12.13.18 Conference Summary

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

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

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  • 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.

Differential:

  • 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

Radiograph_of_a_ventriculoperitoneal_shunt.jpg
  • 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