CPR Forth Year

1. X
Drug – related emergency

2. Metabolism of drugs
 Definitions : Toxicology, adverse drug
reactions ,
 Classification of A D Rs


Drugs used in dentistry & their ADR

over dose reactions in details

3. Metabolism of drugs
A given drug………..>circulation
 ……. Redistribution [ ex in skeletal ms]
…..biotransformed [=metabolism ,or
detoxication ….in liver ]
 Then excreted [….by kidney …]


5. Toxicology:
 Is the study of the harmful effects of
drugs on biological systems

Whenever a drug is given two types of
reactions may be noted : desirable…. &
undesirable [adverse drug reactions ADR]
 ADRs : adverse drug reactions …..are
the undesirable reactions when a drug is
given


6. Side effects
Over dose
Allergy
idiosyncrasy

7. Classification of A D Rs

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Oldly : side effects, intolerance ,drug induced disease…
Now
Based on effects ADR are divided into
effects as direct extension of drug action……
side effects………..I
overdose reactions……….II
effects result from altered patient
effects result from altered immune response
ex: allergy &………………………III
idiosyncrasy…………………….IV

8. I-side effects reactions
Are the undesirable effects of drugs that
occur when the drugs are given .
 Ex adrenaline……..bronchodilator

but …….palpitation


9. II- over dose reactions
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Definition
are reactions that result from toxic amounts of a
drug
many drugs can cause ….. over dose reactions ------->emergency in dentistry as ex :
Analgesic
Antibiotic
Anti anxiety
Local anesthetics………….. commonest

10. III-Drug allergy

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Definition :
It is a hypersensitive response to an allergen to which
the individual has been previously exposed to
It is seen clinically as
fever
Angioedema
Urticaria
Dermatitis
Blood elements depression
Photosensitivity
anaphylaxis

12. many drugs can cause ….. Drug allergic
reactions as

Penicillin

Aspirin

Latex

Bisulfites


13. NB:
 allergic reaction are not related to the dose
of the drug …[DD ..overdose reactions]
but to the immune system
 allergic reaction may appear similar for
the different drugs because they are
caused by the same mechanism


14. IV-idiosyncrasy
A unique strong hypersensitivity reaction
that belong …. To a particular drug in a
specific individual
 it Can’t be explained by allergy or over
dose..
 Clinically a wide range of manifestations
as depression…..& stimulation…….
 Ex a depressant [barbiturate…..]…..>>
stimulation


16. Drugs used in dentistry & their ADR
Common drugs are
 Local anesthetics
 Antibiotics
 Analgesics
 Anti anxiety drugs

17. Drugs used in dentistry & their ADR
ADR
Local ane
inject
…[AMIDE]
Local ane
topical
vasoconst
Side eff
Psych dis
-sedation
-Vasod sy
-hyperven
RARE
over
allergic idiosyn
dose
r
crasy
- CNS
extreme RARE
depres
RARE
-seizures
++
cns sti
+++++

18. ADR
Antibiot
Parent
oral
Analgesic
Nonopi
-aspirin
Side eff
-acetamin
Depr
opioids
+++
nausea
Vomit
++
over dose
Salicylism
+++
Depr CNS
allergic r
++++
penic
high allergic
l++++.Urtic,b
ron.sp
++++
++
CNS depres rare

19. ADR
Side eff
over dose
Antianxiety
cns
-barbitu Hange over depression
-nonbarb drowsiness cns
depression
allergic r
Uncommon
uncommon

20. II- over dose reactions in details
Definition
 are reactions that result from toxic amounts of a
drug






many drugs can cause ….. over dose reactions ------->emergency in dentistry as ex :
Analgesic
Antibiotic
Anti anxiety
Local anesthetics………….. Commonest

21. Local anesthetics
Are the most common drugs used in dentistry
 Types:




Chemically Local anesthesia are divided into :
a- amide type
like… lidocaine, mepivacaine …
these
produce overdose & side effects reactions
but rarely produce allergic reactions
b-ester type
Like benzocaine ,tetracaine procaine –procainamide
these are highly allergic

