Local and general anesthesia. Indications and contraindications, principles of premedication, neuroleptanalgesia. Complications, their prevention and treatment. Basics of the cardiopulmonary resuscitation.
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Maxillofacial region takes nerve supply from motor, sensory and vegetative (sympathetic and parasympathetic) nerves.
Cranial nerves give innervation:
V (trigeminal),
VII (facial),
IX (glossopharyngeal),
X (vagus),
XII (hypoglossal),
I (olfactory) – sense of smell
Sensory nerves:
V ( trigeminal ),
IX (glossopharyngeal),
X (vagus), branches from cervical plexus (major auricular and minor occipital nerves).
Motor nuclei of the brainstem give nerve fibers to the jaw muscles
(V trigeminal), to mimic muscles (VII facial), to the muscles of palate and pharynx, (X vagus), to the muscles of the tongue
(XII – hypoglossal).
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Depicting of the tooth extraction is the favourite theme of the dutch artists in XVII century. It is noticed the absence of anesthesia during the operation and presence of highly interested spectators.
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DENTIST Jan Miense Molenar
(1610-1668)
DENTIST Jan Steen
(1626-1679)
Saint Apollonia –
Patroness of dentistry
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The appearance of the local anesthesia without going to Ancient times should be associated with discovering of Cocaine by Anrep (1880) and Coller (1884), and possibility of its injection with hollow needle, which had been provided by Wood (1853).
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Horace Wells and William Morton, the dentists, are appeared to be the founders of the narcosis. Wells was the first who used the nitrous monoxide (NO) for an anesthetization and tried it on himself in tooth extraction in 1844, and Morton used Aether for the same purpose in 1846. On the 16th of October narcotized the patient and american surgeon Wapren performed removing of the neck tumor.
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I. А. Nesmejanov: “Surgery owes anesthesia and her mother odontology
for its development and humanity".
CHRONOLOGY OF THE MOST IMPORTANT DISCOVERIES IN MEDICINE RELATED TO ANESTHESIA OF THE TEETH
1844 – anesthesia with nitrous monoxide in teeth extraction — Н. Well, USA.
1846 – anesthesia with Aether in teeth extraction — W. Т. С. Morton, USA.
1853 – development of hollow needle with skew tip — F. А. Wood, Scotland.
1853 – development of the syringe for subcutaneous injections - С. С. Pravaz, France.
1880 – discovery of the anesthetizing properties of Cocaine after subcutaneous injection or application –
V. К. Аnrep, Russia,
1884 – topical anesthesia with Cocaine at ophtalmological practice — К. Koller, Austria.
1884 – conduction anesthesia of the inferior alveolar nerve — W. S. Halsted, USA.
1884 – conduction anesthesia of the infraorbital nerve — Nash С. A., R. J.Hall, USA.
1885 – intrapulpal injection — Vosk, Germany.
1885 – topical anesthesia with Cocaine of the denuded pulp of the cuspid - Е. Н. Raynold, USA.
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1885 – infiltration anesthesia of the teeth — A. Woltler, H. Landerer, A. Witzel, Germany.
1891 - spongious /intraosteal/ anesthesia — Otte, Norway.
1901 – adding of epinephrine to the solution of the local anesthetic — Н. Braun, Germany.
1905 – sinthesis of Novocainum /Procainum/ — A. Einhorn, Sweden.
1906 – metal dental syringe — G. Fischer, Germany.
1907 – intraseptal anesthesia — R. Noque, USA.
1917 – dental syringe with disposable cartrige — Н. S. Cook, USA.
1940 – torusal anesthesia — М. М. Weisbrem, USSR.
1943 – sinthesis of Lidocaine — N. Lofgteti, Sweden.
1947 – electric stimulation of the teeth for evaluating efficiency of anesthesia — G. Bjorn, Sweden.
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Analgesia – removing of the painful sensations during medical procedures. �Аnesthesia – removing of all sensations (including pain) during medical procedures.
I. Genelal anesthesia - narcosis:
1.Inhalation
а) mask
б) nasopharingeal
в) endotracheal
2.Non-inhalation (often – injection)
а) intramuscle
б) intravenous
в) epidural
г) rectal
II. Local anesthesia
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The general anesthesia (narcosis) is a condition of the convertible inhibition of CNS is achieved by pharmacological agents, influence of physical or mental factors.
