Anesthesiology Final

Front 1

Supraperiosteal Injection:
Insertion and depth
Distribution
Needle Type, amnt anesthetic
Contraindication

Back 1

Insertion – anywhere in maxilla at vestibule above desired area of anesthesia, penetrating 3-4 mm.

Distribution – single tooth/root, buccal gingiva, periosteum, alveolar bone

Needle Type – 27 short, dispensing 0.5-1.5 mL depending on incisor / molar

Contraindication – any infected tissue

Rare positive aspiration
No bony contact

Front 2

Anterior Superior Alveolar Nerve Block:
Insertion –
Distribution –
Needle Type –

Back 2

Anterior Superior Alveolar Nerve Block
Insertion – at apex of canine, penetrating 3-4 mm.
Distribution – CI, LI, C, buccal gingival
Needle Type – 27 short

Front 3

Middle Superior Alveolar Nerve Block
Insertion –
Distribution –
Needle Type –

Back 3

Middle Superior Alveolar Nerve Block
Insertion – apex of maxillary 2PM, penetrating 3-4 mm.
Distribution – Maxillary PMs, MB root of 1M, buccal gingiva
Needle Type – 27 short, dispensing 1.0-1.5 mL

Front 4

Posterior Superior Alveolar Nerve Block
When it's used -
Insertion –
Distribution –
Needle Type –

Back 4

Posterior Superior Alveolar Nerve Block
Used when needle anesthesia in 2+ maxillary molars, there is infection or failure of anesthesia at site of supraperiosteal injection
Risks – hematoma, no bony landmarks, second injection needed for 1M
Insertion – above DB root of maxillary 2M, posterior to zygomatic buttress thru buccinator, penetrating 16 mm.
Distribution – all molars except
MB root of 1M (MSA injection)
Needle Type – 25 short
Positive aspiration more common
No bony contact

Front 5

Infraorbital Block (Anterior Superior Nerve Block)
Insertion –
Distribution –
Needle Type –

Back 5

Infraorbital Block (Anterior Superior Nerve Block)
Insertion – lateral to apex of maxillary 2PM, penetrating 15 mm.
Foramen entrance inferior to IO rim at IO notch (zygomatico-maxillary suture) along line from inner pupil of eye to labial commissure
Distribution – midline to MB root of maxillary 1M affects MSA, ASA, inferior palpebral, lateral nasal, superior labial
Needle Type – 25 long, dispensing 1.0mL
Passes through levator anguli oris muscle

Front 6

Greater Palatine Nerve Block
Insertion –
Distribution –
Needle Type –
General Considerations -

Back 6

Greater Palatine Nerve Block
Insertion – anterior to foramen at jxn of alveolar process and lateral plate of hard palate, penetrating 4-6 mm.
Distribution – posterior 2/3 of palatal tissues up to 1PM only on ipsilateral side
Needle Type – 27 short (due to injecting in confined space), dispensing 0.25-0.50 mL
Rare positive aspiration
Bony Contact
General considerations – one of the most painful dental injections
Topical – poor results due to keratinized mucosa
Pressure anesthesia – use of ball burnishers and cotton tip applicators
Control of needle and slowly inject

Front 7

Nasopalatine Nerve Block
Insertion –
Distribution –
Needle Type –
General Considerations –

Back 7

Nasopalatine Nerve Block
Insertion – lateral border of incisive papilla, penetrating 3-5 mm.
Distribution – entire premaxilla, crossing midline from Canine to Canine, mucoperiosteum, bone, gingiva
Needle Type – 27 short, dispensing 0.2-0.3 mL
General Considerations – also incredibly painful
Topical/pressure do not work well here
Most effective: first conduct supraperiosteal injection between CIs, then intrapapillary injection between CIs and then into incisive papilla
Careful to insert small volume because of confined space (too much will lead to pain)

Front 8

V2 Block - High Tuberosity
Contraindications –
Insertion –
Distribution –
Needle Type –

