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R. John Brewer NREMT-P Dental Education Inc. Drug Related emergencies. Drug Related emergencies. The administration of drugs is common in the practice of dentistry and oral surgery. The majority of the drugs used in dentistry can be divided into four categories. Local anesthetics Analgesics
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R. John Brewer NREMT-P Dental Education Inc. Drug Related emergencies
Drug Related emergencies • The administration of drugs is common in the practice of dentistry and oral surgery. • The majority of the drugs used in dentistry can be divided into four categories. • Local anesthetics • Analgesics • Antibiotics • CNS Depressants
Local anesthetics • Important part of the dental treatment plan when potentially painful procedures are considered.
Analgesics • Prescribed for relief of preexisting pain or alleviation of potential post-operative pain.
antibiotics • Used in the management of infections
Central nervous system depressants • Prescribed for all phases of the dental treatment for the prevention and management of dentistry related fears.
Drug related emergencies • Whenever a drug is administered, a rational purpose should exist for its use. • Indiscriminate administration of drugs is one of the major reasons the number of incidents of serious or life threatening emergencies in the medical and dental office have increased.
Drug related emergencies • It is estimated well over 100,000 patients have died in hospitals due to adverse drug reactions. • It is estimated that over 2 million patients have suffered serious but non fatal adverse drug reactions.
Drug related emergencies • Toxicology is the study of the harmful effects of chemicals on biological systems. These effects range from minor to serious, or even cause death. • Whenever a drug is administered, two types of reactions may be noted. • Desirable drug reaction • undesirable drug reaction
Drug related emergencies • General principles of toxicology • No drug ever exerts a single action. • No useful drug is entirely devoid of toxicity. • The potential toxicity of the drug rests in the hand of the user.
Drug related emergencies • Our goal is to give the correct drug in the correct dose, via the correct route to the correct patient at the correct time for the correct reason. • It is very important you know about the drugs that you have in the office or prescribe to the patient.
Drug related emergencies • Most Adverse drug reactions do not pose a threat to the patients life. • There are three responses to drugs that are life threatening: • Overdose reaction • Allergic reaction • Idiosyncrasy reaction
Overdose reaction • A condition that results from exposure to toxic amounts of a substance that does not cause adverse effects when given in smaller amounts .
Allergy • Defined as a hypersensitive response to an allergen to which the individual has been previously exposed, and now has developed antibodies. • Allergic reaction is possible with any drug or substance.
allergy • The drugs and substances most likely to cause allergic reactions. • Aspirin • Penicillin • Bisulfites • Latex
Idiosyncrasy reactions • An individuals unique hypersensitivity to a particular drug, food, or other substance. • Management is to position the patient, ABC’S are vital.
Drug related emergencies • The major cause of drug related emergency situations in the dental office is the “administration” of local anesthetics. • Although true Adverse reactions occur ,most reactions are related to the injection(seeing the needle)
Drug related emergencies • Syncope and hyperventilation are the most common “drug related” emergencies. • These episodes usually result from emotional stress receiving the local, not from the drug itself.
Local anesthetics • Locals is the most widely used drugs , are the safest, and most effective drugs for the prevention, and management of pain. • It is important to stress again that most adverse drug reactions to locals are a result of the administration, not the drug.
Local anesthetics • The next most common adverse drug reaction is the toxic reaction. This is produced by a relative overdose secondary to accidental intravascular injection. • True documented allergic reactions to locals is extremely rare.
Antibiotics • Prescribed to treat established active infections • Should only be used when indicated due to resistant bacteria strains and allergies.
Analgesics • Pain relieving drugs make up a significant portion of scripts written by dentists.
analgesics • Two categories of analgesics mild- non opioid strong opioid
analgesics • Mild- asa, ibuprofen, Tylenol Strong- Opioid- codeine, demerol, diludid, vicodin oxycontin
analgesics • Adverse drug reactions to the mild analgesics are GI upset, nausea, constipation, itching • Adverse drug reactions to the opioids are nausea, vomiting, and orthostatic hypotension, respiratory depression, respiratory arrest.
analgesics • Aspirin, Tylenol and Codeine remain the most commonly prescribed drugs.