It assumes:
1. suppression of perception of pain stimulations,
2. achievement of neurovegetative blockade and a muscular relaxation.
3. deenergizing of consciousness,
4. maintenance of an adequate gas exchange and a circulation, a regulation of metabolic processes..
General anesthesia includes:
1. Inhalation narcosis.
2.NLA – neuroleptanalgesia.
3.Ataralgesia.
4.Central analgesia.
5.Audioanesthesia and hypnosis.
6.Electric narcosis.
7.Acupuncture, electric acupuncture.
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Neuroleptanalgesia (NLA) is loss of pain sensitivity, which is achieved due to rational cooperation of deep analgesia and neurolepsia by the introduction of analgesic and neuroleptic drugs. It is possible to be combined with local anesthesia and narcosis
Ataralgesia – sort of NLA, when ataraxia and analgesia are achieved by the introduction of tranquilizers and analgesics.
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Central analgesia is elimination of pain sensations due to introduction of great doses of analgetics.
Audioanestesia is based on stimulation of auditory analyzer by the certain frequency signal, which causes inhibition in other parts of brain cortex. It’s achieved by an influence of signal of an appropriate frequency range on the auditory analizer.
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Electric narcosis is provided with generation of sinusoid, pulsing and interferential electric current. In dental practice it is used an electric anesthesia of hard tissue of the teeth with INААN-1, ELOZ - 1, 2 facilities. The active lead is connected to the handpiece or excavator. The efficiency is vary.
Acupuncture: 116 active points among 693 are used to treat dental problems, mostly for the pain relief.
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Indications to a narcosis:
�Indications to a narcosis at outpatient basis��
General
Specific
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Contraindications:�
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Stages of a narcosis:�
1. Initial narcosis
2. Agitation
3. Surgical stage (2-3 phases is marked)
4. Awakening or terminal stage (death)
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Methods of the intubation of the trachea:�
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1. Direct intubation�2. Retrograde intubation
1. Under visual survey
2. Blind
3. Through the flexible conductor
4. Through the light conductor
Local:
1. Non injection
а) Chemical
b) Physical
2. Injection
а) Cocaine, Dicaine
Anaesthesine, Piromecaine, 10 % Lidocaine, Xilocaine;
b) Chlorethyl.
1. Synergistic
2. Non-synergistic
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METHODS OF LOCAL ANESTHESIA:
On maxilla
On mandible
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Central (subbasal) anesthesia)
At the round foramen (2rd branch of V cranial nerve)
At the oval foramen (3rd branch of V cranial nerve)
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Anesthesia destination and schematic position of the mail anatomic formations of the mandible�
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Topographic relations and landmarks
for local Gou-Geits anesthesia on mandible
Range of the fear and pain controlling in a cure of a dental patient
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Indications for the topical anesthesia:�
1. Anesthetization of the mucosa for the subsequent injection.
2. Removing of the superficial neoplasty of the mucosa.
3. Extraction of the loosened teeth.
4. Extraction of the decidui teeth.
5. Splinting.
6. Dressing, removing of the suture.
7. Biopsy.
8. Dissection of the mucosal “hood”.
9. Painfulness of the mucosa.
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Vegetative ganglions are located through the way of the branches of the trigeminal nerve:
1.ciliare (I branch)
2.pterygopalathial (II branch)
3.submandibular, sublingual and oticum – III branch.
Sympathetic nerves goes to the facial region from the upper sympathetic ganglion of the neck.
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Premedication – preoperative and preanesthetic preparation of the patient.
Aims of the premedication
1. The normalization of the general condition of the patient.
2. The creation of mental and emotional rest before operation.
3. Increasing local and general anesthesia action and its duration.
4. The prevention of undesirable reflex influences during operation
5. Reducing number of complications.
Potentiation (synergistic anesthesia, sedative premedication) – emphasizing of the local anesthesia. Has the same aims excluding the first one.
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Possible mechanisms of the action of local anesthetics:�
- Dissolving in the lipids of the nerve fiber it provokes the block of these nerve formations.
