complications of la iii

8/4/2019 Complications of LA III

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1. Syncope (Fainting, Vasovagal Attack)

2. Toxicity

3. Respiratory complications Hyperventilation syndrome

4. Allergy

5. Cardiac complications Hypertension Angina pectoris Cardiac arrest

6. Idiosyncrasy

7. Viral Infection (Hepatitis/AIDS)


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Etiology:

Psychogenic: Anxiety, stress, Pain specially of sudden unexpected nature

Non-psychogenic:

Long term sitting/standing during surgery, Postural hypotension Hypoglycemia, Exhaustion (humid crowded environment)


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Presyncope period: Pt feels faint and may feel nauseating Pale cold forehead and hands DiaphoresisTachycardia Deep irregular respiration (yawning &Hyperpnea)


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Syncopal: Loss of consciousness (sudden & transient) Bradycardia and hypotension (could be severe) Shallow irregular diminished ventilation Possible convulsive movements (muscular twitches

of extremities as well as face) Pupillary dilatation in late stages


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Post syncopal period: After regaining consciousness (few minutes); the

patient feels weak and nauseating, mentally

confused. Till blood pressure and Ht rate graduallyis restored to base line levels

Pathophysiology?Pathophysiology?


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Management: Stop dental procedures immediately Pt position: supine (trendelenberg) or astronauts position Patent airway- loosen tight cloths (tie, belt,..)

Stimulate respiration and consciousness by inhalation of aromaticspirit/ammonia

Oxygen supplement Monitor vital signs If recovery does not begin within 5 minutes start CPR/consider other causes on

loss of consciousness (e.g. hypoglycemia, adrenal or thyroid crisis,) Incomplete recovery (consciousness regained with persistent bradycardia) give

atropine 0.4 mg IV (every three to five minutes, up to a maximum dose of 0.04mg/kg)>>Inhibits parasympathetic system CN X

Persistent low BP; administer epinephrine 0.3-0.5 SC(sympathomimetic/vasopressor &bronchodilator)


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Etiology:

Too large an amount of injected LA solution Rapid absorption of the LA drug (inadvertent IVinjection)

Slow detoxification of the drug Using stronger solutions


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Symptoms:A) Early: excitatory phase Talkativeness, apprehension, excitement Increased blood pressure and pulse rate Convulsions (starts with facial muscles may spread to extremities)

followed by depressionB) Late signs: depressive phase*Drop in BP (Weak pulse)ApneaUnconsciousness

Cardiac arrest-death

* Lidocaine occasionally only exhibits the depression stage.


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Treatment: (ask nurse to call for emergency medicalservice while:)

Pt position (head as low as possible)-astronauts./trendelenberg. Administer O2 (10 L flow/min) Administer 5-15 mg Valium IV to stop convulsions (or the sleep

dose of thiopentone 2.5 % 100-150mg IV) Treat bradycardia with 0.4 atropine IV. Restore BP with epinephrine SC or Methedrine IV Unconscious pt: maintain Airway, administer CPR, transport to

hospital.


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Symptoms:1.Rapid shallow breathing

2.Confusion3.Dizziness( light headedness)4.Tightness of chest (pain)5.Paraoral Parasthesia, as well as on

extremities6.Carpo-pedal spasm


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Treatment:Explain problem to Pt and Reassure.

Instruct Pt to breath slowly into apaper bagValium 10 mg orally (to reduce

anxiety).Postpone dental treatment dismiss

pt escorted.


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A type of antigen-antibody reactionThe antigen is the external substance

administered to the body that would induce

the reaction; it can be the LA drug itself orone of its constituents.LA drug: e.g.:Procaine and amethocaine. (6%

hypersensitivity) not used any more.Lidocaine has 0% allergic side effect.Most commonly allergic reactions take place

as a result of contact with the preservativesodium metabisulphite which prevents the

oxidation of the VC material.


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A) The immediate is one which occurs when host has alreadycirculating antibodies and usually manifests as:,mild pruritus,mildurticaria.

It is caused by histamine release and seldom continues more than24 hrs.

Managed : with antihistamines (Benadryl: diphenhydramine 25-50 mg

orally/IV or IM) and repeat dose every 6 hrs for 2 days) Severe cases might progress to anaphylaxis : in the form of rapid

skin reaction rash, severe itching, angioneurotic edema, swellingaround the eye and other sites,CVS drop in BP, respiratory distressstridor& wheezes, cyanosis, hoarseness of voice, loss ofconsciousness (anaphylactic shock).

Management of Anaphylactoid reactions:

Summon EMS (emergency medical services: 998) Administer steroid-hydrocortisone sodium succinate 100 mg IM/or IVor (betamethazone IM)

Administer epinephrine 0.3-0.5 SC or IM (CI if pt developshypertension rather than hypotension). Repeat if needed after 10min.

Administer theophylline 250 mg IV (CI in hypotension)- or

sulbutamol. O2 & CPR if needed


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B) delayed reactions take placeseveral hours or days after the

exposure to the antigen: in the formof urticarial rash pluslymphadenopathy and occasionalpyrexia, arthralgia and rarely oralulcerations.

Treatment: Antihistamines and

corticosteroids


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All are mainly caused either directly by the effectof the VC or indirectly due to apprehension.

Hypertension might be manifested asheadache>> stop procedure and monitor

BP,Call for EMS. Angina presents as a constricting pain around

the chest radiating to neck sometimes the jawsand or left arm.

Pain is relieved by the application of a sublingual

tablet of glyceryl trinitate. A cardiac arrest is characterised by suddencessation of breathing, absence of BP or pulse,progressive cyanosis and dilated pupils.

Treatment of CA should commence immediatelywithin 3 minutes before pt suffers completeand permanent cerebral cortical damage.


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Individualized reaction to the drug thatdeviates from the conventional expected

pathological pattern.

E.g.: quite a small amount of the drug mightcause symptoms of overdosage and toxicity.It might be due to the LA drug or the VCsubstance.Difficult to assess (confused with syncope)yet it is safe to discontinue the injection andmonitor the patient.Should the Pt collapse, O2 is to beadministered.

Patient may need to be transported to a


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complications of la iii

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