12.13.18 Conference Summary

Supertrack Series: Dental Emergencies

Dr. Laura Throckmorton, PGY-1

Tooth Numbering System

Tooth Numbering System

Tooth Anatomy

Tooth Anatomy

  • Infections: all start with a cavity…

    • Pulpitis

      • Reversible (dental pain x seconds when eating hot/cold) vs Irreversible (infection of pulp, constantly painful)

      • Only painful for a full days because eventually have pulp necrosis, which kills the nerve

        • Treat: Pain management, dental referral, ?abx- might not be useful

    • Periapical abscess

      • Progression from pulpitis, formation of pus at tooth apices- difficult to see on exam

        • Treat: Pain management, dental referral, antibiotics if surrounding cellulitis or spread to surrounding teeth

    • Deep space infection

      • Progression from periapical abscess: accumulated pus perforates bone at thinnest point to periapical areas or deeper fascial spaces

      • Trismus, facial swelling, fever

        • Treat: admit, abx

  • Gingivitis -> periodontitis (loss of supportive bone structrue and detachment of periodontal ligament) -> periodontal abscess (red, fluctuant swelling of gingiva)

  • Pericoronitis: impaction of foot particles and organisms under gingival flap of partially erupted tooth

  • Ludwig’s Angina:

    • Most commonly infection of 2nd or 3rd mandibular molars

    • Infection and swelling of submandibular region- can also infect tongue, epiglottis, deep space infection -> mediastinitis

      • Treat: CT, abx (unasyn, clindamycin, PCN + flagyl), airway management

  • Dental Trauma

    • Fractures

      • Ellis Classes

        • 1: Enamel

        • 2: Dentin involvement: Risk of pulpitis = dental follow up same day

        • Pulp involvement

    • Tooth avulsion

      • Replace w/i 15 minutes = 98% chance of retention

      • Saline, milk, specific lesion

      • Don’t touch tooth root, rinse off contamination, needs splinting

        • Dentist within three days, no biting tooth for 7-10 days

    • Dry socket post extraction:

      • 2-4 days after

      • Pain, swelling, halitosis, empty socket, unpleasant taste

      • Ensure no oroantral fistula

      • Consider osteomyelitis

EBM: Primary Headache in the ED

Dr. Mark Bialas, PGY-4

  • Red Flags: acute onset, severe, focal neuro deficit, fever, neck pain

  • Who needs imaging: Red flags + HIV positive

  • Cluster and tension headaches respond to many of the same therapies as migraines

    • NSAIDs, triptans, anti-dopaminergic agent

  • Tension Headaches:

    • NSAIDs work best, also can respond to migraine meds

    • Metoclopramide vs Ketorolac: Metoclopramide worked better: Annals 2013

      • Many patient’s developed migraine features

      • Tension headache rarely needs ED care

  • Cluster:

    • Always unilateral + should have autonomic symptoms

    • Occur multiple times per day or week

    • Treatment: 100% oxygen first

      • High flow oxygen vs room air, 2009

        • 78% vs 20% had pain control with oxygen

      • subQ sumatriptan can also help

    • Can be on verapamil as outpatient to reduce freqency

  • Migraines

    • Most commonly treated headache in the ED

    • Treatment:

      • Antidopaminergic agents:

        • Effective for pain and GI symptoms

        • Consider redosing for pain relief before moving to second line treatments

        • Metoclopramide vs compazine

          • Annals 1995: 10 mg metoclopramide vs 10 mg compazine vs placebo: Compazine out performed metoclopramide

          • Three studies: at equal doses, compazine was better. With 20 mg metoclopramide, effects about equal

        • Give benadryl or not?

          • Annals 2016

            • Metoclopramide Akathisia: 5% in diphenhydramine group, 8% in placebo group- not significant

          • Compazine

            • absolute reduction in akathasia with diphenhydramine was 22%

      • Haldol?

