‫د\صفوان‬
General (systemic) Complications with local anaesthetic
techniques
General complications are either due to LA agent or V.C agent
1- Toxicity:
symptoms manifested as a result of overdosage or excessive administration of
the solution
Causes:
1. The use of too large volume of the solution.
2. Accidental intra-vascular injection.
3. The use of too great concentration of LA.
4. Rapid absorption into the blood stream due to injection in highly vascular area
without VC and Rapid injection increases the rate of absorption of the drug.
5. Slow biotransformation of the drug (advanced liver diseases).
6. Slow elimination of the drug from the body (impaired kidney functions).
Signs & symptoms:
a) early central nervous system stimulation
(Step A /Cortical Stimulation phase)
b) followed by a proportionate degree of
depression (Step B/Cortical Depression
phase
1.
2.
3.
4.
5.
6.
7.
8.
1.
2.
3.
4.
5.
6.
Talkative
Restless
Apprehensive
Excited
Convulsions (tonic-clonic)
Increased blood pressure.
Increased pulse rate.
Increased respiratory rate
CNS depression
Loss of consciousness
Nausea & vomiting.
decreased blood pressure.
decreased pulse rate.
Decreased respiratory rate.
Adverse CVS responses do not usually develop until long after CNS action have appeared
‫د\صفوان‬
Prevention of toxicity:
1. pre-analgesic evaluation of the patient.
2. use the least possible volume.
3. use the weakest possible concentration.
4. slow injection.
5. aspirate before injection.
6. the use of vasoconstrictors.
Management:
Management of CNS stimulation
1. Keep patient in supine position with feet slightly
elevated
2. O2 administration
3. Monitoring of vital signs
4. Diazepam ( valium ) iv 2.5-5 mg
5. sleep dose of thiopentone (Pentothal)
intravenously to stop convulsions (100 - 150
mg).
Management of CNS depression
1. Keep patient in supine position with feet
slightly elevated
2. O2 administration, do not give niketh-amide
(coramine) as this will restart convulsions.
3. Monitoring of vital signs
4. vasopressor ( phenylephrine or methyl
amphetamine or Methedrine )
5. start basic life support (BLS) including CPR
2- Idiosyncrasy:
➢ Bizarre reaction to normal therapeutic non-toxic dose of local anaesthesia
➢ Not toxicity or allergic reaction
➢ IDR are rare but unpredictable and often life threatening (type B reaction)
Signs and symptoms: ‫زي الفيز التانيه في التوكسيسيتي‬
1.
CNS depression
2.
Loss of consciousness
3.
Nausea & vomiting.
4.
decreased blood pressure.
5.
decreased pulse rate.
6. Decreased respiratory rate.
Management:
same as management of CNS depression of toxicity
‫د\صفوان‬
3-Fainting :
The most common complication
Causes:
Psychogenic factors
Non - psychogenic factors
anxiety, fear, sight of unpleasant objects as
surgical tools or blood, and emotional stress.
-Pain
-Sitting in an upright position for a long period
of time
-Hunger, causing low glucose supply to the
brain
-Exhaustion
Clinical features:
Pre-syncope period
Syncope
Post- syncope period
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•
•
•
•
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•
Patient feels pale, sweating,
cold feels unwell (Signs and
symptoms)
Hypotension
Tachycardia
Deep irregular respiration
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•
•
•
Loss of consciousness
muscular twitches (tremors)
or convulsions
hypotension
brady-cardia
shallow irregular respiration
Relaxation of tongue may
occur with apnea and
dilatation of pupils
•
After regaining
consciousness, the patient
feels weak and nauseating
Blood pressure and heart
rate slowly return to normal
Management:
1- Stop any dental procedure.
2- Place the patient in a supine or Trendelenburg position
3- Maintain a patent airway
4- Stimulation of respiration
5- Oxygen administration (stimulation to smell with ammonia or atropine).
6- monitoring the vital signs.
7- No further dental management ,patient should be dismissed ( for the next
appointment take valium the night before).
8- If unconsciousness persists for more than 5 minutes; or complete
recovery is not evident after 15-20 minutes; other causes of loss of
consciousness should be considered.
9- For persistent bradycardia, give atropine 0.4 mg. IV
10- For persistent hypotension give Neo synephrine 2-5 mg. I.M. or 0.2 mg.
I.V. or vasoxy 15mg. I.M.
‫د\صفوان‬
4- Allergy and Hypersensitivity
Anaphylactic shock
•
Antigen-antibody reaction (Ag-Ab reaction) can be caused by any of the
constituents such as the anesthetic drug, vasoconstrictor, or other
ingredients such as bacteriostatic agents.
•
Procaine is the most common LA agent to produce Allergic reaction ( 6% higer
than other LA agents)
Two main types of reactions:
The immediate reaction
• Occurs immediately when antibodies already
present
Delayed hypersensitivity reactions
usually takes several hours or days to appear
• Signs and symptoms (manifestations):
1- angioneurotic edema.
2- Rapid swelling around the lips, tongue, eyes
and occasionally other sites. due to the
release of histamine producing a
vasodilatation
3- Bronchospasm and laryngeal edema
4- Stridor
5- Dyspnea (difficult breathing)
6- Wheeze
7- Tachycardia
8- Arrhythmia
9- Sudden increase in secretion
10- The greatest danger may arise from oedema
of the glottis which can cause respiratory
obstruction.
•
Signs and symptoms (manifestations):
1- urticarial rash of the skin
2- pyrexia
3- lymphadenopathy
4- arthralgia
5- oral ulceration
‫د\صفوان‬
Management or treatment:
The immediate reaction
1- supine position
2- 0.3-0.5 mg Adrenaline (epinephrine) 1:1000
subcutaneously ‫مهم موت‬repeated every 5-15
minutes if symptoms do not improve
3- Antihistamine and bronchodilators as
promethazine hydrochloride 25 mg IM.
4- Intravenous hydrocortisone sodium
succinate l00mg (in severe signs)
5- oxygen
6- cricothyrotomy or a tracheostomy (open
airway).
7- Call for medical assistance
8- Monitor vital signs
•
•
Delayed hypersensitivity reactions
1-antihistamines
2-corticosteroids
3-antibiotics to treat any secondary infection
occurred with ulceration
Adrenaline and O2 are lifesaving and 1st Treatment option in anaphylactic shock
Antihistamines and bronchodilators are not the 1st line in anaphylaxis
During management of Anaphylactic shock first line of ttt are Antihistamines and
bronchodilators
a- True
b- False
During management of Anaphylactic shock first line of treatment is adrenaline (T-F)
Vasoconstrictors ‫في محاضره ال‬Bronchodilatation ‫اوعي تنسي ان االدرينالين بيعمل‬
During management of Anaphylactic shock first line of ttt is adrenaline and given
abcd-
Sublingually
Subcutaneous
Intramuscular
Intra-venous
During management of Anaphylactic shock first line of ttt is adrenaline and given
a- 0.3-0.5 mg Adrenaline (epinephrine) 1:10000
b- 0.3-0.5 mg Adrenaline (epinephrine) 1:1000
c- Non-of the above
‫د\صفوان‬
5- Hyper ventilation syndrome
Clinical features:
1-Apprehension 2-Paleness 3-cold sweating. 4-dizzy 5-tightness in the chest
6-headache 7-Patient might feel suffocation. 8-tingling or par-aesthesia in the
extremities and might develop muscular twitching or carpo-pedal spasm
9-might loose consciousness 10-Hypertension, tachycardia and rapid respiration.
Hyperventilation associated with Decreased carbon dioxide level in the blood resulting
in decreased blood ionized calcium level leading to :
1- tingling and paraesthesia
2- neuromuscular irritability
3- muscular twitches in the extremities and carpo-pedal spasm and possible
convulsions
Management:
1- Stop any dental procedure; place the patient in an upright
2- Let the patient breathe into a small paper bag, held over the face to allow
rebreathing of the exhaled air.
3- Valium 10mg orally
4- Keep the patient under observation
6-Cardiac arrest:
unexpected death' or 'acute collapse'
very rare
patient suddenly becomes unconscious, pulseless, stops breathing and
the pupils dilate. It can be detected by the absence of the carotid pulse
Management:
A. Airway
B. Breathing
C. Closed cardiac massage
maintained by holding the
chin forwards
mouth over the patient's
open mouth
both hands over the lower
end of the sternum and
compress the chest about
1.5 inch, seventy times per
minute.
oxygen bag
‫د\صفوان‬
7- other types of collapse
usually requires hospitalization and therefore an ambulance should be summoned
A- Epilepsy
B- Angina Pectoris
The patient has a
tonic spasm
lasting about 30
seconds followed
by clonic
convulsions
during which the
patient may
involuntarily
defecate.
This causes a
constricting pain
around the chest
which may radiate
into the neck,
down the left arm
(referred pain)
Management:
placing a suitable
pack between the
patient's teeth to
prevent tongue
biting
Management:
1-crushing a
vitrella of amyl
nitrite and
inhaling the vapor
2-placing a tablet
of glyceryl
trinitrate under
the tongue
C- Coronary
Thrombosis:
severe chest pain
due to myocardial
ischemia and
dyspnea
,the attack frequently
occurring at rest and
being of sudden
onset
D- Diabetes
The most important
complications that may
occur are those of coma,
associated either with
raised blood sugar level
due to insulin lack, or with
lowered blood-sugar due to
relative insulin overdosage.
E- Respiratory Obstruction
Management:
1-clearing any foreign
bodies such as dentures
2-clearing the airway
3-pushing the mandible
forward to bring the
tongue forward with
4-administering oxygen
hyperglycemia is usually of 5-inserting a
gradual onset
cricothyrotomy needle
The breath smells acetone
through the cricothyroid
The patient requires large
membrane or
doses of insulin and should tracheostomy
be hospitalized.
within about 4 minutes
irreversible brain damage
Management:
Management:
will occur
1-maintain the airway Hypoglycemic coma is
2-give oxygen
more common than
3-intravenous
diabetic coma and is due to
morphine
an overdose of insulin
slowly over 5
In emergency, injection of
minutes to relieve the 0.5 ml of 1:100 adrenaline
pain
subcutaneously may
restore consciousness so
that sugar may be given
orally.
F- Steroid Crisis
Thyroid Crisis:
The signs and
symptoms of the
collapse resemble
those of a faint and
include a thready
pulse with
hypotension and
frequently fever.
1-The patient becomes
very restless,
disoriented and semiconscious. With Rapid
thready pulse.
2. Hyperthermia which
may reach a lethal body
temperature.
3. Cardiac arrhythmia
(may lead to cardiac
failure).
Management:
1-Laying flat
2-administering 100
mg hydrocortisone
hemisuccinate
preferably
intravenously or
intramuscularly
Management:
1. Urgent medical
assistance.
2. Oxygen inhalation
and keep patent
airway, .,
3. Corticosteroids.
4. IV fluids to correct
dehydration.
5. Cold packs to
decrease body
temperature.
‫د\صفوان‬
Complications of Local Anesthesia and Management
any deviation from the normally expected Pattern during or following the administration
of the local anaesthesia.
normally expected Pattern: lack of pain sensation in the area innervated by the
anaesthetized nerves
classifications of Local Anesthesia Complications
a- Local Complications
b- General (Systemic) Complications
‫د\صفوان‬
Local Complications with local anaesthetic techniques
1-PAIN
•
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Causes:
Blunt needle
Multiple needle punctures
Injection through muscle, ligament or gland.
Too rapid injection of the solution (must be over 1 minute)
Injection of cold solution
Biting on lip due to numbness
• Management :
1- Analgesics
2- HAEMATOMA FORMATION AT THE SITE OF INJECTION:
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Effusion of the blood into the tissues
Very common complication.
Common sites :
1- region of the posterior superior dental nerve (tuberosity)
2- mental and infra-orbital foramina.
