ANESTHETIC

EMERGENCIES
 CONTENTS

 Definition of Pain
 Definition of Local Anesthesia
 Local Complications of LA
 Systemic Complications
 Local Anesthetic Considerations in Medically Compromised Patients
 Conclusion
 References
 Definition of Pain

Pain is defined as an unpleasant sensational experience

initiated by noxious stimulus and transmitted over a
specialized neural network to central nervous system (CNS),
where it is interpreted as unpleasant pain sensation.

Medical emergencies in dental office – 7 th edition Stanley F. Malamed

 Definition of Local Anesthesia

Greek word “an” means without and “aisthesis” means

sensation. So anaesthesia is without sensation.

 Local anaesthesia 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

 An important feature of local anaesthesia is that it produces this loss of

sensation without inducing loss of consciousness.

Medical emergencies in dental office – 7 th edition Stanley F. Malamed

Many methods are used to induce local anesthesia:
 Mechanical trauma (compression of tissues)
 low temperature
 Anoxia
 chemical irritants
 neurolytic agents such as alcohol and phenol
 chemical agents such as local anesthetics

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

The following are those properties deemed most desirable for a
local anesthetic:
 It should not be irritating to the tissue to which it is applied.
 It should not cause any permanent alteration of nerve structure.
 Its systemic toxicity should be low.
 It must be effective regardless of whether it is injected into the tissue or is
applied topically to mucous membranes.
 The time of onset of anesthesia should be as short as possible.
 The duration of action must be long enough to permit completion of the
procedure yet not so long as to require an extended recovery.

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Factors affecting onset and duration of action of local anesthetics.

 pH of tissue
 pKa of drug
 Time of diffusion from the needle tip to nerve
 Nerve morphology
 Concentration of drug
 Lipid solubility of drug
 Type of injection: Nerve block has longer
duration than
 infiltration
 Amount of vasoconstrictor used in the solution

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Handbook of local anesthesia – 7TH edition Stanley F. Malamed
A number of potential complications are associated with the administration of
local anesthetics. For purposes of convenience, these complications may be
separated into those that occur locally—in the region of the injection—and those
that are systemic.
Local Complications

• Needle breakage
• Prolonged anesthesia (paresthesia)
• Facial nerve paralysis
• Ocular complications
• Trismus
• Soft tissue injury
• Hematoma
• Pain on injection
• Burning on injection
• Infection
• Edema

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Needle Breakage

• Needle breakage per se is not a significant problem if the needle can be removed without
surgical intervention. Ready access to a hemostat enables the doctor or the assistant to grasp
the visible proximal end of the needle fragment and remove it from the soft tissue.
• The needle fragment remaining in the tissue poses a risk of serious damage being inflicted on
the soft tissues and surrounding structures (e.g., nerve, blood vessels) for as long as the
fragment remains.
o Management
• Immediate referral of the patient to an appropriate specialist (e.g., an oral and maxillofacial
surgeon) for evaluation and possible attempted retrieval.
• More recently, three-dimensional computed tomographic scanning has been recommended to
identify the location of the retained needle fragment.

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

 Prevention

o Do not use short needles for IANB in adults or larger children (length should be determined
by the soft tissue thickness of each individual patient).
o Do not use 30-gauge needles for IANB in adults or children.
o Do not bend needles when inserting them into soft tissue.
o Do not insert a needle into soft tissue to its hub, unless it is absolutely essential for the
success of the injection.
o Observe extra caution when inserting needles in younger, immature, children or in
extremely phobic adult or child patients as they are more apt to make sudden unexpected
movements.

