Deck 17: Local Anesthesia Complications and Management

Question 1

Match the following:

-Adverse reaction

A) Causes CNS and CVA depression
B) Blood leakage into tissue
C) Low oxygen-carrying capacity
D) Undesired response to drug
E) Localized swelling
F) Inability to open mouth
G) Sensation of pain from non-noxious stimuli
H) Follows needle breakage
I) Adverse reaction with no known etiology
J) Requires very low drug dose to cause overdose reaction
K) Allergy
L) Increased sensitivity to stimuli following nerve injury
M) Requires very high drug dose to cause overdose reaction
N) Altered taste sensation

Answer 1

Undesired response to drug

Question 2

Match the following:

-Ageusia

A) Causes CNS and CVA depression
B) Blood leakage into tissue
C) Low oxygen-carrying capacity
D) Undesired response to drug
E) Localized swelling
F) Inability to open mouth
G) Sensation of pain from non-noxious stimuli
H) Follows needle breakage
I) Adverse reaction with no known etiology
J) Requires very low drug dose to cause overdose reaction
K) Allergy
L) Increased sensitivity to stimuli following nerve injury
M) Requires very high drug dose to cause overdose reaction
N) Altered taste sensation

Answer 2

Altered taste sensation

Question 3

Match the following:

-Angioedema

A) Causes CNS and CVA depression
B) Blood leakage into tissue
C) Low oxygen-carrying capacity
D) Undesired response to drug
E) Localized swelling
F) Inability to open mouth
G) Sensation of pain from non-noxious stimuli
H) Follows needle breakage
I) Adverse reaction with no known etiology
J) Requires very low drug dose to cause overdose reaction
K) Allergy
L) Increased sensitivity to stimuli following nerve injury
M) Requires very high drug dose to cause overdose reaction
N) Altered taste sensation

Answer 3

Localized swelling

Question 4

Match the following:

-Dysesthesia

A) Causes CNS and CVA depression
B) Blood leakage into tissue
C) Low oxygen-carrying capacity
D) Undesired response to drug
E) Localized swelling
F) Inability to open mouth
G) Sensation of pain from non-noxious stimuli
H) Follows needle breakage
I) Adverse reaction with no known etiology
J) Requires very low drug dose to cause overdose reaction
K) Allergy
L) Increased sensitivity to stimuli following nerve injury
M) Requires very high drug dose to cause overdose reaction
N) Altered taste sensation

Question 5

Match the following:

-Hematoma

A) Causes CNS and CVA depression
B) Blood leakage into tissue
C) Low oxygen-carrying capacity
D) Undesired response to drug
E) Localized swelling
F) Inability to open mouth
G) Sensation of pain from non-noxious stimuli
H) Follows needle breakage
I) Adverse reaction with no known etiology
J) Requires very low drug dose to cause overdose reaction
K) Allergy
L) Increased sensitivity to stimuli following nerve injury
M) Requires very high drug dose to cause overdose reaction
N) Altered taste sensation

Question 6

Match the following:

-Hyperesthesia

A) Causes CNS and CVA depression
B) Blood leakage into tissue
C) Low oxygen-carrying capacity
D) Undesired response to drug
E) Localized swelling
F) Inability to open mouth
G) Sensation of pain from non-noxious stimuli
H) Follows needle breakage
I) Adverse reaction with no known etiology
J) Requires very low drug dose to cause overdose reaction
K) Allergy
L) Increased sensitivity to stimuli following nerve injury
M) Requires very high drug dose to cause overdose reaction
N) Altered taste sensation

Question 7

Match the following:

-Hyper-responder

A) Causes CNS and CVA depression
B) Blood leakage into tissue
C) Low oxygen-carrying capacity
D) Undesired response to drug
E) Localized swelling
F) Inability to open mouth
G) Sensation of pain from non-noxious stimuli
H) Follows needle breakage
I) Adverse reaction with no known etiology
J) Requires very low drug dose to cause overdose reaction
K) Allergy
L) Increased sensitivity to stimuli following nerve injury
M) Requires very high drug dose to cause overdose reaction
N) Altered taste sensation