Back 8

V2 Block – High Tuberosity
Indicated for major surgery and diagnosis of neuralgias/tics
Contraindications – pediatric population, uncooperative patients, hemorrhage risk
Insertion – bevel facing down, bent 30° at hub, insert at height of maxillary vestibule posterior to zygomatic process, normally adjacent or just slightly posterior to DB root of maxillary 2PM, penetrating 30-35 mm.
Distribution – entire hemimaxilla
Needle Type – 25 long
Aspiration is very important in the V2 block because there is a great deal of vasculature present

Front 9

V2 Block – Pterygopalatine Approach
Insertion –
Distribution –
Needle Type –
Complications -

Back 9

V2 Block – Pterygopalatine Approach
Insertion – bent 30° at hub, insert into greater palatine foramen, penetrating 25-30 mm., aiming for Pterygopalatine fossa 10 mm. below V2 nerve
Distribution – entire hemimaxilla
Needle Type – 27 long, dispensing 1 entire cartridge (~ 1.8 mL)
Complications
Needle breakage, lateral deflection into infratemporal fossa, medial penetration into nasal cavity, superior penetrating into orbit

Front 10

Disadvantages of Mandibular over Maxillary –
Advantages over Maxillary –

Back 10

Disadvantages over Maxillary – lower success rates due to higher bone density, anatomic variations, greater distances to target zones
Greater chance of positive aspiration (10-15%), contraindicated in possible self-injury patients, large area of anesthesia
Advantages over Maxillary – one injection sufficient, large area of anesthesia, bony contact

Front 11

Pterygomandibular Space – borders
Contents –

Back 11

Pterygomandibular Space – borders  buccinator, ramus, Medial Pterygoid, Parotid
Contents – lingual nerve, inferior alveolar nerve / vein / artery, sphenomandibular ligament

Front 12

Inferior Alveolar Nerve Block - Insertion/depth –
Target –
Distribution –
Needle Type/amount –

Back 12

Insertion – from over the opposite premolars through buccinator muscle lateral to pterygomandibular raphe and medial to insertion at the temporalis muscle, at a height that bisects thumbnail when placed in the deepest concavity of coronoid notch, contact bone and then withdraw slightly, penetrating 20-25 mm.
Target – mandibular sulcus superior to mandibular foramen behind lingual
Distribution – mandibular teeth on side of injection plus periosteum, alveolar bone, buccal tissues served by mental nerve
Needle Type – 25 long, dispensing one carpule (1.8 mL)

Front 13

Gow Gates Block
Advantage –
Disadvantage –
Insertion/depth –
Target –
Distribution -
Needle Type/amount –

Back 13

Gow Gates Block
Advantage – total mandibular anesthesia, high success rate, less positive aspiration than standard, less trismus and bony contact obtained
Disadvantage – longer onset, learning curve (technique specific) – difficult to administer

Insertion – Through buccinator from opposite canine or premolars in path established by intratragic notch and angles of wide open mouth, penetrating 23-27 mm.
Medial to deep tendon of temporalis at height of ML cusp of Maxillary 2M distal to maxillary 2M
Target – neck of mandibular condyle just below insertion of lateral pterygoid when mouth is wide open
Distribution - inferior alveolar, mental, incisive, lingual, mylohyoid, auriculotemporal, buccal
(only block to anesthetize all of these at once)
Needle Type – 25 long, dispensing 1 carpule (~ 1.8 mL)

Front 14

Akinosi Closed Mouth Block
Advantages –
Disadvantages –
Insertion/depth –
Target –
Distribution –
Needle Type/amount –

Back 14

Akinosi Closed Mouth Block
Advantages – limited mouth opening [trismus], difficulty in finding landmarks, less trismus, lower aspiration
Disadvantages – difficult to visualize path of needle/depth of insertion, no bony contact

Insertion – into retromolar mucosa midway between maxilla and ramus of closed mouth at level of mucogingival junction  until tip of needle is halfway between anterior and posterior planes of the ramus, penetrating 23-27 mm.
Target – midway anterioposteriorly in superior portion of pterygomandibular space several mm. medial and inferior to union of the mandibular ramus and condylar neck
Distribution – inferior alveolar, incisive, mental, lingual, mylohyoid
Needle Type – 25 long bent 15-30° at hub

Front 15

Long Buccal Block
Insertion/depth –
Distribution –
Needle Type/amount –

Back 15

Long Buccal Block
Only nerve from anterior division of V3
Insertion – through buccinator at point just medial to external oblique ridge at level of the occlusal plane to hit buccal nerve as it crosses mandibular ramus
Distribution – medial side of mandibular ramus anterior to inferior alveolar nerve, buccal gingiva between 2PM to the 2M, cheek, penetrating 2-3 mm.
Needle Type – 25 long, dispersing 0.5 mL

Front 16

Mental Nerve Block
Insertion/depth –
Target –
Distribution –
Needle Type/amount –
Bony Contact?

