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Complications Of Dental Local Anesthesia
1. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
COMPLICATIONS
OF
LOCAL
ANESTHESIA
Dr.
Hesham
El-‐Hawary
Lecturer
OMFS
Faculty
of
Oral
&
Dental
Medicine
Cairo
University
3. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
ComplicaJons
Any
devia&on
from
the
normally
expected
paKern
during
or
aMer
securing
local
analgesia
4. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
ComplicaJons
Any
devia&on
from
the
normally
expected
paKern
during
or
aMer
securing
local
analgesia
Classifica&ons
§ Primary
or
Secondary
§ Mild
or
Sever
§ Transient
or
Permanent
§ AKributed
to
soluJon
or
needle
inserJon
5. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
ComplicaJons
from
local
Anesthesia
I. ComplicaJons
associated
to
the
absorpJon
of
the
soluJon
used
II. ComplicaJons
associated
with
needle
inserJon
6. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
ComplicaJons
associated
with
absorpJon
of
the
anestheJc
soluJon
1. Systemic
drug
reac&ons
due
to
the
local
anesthe&c
agent:
1. Toxicity
2. Allergy
3. AnaphylacJc
reacJons
4. Idiosyncrasy
2. Local
reac&ons:
1. InfecJons
due
to
contaminated
soluJons
2. Local
Jssue
irritaJon
7. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
ComplicaJons
associated
with
needle
inserJon
1. FainJng
and
syncope
2. Muscle
trismus
3. Pain
4. Edema
5. InfecJon
6. Broken
needles
7. Prolonged
anesthesia
8. Haematoma
formaJon
9. Sloughing
and
ulceraJon
10. Bizarre
Neurological
symptoms
8. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Keep
in
mind
• A:
Airway
» Clear
» Adequate
RespiraJon
• B:
Bleeding
» Stopped
» Achieve
inlet
to
vessels
• C:
CirculaJon
» Fluids
if
needed
• D:
Drugs
to
treat
the
present
condiJon
9. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Keep
in
mind
• Call
medical
emergency
service
• The
paJent
posiJon
– Placed
in
horizontal
posiJon
on
his
back
– Tilt
the
paJent
in
a
slightly
head
down
posiJon
or
– elevate
the
legs
to
help
increase
cerebral
circulaJon
• Adequate
oxygenaJon
• Check
the
paJent's
cardiac
and
cardiovascular
status
• Start
I.V.
fluids
(e.g.
5%
dextrose
in
H2O)
• Drugs
according
to
the
condiJon
• If
complete
circulatory
standsJll
– IV
injecJon
of
atropine
– SJmulaJon
of
the
heart
by
introducing
a
needle
directly
into
it
– Intracardiac
injecJon
of
epinephrine
0.1
ml
of
1.1000
soluJon
10. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
ComplicaJons
due
to
absorpJon
of
the
injected
soluJon
Systemic
complicaJons
1. Toxicity
2. Idiosyncrasy
3. Allergy
4. Anaphylaxis
11. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
• DefiniJon
• EJology
• Clinically
(Signs
&
Symptoms)
• PrevenJon
• Treatment
13. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
DefiniJon
It
refers
to
the
symptoms
manifested
as
a
result
of
overdosage
or
excessive
administra&on
of
the
soluJon
14. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
EJology
• Large
dose
of
drug
• Accidental
intravenous
injecJon
• High
concentra&on
of
a
drug
• Unusually
slow
detoxifica&on
as
a
result
of
severe
liver
disease
• Slow
elimina&on
as
a
result
of
kidney
trouble
• Use
of
highly
toxic
drugs
whose
margin
of
safety
is
narrow
• InjecJon
of
soluJon
in
highly
vascular
area
without
the
addiJon
of
vasoconstrictor
substance
15. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Clinically
I. Early
C.N.S.
s&mula&on
symptoms
1) Cerebral
Cortex
1. TalkaJve
2. Restlessness
3. Apprehensive
4. Excited
5. Convulsive
2) Medulla
1. Lethargy
2. Sleepiness
3. Unconscious
17. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
N.B.
Death
usually
occur
due
to
respiratory
depression
and
hypoxia
and
its
subsequent
effect
on
the
cardiovascular
system
18. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
PrevenJon
1. Pre-‐analgesic
evalua&on
of
the
paJent
2. Use
the
weakest
possible
concentraJon
3. Use
vasoconstrictor
whenever
possible
4. Use
of
the
least
possible
volume
5. Aspirate
before
injecJon
6. Slow
injecJon
7. Monitor
the
paJent
carefully
aMer
injecJon
19. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Treatment
• Mild
S&mula&on
– No
treatment
– Stop
further
injecJon
• Moderate
sJmulaJon
• Convulsions
phase
• Depression
phase
20. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Treatment
• Mild
SJmulaJon
• Moderate
s&mula&on
– IV
injecJon
of
Barbiturates
• 0.2%
soluJon
of
sodium
thiopental
• Secobarbital
(Seconal)
– Oxygen
inhalaJon
• Convulsions
phase
• Depression
phase
21. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Treatment
• Mild
SJmulaJon
• Moderate
sJmulaJon
• Convulsions
phase
– AnJconvulsent
IV
/
IM
• Coramine
(150-‐450
mg.