Antianxiety drugs • The use of these drugs for all phases of dental care has increased significantly over the years. • The most common drugs prescribed is the benzodiazepines.
Local anesthetic overdose • An overdose of a local is related to the blood level of the local in the myocardium and Central nervous system. • There are several factors which influence the rate at which blood levels increase or for which blood levels remain elevated. These factors could be drug or patient related.
Patient factors of Local anesthetic overdose • Normal distribution curve. This is where the majority of patients responds appropriate with “normal dose”, However some are less responsive, and some become more responsive to the local.
Patient factors • Age Due to absorption, metabolism, and excretion drug doses should be decreased for patients under 6 years and over 65 years. - Weight > Lean body weight more of the drug the patient can tolerate. ***A lack of consideration of body weight is one of the major causes of overdose reactions.
Patient factors • Pathological process Presence of Pre-existing disease may alter bodies ability to transform a drug into a biologically inactive substance. • Patients with CHF demonstrate blood levels of locals 2x those found in healthy patients receiving the same dose.
Pathologic factors • Patients with chronic lung disease are at increased risk for local overdose. CO2 retention results in the decrease of the seizure threshold for local anesthesia. If a patient has a PCO2 of 65-81 their seizure threshold is lowered by approx 53%.
Patient factors • Genetics It is been reported that there are certain individuals that possess genetic deficiencies that alter their response to certain drugs.
Patient factors • Attitude It has been shown that the seizure threshold for locals is lowered in patients who are overly stressed.
Drug Factors • Vasoactivity Locals that are more lipid soluble and more highly protein bound are retained longer, therefore having a slower absorption rate. This increases the margin of safety. The greater the degree of vasodilatation, the more rapid the local is absorbed.
Drug factors • Dosage : • The larger the dose the higher the peak blood level.
Drug factors • Route of Administration: Inadvertent intravascular is the factor that causes most overdoses.
Drug factors • Rate of Injection The rate of injection is vital in the cause or prevention, of overdose reactions to all drugs.
Drug factors • Local Anesthetic overdose reactions can result from the combination of inadvertent intravascular injection, combined with too rapid a rate of ingestion. • Both 100% preventable
Vascularity of injection site • The more vascular the area, the faster the absorption rate will be.
Presence of vasoconstrictors • The addition of a vasoconstrictor to a local results in a decrease rate of systemic absorption of the drug.
Signs , Symptoms of a local anesthetic overdose • Low to moderate overdose • Confusion • Talkativeness • Apprehension • Excitedness • Slurred speech • Generalized stutter • Muscular twitching, tremor to face,and extremities
Signs, symptoms (cont) • Nystagmus • Elevated blood pressure • Elevated heart rate • Elevated respiratory rate
Symptoms of local overdose • headache • Feeling lightheaded • dizziness • Blurred vision • Ringing in ears • Numbness of tongue • Flushed or chilled feeling • Drowsiness • Disorientation and loss of consciousness
Management of Local Anesthetic overdose • Management is based on its severity. • -again most cases are mild in nature requiring little or no treatment. Most local overdoses again are self limiting. • Rarely should you go beyond just administering a little 02. • Over treatment has the potential to become a problem.
Management of mild overdose with sudden onset • It is imperative when administering a local, that the patient remain under continual observation, during and after administration of the local. • Again mild local reactions, will begin in 5-10 minutes following injection.
Management of mild overdose • Terminate procedure • Position of comfort • ABC’s • 02 administration • Vital signs • Iv access • Administration of anti-convulsant. • EMS
Management of severe overdose with rapid onset • If signs symptoms appear immediately (seconds to 1 minute)intravascular injection is the most likely cause. • Clinical findings are going to be much more severe and rapid. • Patient may immediately become unconscious, and have seizures.
management • Position patient supine - remove syringe • 911 • ABC’s • 02 administration • Protect patient • Vital signs • IV therapy/ anticonvulsant • Manage the postictal patient