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Prolonged Anesthesia or Paresthesia

Cause
 Trauma to any nerve may lead to paresthesia.
 Injection of a local anesthetic solution contaminated by alcohol or sterilizing solution near a nerve
produces irritation, resulting in edema and increased pressure in the region of the nerve, leading
to paresthesia.
 Persistent anesthesia, rarely total, in most cases partial, and in most cases transient, can lead to
self-inflicted soft tissue injury.
 Biting or thermal or chemical insult can occur with- out a patient’s awareness until the process has
progressed to a serious degree.
 When the lingual nerve is involved, the sense of taste (via the chorda tympani nerve) may also be
impaired.
Prevention
 Strict adherence to the injection protocol and proper care and handling of dental cartridges help
minimize the risk of paresthesia.

Managem
ent
 Most paresthesias resolve within approximately 8 weeks without treatment.Only when damage to
the nerve is severe will the paresthesia be permanent, and this occurs only rarely.
 In most situations the degree of paresthesia is minimal, with the patient retaining most of the
sensory function to the affected area.
Handbook of local anesthesia – 7TH edition Stanley F. Malamed
 Facial Nerve
Paralysis
Cause
 Transient facial nerve paralysis is commonly caused by the introduction of local anesthetic into
the capsule of the parotid gland
Proble
m
 Loss of motor function to the muscles of facial expression produced by local anesthetic
deposition is normally transitory.
 It lasts no longer than several hours, depending on the local anesthetic formulation used, the
volume injected, and proximity to the facial nerve.
 A secondary problem is that the patient is unable to voluntarily close one eye.

Facial nerve paralysis. Inability to close

eyelid (A) and drooping of lip on
affected side (patient’s left) (B).

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Management
 Reassure the patient. Explain that the situation is transient, lasting several hours, and will resolve
with- out residual effect. Mention that it is produced by the normal action of local anesthetic drugs
on the facial nerve, which is a motor nerve to the muscles of facial expression.
 Contact lenses should be removed until muscular movement returns.
 An eye patch should be applied to the affected eye until muscle tone returns. If resistance is
offered by the patient, advise the patient to manually close the affected eyelid periodically to
keep the cornea lubricated.
 Record the incident in the patient’s record.
 Although no contraindication is known to reinjecting the patient to achieve mandibular
anesthesia, it may be prudent to forego further dental care in the affected quadrant at this
appointment.

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Ocular Complications

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Management of Ocular Complications

 It is recommended that consultation with an ophthalmologist be obtained whenever

there is uncertainty as to the cause.
 Diplopia and strabismus always have a transient character and that 75% of the cases
resolve within 6 hours.
 In conditions such as convergent strabismus or binocular diplopia, at least until the
anesthetic effect resolves, a “wait and observe” approach is recommended
 Supportive measures, such as patient reassurance and patching of the affected eye,
should be undertaken, as monocular vision is devoid of distance judging capability,
making it more dangerous for the patient to operate a motor vehicle.

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

 Trismus
Although post injection pain is the most common local complication of local anesthesia,
trismus can become one of the more chronic and complicated problems to manage.

Causes
 Trauma to muscles or blood vessels in the infratemporal fossa
 Local anaesthetic solutions into which alcohol or cold sterilizing solutions have diffused produce
irritation of tissues (e.g., muscle), potentially leading to trismus.
 Haemorrhage is another cause of trismus.

acute phase of trismus, pain produced by hemorrhage leads to muscle spasm and limitation of movement
econd, or chronic, phase usually develops if treatment is not begun.
nic hypomobility occurs secondary to organization of the hematoma, with subsequent fibrosis and scar cont
ion may produce hypomobility through increased pain, increased tissue reaction (irritation), and scarring.

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Prevention

 Use a sharp, sterile, disposable needle.