Question 8

Match the following:

-Hyper-responder

A) Causes CNS and CVA depression
B) Blood leakage into tissue
C) Low oxygen-carrying capacity
D) Undesired response to drug
E) Localized swelling
F) Inability to open mouth
G) Sensation of pain from non-noxious stimuli
H) Follows needle breakage
I) Adverse reaction with no known etiology
J) Requires very low drug dose to cause overdose reaction
K) Allergy
L) Increased sensitivity to stimuli following nerve injury
M) Requires very high drug dose to cause overdose reaction
N) Altered taste sensation

Question 9

Match the following:

-Hypersensitivity

A) Causes CNS and CVA depression
B) Blood leakage into tissue
C) Low oxygen-carrying capacity
D) Undesired response to drug
E) Localized swelling
F) Inability to open mouth
G) Sensation of pain from non-noxious stimuli
H) Follows needle breakage
I) Adverse reaction with no known etiology
J) Requires very low drug dose to cause overdose reaction
K) Allergy
L) Increased sensitivity to stimuli following nerve injury
M) Requires very high drug dose to cause overdose reaction
N) Altered taste sensation

Question 10

Match the following:

-Idiosyncratic

A) Causes CNS and CVA depression
B) Blood leakage into tissue
C) Low oxygen-carrying capacity
D) Undesired response to drug
E) Localized swelling
F) Inability to open mouth
G) Sensation of pain from non-noxious stimuli
H) Follows needle breakage
I) Adverse reaction with no known etiology
J) Requires very low drug dose to cause overdose reaction
K) Allergy
L) Increased sensitivity to stimuli following nerve injury
M) Requires very high drug dose to cause overdose reaction
N) Altered taste sensation

Question 11

Match the following:

-Overdose

A) Causes CNS and CVA depression
B) Blood leakage into tissue
C) Low oxygen-carrying capacity
D) Undesired response to drug
E) Localized swelling
F) Inability to open mouth
G) Sensation of pain from non-noxious stimuli
H) Follows needle breakage
I) Adverse reaction with no known etiology
J) Requires very low drug dose to cause overdose reaction
K) Allergy
L) Increased sensitivity to stimuli following nerve injury
M) Requires very high drug dose to cause overdose reaction
N) Altered taste sensation

Question 12

Match the following:

-Trismus

A) Causes CNS and CVA depression
B) Blood leakage into tissue
C) Low oxygen-carrying capacity
D) Undesired response to drug
E) Localized swelling
F) Inability to open mouth
G) Sensation of pain from non-noxious stimuli
H) Follows needle breakage
I) Adverse reaction with no known etiology
J) Requires very low drug dose to cause overdose reaction
K) Allergy
L) Increased sensitivity to stimuli following nerve injury
M) Requires very high drug dose to cause overdose reaction
N) Altered taste sensation

Question 13

Match the following:

-Embedded needle

A) Causes CNS and CVA depression
B) Blood leakage into tissue
C) Low oxygen-carrying capacity
D) Undesired response to drug
E) Localized swelling
F) Inability to open mouth
G) Sensation of pain from non-noxious stimuli
H) Follows needle breakage
I) Adverse reaction with no known etiology
J) Requires very low drug dose to cause overdose reaction
K) Allergy
L) Increased sensitivity to stimuli following nerve injury
M) Requires very high drug dose to cause overdose reaction
N) Altered taste sensation

Question 14

Match the following:

-Methemoglobinemia

A) Causes CNS and CVA depression
B) Blood leakage into tissue
C) Low oxygen-carrying capacity
D) Undesired response to drug
E) Localized swelling
F) Inability to open mouth
G) Sensation of pain from non-noxious stimuli
H) Follows needle breakage
I) Adverse reaction with no known etiology
J) Requires very low drug dose to cause overdose reaction
K) Allergy
L) Increased sensitivity to stimuli following nerve injury
M) Requires very high drug dose to cause overdose reaction
N) Altered taste sensation

Question 15

Local complications occur more frequently than systemic complications following injections of local anesthetic.

