Local anesthetic complication

[Aloha Kid]

Saw an interesting case in the ED. A normal guy prior to dental procedure was sent in from the dental clinic after complications of local bupivicaine w/ epi injection. Apparently a R inferior alveolar N block was in the process when the guy suddenly felt his throat closing off, difficulty controlling secretions, dizziness, and hoarseness (couldn't speak). By the time he arrived to the ED, he was improved with no further symptoms except hoarseness of his voice which also resolved. No treatment was given to him at that point. On exam he had no solid evidence of allergic reaction or anaphylaxis. But he did have a R sided tongue deviation, and poor palatal elevation on the R.

The dentist was thinking anaphylaxis, medication reaction. The ED was thinking stroke. What do you guys think? Can you have CN 9/10/11 compications with local anesthetic OR is this more likely stroke?

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[aphistis]

Saw an interesting case in the ED. A normal guy prior to dental procedure was sent in from the dental clinic after complications of local bupivicaine w/ epi injection. Apparently a R inferior alveolar N block was in the process when the guy suddenly felt his throat closing off, difficulty controlling secretions, dizziness, and hoarseness (couldn't speak). By the time he arrived to the ED, he was improved with no further symptoms except hoarseness of his voice which also resolved. No treatment was given to him at that point. On exam he had no solid evidence of allergic reaction or anaphylaxis. But he did have a R sided tongue deviation, and poor palatal elevation on the R.

The dentist was thinking anaphylaxis, medication reaction. The ED was thinking stroke. What do you guys think? Can you have CN 9/10/11 compications with local anesthetic OR is this more likely stroke?

Lacking more complete information about the patient, I'd favor CVA/TIA over drug allergy. True anaphylactic reactions to amide local anesthetics are incredibly rare, and it still wouldn't explain the motor deficits. You're also nowhere near CN 9, 10, or 12 (CN 11 is spinal accessory; hypoglossal is 12) on inferior alveolar blocks. The whole picture just doesn't fit together very well for the injection to have directly caused all those problems.

On the other hand, you can always just cross your fingers and wait 8-12 hours to see if the symptoms resolve when the block wears off.

 

[OceanDMD]

Saw an interesting case in the ED. A normal guy prior to dental procedure was sent in from the dental clinic after complications of local bupivicaine w/ epi injection. Apparently a R inferior alveolar N block was in the process when the guy suddenly felt his throat closing off, difficulty controlling secretions, dizziness, and hoarseness (couldn't speak). By the time he arrived to the ED, he was improved with no further symptoms except hoarseness of his voice which also resolved. No treatment was given to him at that point. On exam he had no solid evidence of allergic reaction or anaphylaxis. But he did have a R sided tongue deviation, and poor palatal elevation on the R.

The dentist was thinking anaphylaxis, medication reaction. The ED was thinking stroke. What do you guys think? Can you have CN 9/10/11 compications with local anesthetic OR is this more likely stroke?

I had a hygienist who was giving an IA injection with a long 27 gauge needle inject and angle too medial (basically she was angled from the lower incisors rather than the premolars. Same type of complication, exactly. After talking with our OMFS who was in the same building, we felt it likey to be a accidental block of the glossopharyngeal nerve (based on the depth and needle angle. I think that CN IX--its been a while--which gives sensation to the pharynx. 10 and 11 are right there as well. With that pharynx feeling funny, patients often mistake it with the inability to breath, swallow, and tend to freak out. Dizziness and secretion control is likely related to the anxiety involved(or maybe some anesthetic nipped the vagus?). The tongue may have resulted from a partial block in CN 12 which courses behind the mandible. Sounds like a screwed up IA block.

That same hygienist may be doing simple extractions soon....

 

[shamrock2006]

Yea that's definitely interesting. And right, you arent terribly close CN 9, 10, or 12. However, w/ an IAN block you are close to PNS branches of CN 9 (lesser petrosal nerve to the parotid gland) and CN 7 (chorda tympani running w/ lingual nerve to submandibular/sublingual glands). So somehow messing w/ those could have contributed to difficultly controlling secretions. The rest...i dunno, i'm on spring break so its not my job to think of anything other than biochem and physio

 

[shabu2]

I had a hygienist who was giving an IA injection with a long 27 gauge needle inject and angle too medial (basically she was angled from the lower incisors rather than the premolars. Same type of complication, exactly. After talking with our OMFS who was in the same building, we felt it likey to be a accidental block of the glossopharyngeal nerve (based on the depth and needle angle. I think that CN IX--its been a while--which gives sensation to the pharynx. 10 and 11 are right there as well. With that pharynx feeling funny, patients often mistake it with the inability to breath, swallow, and tend to freak out. Dizziness and secretion control is likely related to the anxiety involved(or maybe some anesthetic nipped the vagus?). The tongue may have resulted from a partial block in CN 12 which courses behind the mandible. Sounds like a screwed up IA block.

That same hygienist may be doing simple extractions soon....

No possible way to hit CN 9 from a IAN Block. unless you injected medial of the raphae and into the root of the tongue. The innervation to pharynx comes from inferior to superior. My vote goes for something CNS, not from block.

