

Back 85

1. convenient
2. sterility
3. constant dosage
4. does NOT contain parabens (antimicrobials)
BUT they are more expensive

Front 86

what function do sodium bisulfite/metabisulfite have on the local anesthetic

Back 86

antioxidant used to stabilize the vasoconstrictor

Front 87

what is the least stable component of the local anesthetic

Back 87

VASOCONSTRICTOR
acid med. required for stability and broken down by heat, light, O2 and alkalinity

Front 88

true or false you must autoclave the cartridges

Back 88

false they are considered clean as they come from the container

Front 89

why do you not want to soak your cartridge in alcohol

Back 89

b/c the soaking will penetrate diaphragm you may wipe the diaphragm with alcohol before loading syringe (optional)

Front 90

describe the steps when assembling the syringe

Back 90

1. retract piston
2. place cartridge with rubber stopper placed first
3. engage harpoon into rubber stopper
4. attach needle, express a few drops to test for proper assembly

Front 91

true or false: when unloading the cartridge you pull back the plunger, remove the cartridge, remove the needle

Back 91

TRUE!
cartridge must be removed before needle to prevent CARTRIDGE FROM IMPLODING

Front 92

In this basic injection technique local anesthetic is deposited in close proximity to a nerve trunk. Resulting in the blockade of nerve impulses distal to this point

Back 92

nerve block

Front 93

this basic injection technique relies on the ability of local anesthetics to diffuse through numerous structures to reach the nerve or nerves
ie: periosteum, cortical bone, nerve memb.

Back 93

field block/infiltration/supraperiosteal

Front 94

In this basic anesthetic technique to be effective requires diffusion through mucous membranes and nerve membrane of the nerve endings near the tiss surface

Back 94

topical

Front 95

In this basic injection technique diffusion of local anesthetic sol. through the cancellous bone (spongy

Back 95

PDL/intraosseous

Front 96

this is the only nerve block that does not use a 25 G short needle

Back 96

palatal = 27/30G short/ultrashort

Front 97

what usually lasts longer nerve block or infiltration anesthesia

Back 97

nerve block

Front 98

what usually lasts longer soft tissue or pulpal anesthesia

Back 98

soft tissue

Front 99

what is the most common medical emergency encountered in the dental office setting

Back 99

syncope: physiologic response to stress and anxiety of dental procedures = pooling of blood in skeletal muscle leads to drop in BP and results in cerebral ischemia = light headedness, pallor, possible loss of consciousnes s

Front 100

how would you combat syncope

Back 100

place patients in supine or semi-supine position to improve venous return and cerebral blood flow