1. Presented by: Dane Smith, DDS Medical Emergencies in the Dental Office

2. A B C D Airway Breathing Circulation Drugs

3. Prevention Assessing your patient Using a medical history

4. Patient History Form

5. A B C D Airway Breathing

6. Nitrogen, CO 2, etc. Atmospheric Pressure 20% O 2 Airway Lungs Veins Arteries Tissues Mitochondria ATP - ADP H 2 O/CO 2 Carbon-based molecules O2O2

7. A B C D Circulation

8. Tissue Liver Kidneys Lungs Out of Body

9. LOCAL ANESTHETICS

10. Used in your OfficeMg/CarpuleCarpules for 100lb patientMaximum Carpules

11. Clinical manifestations of local-anesthetic overdose SignsSymptoms Low to Moderate overdose levels ConfusionHeadache TalkativenessLight headedness ApprehensionDizziness ExcitednessBlurred Vision, unable to focus Slurred speech Ringing in ears Generalized StutterNumbness of tongue & perioral tissues Muscular twitching and tremor of the faceFlushed or chilled feeling And extremitiesDrowsiness NystagmusDisorientation Elevated blood pressureLoss 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

12. Tissue Liver Kidneys Lungs Out of Body

13. 0.4 47.2 0.5 59 1 1018 1.5 1527 2 2036 3 3054 4 4072 Miligrams of local anesthetic per cartridge (1.81 ml) commonly used in dentistry % Total Concentration = mg/ml x 1.8 ml = mg/cartridge

14. Patient Weight (lb) Lidocaine 2% with/without Vasoconstrictor; 2.0 mg/lb Up to 300 mg max Carbocaine Mepivacaine 2% or 3% with or without vasoconstrictor 2.0 mg/lb Up to 300 mg max Citanest Prilocaine 4% with/without Vasoconstrictor 2.7 mg/lb Up to 400 mg max Septocaine Articaine (for adults) 4% with Vasoconstrictor; 3.2 mg/lb Up to 500 mg max Septocaine Articaine (for kids) 4% Vasoconstrictor; 2.3 mg/lb Up 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 MgMg No. of Cartridges Marcaine.5% w 1:200,000 epi 90 mg max From S. Malamed

15. 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

16. Lidocaine 2% w 1/100,000 epi Carbocaine 3% W vasoconstrictor Citanest 4% w 1/200,000 epi Septocaine 4% w 1/100,000 epi For kids Malamed100lbs Max 5.5 c 8.3c 100lbs Max 3.5c 5.3c 100lbs Max 3.75c 5.5c 100lbs Max 3.0c 7.0c Insert 8.8c 13.8c5.5c 7.4c 5.5c 8.3c4.7c 6.9c Dane’s Rule5c3.3c2.5c Comparables for 100lbs Marcaine.5% w 1/200,000 epi 9mg/1lbs 1c/10lbs 10c max

17. 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

18. Epinephrine1 : 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% Levonordefrin1 : 20,000Healthy adult 1.00 mg Mepivacaine 2% Cardiac patient 0.2 mg Procaine 2% with propoxycaine 0.4% Levarterenol 1 : 30,000Healthy 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

19. 1:1000 Epinephrine 1.0 Not Applicable Not available in local anesthetic cartridges (emergency kit) 1:10,000Epinephrine 0.1 Not Applicable Not available in local anesthetic cartridges (emergency kit) 1:20,000 Levonordefrin 0.5 0.09 10 (H), 2 (C) 1:30,000Levarterenol 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 cartridges Dilution available mg/ml cartridge (1.8 ml) used for healthy patient (H) and for cardiac patient (C) Dilutions of vasoconstrictor used in dentistry From S. Malamed

20. A B C D DRUGS

21. Dose.125 mg.3 mg Epinephrine Lungs HeartArteries Beta 2Beta 1Alpha Bronchodilation Oxygen Availability 1. Heart Rate 2. Contractility 3. Centralized Perfusion 4. Counteracts effects of histamine Blood Pressure Vascular Resistance Peripheral Vascular Constriction

22. Pain Non-Narcotics 1. Side effects 2. Drug interactions Acetaminophen Ibuprophen Aspirin Narcotics Nitrous Oxide Codeine Hydrocodiene (vicodin) Oxycodone (percodon) Potential Medical Concerns 1. Side effects 2. Drug interactions 1. Side effects 2. Drug interactions

23. Antibiotics Penicillins Cephalosporins Biaxin 1.Dosage & Frequency 2. Potential Medical Concerns 3.Side Effects 4.Drug Interactions Erythromycins Clindamycins Tetracyclines

24. THE END