Presented by: Dane Smith, DDS

Medical Emergencies in the Dental Office

A B C D

• Airway

• Breathing

• Circulation

• Drugs

Prevention

Assessing your patient

Using a medical history

Patient History Form

A B C D

Airway

Breathing

Nitrogen, CO2, etc.

Atmospheric Pressure20% O2

Airway

Lungs

Veins Arteries

Tissues

Mitochondria

ATP - ADP

H2O/CO2Carbon-based moleculesO2

A B C D

Circulation

Tissue

Liver

Kidneys Lungs

Out of Body

LOCAL ANESTHETICS

Used in your Office Mg/Carpule Carpules for 100lb patient Maximum Carpules

Clinical manifestations of local-anesthetic overdoseSigns Symptoms Low to Moderate overdose levels

Confusion Headache

Talkativeness Light headedness

Apprehension Dizziness

Excitedness Blurred Vision, unable to focus

Slurred speech Ringing in ears

Generalized Stutter Numbness of tongue & perioral tissues

Muscular twitching and tremor of the face Flushed or chilled feeling

And extremities Drowsiness

Nystagmus Disorientation

Elevated blood pressure Loss of consciousness

Elevated heart rate

Elevated respiratory rate

Moderate to High overdose levels

Generalized tonic-clonic seizure, followed by:

Generalized CNS depression

Depressed blood pressure, heart rate and respiratory rate

Tissue

Liver

Kidneys Lungs

Out of Body

0.4 4 7.2

0.5 5 9

1 10 18

1.5 15 27

2 20 36

3 30 54

4 40 72

Miligrams of local anesthetic per cartridge (1.81 ml) commonly used in dentistry

% Total

Concentration = mg/ml x 1.8 ml = mg/cartridge

PatientWeight (lb)

Lidocaine2% with/withoutVasoconstrictor;2.0 mg/lbUp to 300 mg max

CarbocaineMepivacaine2% or 3% with or without vasoconstrictor2.0 mg/lbUp to 300 mg max

CitanestPrilocaine4% with/withoutVasoconstrictor 2.7 mg/lbUp to 400 mg max

SeptocaineArticaine (for adults)4% withVasoconstrictor; 3.2 mg/lbUp to 500 mg max