 Properly care for and handle dental local anesthetic cartridges.
 Use an aseptic technique. Contaminated needles should be changed immediately.
 Practice the atraumatic insertion and injection technique.
 Avoid repeated injections and multiple insertions into the same area by gaining knowledge of
anatomy and proper technique. Use regional nerve blocks instead of local infiltration
(supraperiosteal injection) wherever possible and rational.
 Use minimum effective volumes of local anesthetic. Refer to specific technique protocols for
recommenda- tions.
Management

 With mild pain and dysfunction, the patient reports minimum difficulty opening his or her
mouth.
 In the interim, prescribe heat therapy, warm saline rinses, analgesics, and, if neces- sary,
muscle relaxants to manage the initial phase of muscle spasm.
 Heat therapy consists of applying hot, moist towels to the affected area for approximately 20
minutes every hour.
 The patient should be advised to initiate physiotherapy consisting of opening and closing the
mouth, as well as lateral excursions of the mandible, for 5 minutes every 3 to 4 hours.
Chewing gum (sugarless, of course!) is yet another
Handbook ofmeans of providing
local anesthesia lateral
– 7TH edition Stanley movement
F. Malamed of
 If pain and dysfunction continue unabated beyond 48 hours, consider the possibility of infection.
Antibiotics should be added to the treatment regimen described and their use should be
continued for 7 days.
 For severe pain or dysfunction, if no resolution is noted within 2 or 3 days without antibiotics or
within 5 to 7 days with antibiotics, or if the ability to open the mouth has become limited, the
patient should be referred to an oral and maxillofacial surgeon for evaluation.
 Temporomandibular joint involvement is rare in the first 4 to 6 weeks after injection. Surgical
intervention to correct chronic dysfunction may be indicated in some instances.

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Soft Tissue Injury

Self-inflicted trauma to the lips and tongue is frequently caused by the patient inadvertently
biting or chewing these tissues while still anesthetized

Cause
Trauma occurs most frequently in younger children, in mentally or physically disabled children or
adults, and in older-old patients (older than 85 years); however, it occurs in patients of all ages.

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Problem
 Trauma to anesthetized tissues can lead to swelling and significant pain when the anesthetic
effects resolve.
 A young child or a handicapped individual may have difficulty coping with the situation, and
this may lead to behavioral problems.
 The possibility that infection will develop is remote in most instances.

Prevention
 A local anesthetic of appropriate duration should be selected if dental appointments are brief.
 A cotton roll can be placed in the buccal or labial fold between the lips and the teeth if they
are still anesthetized at the time of discharge. The cotton roll is secured with dental floss
wrapped around the teeth (to prevent inadvertent aspiration of the roll)

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Management
 Analgesics (e.g., age-appropriate dose of ibuprofen) for pain, as necessary;
 Antibiotics, as necessary, in the unlikely situation that infection results;
 Lukewarm saline rinses to aid in decreasing any swelling that may be present;
 Petroleum jelly or other lubricant to cover a lip lesion and minimize irritation.

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

 Hematoma
 The effusion of blood into extravascular spaces can be caused by inadvertent nicking of a blood
vessel (artery or vein) during administration of a local anesthetic.
 A hematoma that develops subsequent to nicking of an artery usually increases rapidly in size
until management is instituted because of the significantly greater pressure of blood within an
artery.
 Nicking of a vein may or may not result in the formation of a hematoma.
Cause
 A large hematoma may result from arterial or venous puncture after a PSA nerve block or an
IANB.
 Hematomas that occur after the IANB are usually visible only intraorally, whereas hematomas
that occur after the PSA nerve block are visible extraorally

Hematoma following posterior superior alveolar nerve block. Hematoma that developed after mental nerve block.
Handbook of local anesthesia – 7TH edition Stanley F. Malamed
Problem
 A hematoma rarely produces significant problems, aside from the resulting “bruise,” which may
or may not be visible extraorally.
 Possible complications of hematoma include trismus and pain.
 Swelling and discoloration of the region usually subside gradually, with complete resolution
occur- ring between 7 and 21 days.