        • Similar in efficacy to metoclopramide

      • NSAIDs

        • Limited data with ketorolac in headaches

      • Triptan

        • NNT 2.5

        • NNH (chest pain, flushing: 4

        • Better in patients that are known to respond

        • Anti-dopaminergics work better in the ED in studies

    • Second line treatment:

      • Propofol and ketamine

        • Some evidence for acute relief

        • Propofol: 30-40 mg IV with 10 mg-20 mg boluses q3-5 minutes up to 13- mg

        • Ketamine 0.1 mg/kg per dose

      • Magnesium

        • Has not shown consistent benefit in headache

        • Dex/metoclopramide vs Magnesium (1g)

          • Magnesium outperformed dex with metoclopramide

      • Opioids

        • Overuse headaches, repeat visits, poor pain control

      • Dexamethasone

        • Lower headache recurrence rates within 72 hours post discharge

      • DHE

        • Potent vasoconstrictor and 5-HT receptor agonist

        • Inferior to sumatriptan in trials

      • Nerve blocks

        • Greater occipital nerve blocks vs placebo

        • Nerve blocks better than placebo, addition of steroids did not help with pain reduction

Toxicology Series: Stimulants

Dr. Zeinab Shafie, PGY-1

  • 35 yo female, agitated, presented with chest pain. Hyperthermic to 40, tachycardic 120s, hypertension

    • Differential: sepsis, meningitis, sympathomimetic, antcholingeric, ASA, thyrotoxicosis, heat illness, NMS, pheochromocytoma

  • Cocaine:

    • HUGE public health concern, 40% of ED visits related to drugs of abuse are cocaine

  • Sympathomimetic Toxidrome

    • Diaphoresis differentiates from anticholinergic (“dry as a bone”)

    • MOA: Cocaine inhibits reuptake receptor of epinephrine, norepinephrine

  • ABCs

    • Use nondepolarizing agent for intubation induction

  • Crack: Can cause intraoral burns

  • Crack lung: Diffuse alveolar damage

  • Pneumothorax, pneumomediastinum from valsalva when snorting and not exhaling

  • Cardiovascular:

    • Sympthatic stimulation = vasospasm, vasoconstriction

    • Can cause MI’s if old lesion vs vasospams

    • Heart failure (neg ionotropic effect)

    • Treatment: Benzos + treat ischemia

    • HTN: benzos, CCB (does not address heart rate), nitroglycerin, phentolamine (increase HR)

      • REMEMBER: HTN is self limited- they will crash and can be hypotensive

    • Arrhythmias

      • Sinus tachycardia, atrial tachycardia, a fib, prolonged QT

      • Supportive care

    • GI:

      • Body packer (purposely in orifice) vs stuffer (in GI tract after swallowing, less protected packages)

      • Ultrasound or x-ray to look for the packets

      • Asymptomatic = NG tube with polyethylene glycol

    • CNS:

      • Agitation -> hyperthermia

        • Mortality up to 33%

      • Seizures, coma, headache, stroke, anterior cord syndrome (rare)

      • Supportive care, benzos

    • Pregnancy:

      • Placental abruption, effect fetal development

  • Levamisole: cutting agent

    • Cattle dewormer, can cause agranulocytosis, leukoencephalopathy, severe cutaneous vasculitis/necrosis

      • Check a CBC

  • Dispo:

    • Observe to baseline function (6-8 hours)

  • Cocaine induced chest pain:

    • Serial troponins, definitely while symptomatic

    • Take age, other risk factors into account

CPC (Clinicopathological Conference)

Dr. Nik Sekoulopoulos, PGY-2 vs Dr. Matthew Stull

Case: Young female with abdominal pain, nausea, vomiting, headache for 90 minutes originally discharged home with symptom control. Came back with confusion, ataxia, headache, vomiting, epigastric pain radiating to her chest.