22. by method of administration local
anesthetics are divided into
 a-injectable

most injectable anesthetics are amide,
less are esters

so produce more overdose reactions
& less allergic


23. b- topical anesthetics

mostly of ester type

few are amide [as lidocaine which
contains preservative that produce allergy
… so allergy should be considered in all
topical local anesthetics


24. 
N B injectabe cartridges contain


1- local anesthetic [mostly amide ; less ester ]
2- other substances as

methylparaben [ bacteriostatic ,highly allergic
more in ester cartridges]

,,Na metabisulfite…antioxidant




25. Predisposing factor for ADR of Local
anesthetics
 A- patient factors:

distribution curve

age

sex

weight

Genetics

Attitude & environment


28. B- Drug factors
 route of administration
 Dose
 Rate of injection
 Site of injection
 Presence of vasoconstrictors


31. Causes of over dose react of local
anesth
Defective biotransformation &
 elimination
 Too large dose
 Rapid absorption of local anesth
administration tech


33. NB ADR of Local anesthetics [injectable] :
 Side effects : psychogenic effects as
vasodepressor syncope &
hyperventilation
 Overdose reactions :by relative overdose
not real overdose
 Allergic reactions : rare
 Idiosyncrasy : rare

34. S/S of overdose of local an
Rapid I V -- S/S within 5-10 min

if vasoc………in 30 min
 In small…moderate overdose there were:

CNS -excitation…….[no depression]

-….. confusion

-talkative 
- apprehension

-excited ness…………..


35. In high overdose

-generalized convulsions[ tonic &
clonic]

- followed by depression :
depressed blood pre….

-symptoms : headache, dizziness
,ringing in ears, drowsiness


36. Adverse d r of injectable local anesthesia see also topical local anesthesia

37. SYSTEMIC EFFECTS OF Local anesthetics:
 C V S ……. depress
 C N S …..excit….then depress…
 excitation [due to removal of cerebral
cortex inhibitory effects]……talkativeness
,tremors,..

depression[ respiratory depression

cardiovascular depression….]



38. management
in Mild overdose reactions
 R- recognize overdose reaction

onset is rapid in 5-10 min

talkative

anxiety

increased H R ,,BL P , resp
 T- terminate dental ttt
 p …..in comfortable position


39. A B C …..as needed
 D : definitive ttt

O2

monitor vital signs

give anticonvulsant if needed

medical assistance

permit recovery & discharge


40. in severe overdose reactions
 R- recognize the overdose reaction

onset is very rapid [appear during
injection or in seconds]

generalized seizures……>>>

loss of consciousness

T- terminate dental ttt
 p …..supine ……legs slightly elevated


41. A B C …..as needed
 D : definitive ttt

medical assistance

O2

monitor vital signs

IV anticonvulsant

post convulsive ttt [see postictus ttt]

permit recovery & discharge


43. Epinephrine overdose
Forms of Epinephrine or adrenalin …

with local anesth……..1:250,000

1: 50,000

local hemostasis……..

in gingival retraction cord … racemic
epinephrine………..


44. Clinic
 symptoms : Fear, anxiety, restlessness,
tremors, palpitation ,dizziness..
 signs: increased blood pressure

increased respiratory rate
 Managem

R :recognition of …..

T : terminate dental ttt

P :position :comfortable


45. A B C …..as needed
 D : definitive ttt

O2

vasodilators


46. CNS depressant overdose
Management
 R :recognition of …..
 T : terminate dental ttt
 P :position :comfortable
 A B C …..as needed
 D : definitive ttt
O2
monitor vital signs
In barbiturate overdose……
in benzodiazepine overdose…..

47. 
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NB
In barbiturate overdose……
continue P A B C management
In benzodiazepine overdose…..
give the specific antagonist …..>
flumazenil