Prevention
 Knowledge of the normal anatomy involved in the pro- posed injection is important, although keep
in mind that “normal” anatomy may differ considerably from patient to patient. Certain techniques
are associated with a greater risk of a visible hematoma. The PSA nerve block is the most
common, followed by the mental/incisive nerve block and the IANB.
 Modify the injection technique as dictated by the patient’s anatomy. For example, the depth of
penetration for a PSA nerve block may be decreased in a patient with smaller facial
characteristics.
 Use a short needle (27-gauge short needle is recommended) for the PSA nerve block to decrease
the risk of hematoma that is commonly a result of needle over- insertion.
 Minimize the number of needle penetrations into tissue.
 Never use a needle as a probe in tissues.
Handbook of local anesthesia – 7TH edition Stanley F. Malamed
Management
 Immediate
o Direct pressure should be applied to the site of bleeding.
o Localized pressure should be applied for a minimum of 2 minutes.
 Inferior Alveolar Nerve Block
o Pressure is applied to the medial aspect of the mandibular ramus.
 Anterior Superior Alveolar (Infraorbital) Nerve Block
o Pressure is applied to the skin directly over the infraorbital foramen.
o Immediate clinical manifestation is development of a soft tissue “lump” below the lower
eyelid.
 Incisive (Mental) Nerve Block
o Pressure is placed directly over the mental foramen, exter- nally on the skin or intraorally
on the mucous membrane.
 Buccal Nerve Block or Any Palatal Injection
o Place pressure at the site of bleeding.
 Posterior Superior Alveolar Nerve Block
o The PSA nerve block usually produces the largest and most esthetically unappealing
hematoma.
o The infratemporal fossa, into which bleeding occurs, can accommodate a large volume of
blood.
o The hematoma is usually not recognized until a colorless swelling appears on the side of the
face around the temporomandibular joint area (usually a few minutes after the injection is
completed).
o It is difficult to apply pressure to the site of bleeding
Handbook inanesthesia
of local this situation because
– 7TH edition Stanley F.of the location
Malamed
o Bleeding normally ceases when external pressure on the vessels exceeds internal pressure, or
when clotting occurs.
o Digital pressure can be applied to the soft tissues in the mucobuccal fold as far distally as can be
tolerated by the patient (without eliciting a gag reflex).
o Apply pressure in a medial and superior direction.
o If available, ice should be applied (extraorally) to increase pressure on the site and help to
constrict the punctured vessel.

 Subsequent
o The patient may be discharged once bleeding stops.
o Advise the patient about possible soreness and limitation of movement (trismus).
o Discoloration will likely occur as a result of extravascular blood elements; it is gradually resorbed
over 7 to 21 days.
o Do not apply heat to the area for at least 4 to 6 hours after the incident.
o Ice may be applied to the region immediately on recognition of a developing hematoma. Ice acts
as both an anal gesic and a vasoconstrictor, and it may aid in minimizing the size of the
hematoma.

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Pain on Injection
Pain on injection of a local anesthetic can best be prevented through careful adherence to the basic
protocol of atraumatic injection

Causes
 Careless injection technique and a callous attitude (“Palatal injections always hurt” or “This will
hurt a little”) all too often become self-fulfilling prophecies.
 A needle can become dull following multiple insertions.
 Rapid deposition of the local anesthetic solution is more uncomfortable than slow deposition and
may cause tissue damage.
 Needles with barbs (from impaling bone) may produce pain as they are withdrawn from tissue.

Problem
Pain on injection increases patient anxiety and may lead to sudden unexpected movement,
increasing the risk of needle breakage, traumatic soft tissue injury to the patient, or needlestick
injury to the administrator.

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Prevention
 Adhere to proper techniques of injection, both anatomic and psychological.
 Use sharp needles.
 Use topical anesthetic properly before injection.
 Use sterile local anesthetic solutions.
 Inject local anesthetics slowly. The ideal rate is 1.0 mL per minute; the
recommended rate is 1.8 mL or a 2.2-mL cartridge over 1 minute.
 Make certain that the temperature of the solution is correct. A solution that is too
hot or too cold may be more uncomfortable than one at room temperature.
 Buffered local anesthetics, at a pH of approximately 7.4, have been demonstrated
to be more comfortable on administration.

Management
 No management is necessary.
 Steps should be taken to prevent the recurrence of pain associated with the injection
of local anesthetics.

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Burning on Injection
 Causes
o The primary cause of a mild burning sensation is the pH of the solution
o Rapid injection of local anesthetic, especially in the denser, more adherent tissues of the palate,
produces a burning sensation.
o Contamination of local anesthetic cartridges can result when they are stored in alcohol or other
sterilizing solutions, leading to diffusion of these solutions into the cartridge.

Problem
 Although usually transient, the sensation of burning on injection of a local anesthetic
indicates that tissue irritation or damage is occurring.
 When a burning sensation occurs as a result of rapid injection, a contaminated solution, or an
overly warm solu-tion, the likelihood that tissue may be damaged is greater, and subsequent
complications, such as postanesthetic trismus, edema, or possible paresthesia, are reported.
Prevention
 By buffering the local anesthetic solution to a pH of approximately 7.4 immediately before
administration, it is possible to eliminate the burning sensation that some patients experience
during injection of a local anesthetic solution containing a vasopressor.
 Slowing the speed of injection also helps. The ideal rate of injectable drug administration is 1 mL
per minute. Do not exceed the recommended rate of 1.8 mL per minute.
 The cartridge of anesthetic should be stored at room temperature in the container (blister pack or
tin) in which it was shipped, or in a suitable container without alcohol or other sterilizing agents.
Handbook of local anesthesia – 7TH edition Stanley F. Malamed
Management
 Because most instances of burning on injection are transient and do not lead to
prolonged tissue involvement, formal treatment is usually not indicated.
 In those few situations in which post injection discomfort, edema, or paresthesia
becomes evident, management of the specific problem is indicated.

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Infection
Infection subsequent to local anesthetic administration in dentistry is an extremely rare
occurrence since the introduction of single-use sterile needles and glass cartridges.

Causes
 Contamination of the needle before administration of the anesthetic.
 Improper technique in the handling of local anesthetic equipment and improper tissue
preparation for injection are other possible causes of infection.

Problem
 Cause a low- grade infection when the needle or solution is placed in deeper tissue.
 This may lead to trismus if it is not recognized and proper treatment is not initiated.

Prevention
 Use sterile disposable needles.
 Proper care and handling of needles. Take precautions to avoid contamination of the needle
through contact with nonsterile surfaces; avoid multiple injections with the same needle, if
possible.
 Proper care and handling of local anesthetic cartridges.
 Properly prepare the tissues before penetration. Dry them and apply topical antiseptic
(optional).

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Management

 Immediate treatment consists of those procedures used to manage trismus: heat and analgesic if
needed, muscle relaxant if needed, and physiotherapy.

 Trismus produced by factors other than infection normally responds with resolution or reduction
within several days.
 If signs and symptoms of trismus do not begin to respond to conservative therapy within 3 days,
the possibility of a low- grade infection should be entertained and a 7- to 10-day course of
antibiotic therapy should be started.

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Edema
Causes
Trauma during injection.
Infection.
Allergy: angioedema is a possible response to ester-type topical anesthetics in an allergic patient
(localized tissue swelling occurs as a result of vasodilation secondary to histamine release).
Hemorrhage (effusion of blood into soft tissues produces swelling).
Injection of irritating solutions (alcohol-containing cartridges or cold sterilizing solution–containing
cartridges).
Problem
 Edema related to local anesthetic administration is seldom of sufficient intensity to produce
significant problems such as airway obstruction.
 Most instances of local anesthetic– related edema result in pain and dysfunction of the region
and embarrassment for the patient.
 Edema of the tongue, pharynx, or larynx may develop, and is a potentially life-threatening
situation that requires vigorous management (including activation of emergency medical
services).

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

Prevention
 Proper care and handling of the local anesthetic armamentarium.
 Use atraumatic injection technique.
 Complete an adequate medical evaluation of the patient before drug administration.

