DAANCE Office Anesthesia Emergencies 5 — Questions and Answers
Question 1: A patient sedated with midazolam and fentanyl has a Glasgow Coma Scale score of 8. The dental anesthesia assistant should FIRST:
- Administer flumazenil 0.2 mg IV
- Open the airway and apply supplemental oxygen (Correct answer)
- Insert a laryngeal mask airway
- Call 911 and wait for EMS
Correct answer: Open the airway and apply supplemental oxygen
A GCS of 8 indicates severe altered consciousness; the immediate priority is airway management and oxygenation before any pharmacological reversal.
Question 2: Which sign BEST distinguishes laryngospasm from simple airway obstruction due to soft tissue in a sedated patient?
- Paradoxical chest and abdominal movement with no air movement despite ventilation attempts (Correct answer)
- Snoring respirations that resolve with jaw thrust
- SpO2 of 93% on room air
- An end-tidal CO2 of 35 mmHg
Correct answer: Paradoxical chest and abdominal movement with no air movement despite ventilation attempts
Laryngospasm produces paradoxical chest and abdominal movements (see-saw pattern) and complete resistance to positive-pressure ventilation, distinguishing it from partial soft-tissue obstruction.
Question 3: Which medication is the definitive treatment for laryngospasm that fails to resolve with CPAP and positive-pressure ventilation?
- Epinephrine 0.3 mg IM
- Succinylcholine 0.1–0.2 mg/kg IV (Correct answer)
- Naloxone 0.4 mg IV
- Atropine 0.5 mg IV
Correct answer: Succinylcholine 0.1–0.2 mg/kg IV
A small dose of succinylcholine (0.1–0.2 mg/kg IV) is used to break laryngospasm that does not respond to airway maneuvers and CPAP.
Question 4: A patient with a known sulfa allergy is scheduled for IV sedation. Which drug should be avoided due to potential cross-reactivity?
- Midazolam
- Propofol (Correct answer)
- Ketamine
- Nitrous oxide
Correct answer: Propofol
Propofol contains a sulfite preservative in some formulations and has a para-aminobenzoic acid (PABA) component; it is generally avoided in patients with sulfa or egg/soy allergies.
Question 5: During moderate sedation monitoring, a patient's blood pressure drops from 130/80 to 78/50 mmHg after IV midazolam and fentanyl. The BEST immediate intervention is:
- Administer phenylephrine 100 mcg IV push
- Place patient in Trendelenburg, administer IV fluid bolus, and reduce further sedation agents (Correct answer)
- Give epinephrine 1:10,000 IV
- Administer atropine 0.5 mg IV
Correct answer: Place patient in Trendelenburg, administer IV fluid bolus, and reduce further sedation agents
Mild-to-moderate sedation-related hypotension is first managed with positioning, IV fluid bolus, and stopping further sedative administration before vasopressors.
Question 6: An adult patient in the dental office develops a tonic-clonic seizure with no prior history of epilepsy. Which drug is the MOST likely precipitant in the setting of local anesthetic injection?
- Lidocaine toxicity causing CNS excitation (Correct answer)
- Midazolam paradoxical reaction
- Nitroglycerin-induced vasodilation
- Atropine-induced dysrhythmia
Correct answer: Lidocaine toxicity causing CNS excitation
High plasma levels of lidocaine cause CNS toxicity with initial excitation (seizures, tinnitus) before CNS depression, often due to intravascular injection.
Question 7: When using an AED on a patient in cardiac arrest during office-based anesthesia, the anesthesia assistant should ensure:
- The patient is on a wet floor to improve conductance
- All personnel stand clear and no one is touching the patient before delivering the shock (Correct answer)
- CPR continues without interruption while the shock is delivered
- The AED pads are placed only in the anterior-posterior position
Correct answer: All personnel stand clear and no one is touching the patient before delivering the shock
All personnel must stand clear and avoid contact with the patient before AED shock delivery to prevent inadvertent current transmission.
DAANCE Office Anesthesia Emergencies 5
A patient sedated with midazolam and fentanyl has a Glasgow Coma Scale score of 8.
The dental anesthesia assistant should FIRST: