The document discusses local anesthesia and its potential complications. It defines local anesthesia and lists local and systemic complications. It discusses the principles of drug toxicity and the role of the user in potential toxicity. It describes overdose reactions involving the central nervous system and treatments. It provides guidelines for safe administration of local anesthesia and managing complications like overdose reactions and allergic responses.

1.  
Shashank Trivedi
(110301192)

2. Local Anesthesia has been defined
as…
“Loss of sensation in a
circumscribed area of the body
caused by depression of excitation
in nerve endings or inhibition of
the conduction process in
peripheral nerves.”

3. Local Complications
1. Needle breakage
2. Paresthesia
3. Facial nerve paralysis
4. Trismus
5. Soft tissue injury
6. Hematoma
7. Pain/Burning on injection
8. Infection
9. Edema
10. Sloughing of tissues
11. Post anesthetic intraoral
lesions
Systemic Complications
1. Overdose reactions
-LA Toxicity
-Vasoconstrictor Toxicity
2. Allergy
3. Idiosyncrasy

4.  Principle 1:
“No drug ever exerts a single action.”
 Principle 2:
“No clinically useful drug is entirely devoid of toxicity.”
 Principle 3:
“The potential toxicity of a drug rests in the hands of the
user.”

5. 
Overdose
Reactions

6. It refers to the symptoms manifested
as a result of overdosage or
excessive administration of the
solution.

7.  Large dose of drug
 Accidental intravenous injection
 High concentration of a drug
 Unusually slow detoxification as a result of
severe liver disease
 Slow elimination as a result of Kidney problem
 Use of highly toxic drugs whose margin of safety
is narrow
 Injection of solution in a highly vascular area
without the addition of vasoconstrictor substance

8. Cerebral Cortex
1. Talkative
2. Restlessness
3. Apprehensive
4. Excited
5. Convulsive
Medulla
1. Lethargy
2. Sleepiness
3. Unconscious
Early CNS Stimulation Symptoms

9. Cerebral Cortex
1. Blood Pressure
2. Pulse rate
3. Respiratory rate
4. Nausea
5. Vomiting
Medulla
1. Blood pressure
2. Pulse rate
3. Heart rate
4. Respiratory
depression
5. Unconsciousness
Late CNS Depression Symptoms
Death usually occur due to respiratory depression and
hypoxia and its subsequent effect on the

10.  Pre-analgesic evaluation of the patient
 Use the weakest possible concentration
 Use vasoconstrictor whenever possible
 Use the least possible volume
 Aspirate before injection
 Slow injection
 Monitor the patient carefully after injection

11. P…Position
A…Airway
B…Breathing
C…Circulation
D…Definitive care

12.  Mild Stimulation
 Moderate Stimulation
 Convulsion phase
 Depression Phase
1. No treatment
2. Stop further injection
1. IV injection of barbiturates
0.2% solution of sodium thiopental
Secobarbital
2. Oxygen inhalation

13.  Mild Stimulation
 Moderate Stimulation
 Convulsion phase
 Depression Phase
Anticonvulsant IV/IM
-Coramine(150-450 mg IV)
-Midazolam or Diazepam(100 mg IV)
-Wyamine(7.5 mg IV)
1. Artificial Respiration
2. IV Fluids
3. Sympathomimetic drugs

14. 

15. Signs
1. Sharp elevation in
BP,primarily systolic.
2. Elevated heart rate.
3. Possible cardiac
dysrhythmias
(premature ventricular
contractions/ventricular
tachycardia/ventricular
fibrillation)
Symptoms
1. Fear/anxiety
2. Tenseness
3. Restlessness
4. Throbbing headache
5. Tremor
6. Perspiration
7. Weakness
8. Dizziness
9. Pallor
10. Respiratory difficulty
11. Palpitations

16.  Most instances of Epinephrine overdose are of short
duration that require little or no formal management.
However,the reaction may be prolonged and some
management is desirable.
1. Terminate the procedure: if possible,remove the source
of epinephrine.Stopping the injection of LA does not
remove epinephrine that has been
deposited;however,release of endogenous epinephrine
and norepinephrine from the adrenal medulla and nerve
endings is lessened once the anxiety-inducing stimulus
is eliminated.
2. Basic management follows the usual P-A-B-C-D
algorithm.

17. 3. Definitive care(D)
1. Reassure the patient that the signs and symptoms are
transient and will subside shortly.
2. Monitor vital signs and administer Oxygen.
BP and heart rate should be checked every 5 minutes
during the episode.
3. Hyperventilation can be seen in an apprehensive
patient,this is a contraindication for the administration of
oxygen.
4. Recovery: Permit the patient to remain in the dental
chair as long as necessary to recover.
Do not discharge the patient if any doubt remains about
his/her ability to provide self-care.

18. 

19.  Allergy is a hypersensitive state,acquired
through exposure to a particular allergen,re-
exposure to which produces a heightened
capacity to react.
 Allergic reactions cover a broad spectrum of
clinical manifestations ranging from mild and
delayed responses occurring as long as 48
hours after exposure to the allergen,to
immediate and life threatening reactions

21.  Allergic response to LA include
dermatitis,bronchospasm and Systemic
Anaphylaxis.
 The most frequently encountered are localized
dermatologic reactions.
 Hypersensitivity to the ester type LA-
Procaine,Propoxycaine,Benzocaine,Tetracaine,a
nd related compounds such as Procaine
Penicillin G and Procainamide is more frequent.
 Allergic reactions have been documented for the
various contents of the dental LA cartridge.

22. INGREDIENT
Local Anesthetic
Agent
Vasoconstrictor
(Epinephrine)
Sodium metabisulfite
Methylparaben
Sodium Chloride
Sterile water

23.  Sodium bisulfite allergy:
People who are allergic to bisulfites(most often steroid-dependent
asthmatics) may develop a severe response(bronchospasm).
In presence of documented sulfite allergy,it is suggested that a LA solution
without a vasopressor(“Plain Local Anesthetic”)should be used.
No cross allergenicity is present between sulfites and sulfa type drugs.
 Latex Allergy:
The thick plunger at one end and the thin diaphragm at the other end of
the cartridge,through which the needle penetrates contained LATEX.
A study reveals that latex allergen can be released into the local
anesthetic solution as the needle penetrates the diaphragm.
Dental cartridges presently available in US and Canada are latex free.
 Topical Anesthetic Allergy:
Topical anesthetics possess the potential to induce allergy. The incidence
of allergy to Esters is greater than Amides. The degree of allergic
response depends on the site of application,dose and systemic
absorption.

24.  Immediate reactions develop within seconds to hours of
exposure.They include Type I,II, and III hypersensitivity
reactions.
 With delayed reactions,clinical manifestations develop
hours to days after antigenic exposure(Type IV).
 Immediate reactions,particularly Type I anaphylaxis are
significant.Organs and tissues involved in immediate
allergic reactions include skin,CVS,Respiratory system,
and GI system.
 Generalized anaphylaxis involves all these systems.
 Type I reactions may involve only one system,in which
case they are referred to as localized allergy.
Eg:Bronchospasm,Urticaria.

25.  DERMATOLOGIC REACTIONS:
The most common allergic reaction associated with LA
administration consists of urticaria and angioedema.
Intense itching(pruritis) is frequently present with urticaria.
Allergic skin reactions,if sole manifestation of an allergic
response,normally are not life threatening;however,those that occur
rapidly after drug administration may be the first indication of a more
generalized reaction to follow.

27.  RESPIRATORY REACTIONS:
Clinical signs and sypmtoms of allergy may solely be related to the
respiratory tract,or respiratory tract involvement may occur along with other
systemic responses.
Signs and symptoms of bronchospasm,the classic respiratory allergic
response,include the following:
-Respiratory distress
-Dyspnea
-Erythema
-Cyanosis
-Diaphoresis
-Tachycardia
-Increased anxiety
-Use of accessory muscles of respiration
 Laryngeal edema(life threatening emergency) is a swelling of the soft tissues
surrounding the vocal apparatus with subsequent obstruction of the airway.