 Management
 The management of edema is predicated on reduction of the swelling as quickly as possible and
on the cause of the edema.
 After hemorrhage, edema resolves more slowly (over 7 to 21 days) as extravasated blood
elements are resorbed into the vascular system.
 Edema produced by infection does not resolve spontaneously but may become progressively
more intense if untreated.
 If signs and symptoms of infection (pain, mandibular dysfunction, edema, warmth) do not appear
to resolve within 3 days, antibiotic therapy should be instituted as outlined previously.
 Allergy-induced edema is potentially life threatening. Its degree and location are highly
significant.

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

ema occurs in any area where it compromises breathing, treatment consists of the following:

 P (position): if unconscious, the patient is placed supine.

 C-A-B (circulation, airway, breathing): basic life support is administered, as needed.
 D (definitive treatment): emergency medical services (e.g., 9-1-1) are summoned.
 Epinephrine is administered: 0.3 mg (0.3 mL of a 1:1000 epinephrine solution) for weight
greater than 30 kg), 0.15 mg (0.15 mL of a 1:1000 epinephrine solution) for weight between 15
and 30 kg, IM in the vastus lateralis every 5 minutes until respiratory distress resolves.
 Histamine blocker is administered intramuscularly or intravenously.
 Corticosteroid is administered intramuscularly or intra-venously.
 Preparation is made for cricothyrotomy if total airway obstruction appears to be developing.
This is extremely rare but is the reason for summoning emergency medical services as quickly
as possible.
 The patient’s condition is thoroughly evaluated before his or her next appointment to
determine the cause of the reaction.

Handbook of local anesthesia – 7TH edition Stanley F. Malamed

 Systemic Complications

Anaphylaxis
 An acute systemic allergic reaction
 “ana” means against
 “prophylaxis” Protection
 The result of a re-exposure to an antigen that elicits an IgE mediated exposure
 Usually caused by a common environmental protein that is not intrinsically harmful
 Type I hypersensitivity reaction.

Robbins Basic Pathology – 9TH Edition

 Local anesthetics belong to the amide or ester group
 Metabolism of amide local anesthetic is primarily in the liver, where as that of esters via plasma
cholinesterase
 Anaphylactic reactions to amide LA are extremely rare, and true allergic reactions to esters
account for <1% of all drug reactions to LA
 True Type I IgE mediated allergic reactions are usually due to the paraaminiobenzoic acid
metabolite from esters or methylparaben.
 Epinephrine, metabisulfite present in the LA can also cause adverse drug reaction
 Vasovagal responses, tachycardia, lightheadedness, metallic taste, and perioral numbness can
result from intravascular injection of the local anesthetic, epinephrine, or both
 The most common immune-mediated reaction to local anesthetics is a delayed hypersensitivity
reaction (Type IV reaction), or contact dermatitis

Robbins Basic Pathology – 9TH Edition

ALLERGY SKIN TEST
Skin allergy testing is a method for medical diagnosis of allergies that attempts to provoke a small, controlled, allergic
response.

Allergy skin tests are used to find out which substances cause a person to
have an allergic reaction.

Skin testing is usually done at a doctor's office. A nurse generally administers the test, and a doctor interprets the
results. Typically, this test takes about 20 to 40 minutes. Some tests detect immediate allergic reactions, which develop
within minutes of exposure to an allergen. Other tests detect delayed allergic reactions, which develop over a period
of several days.

 SKIN PRICK TEST

 SKIN SCRATCH TEST

 PATCH TEST

 INTRADERMAL TEST

Robbins Basic Pathology – 9TH Edition

SKIN PRICK/ SCRATCH TEST

A skin prick test, also called a puncture or scratch test, checks for immediate allergic reactions to as many as 40
different substances at once. This test is usually done to identify allergies to pollen, mold, pet dander, dust mites
and foods. In adults, the test is usually done on the forearm. Children may be tested on the upper back.

Allergy skin tests aren't painful. This type of testing uses needles (lancets) that barely penetrate the skin's surface.
You won't bleed or feel more than mild, momentary discomfort.