Question 16

Hematomas are local complications occurring most frequently after inferior alveolar nerve blocks.

Question 17

Hematomas on the palate are generally well-confined due to the tight tissue covering the bone.

Question 18

As a consequence of local anesthetic, the primary causes of trismus are hemorrhage and muscle trauma following injection.

Question 19

In the event a needle breaks and embeds in the tissue, it should be removed as soon as possible to avoid infection.

Question 20

Lip biting following local anesthesia is not uncommon in children even when both patient and parent are warned of the risk.

Question 21

The lingual nerve is most frequently involved in paresthesias following dental injections.

Question 22

Signs and symptoms of local anesthetic overdose are those of CNS and CVS depression.

Question 23

Local anesthetic overdose and allergy are both dose dependent and can be prevented by adhering to MRD guidelines.

Question 24

Minimizing the number of needle penetrations is the least effective way to avoid hematomas.

Question 25

An adverse reaction to a drug with no known etiology is called an ________ reaction.

Question 26

Undesired events that occur in response to the pharmacologic actions of a drug are called ________ reactions.

Question 27

A patient who requires very low drug doses in order to experience an overdose is referred to as a ________.

Question 28

A patient who requires a high drug dose in order to experience an overdose is referred to as a ________.

Question 29

A partially altered taste sensation is referred to as ________.

Question 30

A ________ is formed by the leaking of blood from vessels into surrounding tissues.

Question 31

________ is defined as a motor disturbance of the trigeminal nerve and an inability to open the mouth.

Question 32

The recommended treatment for trismus includes the application of ________ for 20 minutes every hour.

Question 33

A recommended treatment for hematomas includes the immediate application of pressure and ________.

Question 34

In the event a needle becomes embedded in the tissue and cannot be retrieved, the patient should be informed that a needle has broken off and embedded in the tissue and it is necessary for the patient to see an oral surgeon for ________.

Question 35

A drug called ________ limits the duration of soft tissue anesthesia and may reduce the potential for post-injection self-injury.

Question 36

An altered sensation and/or a persistent partial or complete numbness is referred to as ________.

Question 37

Systemic complications from local anesthetics occurs ________ frequently compared to local complications.

Question 38

Allergy may occur due to the inclusion of ________ preservatives in vasoconstrictor-containing solutions of local anesthetic drugs.

Question 39

The occurrence of trismus and hematoma can be minimized by ________ the number of needle penetrations.

Question 40

The most common adverse events related to local anesthetic include all of the following except

A) Syncope
B) Postoperative discomfort
C) Self-injury
D) Anaphylaxis

Question 41

A patient calls the office and complains of sloughing of the mucosal tissue on the side of
The mouth that was treated. What is the most likely cause?

A) Mucosa was dried too vigorously
B) The patient used too much salt when rinsing post-operatively
C) The patient chewed their check while still numb
D) Topical anesthetic was in contact with a large area of mucosa for too long

Question 42

What is the main cause of hematoma?

A) Poor operator technique
B) Failure to aspirating
C) Tearing a blood vessel
D) Anatomical anomalies

Question 43

Which of the following statements is true when considering hematoma formations following inferior alveolar nerve blocks?

A) Outward or intraoral signs of hematoma occur immediately during or following injections because the blood leakage quickly follows the facial planes.
B) Outward signs of hematoma are uncommon during or immediately following injection because the pterygomandibular space accommodates large quantities of blood medial to the ramus.
C) Outward signs of hematoma are immediately noticeable under the mandible due to the large unrestricted areas of soft tissue.
D) Hematoma is very rare following inferior alveolar nerve blocks because the venous plexus is located superior to the IA nerve.

Question 44

Which of the following muscles experiences trismus more frequently?