  • Vascular: Migraine (complex), ICH, infarct, dissection, central venous thrombosis, seizures

  • Infectious: Meningitis/encephalitis, CJD, syphilis, sepsis (cholecystitis, colitis, pancreatitis, perforated ulcer, other sources)

  • Trauma: intimate partner violence

  • Autoimmune: Demyelinating disease (MS, ADEM, Miller-Fisher Syndrome)

  • Metabolic: Electrolytes (calcium, ammonia), pheochromocytoma, hypo/hyperthyroidism, adrenal insufficiency, vitamin deficiencies

  • Iatrogenic: intoxication, ingestion (toluene, phenytoin, CO poisoning)

  • Neoplastic: intracranial mass, neuroendocrine tumor, carcinoid

  • Congenital/Anatomic: hereditary ataxias

Test of choice: Carbon Monoxide

  • Carbon Monoxide Poisoning:

    • Left shift of oxygen curve, uncouple oxidative phosphyloration

    • Symptoms: headache, visual disturbances, vomiting, confusion, ataxia, tachypnea, seizure, syncope, retinal hemorrhages

    • Indications for hyperbaric oxygen: Syncope, AMS, focal neuro deficit, elevated troponin/ischemia, cardiogenic shock

    • CPAP vs NRB: CPAP can correct faster in one study

Ocular Ultrasound

Dr. Jason Tehranisa

Retinal Detachment courtesy of ALIEM.com

Retinal Detachment courtesy of ALIEM.com

  • Eye anatomy: anterior chamber, lens, optic nerve, optic disc, macula, retina, vitreous

  • Ocular scanning:

    • Linear probe

    • Cover eye with tegaderm, lots of gel

    • Hold probe like a pencil, stabilize hand on nasal bridge and/or forehead

    • Can try to see pupil constrict using consensual pupillary constriction

    • Open globe- realistically, don’t try. IF you need to, cool gel and NO pressure on eye

    • Optic nerve

      • 2018 study N = 35

        • optic nerve sheath diameter in patient’s with HACE

          • Good correlation vs CT scans

      • Nerve sheath diameter at 4.8 mm = ICP of 20

      • Think about increased ICP at 5 but correlate clinically, >6 = increased ICP

      • Measuring: Optic nerve maximum width all the way down, measure at its widest point

    • Retinal Detachment

      • ED diagnostic accuracy of retinal detachment demonstrated sensitivity 97-100%, specificity 83-100%

        • Studies were not blinded, were ultrasound trained docs

      • Studies in 2018 with all ED physicians (not specifically trained)

        • Sensitivity 75%, specificity 94%

      • Macula detachment

        • Temporal location

          • lateral to optic nerve

        • Macula on vs macula off

        • Need more emergent surgery with macula on

    • Vitreous detachment

      • Turn your gain up

      • At risk for retinal detachment

      • Not anchored like a retinal detachment

    • Vitreous Hemorrhage

      • Extravasation of blood into the vitresous cavity

      • mechanical force, sickle cell

    • Lens dislocation

      • See lens in globe and nothing underneath anterior chamber

VP Shunt Management

Dr. Yifei Duan

  • Shunt failure rate

    • 14-20% failure rate in the first month

    • 40-50% failure rate within 1-2 years of implantation

      • mechanical obstruction, infection (less likely after 6 months), disconnection, distal malfunction, overdrainage/slit ventricle syndrome

    • 50-60% of shunts will require at least 1 revision

  • Work up for shunt failure

    • Figure out the reason for the shunt (ie congenital hydrocephalus (fails fast), NPH, idiopathic intracranial hypertension

    • Presentation: insidious onset vs rapidly unstable patient, mental status change + headache, nausea/vomiting, diplopia/CN6 palsy, seizures

    • ABCs, CT/rapid T2 MRI, shunt series

      • Review previous imaging- sometimes a kink is not a kink if it is always there

      • Look for asymmetry in ventricles, tonsillar crowding at foramen magnum

    • As a congenital hydrocephalus person grows, they can get shunt fractures by outgrowing their shunt

    • Look for loculated fluid near shunt in belly- usually an abscess with distal failure

    • Adjustable valves have a clockface

    • Shunt tap: when to do?:

      • Suspect infection- easy CSF because lumbar puncture only works with communicating hydrocephalus (ie pseudotumor, NPH)

      • Can help relieve pressure quickly

Leah Carter