DH 410 Emergencies in Dental Practice

Drug Overdose and Toxicity Overview

• Major focus on actions of CNS stimulants and depressants, their toxicities, and treatment.
• Recognition of signs and symptoms of common drug abuse and overdose.

CNS Stimulants

• Amphetamines

  • Act as central nervous system stimulants.
  • Examples include Ritalin, Adderall, Phentermine, and Methamphetamine.
  • Trigger sympathetic nervous system, leading to increased heart rate, pupil dilation, and reduced digestion.
  • Prevent reuptake of excitatory neurotransmitters, causing a constant state of excitation.

• Signs and Symptoms of Amphetamine Toxicity

  • Euphoria, restlessness, talkativeness, anxiety, and agitation.
  • Physical symptoms include tachycardia, hypertension, chest pains, heart palpitations, and possible coma or myocardial infarction (MI).
  • Associated clinical signs include "meth mouth" and rampant caries.

• Cocaine

  • A potent CNS stimulant and vasoconstrictor, also used as a local anesthetic.
  • Functions as a dopamine reuptake inhibitor, producing euphoria.

• Signs and Symptoms of Cocaine Toxicity

  • Symptoms include anxiety, agitation, hyperthermia, seizures, and hallucinations.
  • Additional physical symptoms involve tachycardia, chest pain, hypertension, ventricular fibrillation, and potential cerebrovascular accidents (CVA).

Emergency Management of Amphetamine & Cocaine Toxicity

• Urgent actions include contacting EMS, positioning patient for comfort, and monitoring vital signs.
• Follow C-A-B guidelines (Circulation, Airway, Breathing) as necessary.
• Benzodiazepines may be administered by trained professionals.
• Cooling the patient's skin with lukewarm water and air fans is recommended.
• Avoid the use of emetics, as this may induce seizures.

CNS Depressants

• Opioids

  • Derived from the opium poppy, with natural sources like morphine and codeine, and synthetic drugs such as heroin and fentanyl.
  • Can be taken orally, smoked, or injected.

• Mechanism of Action of Opioids

  • Bind to specific opioid receptors in the CNS and spinal cord, resulting in sedation, euphoria, and pain reduction.
  • Inhibit gastrointestinal motility, leading to constipation.

• Signs and Symptoms of Opioid Toxicity

  • Present with lethargy, pupil constriction, shallow breathing, hypotension, bradycardia, and flaccid muscles.
  • Severe overdose can lead to coma, respiratory depression, and death.

• Benzodiazepines

  • Primarily used to treat anxiety, seizures, and muscle spasms.
  • Administered orally or via IM/IV routes (e.g., Valium, Xanax, Ativan).
  • Enhance the action of the inhibitory neurotransmitter GABA in the CNS.

• Signs and Symptoms of Benzodiazepine Toxicity

  • Lethargy, slurred speech, ataxia, mental confusion, and potential for coma or respiratory arrest.

Skin Anatomy

• Epidermis: Composed of keratinized squamous epithelium, avascular in nature.
• Dermis: Dense, fibro-elastic tissue that is highly vascularized; primarily made of fibroblasts which produce collagen and elastin.
• Subcutaneous Layer: Connects the dermis to underlying tissues, containing varying amounts of adipose tissue.

Wound Healing Stages

• Hemostasis: Initial stage to stop bleeding.
• Inflammation: Removes debris and bacteria; prolonged inflammation can lead to poor healing.
• Epithelialization: Occurs within 24-48 hours in sutured wounds; impeded by eschar and debris.
• Fibroplasia: Begins on the fourth day with fibroblasts synthesizing collagen, forming initial scar tissue.
• Contraction: Skin edges move towards the center of the wound, influenced by surrounding muscle.
• Scar Maturation: Scar strength increases rapidly from days 5-17, and continues to remodel for up to 2 years, never fully reaching original skin strength.

Wound Evaluation - History

• Identify factors affecting healing and risk of infection, including:
  • Mechanism and time of injury, environment, potential contaminants, animal species in bites, and patient's medical history.
• Assess tetanus immunization status and consider handedness or vocation.

Wound Infection Risk Factors

• Risk factors include older age, diabetes, width of laceration, and presence of foreign bodies.

Specific Wounds – Face

• Facial wounds are less prone to infection due to high vascularity.
• Debridement should be minimal to maintain facial contours.
• Aggressive layered closure is recommended for facial wounds.

Specific Wounds - Lips

• Anatomy: Includes skin, vermilion border, vermilion, oral mucosa, and obicularis oris.
• Always inspect lip wounds intraorally for foreign bodies like teeth fragments.
• For lacerations through the vermilion border:
  • Use traction for alignment before stitching, starting at the vermilion border.
  • Repair the orbicularis oris and then the skin.
• Through and through lacerations require a three-layer closure:
  • Mucosal layer (rapidly absorbable suture).
  • Orbicularis oris.
  • Skin layer.

Specific Wounds – Intraoral

• Normal irrigation practices apply.
• Lacerations of the buccal mucosa and gingiva may heal without repair if edges are not widely separated.

This quiz covers the recognition and treatment of drug overdose and toxicity in dental practice, focusing on CNS stimulants and depressants. It emphasizes the signs and symptoms of toxicity from commonly abused drugs, and appropriate treatment modalities for affected patients.