A) Medial pterygoid
B) Lateral pterygoid
C) Masseter
D) Buccinator

Question 45

Which of the following nerve blocks is most frequently associated with hematoma formation?

A) Inferior alveolar
B) Greater palatine
C) Gow-Gates
D) Posterior superior alveolar

Question 46

Three days after receiving an inferior alveolar block, a patient calls and complains that the numbness has not worn off and she is experiencing sharp pains in her lower jaw on the same side as the numbness. Which of the following describes what she is experiencing?

A) Paresthesia and dysesthesia
B) Persistent anesthesia and hypoesthesia
C) Paresthesia and anesthesia
D) Paresthesia and an idiosyncratic reaction

Question 47

Which of the following local anesthetic drugs is a concern for patients with atypical plasma cholinesterase?

A) Lidocaine
B) Prilocaine
C) Dyclonine hydrochloride
D) Benzocaine

Question 48

Which of the following local anesthetic drugs is safest to use in the case of a known family history of methemoglobinemia?

A) Benzocaine
B) Prilocaine
C) Tetracaine
D) Lidocaine

Question 49

The day after a dental hygiene procedure, a patient calls to report the right side of his mouth is sore and he is having difficulty opening. Which of the following should be recommended first?

A) Monitor for increased discomfort and call again if pain worsens
B) Open and close the mouth to regain flexibility of the muscles
C) Apply hot, moist towels for 20 minutes every hour
D) Recommend an analgesic for discomfort

Question 50

What is the correct dose of OraVerse following the administration of two cartridges of a local anesthetic drug?

A) Two cartridges or 0.8 mg
B) One cartridge or 1.8 mg
C) One-half cartridge or 0.8 mg
D) Two cartridges or 36 mg

Question 51

The recommended first step in paresthesia management is

A) Explain that most paresthesias resolve over time
B) Diagram the extent and degree of sensory deficit
C) Speak personally with and reassure the patient
D) Schedule an appointment to evaluate the paresthesia

Question 52

Which of the following injection technique errors can cause facial nerve paralysis following an IA nerve block?

A) Penetration into the medial pterygoid muscle
B) An overdose of anesthetic drug
C) Overinsertion into the capsule around the deep lobe of the parotid gland
D) Overinsertion into the capsule around the TMJ

Question 53

Allergies to topical anesthetic drugs that manifest in mucosal signs and symptoms hours or days after application:

A) Are usually an indication of allergy to amide type anesthetics and all amide drugs should be avoided in the future
B) Are considered delayed hypersensitivity reactions however the drug type should be avoided in the future
C) Have a high potential to progress to anaphylaxis
D) Usually occur due to secondary infections from needle penetrations

Question 54

During an inferior alveolar block, a patient makes a sudden movement in response to needle contact with bone. The needle bends and breaks off at the hub. The broken shank of the needle is visible. Which of the following is a recommended first response?

A) Gently remove the needle with gloved fingers
B) Contact an oral surgeon and transport the patient to the oral surgeon's office
C) Ask the patient to keep the mouth open and attempt to remove the needle with a hemostat
D) Take a radiograph to determine if the needle remains in contact with bone. If not, remove the needle with a sterile hemostat

Question 55

Which of the following local anesthetic complications occurs most frequently?

A) Overdose
B) Allergy
C) Idiosyncratic reaction
D) Dysesthesia

Question 56

Which of the following patient factors is not a predisposing factor in overdose reactions?

A) Allergy
B) Age
C) Disease status
D) Concomitant medications

Question 57

Which of the following initial signs and symptoms should alert the clinician to a potential overdose reaction?

A) Itching and hives
B) Tremors and seizures
C) Metallic taste and circumoral tingling/numbness
D) Visual hallucinations and confusion

Question 58

Which of the following signs and symptoms should alert the clinician to a potential vasoconstrictor overdose?