Causes:
1- Needle trauma to ptery-goid venous plexus
Management :
1- Ice packs initially then hot fomentation later on
2- It will take a week or two to disappear
3- Drugs as hyaluroni-dase, pipeline or chymotrypsin may accelerate dispersion
of the bruising
‫د\صفوان‬
3-TRISMUS
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Difficulty in opening the jaws due to muscle spasm.
Casues :
1- Repeated injection
2- Too high injection due injury to lateral pterygoid muscle.
3- Too low injection due to injury to the medial pterygoid
muscle.
4- Infection after injection.
• Management:
Physiotherapy
Gradual mouth opening using tongue depressor
Hot fomentation
Analgesics and muscle relaxant
In case of infection pus must be drained and antibiotic therapy.
pressing the mandible open under general anesthesia to break down the fibrous
bands, which might be formed as a result of hematoma in the region of medial
pterygoid muscle.
4- BROKEN NEEDLES
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•
Most common breakage site: Hub of the needle ‫مهههم‬
Causes :
1- Insertion of the needle into tissues up to its hub
2- Short needle in nerve block (hub very close)
3- redirection of needle inside tissues
4- using thin diameter needle
5- repeated injection with the same needle for the same patient
6- excessive forces on the needle during insertion
7- Bending of the needle
8- Sudden unexpected movement of the pt
• Management:
1- If the broken needle is visible
try to remove it with curved mosquito
artery forceps (hemostat)
2- If the broken needle is not visible
mark the site of needle breakage with
water proof marker and refere to specialist
• The reasons for not leaving the broken needle inside the tissues are:
1- The fragment is mobile and may travel to a position where it might be dangerous.
2- Psychological effect" worrying about something stuck in the throat".
3- may induce scarring which could lead to trismus, dysphagia, or pain.
4- may cause rupture of a vessel.
‫د\صفوان‬
5- FACIAL PARALYSIS
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• Other name: bells palsy
• Causes:
1- Too high injection (needle is inserted deeper than the vertical ramus of the
mandible) penetrating the capsule of the parotid gland
2- infiltration anaesthesia, if the solution is injected deep
• manifestations:
1- Patient will be unable to close the eyelids on the affected side
2- Deviation of the facial muscles toward the unaffected side of the face when
smiling or blowing cheek
• Management:
Reassure the patient that recovery will be complete within 2 or 3 hours ‫اول ما مفعول‬
‫البنج ينتهي‬
Eye dressing to protect the eye from dryness ‫مههههمه جدا جدا جدا النها اكتر حاجه بخاف منها‬
Refere to neurologist
Immediate steroids (main therapy) to accelerate recovery rate and decreases
degree of dysfunction
6- PROLONGED ANAESTHESIA
impairment of sensation in the lower lip
• Casues:
1- trauma from the needle to the nerve
2- hemorrhage near the nerve
pressure on the neural sheath
3- contaminated anaesthetic solution with alcohol (neurotoxic substance)
4- Infection or Surgery related to the lower molar and premolar roots in close
proximity to a nerve
• management:
1- recovery may take from few days up to 3 months
according to the degree of nerve damage.
a- Neuropraxia: first degree
b- Axonotmesis: 2nd degree
2- Analgesics + vitamin B complex
3- Refere to specialist
In neurapraxia, transient functional loss is observed without
loss of nerve continuity. A complete disruption of the nerve
axon and surrounding myelin along with preservation of
perineurium and epineurium is observed in axonotmesis.
Neurotmesis causes complete functional loss because of
disconnection of a nerve.