SeptocaineArticaine (for kids)4%Vasoconstrictor; 2.3 mg/lbUp to 500 mg max

Mg No. of cartridges

Mg No. of cartridges

Mg No. of cartridges

Mg No. of cartridges

Mg No. of Cartridges

Maximal recommended doses of commonly used local anesthetics

2% 3%

20 40 1.1 40 1.1 0.8 54 0.75 64 0.9 46 0.6

40 80 2.2 80 2.2 1.5 108 1.5 128 1.8 92 1.3

60 120 3.3 120 3.3 2.0 162 2.25 192 2.7 138 1.9

80 160 4.4 160 4.4 3.0 216 3.0 256 3.6 184 2.5

100 200 5.5 200 5.5 3.5 270 3.75 320 4.4 230 3.0

120 240 6.5 240 6.5 4.0 324 4.5 384 5.33

140 280 7.5 280 7.5 5.0 378 5.0 448 6.2

160 300 8.0 300 8.0 5.5 400 5.5 500 7.0

180 300 8.0 300 8.0 5.5 400 5.5 500 7.0

200 300 8.0 300 8.0 5.5 400 5.5 500 7.0

Mg

No. of Cartridges

Marcaine

.5% w 1:200,000 epi

90 mg max

From S. Malamed

9 mg /10 lbs

Of body wt

Not to exceed

10 c

100 lbs

10 = 2.5c

4

100 lbs 10 = 2.5c

4

100 lbs 10 = 3.3c

3

100 lbs 10 = 5c

2

100 lbs

320 mg = 4.7c

68 mg/c

100 lbs 400 mg = 5.5c

72 mg/c

100 lbs 300 mg = 5.5c

54 mg/c

100 lbs 320 mg = 8.8c

36 mg/c

Septaocaine

4% w, 1:100,000 epi

Children/Adults

3.2 mg/lb

Citamest

4% w/1:200,000 epi

4.0 mg/lb

600 mg max

Carbocaine

3% w/

vasoconstrictor

3.0 mg/lb

400 mg max

Lidocaine

2% w/ 1:100,000 epi

3.2 mg/lb

500 mg max

Dane’s Rule

Package Insert

Marcaine

.5% w 1:200,000

90 mg max

Maricaine .5%

9 mg/c

* c= carpules

Lidocaine 2% w 1/100,000 epi

Carbocaine 3%W vasoconstrictor

Citanest 4%w 1/200,000 epi

Septocaine 4%w 1/100,000 epiFor kids

Malamed 100lbs Max5.5 c 8.3c

100lbs Max3.5c 5.3c

100lbs Max3.75c 5.5c

100lbs Max3.0c 7.0c

Insert 8.8c 13.8c 5.5c 7.4c

5.5c 8.3c 4.7c 6.9c

Dane’s Rule 5c 3.3c 2.5c 2.5c

Comparables for 100lbs

Marcaine .5%w 1/200,000 epi

9mg/1lbs

1c/10lbs10c max

Mepivacaine 500 4.7 3.0

Lidocaine 400 4.3 3.0

Prilocaine 400 2.8 2.6

Etidocaine 300 1.4 1.3

Effects of vasoconstrictor (epinephrine 1 : 200,000) on peak local anesthetic level in blood

Local Anesthetic

Dose(mg)

Peak Level (ug/ml

without vasoconstrictor

with vasoconstrictor

From S. Malamed

Epinephrine 1 : 50,000 Healthy adult .2 mg Lidocaine 2%

1 : 100,000 Cardiac patient 0.04 mg Articaine 4%

1 : 200,000 Lidocaine 2%

Articaine 4%

Prilocaine 4%

Levonordefrin 1 : 20,000 Healthy adult 1.00 mg Mepivacaine 2%

Cardiac patient 0.2 mg Procaine 2% with

propoxycaine 0.4%

Levarterenol 1 : 30,000 Healthy adult 0.34 mg Procaine 2% with

(Levophed) Cardiac patient 0.14 mg propoxycaine 0.4%

Vasoconstrictor commonly employed in dentistry

Agent Available Maximal Local Anesthetic concentrations dose agents used with

From S. Malamed

1:1000 Epinephrine 1.0 Not Applicable Not available in local anesthetic cartridges

(emergency kit)

1:10,000 Epinephrine 0.1 Not Applicable Not available in local anesthetic cartridges

(emergency kit)

1:20,000 Levonordefrin 0.5 0.09 10 (H), 2 (C)

1:30,000 Levarterenol 0.034 0.06 5(H), 2 (C)

1:50,000 Epinephrine 0.02 0.036 5(H), 2 (C)

1:100,000 Epinephrine 0.01 0.018 10 (H), 2 (C)

1:200,000 Epinephrine 0.005 0.009 20 (H), 4 (C)

Drug mg per maximum no. of cartridgesDilution available mg/ml cartridge (1.8 ml) used for healthy patient (H) and for cardiac patient (C)

Dilutions of vasoconstrictor used in dentistryFrom S. Malamed

A B C D

DRUGS

Dose .125 mg .3 mg

Epinephrine

Lungs

Heart Arteries

Beta 2 Beta 1 Alpha

Bronchodilation

Oxygen Availability

1. Heart Rate

2. Contractility

3. Centralized Perfusion

4. Counteracts effects of histamine

Blood Pressure

Vascular Resistance

Peripheral Vascular Constriction

Pain

Non-Narcotics

1. Side effects

2. Drug interactions

Acetaminophen

Ibuprophen

Aspirin

Narcotics

Nitrous Oxide

Codeine

Hydrocodiene (vicodin)

Oxycodone (percodon)

Potential Medical Concerns Potential Medical Concerns Potential Medical Concerns

1. Side effects

2. Drug interactions

1. Side effects

2. Drug interactions

Antibiotics

Penicillins

CephalosporinsBiaxin

1. Dosage & Frequency

2. Potential Medical Concerns

3. Side Effects

4. Drug Interactions

ErythromycinsClindamycins

Tetracyclines

THE END