Trauma Tooth-day!

 ·   · 

I know lame pun... But today lets talk dental trauma. Why? Because while we don't see it often it is ALWAYS on boards and inservice, so lets review the simple stuff we need to know. ( Highlighted stuff is the most commonly seen exam questions!)

A tooth:
  • Pulp- vascular, that makes it red/pink colored. If exposed can be painful
  • Dentin- Makes up the bulk of the tooth, yellow colored
  • Enamel- Outer visible layer, white colored (mostly)
Primary teeth- 20 teeth by age 3, lettered not numbered, don't worry about that..
Permanent teeth- 32 in total and should be there between 6-13 years old
Traumatic Injuries:
  • Fracture/Ellis Classification: Remember anatomy from above and think white/yellow/red!
    • Type 1: Supportive care ie pain control soft diet, refer to dentist
    • Type 2: Risk of pulpal necrosis, treat with sealant such as calcium hydroxide and 24 hrs follow up!
    • Type 3: Consider urgent dental consult, pain control and if no dental available at minimum cover with calcium hydroxide and if available glass ionomer. Pt needs URGENT follow up as high risk of abscess and pulp necrosis
  • Luxation:
    • Partial displacement from socket and can involve periodontal ligament and alveolar bone
    • TRX: Dental consult for splinting!
  • Intrusion:
    • Apical displacement into bone- tooth will look shorter or missing
    • GET XRAY!
      • If >3mm tooth needs to be repositioned by DENTAL!
  • Avulsion:
    • Time is tooth- each minute out viability decrease by 1%!!!
      • Best survival if implanted within 15-30min
      • Don't worry if pt is less than 6yrs old
    • Handle only the crown, rinse with sterile saline or tap water for max 10s
      • Irrigate the socket and remove any accumulated clot
      • Place in socket and splint while waiting for URGERY dental consultation
    • If unable to re-implant place in patients mouth- saliva is a great medium = Hanks solution > Milk > Saline. NEVER TAP WATER and DON'T LET THE TOOTH DRY OUT
  • Alveolar Fracture:
    • Consider if multiple teeth are dislocated or are loose on palpation
    • Get CT face, urgent dental consult and DON'T implant any loose teeth.
SOURCES: EMDocs, Uptodate, Tintinallis
 · 
Share

baby its cold outside...

 ·   · 

Today's POTD inspired by two similar yet very different resus patients this morning...So lets talk HYPOTHERMIA.. tis the season!

Definition/Classification:

Causes: AGE IS BIGGEST RISK FACTOR- THINK ELDERLY AND INFANTS!
  • Heat loss- environmental exposure, vasodilation
  • Decreased or impaired thermogenesis:
Endocrine
Hypothyroid, adrenal insufficiency, malnourishment
CNS
Hypothalamic lesions, hypopituitarism
Trauma
Burn, spinal cord injuries
Sepsis
 
Tox
 ETOH, sedatives, vasodilators
Skin
Psoriasis, exfoliating conditions
Psych
 
Iatrogenic
Cold fluids, intraop
Evaluation:
  • Get that probe in! Core temperature is actually better obtained from esophageal or bladder > rectal
  • BGM!
  • Labs: Coags, CBC, BMP, CPK, TSH, sepsis workup?
  • EKG: Osborn waves, T wave inversions, prolongation of PR/QRS/QT, AV block, PVC
    • VF highest when T, 28C
Management: Think about and treat causes!

  • Passive Warming: Mild- think pts able to shiver
    • Warm blankets, keep dry, insulation
  • Active Warming
    • External/Peripheral- Bairhugger, warm fluids,chemical heat pads ( watch for burns)
      • May have drop in temperature from cold diuresis and release of cold peripheral blood to core
    • Central active warming
      • Warmed (40-46C) humidified inspired gases (1 C/h; 1.5°C/h ET tube)
      • Warm IV fluids (42C)
      • Body cavity lavage with 40C fluid e.g. peritoneal (3C/h), gastric, bladder, right-sided thoracic lavage (3-6C/h – use 2 ICCs for continuous flow)
      • CRRT
      • ECMO/ bypass (9-18C/h)
  • Coding:
    • Gentle handling of patient- can cause VF!
    • Cold heart is resistant to meds and pacing hold until temp >30C
    • Double the dose when temp bwn 30-35C
    • Shock Resistant- sources say shock max of 1-3times, goal is to get them warm!
Complications: Acid base disorders, pneumonia, bleeding, other cold injuries, dysrhythmias, DIC, rhabdomyolysis, thromboembolism, pancreatitis, multiorgan failure. Hope everyone is staying warm outside, enjoy the snow

 

sources: life in the fast lane, emdocs

 · 
Share

Chikungunya

 ·   · 

POTD- Wacky Wednesday! This one brought to you from the curious mind of our very own TINA NGUYEN!!!  And why is it wacky? Well because we rarely see it and can hardly say it... today were talking  

What is it?

  • Alpha virus transmitted by mosquitoes Aedes aegyoti and aedes albopictus

Where is it?

  • Endemic to West Africa and Latin America but seen EVERYWHERE!

    • Think of it in recent immigrants or travelers

How do you get it?

  • Mosquito bite, blood products, organ transplant, maternal fetal ( a/w miscarriage, highest transmission if infected during the intrapartum period)

Symptoms:

  • Acute: 1-14 days
    • Fever- High grade, lasts 3-5days
    • Polyarthralgias- bilateral, symmetric, distal>proximal
    • Skin- Nonspecific, 40-75% pts, macpap rash, pruritis
  • Complications:
    • Resp failure, myocarditis, acute hepatitis, renal failure, CNS involvement, hemorrhage, death
    • Prersistent or relapsed disease with arthralgias, tenosynotvitis, raynauds

Workup:

  • Labs: Lymphopenia, thrombocytopenia, Elevated transaminases, ^Cr
  • Diagnosis: RT-PCR if within 1-7days of onset after ELISA testing
    • R/o Dengue and Zika also!

Treatment:

  •  Supportive care- Rest, fluids, acetaminophen, NSAIDs
    • Careful of ASA or NSAIDs until you r/o dengue as they can increase severity of disease
  • Immune-compromised- Consider broad spectrum abx and consult ID!!

 

Sources: CDC, WHO, UpToDate

 

 · 
Share