‫د\صفوان‬
7-ULCERS & SLOUGHING:
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Causes:
Injection of more than .3 ml to .5 ml in the area of hard palate ‫اهم واحده‬
Traumatic ulcers due to lip biting usually occur in children (soft tissue injury)
Cotton-roll ulcers quite frequent
Excessive rubbing of the area before injection
iodine or irritating disinfectants before injection for sterilization of tissues
Neurotrophic ulcers on the mucous membrane of the lip after mandibular
injection due to ischemia caused by vasoconstrictors
7- superficial injection causing laceration of the superficial layer of the mucous
membrane
•
management:
usually resolve within few days or one week
8-BLANCHING OF TISSUES
In remote areas from the site of injection mostly with block anesthesia
•
Causes:
1- Effect of vasoconstrictor on blood vessel supplying the area
2- Injection in tight palatal mucosa
•
Management:
Transient phenomenon and no treatment needed
9- FAILURE TO OBTAIN ANAESTHESIA
a- Causes of Failure of Infiltration Anaesthesia:
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Deposition of the solution in the wrong area
Wrong dose
Incorrect choice of Technique
Presence of inflammation or infection
Intravascular Injection (pterygoid plexus of veins during upper second or third
molar region)
6- Variation in individual tolerance to anesthesia
‫د\صفوان‬
b- Causes of Failure of Regional Anaesthesia:
1- deposition of the solution in the wrong site
2- anatomical variations
3- Variations due to age
a- In children the mandibular foramen is lower than in adults.
b- In edentulous patients reduction in depth of the body of the mandible
occurs, care should be taken to avoid inserting the needle too low
4- Faulty technique
10- INFECTION
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12•
Causes:
Contaminated needle
Contaminated anesthetic solution
Management:
Antibiotics
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Infection from a posterior superior dental injection spread
the pterygoid
plexus of veins
foramen oval
cavernous sinus thrombosis
infra-orbital injection may cause cavernous sinus thrombosis via anterior facial
vein
Infection from inferior alveolar injection may involve pterygomandibular space
11- INTRAVENOUS- INJECTION
• Causes:
1- solution injected into a vessel
• management :
aspiration
INTRAVENOUS- INJECTION is rare with infiltration, most frequent for posterior superior
dental injections (pterygoid venous plexus is very close)
‫د\صفوان‬
12- EDEMA
•
12•
Cause:
infection
allergy
Management:
Physiotherapy and treat the cause
13- VISUAL DISTURBANCES
• Causes:
1- Anesthetic solution infiltrating into orbit during Infra-orbital NB (Diplopia)
2- paralysis of the extrinsic ocular muscles during posterior superior alveolar or
maxillary nerve blocks (anesthetic solution diffused into orbit through inferior
orbital fissure)
management:
no Treatment, disappears after wearing off the effect of anesthesia
14- NAUSEA AND VOMITING
• Causes:
1- diffusion of anesthetic solution into lesser palatine nerve
management:
restrict the puncture anterior to the greater palatine foramen
15- COMPLICATIONS ASSOCIATED WITH JET
Complication
splitting of the mobile oral mucosa
infection
cause
Movement of injector nozzle at the time of
injection
unsterile material
Whenever possible, the site of injection should be on the immobile attached gingiva.
‫د\صفوان‬
16- burning sensation
•
causes :
1- contaminated carpule due to disinfection with alcohol
2- rapid injection
3- increase acidity
Management:
Injecting with slow rate over 60 seconds
N.B:
Ecchymosis and brusing
Leaking of blood from blood vessels into the subcutaneous tissue that underlies the skin
‫د\صفوان‬
‫تجميعات مهمه‬
Complications caused by LA agents
Complications caused by VC
Toxicity
Idiosyncrasy
Fainting
Cardiac arrest
Hypoglycemic coma
-
sudden onset
Too much insulin/ no food
Moist clammy skin
Full pulse
Shallow breathing
Hyperglycemic coma
- Slow onset
- Little or no insulin
- Dry skin
- Weak pulse
- Acetone odor of breath
- Air hunger
• In severe cases of Idiosyncrasy insert a pad of gauze between the teeth to
•
•
•
•
prevent tongue-biting and by cushioning the head to avoid striking the floor.
CNS is much more susceptible than other systems to toxicity (stimulation then
complete depression)
Hematoma = Ecchymosis = Bruising: Leaking of blood from blood vessels into
the subcutaneous tissue
Hematoma starts red then Blue then yellow
Sterile abscess = Ulceration or sloughing