- Local anesthetics infiltrate into a nerve cell as uncharged anions then it dissociates to cations and blocks inner structure.
- It inhibits the dehydrase activity, sinthesis of macroergetic phosphoric compounds and activity of the respiratory enzymes.
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Infiltration anesthesia (direct and indirect):
-subperiosteal,
-apical,
-intraosseos,
-layer-by-layer,
-intraligament.
Conduction anesthesia (nerve block):
-peripherial,
-central (subbasal).
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Technique of the intraligament anesthesia
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Anesthetizing agents:
1.Novocaine (diethylamine ethanic aether of paraaminobenzoid acid). Sinthetized in 1905. Duration of the action 15 - 20 minutes. Dose of the infiltration is 1,25 then 2,5г / hour 0,25%. Quantity in mg: Х mg=%х ml х 10.
2.Тrimecaine (mesocaine). Complex aether. 2 times stronger and longer acting as novocaine. Infiltration up to 2 g.
3.Lidocaine (Хylodont). 2-3 times stronger and longer acting. 2 g 0,25 % 0,5 % - 400 ml
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4.Xylonest (prilocaine). Amide. 3 % 300 mg. With vasoconstrictor. Scandicaine, meaverine.
5.Mepivacaine (carbocaine, scandicaine) – amide compound, is similar to lidocane, but less toxic and acts weaker. Is used as 1 % - 3 % solution. 300 mg, maximum dosage is 3 % - 5,6 cartriges; 2 % with epinephrine - 8,3 cartriges.
6.Bupivacaine (marcaine) - amide drug. В 4-6 times more effective and more toxic as novocaine. Time of the action 12 hours. 0,25 % - 1 % solution - 175 mg.
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7. IV generation - amide, but the acting base is articaine. Combines low toxicity and strong action. Ultracaine 1-2 % (10-20 mg) D-S 40 mg and 0,006 of epinephrine D-S forte 40 mg and 0,012 of epinephrine. 5-6 times more effective as novocaine. It is restricted to adminiser i.v.
8.Septonest 4 %, Ubistesin.
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Instruments for a local anesthesia
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Syringe for the intraligament anesthesia
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Complications: �General.
1.Intoxication. Anesthetics are splitted by serum cholinesterase. Getting the anesthetic into blood results in exacerbation of liver, heart and kidney disease. Dizziness, headache, vomit, paresthesia, hasping and convulsion occure.
First aid: cordiamine 1-2 ml, glycosides (0,5 strophantine, corglicone), vit. C 2-5 ml.
In severe cases: i/v thiopental sodium, hexenal 2,0-10,0 5-10%, aminazine
4,0-5,0 2,5%, bemegride 3,0 - 10,0 0,5 %.
At heart rhythm disturbance - anapriline 1,0-2,00, 25%. At bradycardia - atropine 1-2, validol, izadrine 25 mg.
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2. Syncope - sudden short-time lost of conscience, which is caused by acute brain hypoxia. It is known 4 types:а. Brain syncope (caused by changing of arterial tone of the brain); b. heart syncope обморок (at the heart disease and pathology of the main blood vessels); c. reflecting syncope (caused by the pain and psycoemotional tension);d. hysteric syncope (arises in conflict situations at the presence of spectators, has a demonstrative pattern).
Treatment:
а. Put the patient into horizontal position, provide the inflow of the fresh air:
b. Inhalation of the ammonia spirit;
c. At long-time duration: i/v or i/m 1ml. 10% solution of cofeine sodium benzoate, if there is no any result - i/m 1ml. 5% solution of ephedrine or 1ml.1% solution of mesatone.
d. At the outcome from syncope dental manipulations should be continued with measures to avoid relapse.
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3. Collapse - severe depression of all life functions as a result of acute disorder of the circulation, caused by hypovolemia, heart failure and loss of function of blood vessels to regulate their tone and blood spreading.
Clinical manifestation:
а. Deterioration of the general condition;
b. paleness of the skin;
c. dizziness;
d. cold sweat; sudden fall of the AP;
e. Frequent and weak pulse;
f. tachy- and hypopnoe.