28.  Generalized Anaphylaxis:
This is an acutely life threatening allergic reaction.
Clinical death can occur within a few minutes.
Generalized anaphylaxis can develop after administration of an antigen by
any route but is more common after parenteral administration.
Time of response is variable,but the reaction typically develops
rapidly,reaching maximum intensity within 5-30 minutes.
It is extremelt unlikely that this reaction will ever be noted after
administration of Amide local anesthetic.
Signs and symptoms of generalized anaphylaxis occur as follows:
Skin Reactions Smooth muscle spasm of
GIT/Genitourinary/Bronchospasm
Cardiovascular collapse Respiratory distress
In fatal anaphylaxis,respiratory and cardiovascular disturbances
predominate and are evident early in the reaction.

30.  Delayed Skin Reactions: (developing 60 minutes or more post
exposure)
P-A-B-C:Position the conscious patient comfortably.
A,B,C are assessed as adequate.
Definitive care:
-Oral histamine blocker:50mg diphenhydramine or 10mg
chlorpheniramine
-If still in dental office,the patient should remain in the office under
observation for 1 hour before discharge to ensure that the reaction
does not progress.
-Obtain medical consultation,if necessary,to determine the cause of
reaction.A complete list of all the drugs and chemicals administered
to or taken by the patient should be compiled for use by the allergy
consultant.
-If drowsiness occurs after oral histamine blocker administration,the

31.  Immediate Skin Reactions: (developing within 60 minutes post
exposure)
P-A-B-C:Position the conscious patient comfortably.
A,B,C are assessed as adequate.
Definitive care:
-Administer parenteral histamine blocker:50mg diphenhydramine or
10mg chlorpheniramine
-Monitor and record vital signs every 5 minutes for 1 hour.
-Observe the patient a minimum of 60 minutes for evidence of
recurrence.Discharge in the custody of a responsible adult if any
parenteral drugs have been given.
-Prescribe an oral histamine blocker for 3 days.
-Fully evaluate the patient’s reaction before further dental care is
provided.
-If,at any time during this period,uncertainty exists as to the condition

32.  Bronchospasm:
P-A-B-C:Position the patient comfortably.Most persons
experiencing respiratory distress prefer to be seated upright to
varying degrees.ABC are assessed.
Airway is patent,although patient is exhibiting respiratory
distress.
C is assessed as adequate.
Definitive care:
-Terminate treatment.
-Administer oxygen.
-Administer epinephrine IM.
-Activate emergency medical services.
-on recovery,administer histamine blocker.

33.  Laryngeal Edema:
P-A-B-C:Position the unconscious patient supine.ABC are
assessed.If airway is maintained and the victim’s chest is
making spontaneous respiratory movements but no air is
being exchanged,immediate and aggressive treatment is
mandatory to save the victim’s life.
Definitive care:
-Administer epinephrine IM.
-Activate emergency medical services.
-Administer oxygen
-Maintain the airway.
-Administer Histamine blocker IM/IV and corticosteroid IM/IV
-Perform cricothyrotomy if the preceding steps have failed to
secure patent airway.

35.  P-A-B-C:Position the unconscious patient supine.
ABC are assessed and performed as indicated.
If Conscious,position the patient comfortably.
 Definitive care:
-Administer epinephrine:0.3mL of 1:1000
-Activate emergency medical services.
-Administer oxygen.
-Monitor vital signs.
-perform basic life support if needed.
-Additional drug therapy:may be started once clinical
improvement is noted.This includes the administration of
Histamine blocker and corticosteroid(both IV/IM)
NOTE:Epinephrine and oxygen are the only drugs that should
be administered during the acute phase of the anaphylactic
reaction.

36.  Systemic complications associated with Local Anesthetic
drug administration and techniques are frequently
preventable.
 Preliminary medical evaluation should be completed
before administration of any local anesthetic.
 The weakest effective concentration of local anesthetic
solution should be injected at the minimum volume
compatible with successful pain control.
 Observe the patient both during and after local
anesthetic administration for signs and symptoms of
undesirable reaction.Never give an injection and leave
the patient alone while doing other procedures.

37.  Handbook of Local Anesthesia
-Dr.Stanley F. Malamed
 Image courtesy:google.com