I.V.)
• Metrazol
(100
mg
I.V.)
(Midazolam
or
Diazepam)
• Wyamine
(7.5
mg
I.V.
or
15
mg
I.M.)
or
neosynephrine
– Oxygen
inhalaJon
• Depression
22. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Treatment
• Mild
SJmulaJon
• Moderate
sJmulaJon
• Convulsions
phase
• Depression
phase
– ArJficial
RespiraJon
– IV
fluids
– SympathmemeJc
drugs
26. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
DefiniJon
• Abnormal
reacJon
to
a
drug
or
group
of
drugs
exhibited
when
only
a
small
amount
or
a
nontoxic
dose
of
the
drug
has
been
used
• This
means
that
the
suscepJble
paJent
reacts
adversely
to
a
volume
or
concentraJon
of
the
drug
that
would
not
affect
the
typical
paJent
• Nontoxic
–
Non
Allergic
condiJon
27. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
EJology
• Unknown
• Enzymopathy
– Congenital
– Acquired
• Psychogenic
28. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Clinically
1. Pallor
2. Tachycardia
3. Hypotension
4. Decreased
Heart
rate
5. Collapse
29. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
PrevenJon
1. Do
not
use
any
drug,
which
the
paJent
gives
you
a
history
of
previous
reacJons
to
it
2. Inject
slowly
and
observe
the
paJent
closely
during
injecJon
30. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
PrevenJon
1. Do
not
use
any
drug,
which
the
paJent
gives
you
a
history
of
previous
reacJons
to
it
2. Inject
slowly
and
observe
the
paJent
closely
during
injecJon
Treatment
• The
same
as
the
depression
stage
of
toxic
overdose
• Barbiturates
are
ineffecJve
in
the
treatment
or
prevenJon
of
this
condiJon
32. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
• Allergy
is
a
hypersensi&ve
reac&on
that
occurs
through
exposure
to
an
an&gen
(Ag)
such
as
a
drug
(
as
L.A.
agent)
which
the
pt.
has
been
previously
exposed
to
it
creaJng
an
Ag
-‐
Ab
reacJon
• Anaphylaxis
is
a
severe
form
of
allergic
reacJons
occurs
suddenly
&
end
fatally
in
which
sudden
violent
loss
of
vasomotor
tonus
DefiniJon
33. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
• Allergy
is
a
hypersensi&ve
reac&on
that
occurs
through
exposure
to
an
an&gen
(Ag)
such
as
a
drug
(
as
L.A.
agent)
which
the
pt.
has
been
previously
exposed
to
it
creaJng
an
Ag
-‐
Ab
reacJon
• Anaphylaxis
is
a
severe
form
of
allergic
reacJons
occurs
suddenly
&
end
fatally
in
which
sudden
violent
loss
of
vasomotor
tonus
DefiniJon
35. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Anaphylaxis
1. Drop
in
B.P.
(↓B.P.)
2. Weak
rapid
pulse
3. Inadequate
respiraJon
(↓Respiratory
rate)
4. Death
Clinically
36. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
1. An&histaminic
(benadryl
20
-‐
40
mg
IV
or
IM.)
2. Epinephrine
1:1000
concentraJon
0.3
mg
SC.
or
IM.
3. Bronchodilator
via
inhaler
4. Cor&costeroid
100mg
IV.
hydrocorJsone
hemisuccinate
Management
37. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
ComplicaJons
due
to
absorpJon
of
the
injected
soluJon
Local
ReacJons
1. InfecJon
2. Tissue
irritaJon
38. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
InfecJon
InfecJon
from
contaminated
L.A.
soluJons
are
uncommon
due
to
high
standard
of
asepsis
during
manufacturing
Tissue
Irrita&on
Local
Jssue
irritaJon
through
the
use
of
non
isotonic
L.A.
soluJons
are
uncommon
due
to
high
standard
of
manufacturing
39. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
ComplicaJons
associated
with
needle
inserJon
40. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
FainJng
or
Syncope
• It
is
due
to
temporary
cerebral
ischemia
as
a
result
of
dilaJon
of
the
splanchnic
B.V.
&
reduced
cardiac
output
• Signs
&symptoms:
1. Pallor
2. Cold
3. Sweaty
4. Dizzy
5. Nausea
6. Loss
of
consciousness
41. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Ø Management:
• Stop
dental
procedure
• Place
pt.
in
supine
posiJon
with
slight
head
down
or
elevate
the
legs
(
to
↑ cerebral
circulaJon)
or
• Place
the
hands
of
the
pt.
behind
his
head
and
bend
him
forward
unJl
his
head
is
in
between
the
knee(
to
produce
pressure
on
the
splanchnic
B.V.
to
replace
the
blood
that
drained
from
the
head
• Reassure
pt.