 

[QCkid]

Saw an interesting case in the ED. A normal guy prior to dental procedure was sent in from the dental clinic after complications of local bupivicaine w/ epi injection. Apparently a R inferior alveolar N block was in the process when the guy suddenly felt his throat closing off, difficulty controlling secretions, dizziness, and hoarseness (couldn't speak). By the time he arrived to the ED, he was improved with no further symptoms except hoarseness of his voice which also resolved. No treatment was given to him at that point. On exam he had no solid evidence of allergic reaction or anaphylaxis. But he did have a R sided tongue deviation, and poor palatal elevation on the R.

The dentist was thinking anaphylaxis, medication reaction. The ED was thinking stroke. What do you guys think? Can you have CN 9/10/11 compications with local anesthetic OR is this more likely stroke?

This could simply be a little anasthesia squirting into the mouth and running down the throat coupled with some phsycogenic reaction. The genioglossal and levator muscle weakness would tend to indicate somethng more going on.

 

[BuckeyMcGee]

Signs of a stroke, most likely a stroke resulting from an allergic RXN due to local bupivicaine. Remember, no one is actually allergic to epinephrine, atleast very, very few are...

 

[Aloha Kid]

Neurology was consulted on the case. They felt is was an anesthetic induced complication. The rightward deviation of the tongue they felt was not a weakness but lack of position sense due to anesthesia. The R sided palatal weakness was also attributed to anesthesia since there was gradual improvement overnight and resolution in the AM. One interesting point was made for accidental intrarterial injection leading to epinephrine induced vasoconstriction of select arteries leading to transient ischemia of the involved nerves. Case reports have talked about ipsilateral blindness, palatal ischemia, etc. Aspiration isn't always 100% preventive.

 

[aphistis]

Signs of a stroke, most likely a stroke resulting from an allergic RXN due to local bupivicaine. Remember, no one is actually allergic to epinephrine, atleast very, very few are...

Stroke secondary to anaphylactic amide anesthetic allergy? That'd be a case to get published, but I think it's kind of a long shot here.

 

[aphistis]

Neurology was consulted on the case. They felt is was an anesthetic induced complication. The rightward deviation of the tongue they felt was not a weakness but lack of position sense due to anesthesia. The R sided palatal weakness was also attributed to anesthesia since there was gradual improvement overnight and resolution in the AM. One interesting point was made for accidental intrarterial injection leading to epinephrine induced vasoconstriction of select arteries leading to transient ischemia of the involved nerves. Case reports have talked about ipsilateral blindness, palatal ischemia, etc. Aspiration isn't always 100% preventive.

Interesting consult report. Bupivicaine is a pretty weak (1:200k) epi solution to begin with, and the distribution of the neural deficit doesn't correspond to any single vessels (unless the dentist was using the external carotid approach to the IANB ).

However it arose, I'm glad the patient turned out OK.

 

[Bifid Uvula]

The symptoms are pretty consistant with...

Imagine a patient swallowing a good amount of topical anesthetic, and possibly swallowing some local anesthetic. Couple this with a Mandibular Block that not only nailed the IAN and Lingual Nerve but also the Mylohyoid Nerve. Then imagine a needle that has gone too far posterior/medial into the pharyngeal muscles and you've got one "numb" patient that is freaking out.

They feel they can't swallow, they think their throat is swollen, they can't feel their tongue, they can't feel the right floor of mouth etc...

You are nowhere near XI and better not be near IX or X...

 

[QCkid]

The symptoms are pretty consistant with...

Imagine a patient swallowing a good amount of topical anesthetic, and possibly swallowing some local anesthetic. Couple this with a Mandibular Block that not only nailed the IAN and Lingual Nerve but also the Mylohyoid Nerve. Then imagine a needle that has gone too far posterior/medial into the pharyngeal muscles and you've got one "numb" patient that is freaking out.

They feel they can't swallow, they think their throat is swollen, they can't feel their tongue, they can't feel the right floor of mouth etc...

You are nowhere near XI and better not be near IX or X...

Thats basically what I was trying to say. Thanks for filling in the blanks.

 

[SuperC]

Thinking outside the box...

I wonder if the pt were older on an ACE inhibitor. We have been told that strange hypersensitivity rxns can be associated with long term use of ACEi's.
-C

 

[BuckeyMcGee]

Are you referring to ACE inhbitor induced angioedema? This is rather extremley rare and found most among blacks. The reaction would be noted early on when the patient began medication if present at all and would likely not be a result of any complications due to LA. The hypersensitivity reactions aren't necessarily "strange", they've been well researched and there is a considerable amount of literature on this subject.

 

[li1p0ptart]

Signs of a stroke, most likely a stroke resulting from an allergic RXN due to local bupivicaine. Remember, no one is actually allergic to epinephrine, atleast very, very few are...

if you're allergic to epinephrine you're pretty much not alive..

And it would be more likely an allergy to the sodium bisulfite than to bupivicaine. but obviously that wasn't it, nor would it be likely to lead to a stroke as already stated.

 

[BuckeyMcGee]

if you're allergic to epinephrine you're pretty much not alive..

And it would be more likely an allergy to the sodium bisulfite than to bupivicaine. but obviously that wasn't it, nor would it be likely to lead to a stroke as already stated.

You are correct, however there are some (very few) that are actually allergic to epinephrine, and they die early on, . The allergic reaction could possibly lead to stroke...anything is possible, remember that, .