Back 16

Mental Nerve Block
Insertion – mandibular vestibule 10 mm. lateral to buccal surface of teeth and several mm. distal to foramen, and penetrate 5-10 mm. until inferior portion of foramen is contacted
Target – mental nerve as it exits the foramen between apices of 1PM and 2PM
Distribution – buccal gingiva between 2PM and midline
Needle Type – 27 short, dispersing 1.0 mL
No bony contact

Front 17

Incisive Nerve Block
Advantages –
Disadvantages –
Distribution –

Back 17

Incisive Nerve Block
Advantages – no lingual block, negates need for bilateral inferior alveolar blocks, high success rates
Disadvantages – midline difficulty

Distribution – buccal mucosa anterior to mental foramen, lower lip and skin of chin, pulp of lower PMs, C, Incisors – anesthesia at midline may be incomplete due to cross-innervation

Front 18

Lingual Nerve Block
Insertion –
Distribution –
Needle Type –
bony contact?
Accessory innvervation?

Back 18

Lingual Nerve Block
Insertion – from opposite PMs, inject medial to insertion of temporalis and lateral pterygomandibular raphe, penetrating 10 mm.
Distribution – lingual soft tissues including gingiva and floor of the mouth mucosa and tongue
Needle Type – 25 long, dispersing 0.5 mL
No bony contact
Mylohyoid n. often gives anomalous innervation to PM, explaining why this block will sometimes not provide anesthesia to this area

Front 19

Does topical anesthetic cause vasoconstriction?

Back 19

no

Front 20

only ester used clinically in dentistry?

Back 20

Benzocaine

Front 21

EMLA contains what two LAs?

Back 21

lidocaine and prilocaine

Front 22

When is a PDL injection contraindicated?

Back 22

cases of infection and primary teeth

Front 23

Where does V1 exit the skull? What is the cutaneous distribution?

Back 23

superior orbital fissure, NFL.

Front 24

V2 exits where?

Back 24

foramen rotundum

Front 25

V3 exits where?
What is its special sensory function?

Back 25

Foramen ovale
Chorda tympani via CN VII innervates anterior 2/3 of tongue for taste

Front 26

what is the only LA that is a vasoconstrictor?

Back 26

Cocaine

Front 27

Definition of local anesthesia?

Back 27

reversible loss of sensation without loss of consciousness

Front 28

Mechanism of LA action

Back 28

decrease NA influx via reversible binding to Na receptor, Na can't flow in, K cant flow out (stops depolarization)

Front 29

critical length theory

Back 29

only a few nodes of ranvier must be inactivated for complete stoppage of depolarization

Front 30

use dependance

Back 30

more frequently firing nerves will be more easily blocked

Front 31

differential blockade order

Back 31

pain -> cold -> hot -> touch -> deep pressure -> motor

(recovery in reverse)

Front 32

which nerve fibers does LA most easily block?

Back 32

small myelinated rapidly firing (a delta, and c fibers)

Front 33

What are the hydrophilic and hydrophobic component of LAs?

Back 33

All have a hydrophilic terminal amine and a hydrophobic aromatic group (benzene/thiophene)

Front 34

Which form of the LA crosses the neuron membrane?
Which form binds the the Na channel?

Back 34

neutral form crosses membrane (5-10%), ionized form binds to Na channel

Front 35

Lipid solubility dictates what quality of LAs?

Back 35

rate of absorption and potency

Front 36

Protein binding ability dictates what quality of LAs?

Back 36

duration of action and ability to vasodilate

Front 37

what are 3 purposes of adding Epi

Back 37

reduce systemic exposure, hemostasis, prolong local duration of action

Front 38

what is the max dose of epi in healthy individuals?