A) Intense anxiety and nausea
B) Bradycardia and hypotension
C) Itching and hives
D) Visual hallucinations and confusion

Question 59

A clinician has administered an injection for a restorative procedure. The patient immediately becomes anxious and restless, clutching his chest. The clinician reassures the patient in a calm voice after which the patient's breathing slows and he feels calmer. Which of the following describes what has likely occurred?

A) Local anesthetic overdose
B) Vasoconstrictor overdose
C) Hypersensitivity reaction to the sulfite preservative
D) Mild myocardial infarction

Question 60

A patient is experiencing initial signs and symptoms of a mild overdose of a local anesthetic drug. Which of the following correctly describes the next step?

A) Administer oxygen, then dismiss the patient and refer to a physician for follow-up evaluation
B) Administer oxygen and diazepam to prevent seizures
C) Adminsiter oxygen, then dismiss the patient and reschedule the appointment
D) Administer oxygen, observe, and monitor

Question 61

A patient is experiencing moderate signs and symptoms of an overdose of a local anesthetic drug and office emergency protocol has been activated. Which of the following correctly describes the next step?

A) Perform CPR
B) Reassure, observe, and monitor the patient
C) Administer oxygen
D) Administer diazepam to prevent seizures

Question 62

Which of the following is the correct response for the management of a severe systemic allergic reaction?

A) 100 mg oral Benadryl
B) 25 mg Benadryl IM
C) 0.3 mg epinephrine IM or subcutaneous
D) 1000 mg epinephrine IM or subcutaneous

Question 63

Which statement describes the best management protocol for a suspected idiosyncratic reaction to a local anesthetic drug?

A) Immediately stop procedures and transport the patient to ER
B) No response will be adequate because the reaction to treatment will be idiosyncratic
C) Respond appropriately to whatever signs and symptoms develop
D) Respond the same as for an existing overdose of a drug

Question 64

Which of the following is the most important consideration when preventing overdoses of local anesthetic drugs?

A) Calculating safe doses
B) Aspiration
C) Slow administration
D) Identifying allergies

Question 65

Which of the following is the most important precaution in order to avoid hematoma formation?

A) Avoid PSA nerve blocks because infiltrations are safer injections
B) Avoid using large gauge needles that are flexible and can unknowingly pierce vessels
C) Avoid multiple needle penetrations
D) Never inject before carefully assessing the anatomy in the area of the injection

Question 66

Avoiding PSA nerve blocks is a prudent practice

A) Because infiltrations are always much safer
B) For patients on anticoagulant therapy
C) For patients with diabetes
D) Because they require a high degree of clinical skill to administer without causing hematoma formation

Question 67

Explain the anatomical factors that limit the extent of hematoma formation.

Question 68

What are the first two protocols in the recognition and management of hematomas?

Question 69

Discuss possible causes of pain on injection.

Question 70

What strategies are effective for reducing the risk of tissue necrosis following injection?

Question 71

What guidelines are recommended in order to prevent local anesthetic overdose?

Question 72

A clinician administered a PSA injection with a short, 27 gauge needle, bent at the hub to improve access around the maxillary tuberosity. The penetration site was determined and the needle was inserted to the hub contacting bone. The patient quickly jerked his head causing breakage of the needle. The clinician attempted to remove the needle fragment, probing with a gloved finger and a sterile forceps without success. A radiograph was taken showing the needle against the posterior wall of the tuberosity. He explained to the patient that the needle could remain in place because the body would "wall off" the needle and it would not cause any problems, and that trying to remove the needle would cause unnecessary trauma.

-What needle choice and technique error(s), if any, was/were made prior to the injection?

Question 73

A clinician administered a PSA injection with a short, 27 gauge needle, bent at the hub to improve access around the maxillary tuberosity. The penetration site was determined and the needle was inserted to the hub contacting bone. The patient quickly jerked his head causing breakage of the needle. The clinician attempted to remove the needle fragment, probing with a gloved finger and a sterile forceps without success. A radiograph was taken showing the needle against the posterior wall of the tuberosity. He explained to the patient that the needle could remain in place because the body would "wall off" the needle and it would not cause any problems, and that trying to remove the needle would cause unnecessary trauma.