• AromaJc
spirit
(ammonia)
held
under
the
nose
of
the
pt.
for
several
breath
42. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Muscle
Trismus
• Inability
to
open
the
mouth
normally
• EJology:
– InjecJng
into
muscles
or
ligaments
– Needle
borne
infecJon
– Contaminated
irritaJng
soluJons
– Haematoma
formaJon
in
the
muscle
• Preven&on:
43. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Ø Management:
Depends
upon
the
cause
– If
it
is
due
to
trauma
it
necessitates
slight
muscle
exercise
and
drug
therapy
to
relieve
pain
if
present
– If
due
to
infecJon
this
needs
anJbioJcs
1. Heat
therapy
2. Warm
saline
rinses
3. Analgesics
4. Muscle
relaxant
44. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Pain
• E&ology:
– InjecJon
into
a
muscle
or
ligament,
paroJd
gland,
T.M.J.
– Using
a
non-‐isotonic
soluJon
– Very
cold
soluJons
– Contaminated
soluJons
– Too
rapid
injecJon
resulJng
in
Jssue
distenJon
– Numerous
needle
punctures
• PrevenJon
Ø Management:
1. Assure
the
pt.
2. Analgesics
45. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Edema
• It
is
usually
a
symptom
• EJology:
– Trauma
– InfecJon
– Allergy
– Hemorrhage
• Treatment
and
prevenJon
depends
upon
the
cause
46. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
InfecJons
• EJology:
– Contaminated
Non-‐sterile
needles
or
soluJons
– Carrying
surface
bacteria
from
non-‐sterile
mucous
membrane
into
the
deeper
structures
with
the
Jp
of
the
needle
are
the
causaJve
factors
– InjecJon
into
infected
area
• PrevenJon
Ø Management:
– AnJbioJcs
– AnJnflammatory
drugs
47. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Broken
needles
• Do
not
use
old
or
dull
needles
• Do
not
use
short
needles
for
nerve
block
• Do
not
aKempt
to
force
the
needle
against
resistance
• Do
not
change
the
direcJon
of
the
needle
while
it
is
embedded
in
the
Jssues,
always
remove
it
and
redirect
it
• Do
not
use
a
needle
of
a
too
fine
gauge
48. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
• Warn
the
paJent
against
any
movement
during
injecJon
and
ask
him
to
stay
sJll
Jll
you
finish
the
injecJon
• Do
not
surprise
the
paJent
with
a
sudden
unexpected
needle
inserJon
• Do
not
insert
the
needle
so
far
that
it
is
out
of
sight
in
Jssues
• Needles
should
not
be
sterilized
by
flaming
because
the
tamper
of
their
alloy
will
be
destroyed
and
they
break
easily
49. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
On
most
occasions
accidental
breakage
takes
place
at
the
hub
This
enables
the
operator
to
remove
the
broken
needle
by
grasping
the
porJon
remaining
in
view
50. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Prolonged
Anesthesia
• EJology:
– ContaminaJon
of
the
anestheJc
soluJon
with
alcohol
or
some
other
germicidal
soluJon
– Needle
trauma
to
nerve
Jssue
• This
is
manifested
at
the
Jme
of
injecJon,
the
paJent
reports
immediately
feeling
a
hot
sharp
pain
flushing
to
the
terminal
branches
of
the
nerve
trunk
contacted
– Trauma
and
swelling
of
the
soM
Jssue
in
proximity
to
the
nerve
Ø Management:
1. Assure
the
pt.
2. It
takes
some
Jme
to
disappear
51. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Haematoma
and
Ecchymosis
• The
effusion
of
blood
into
the
Jssues
as
a
result
of
punctured
B.V.
leading
to
haematoma
formaJon
• Common
sites:
maxillary
tuberosity
region
Ø Management:
1. No
aKempt
should
be
made
to
aspirate
the
contents
of
the
haematoma
2. It
will
absorb
with
Jme
(7
–
14)
days
3. Ice
packs
may
be
applied
iniJally
to
act
as
analgesic
&
a
vasoconstrictor
to
reduce
size
of
haematoma
52. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Sloughing
and
UlceraJon
• Trauma&c
ulcers
– Appear
on
the
palate
from
excessive
amount
of
soluJon
injected
into
the
dense
mucoperiosteal
Jssue
of
the
palate
• Chewing
the
lip
following
a
mandibular
injecJon
• Pinching
of
the
lip
between
the
forceps
and
the
teeth
• ApplicaJon
of
topical
anesthe&c
may
cause
irritaJon
to
m.m.
lead
to
sloughing
&
ulceraJon
Ø Management:
Usually
resolves
within
a
few
days
or
one
week
without
any
intervenJon
53. COMPLICATIONS OF LOCAL ANESTHESIA Hesham El-Hawary
Bizarre
Neurological
Symptoms
• Very
rare
– Facial
paralysis
– Crossed
eyes
– Muscular
weakness
– Temporary
blindness
• The
best
method
of
prevenJng
these
complicaJons
is
to
follow
closely
the
accepted
techniques
described
above