What is the max dose of epi in uncontrolled cardiac disease?

Back 38

0.2 mg, or 11.1 carpules of 1:100,000 epi

0.04 mg, or just 2 carpules of 1:100,000

Front 39

what are strong contraindications of Epi use?

Back 39

uncontrolled HTN, unstable angina, arrhythmias, recent MI, uncontrolled CHF

Front 40

4 main DDIs with epi

Back 40

Tricyclic antidepressants, nonselective beta blockers (increases blood pressure, alpha blockers (opposes epi), cocaine

Front 41

what is the upper weight limit for LA max dosing?

Back 41

150 lbs

Front 42

Lidocaine (xylocaine)
LA concentration:
epi conc.
duration:
max dose:

Back 42

Lidocaine (Xylocaine)
2% with 36 mg / cartridge
used in most routine procedures
1 : 50,000 or 1 : 100,000
Duration: 1 hour pulpal 3 hour soft tissue
Max dose: 7 mg/kg up to 500 mg (13.8 cartridges) ( ≤ 150 lbs.)

Front 43

Carbocaine (Mepivicaine)
LA concentration:
Indicated uses:
Epi concentration:
Duration:
Max dose:

Back 43

Carbocaine (Mepivicaine)  3% with 54 mg/cartridge
Patients with uncontrolled Htn, cardiac diseases, elderly (sensitive to epi), children
No epi
Duration: 20 min. pulpal 40 min. block
Max dose: 6.6 mg/kg up to 400 mg (7.4 cartridges) ( ≤ 150 lbs.)

Front 44

Prilocaine (Citanest)
LA concentraion:
Indications:
Associated risks:
Epi concentration:
Duration (plain):
Duration (forte):
Max dose:

Back 44

Prilocaine (Citanest)
4% with 72 mg/cartridge
40% less toxic than Xylocaine because of rapid metabolism, less vasodilatory
Associated risks: parasthesia and methemoglobinemia
0 epi (plain) or 1 : 200,000 (forte)
Duration (plain): 3-5 min. pulpal 1.5-2 hrs. soft tissue
Duration (forte): 1-1.5 hrs. pulpal 3-8 hrs. soft tissue
Max dose: 8 mg/kg up to 600 mg (8.3 cartridges) ( ≤ 150 lbs.)

Front 45

Bupivacaine (Marcaine)
LA concentration:
Indicated uses:
Contraindications:
Duration:
Max dose:

Back 45

Bupivacaine (Marcaine)  0.5% with 9 mg/cartridge
Used for long procedures and for post-op pain relief  contraindicated in pediatric patients (duration)
Excellent protein binding  responsible for the longest duration out of all other LA
1 : 200,000
Duration: 90 min. pulpal 4-9 hrs. soft tissue
Max dose: 1.3 mg/kg up to 90 mg (10 cartridges) ( ≤ 150 lbs.)

Front 46

Articaine (Septocaine)
LA concentration:
Benefits:
Associated risks:
Epi concentration:
Duration:
Max dose:

Back 46

Articaine (Septocaine)
4% with 68 mg/cartridge
Ester group decreases half life (↑ metabolism), excellent bone penetration
Associated risks: parasthesia (w/ mandibular block), may worsen methemoglobinemia
1 : 100,000 and 1: 200,000
Duration: 2.25 hrs. pulpal with infiltration 4 hrs. with block
Max dose: 7 mg/kg up to 500 mg (7.3 cartridges) ( ≤ 150 lbs.)

Front 47

Amides are metabolized where?
Drugs/conditions to be weary of:

Back 47

in the liver (increased adverse reactions in liver compromised patients

Drugs/conditions: Cimetidine, propranolol, CHF

Front 48

Esters are metabolized where?

Back 48

in the blood blasma by cholinesterases

Front 49

General pattern of LA overdose

Back 49

CNS excitation -> CNS depression

Front 50

Aspirations:
True +
True -
False +
False -

Back 50

True + blood in cartridge

True - no blood in cartridge

False + not in vessel but blood appears in cartridge

False - in vessel but blood does not appear in cartridge