PROCEDURE

After cleaning the test site with alcohol, the nurse

draws small marks on your skin and applies a drop
of allergen extract next to each mark. He or she
then uses a lancet to prick the extracts into the
skin's surface. A new lancet is used for each
allergen.

Review of Pharmacology- 14TH Edition - Gobind Rai Garg, Sparsh Guptha

RESULT
About 15 minutes after the skin pricks, the nurse observes
your skin for signs of allergic reactions. If you are allergic to
one of the substances tested, you'll develop a raised, red,
itchy bump (wheal) that may look like a mosquito bite. A
nurse will then measure the bump's size

After the nurse records the results, he or she will clean your
skin with alcohol to remove the marks

Review of Pharmacology- 14TH Edition - Gobind Rai Garg, Sparsh Guptha

INTRADERMAL TEST

This is a skin end point titration (SET) which uses intradermal injection of allergens at increasing concentrations to
measure allergic response

The intradermal test is sensitive more than the skin prick test

To prevent a severe allergic reaction, the test is started with a very dilute solution. After 10 minutes, the injection site
is measured to look for growth of wheal, a small swelling of the skin

Two millimeters of growth in 10 minutes is considered positive. If 2 mm of growth is noted, then a second injection at
a higher concentration is given to confirm the response

The end point is the concentration of antigen that causes an increase in the size of the wheal followed by confirmatory
whealing. If the wheal grows larger than 13 mm, then no further injection are given since this is considered a major
reaction

Review of Pharmacology- 14TH Edition - Gobind Rai Garg, Sparsh Guptha

Review of Pharmacology- 14TH Edition - Gobind Rai Garg, Sparsh Guptha
PATCH TEST

Patch testing is generally done to see whether a particular substance is causing allergic skin irritation (contact dermatitis).
Patch tests can detect delayed allergic reactions, which can take several days to develop

Patch tests don't use needles. Instead, allergens are applied to patches, which are then placed on your skin. During a
patch test, your skin may be exposed to 20 to 30 extracts of substances that can cause contact dermatitis. These can
include latex, medications, fragrances, preservatives, hair dyes, metals and resins

You wear the patches on your arm or back for 48 hours. During this time, you should avoid bathing and activities that
cause heavy sweating. The patches are removed when you return to your doctor's office. Irritated skin at the patch site
may indicate an allergy

Review of Pharmacology- 14TH Edition - Gobind Rai Garg, Sparsh Guptha

 Systemic Complications

The deleterious effects of toxic doses of lignocaine on various

systems are as follows:

Central Nervous System

Toxic doses of local anesthetic agents first produce stimulation, followed by depression.
The manifestations of stimulation vary from mild restlessness to severe convulsions.
The depression is manifested as drowsiness to loss of consciousness.

Text book of oral and maxilliofacial surgery - 5 th edition Neelima Anil Malik
Cardiovascular System

The effects on cardiovascular system vary with the dose used.

Moderately large doses

It produces overall inhibition on the contractility of heart muscle, in the form of:
o A decrease in the electrical excitability of myocardium.
o A decrease in the force of contraction (negative inotropic effect).
o A decrease in the rate of electrical impulse conduction (negative chronotropic effect).

Large doses
In large doses such as, 50–100 mg (1.5 mg/ kg body weight), it is given IV during GA and surgery
to correct ventricular arrhythmias that occur during surgical procedures.

Vasculature

Vasodilatation is produced by direct relaxing effect on smooth muscle of vessel walls.

In toxic doses, this action contributes to hypotension and cardiovascular collapse.

Text book of oral and maxilliofacial surgery - 5 th edition Neelima Anil Malik
Respiratory System

o In small doses, it causes mild bronchodilatation.

o In large doses, it causes respiratory arrest (apnea) (the most common cause of death
related to overdose of local anesthetic agent).
o In majority of cases, respiratory arrest precedes cardiac arrest.
o However, artificial ventilation and basic life support (BLS) measures will prevent
serious sequelae.