Treatment:
а. put the patient into horizontal pozition;
b. prednisolon 1-2 mg/kg of the body;
c. i/v isotonic solution, 5% solution of glucose no less then 500 ml., poliglukine, gelatinol;
d. At a positive effect - hospitalization.
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4. Anaphylactic shock – general severe allergic reaction of immediate type after drug administration.
Clinical forms:
1. Respiratory shock – asphyxia is prevailed caused by bronchial spasm or laryngeal spasm and larynx edema.
2. Skin shock is characterized by skin itch and nettle rush, Quincke’s edema, appearence of skin hyperemia on flexing surfaces of forearms and front wall of the chest.
3. Vascular shock, which circulation and neurologic disorders prevail at (in the first case clinical manifestations of myocardial infarction and edema of lungs, in the second – stroke or epilepsy).
4. Аbdominal shock is characterized by stomachache, vomiting and diarrhea.
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Principles of treatment, concrete actions:
Conducting of medicinal therapy, directed on recovery of circulation and respiration:
1. Halt introduction of medication, which has caused shock.
2. Put down and warm up (hot-water bottles to the hands and feet) a patient, fix a tongue to avoid asphyxia.
3. Unzip tight clothes.
4. Provide the influx of air to the patient.
5. Carry out symptomatic therapy.
6. If a condition of the patient gets worse do the closed heart compression and artificial respiration.
7. Make aspiration of sputum from respiratory tracts.
8. Quickly hospitalize a patient if he has a respiratory form.
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Ischemic heart failure is caused by disparity between oxygen consumption of myocardium and its transportation through the coronary vessels.
Clinical forms:
а. angina – sudden pain or other unpleasant sensations in the chest (weight, compression, burning etc.) , which is lasts from 2-5 to 20 miutes, accompanied with peculiar irradiation (left shoulder, neck , mandible, left shoulder-blade).
Treatment:
Stop the attack with nitroglicerine. If there is no any result - baralgine 5-10 ml. or analgine 50% - 2ml. i/v or i/m. In severe cases hospitalization is needed.
b. Myocardial infarction – ischemic necrosis of myocardium, which is caused by severe disparity between consumption of oxygen by myocardium and oxygen transport with coronal artery.
Treatment:
resting, stopping the intervention, influx of the fresh air, АP>=100- к 0,5 mg. of nitroglicerine under tougue, obligatory stopping of pain with i/m introducting of 1-2 2% promedolum, i/m tramadolum. Hospitalization is obligatory.
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Bronchial asthma is a chronic disease of airways, which is characterized with the presence of chronic inflammation in the wall of bronchial tubes, which stipulates its hyperactivity and is realized in attacks of bronchospasm, surplus secretion of bronchial mucus and paroxysmal cough.
Clinical presentation:
а. painful, dry cough with the increasing short breath;
b. Specific pose of patient - sitting with support of hands;
c. breathing is noisy, whistling;дыхание шумное, свистящее;
d. Skin is cyanotic;
e. Discharging great quantity of transparent, viscid sputum.
Treatment:
а. Inhalation of beta-adrenomimetics: orcipremamine (anulent, asthmolent, phenoterol etc. (don’t succeed 2 doses for 1 inhalation);
b. Provide an access of the fresh air;
c. Reflexotherapy with intense spot massage of jugular fossa, middle of the sternum and xyphoid process;
d. If treatment is uneffective and respiratory insufficiency is progressing call an emergeny.
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Local complications:
1. Skin burning
2. Diplopia
3. Functional paresis of mimic muscles
4. Injuring of the vessels with needle, hematoma
5. Injuring of the nerves (neuralgia, neuritis, paresthesia, paralysis)
6. Breaking of the needle
7. Injuring of an angle of mouth, lower lip
8. Development of a mattery process
9. Necrosis
10. Postinjection pulpitis, periodontitis
11. Dermatitis
12. Postinjection pain.
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Algorithm of the cardiopulmonary resuscitation
Competence of any doctor:
A. Airways
B. Breathing
C. Circulation
D. Drugs
Competence of resuscitation spesialists:
E. Electrocardiography
F. Fibrillation
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THANK YOU �FOR YOUR ATTENTION�
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