-What injection techniques errors, if any, were made during the injection?

Question 74

A clinician administered a PSA injection with a short, 27 gauge needle, bent at the hub to improve access around the maxillary tuberosity. The penetration site was determined and the needle was inserted to the hub contacting bone. The patient quickly jerked his head causing breakage of the needle. The clinician attempted to remove the needle fragment, probing with a gloved finger and a sterile forceps without success. A radiograph was taken showing the needle against the posterior wall of the tuberosity. He explained to the patient that the needle could remain in place because the body would "wall off" the needle and it would not cause any problems, and that trying to remove the needle would cause unnecessary trauma.

-Was the clinician correct in attempting to remove the needle? Why or why not?

Question 75

A clinician administered a PSA injection with a short, 27 gauge needle, bent at the hub to improve access around the maxillary tuberosity. The penetration site was determined and the needle was inserted to the hub contacting bone. The patient quickly jerked his head causing breakage of the needle. The clinician attempted to remove the needle fragment, probing with a gloved finger and a sterile forceps without success. A radiograph was taken showing the needle against the posterior wall of the tuberosity. He explained to the patient that the needle could remain in place because the body would "wall off" the needle and it would not cause any problems, and that trying to remove the needle would cause unnecessary trauma.

-Was the patient given adequate advice regarding the broken needle?

Question 76

A clinician administered an IA nerve block with a long, 25 gauge needle. Although no contact with bone was made, she was certain that the penetration depth was adequate because only 3 mm of the needle was visible. She confirmed negative aspiration in two planes and deposited one cartridge of 2% lidocaine with 1:100,000 epinephrine. After several minutes, the patient's teeth were not numb however the side of their face, including the lower eyelid, around the mouth and chin, were extremely numb.

-What was the most important technique error made by this clinician?

Question 77

A clinician administered an IA nerve block with a long, 25 gauge needle. Although no contact with bone was made, she was certain that the penetration depth was adequate because only 3 mm of the needle was visible. She confirmed negative aspiration in two planes and deposited one cartridge of 2% lidocaine with 1:100,000 epinephrine. After several minutes, the patient's teeth were not numb however the side of their face, including the lower eyelid, around the mouth and chin, were extremely numb.

-Why was the depth of insertion an indicator of a potential problem?

Question 78

A clinician administered an IA nerve block with a long, 25 gauge needle. Although no contact with bone was made, she was certain that the penetration depth was adequate because only 3 mm of the needle was visible. She confirmed negative aspiration in two planes and deposited one cartridge of 2% lidocaine with 1:100,000 epinephrine. After several minutes, the patient's teeth were not numb however the side of their face, including the lower eyelid, around the mouth and chin, were extremely numb.

-Describe the correct procedure to follow when bone is not contacted in an IA nerve block.

Question 79

A clinician administered an IA nerve block with a long, 25 gauge needle. Although no contact with bone was made, she was certain that the penetration depth was adequate because only 3 mm of the needle was visible. She confirmed negative aspiration in two planes and deposited one cartridge of 2% lidocaine with 1:100,000 epinephrine. After several minutes, the patient's teeth were not numb however the side of their face, including the lower eyelid, around the mouth and chin, were extremely numb.

-If bone is not contacted after repositioning the needle, what is the appropriate procedure?

Question 80

A clinician administered an IA nerve block with a long, 25 gauge needle. Although no contact with bone was made, she was certain that the penetration depth was adequate because only 3 mm of the needle was visible. She confirmed negative aspiration in two planes and deposited one cartridge of 2% lidocaine with 1:100,000 epinephrine. After several minutes, the patient's teeth were not numb however the side of their face, including the lower eyelid, around the mouth and chin, were extremely numb.

-What structure did the needle penetrate and what nerve was anesthetized causing anesthesia of the side of the face, the lower eyelid, and around the mouth and chin?