Text book of oral and maxilliofacial surgery - 5 th edition Neelima Anil Malik
 Local Anesthetic Considerations in Medically Compromised Patients

Hypertension
 Adequate analgesia and anaesthesia must be provided.
An aspirating syringe should be used to give a local anaesthetic, since epinephrine (adrenaline) in the anaesthetic
given intravenously may (theoretically) increase hypertension and precipitate dysrhythmias. Blood pressure tends
to rise during oral surgery under local anaesthesia and epinephrine (adrenaline) can contribute to this.
 Epinephrine in combination with local anaesthetics is contraindicated in an hypertensive patient with systolic
pressure of more than 200 mmHg and/or diastolic pressure of more than 115 mmHg.
 Epinephrine-containing local anaesthetics should not be given in large doses to patients taking nonselective beta-
blockers, since interactions between epinephrine and the beta-blocking agent may induce hypertension and
cardiovascular complications.
 Conscious sedation may be advisable to control anxiety.

Text book of oral and maxilliofacial surgery 3 rd edition – S M Balaji

 Congestive heart failure

 Bupivacaine should be avoided as it is cardiotoxic. Otherwise, local anaesthesia can be used safely.
 Interactions between excessive doses of the local anaesthetic and nonselective beta-blockers should be assessed.

Renal disorders

Local anaesthesia is safe unless there is a severe bleeding tendency.

Hyperthyroidism

Local anaesthetics containing epinephrine should in theory be avoided because of the possible risk of dangerous dysrhythmias.
However, there seems little clinical evidence for this and the risk is probably only real if an overdose is given.

Text book of oral and maxilliofacial surgery 3 rd edition – S M Balaji

 Haemophilia A
 Local anaesthesia should be avoided in the absence of factor VIII replacement.
 Regional (inferior dental or posterior superior alveolar) blocks or injections in the floor of the mouth
must not be used, since they can cause haemorrhage into tissue spaces causing airway obstruction.
 Submucosal infiltrations have caused widespread haematoma formation, but intraligamentary
injections may be safe.
 Infiltration anaesthesia may be used with caution and is adequate for conservation work in children,
but lingual infiltration must be avoided.

Text book of oral and maxilliofacial surgery 3 rd edition – S M Balaji

 Dysrhythmia
 An aspirating syringe is advised. Epinephrine accidentally entering the blood may (theoretically) increase
hypertension and precipitate dysrhythmias. Blood pressure tends to rise during oral surgery under local
anaesthesia and epinephrine (adrenaline) theoretically can contribute to this.
 Adequate analgesia is essential. Pain can cause dangerous increase of endogenous epinephrine than that of
anaesthesia.
 Epinephrine-containing local anaesthetics should not be given in large doses to patients taking beta-blocking
agent. It may induce hypertension and cardiovascular complications. Mepivacaine 3% is preferable to
lidocaine.
 Intraosseous or intra ligamental injections with local anaesthetic agents containing a vasoconstrictor should
usually be avoided to prevent excessive systemic absorption.

Text book of oral and maxilliofacial surgery 3 rd edition – S M Balaji

 Conclusion

In conclusion, understanding and effectively managing local anesthetic emergencies are crucial for every
healthcare provider.

By staying informed about potential complications, maintaining preparedness with proper equipment
and protocols, and prioritizing patient safety, we can mitigate risks and ensure optimal outcomes in
clinical practice.
 References
Medical emergencies in dental office – 7th edition Stanley F. Malamed
Handbook of local anesthesia – 7TH edition Stanley F. Malamed
Text book of oral and maxilliofacial surgery - 5th edition Neelima Anil Malik
Text book of oral and maxilliofacial surgery 3rd edition – S M Balaji
Review of Pharmacology- 14TH Edition - Gobind Rai Garg, Sparsh Guptha
Robbins Basic Pathology – 9TH Edition