Jaw Dislocations

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Today we're talking TMJ dislocations. Ever seen one of these? They're kind of cool to reduce. We'll be discussing several ways to reduce these, starting with the classic way, and followed by 2 creative approaches. How do these occur? After extreme opening of the mouth - ex: yawning, dental work, biting into a very large sandwich (not kidding).

Diagnosis is clinical! These are typically anterior dislocations, meaning the mandibular condyle is displaced anteriorly from its articular groove in the temporal bone. Pictures below.

Now let's talk reduction!

First, the classic intra-oral approach: this involves the physician placing his/her thumbs into the patient's mouth along the lower molars, and applying posterior and inferior force to guide the mandible back into its groove, like so:

Downsides: - Often requires procedural sedation - Requires a surprisingly large amount of force - You have to put your hands into the patient's mouth, which is risky

Luckily, there is not one, but two better ways! The extra-oral reduction technique, and the hands-free "syringe technique." Intrigued?

Extra-oral technique: When the mandible is dislocated, the coronoid process is palpable externally over the cheek. By applying steady posterior pressure over the coronoid, the mandible can be easily reduced. You'll know it's in when the coronoid process is no longer palpable.

Use your other hand to provide support and gentle counter-traction (figure 4).

This video shows it's really as easy as it sounds: https://youtu.be/N3edJvp5DoA

And if that doesn't work, try the hands-free syringe method (diagram below):

- Place a 5 or 10 mL syringe between the patient's molars on the dislocated side. - Instruct the patient to bite down and roll the syringe back and forth between the teeth until reduction is achieved. - This method utilizes the patient's own jaw musculature to create the posterior/inferior forces for jaw relocation.

 

A nice 2 min video overview where the syringe technique is demonstrated: https://coreem.net/procedures/tmj-reduction/

That's all for today. Happy New Year's, everyone!

References: https://www.aliem.com/2016/01/trick-of-the-trade-extra-oral-technique-for-reduction-of-anterior-mandible-dislocation/ https://coreem.net/journal-reviews/syringe-technique/

 

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POTD- PVT

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Todays POTD inspired by a resuscitation case from Drs Kaplan and Odashima- a cardiac arrest pt whose reported initial rhythm was PEA got 4x Epi and bicarb and was then noted to have something similar to the following on EKG:

So lets talk Polymorphic Vtac and what we need to know
PVT- comes from multiple ventricular foci
  • Varying QRS complexes with different amplitudes, axis and duration
  • Normal QT?  think ischemia
    • Usually within 12hrs of onset of symptoms
    • Can be from severe CHF or cardiogenic shock
    • HIGH mortality with NO evidence of specific anti-arrythmic therapy improving mortality
    • TRX: 
      • Unstable> Defib
      • Stable> 5mg Metoprolol Q5min if BP tolerates
        • IV amiodarone may prevent recurrence
        • Urgent CATH, IABP
        • Mag is less effective
    • Can also be Familial catecholaminergic PVT
      • TRX:  Beta Blockers!
 
  • Torsades-must have PVT and QT prolongation
    • QRS "twist " around the isoelectric line
    • Often short lived and self terminating
    • MCC: Drugs
    • Electrolyte abnormalities- hypoK, hypoMg
      • Hypoglycemia? Can cause prolonged QT , but not commonly a/w ventricular dysrhythmias
        • The above patients BGM was around 30 could this be the cause of PVT?
        • Attached is an article regarding hypoglycemia induced arrythmias!  http://diabetes.diabetesjournals.org/content/63/5/1738
    • Initiates when PVC occurs during T wave= " R on T"
    • TRX: 
      • Unstable> Defib
      • Stable>MAG!!!
        • TV overdrive pacing at !100bpm
        • Congenital long QT- use BB to shorten QT
        • 2* bradycardia- Isoproterenol 2mcg/min
A few more Pearls courtesy of LITFL!
Sources: Uptodate, LITFL
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Preeclampsia

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Hi everyone, Our Thursday POTD inspiration comes from a case mentioned to us today by Dr. Kay Odashima. We're talking preeclampsia! This is a can't-miss diagnosis in our pregnant and postpartum patients, so let's review.

Interesting fact: "eclampsia" has its roots in the Ancient Greek eklámpō, meaning to “burst forth violently” 😱

Preeclampsia is seen in women >20 weeks gestation or up to 4 weeks postpartum, and is subdivided into mild or severe, based on the absence/presence of end-organ dysfunction:

Mild:

  • BP >140/90
  • 2+ on urine dipstick
  • Well appearing, mild leg swelling, otherwise asymptomatic, normal bloodwork

Severe:

The diagnostic workup is similar to that done for hypertensive emergency: CBC, BMP, LFTs, coags (if the patient looks sick, to screen for DIC), uric acid, UA / urine dip looking for proteinuria.

Preeclampsia is associated with significant risk for morbidity and mortality, including:

  • DIC
  • Pulmonary edema
  • Intracranial hemorrhage
  • PRES (Posterior Reversible Encephalopathy Syndrome, dx on MRI brain)
  • Placental abruption (in a preeclamptic with vaginal bleeding, assume abruption until proven otherwise!)
  • HELLP syndrome
  • Progression to eclamptic seizuresSafe antihypertensive drugs for treatment: Goal BP: <160/110. Maximize one agent before moving on to a second agent. 

In addition, IV magnesium should be given to any preeclamptic with severe features: dosed at 4 grams IV load (over 5-10 minutes) followed by infusion at 1-2 gram/hr for 24 hr.

Disposition: ALWAYS consult with OB/GYN in any patient with preeclampsia. Even if these mild patients qualify for discharge home, they need extremely close OB follow-up. Patients with severe features need to be admitted to the OB floor and monitored until delivery (ideally at/after 34 weeks if possible). Remember, delivery is the definitive treatment for preeclampsia!

For me, the key takeaways are:

  • "High-normal" BP is NOT NORMAL in this population: >140/90 is considered mild preeclampsia!
  • Preeclampsia can manifest up to 4 weeks postpartum!
  • In a healthy woman presenting with new seizure and no obvious cause, think eclampsia and give mag!

References: http://www.emdocs.net/preeclampsia-and-eclampsia-common-pitfalls-in-diagnosis-and-management/ http://www.acog.org/Resources-And-Publications/Task-Force-and-Work-Group-Reports/Hypertension-in-Pregnancy

 

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