Tooth Avulsion

Piggybacking on Dr. Cueva and Dr. Yetters tooth injury pearls earlier this year, I am here today to give some practical advise that you may not have time to look up in a trauma We are going to go over how to QUICKLY SPLINT A TOOTH AVULSION.

• Note: Time is tooth, after one hour of avulsion viability is severely decreased; preferably <30min!

1)      While setting up for the procedure soak the tooth: Saliva is a great medium (place in mouth) = Hanks solution > Milk > Saline.

2)      Rinse socket with 20-40 mL of saline solution and then pat dry with a surgical sponge.

3)      Implant tooth in anatomical position

4)Splint: Use N95 respirator mask metal piece or metal piece from non-rebreather; both pliable and cut to size to include adjacent teeth.

• File edges of any cut metal to prevent abrasions/laceartions.

5)Dry teeth – most important step!

• Ensure this by using nasal canula or yankhauer connected to O2 source.

6)      Apply metal splint to tooth with dermabond. Apply dermabond between adjacent teeth and to splint.

7)      Hold splint in place for one minute.

Other important tips:

Start prophylactic antibiotics.

Urgent dental consultation.

CT if alveolar fracture suspected.

Hiccups

Hiccups Bout: <48 hours of hiccups

Persistent hiccups: 48 hours – 1 month

Intractable Hiccups: >1 month

Why is this important?  You should workup PERSISTENT AND INTRACTABLE hiccups.

• CNS: stroke, mass, infection, increased ICP

• Diaphragm Irritation: Pneuomonia, cholecystitis, pericarditis, Myocardial Infarction

• Stomach wall irritation: ileus, fullness, ulcer, obstruction

• Phrenic nerve, Vagus Nerve, Recurrent Laryngeal Irritation: Infection, mass, trauma (recent surgery), etc.

• Metabolic/Electrolyte abnormality: Uremia, etc

• Toxins/Drugs: alcohol, etc

• Remember, can possibly an angina equivalent.

• Psychogenic

• Other Infectious Etiologies (Ebola)

History, Physical Exam, Treatment should center around these causes.

History: Alcohol use, medication changes, recent surgeries

Physical:

• HEENT exam including otoscope and throat exam: r/o infection, mass, lymphadenopathy, foreign body etc

• Neuro exam

• Abdominal exam

• Lung exam

Workup:

EKG, CBC, electrolytes, blood urea nitrogen (BUN), creatinine, calcium, liver function tests, and amylase/lipase, ecg, consider cxr.

Treatment:  Most therapies are based on case reports or small studies and are focused on treating the underlying cause.

• Physical Maneuvers (try first): Breatholding, Valsalva (against syringe), ice water gargle, pressing eyeballs, knee to chest to compress chest.

• Pharmacological therapy

o   These aim to resolve the physiological causes of hiccups

• Chlorpromazine 25 mg three times daily PO/IV (if given IV give with bolus).

• Only FDA approved drug based on case series

• Phenothiazine; dopamine antagonist

• Metoclopramide 10 mg three or four times daily orally

• Dopamine antagonist and gastric motility agent

• Baclofen 5-20mg three times daily orally

• Skeletal muscle relaxant

• Haldol 5-10mg PO or IV

Included is a table of pharmacologic treatments based on possible cause:

Gastric Distenstion GERD Diaphragmatic Irritation Central Acting Agents Dopamine Antagonist GABA Agonist Simethicone 25mg (antiflatulant) Metoclopramide 10mg QDS PO (prokinetic) Haloperidol 1.5-3mg qhs Chlorpromazine 10-25mg PO or IV Baclofen Metoclopramide 10mg (prokinetic) PO H2 blocker or PPI Baclofen 5-20mg three times daily orally Haloperidol 5-10mg PO or IV Sodium valproate 200-500mg PO Nifedipine 10-20mg three times daily orally Metoclopramide Midazolam 10-60mg/24h (really for terminal hiccups)! Sodium valproate, aim for 15mg/kg/24h in divided doses

Others: Carvedilol, Gabapentin, Lidocaine oral soln, Olanzapine, amitryptiline, Cisapride, marijuana

*If intractable hiccups remain resistant to non-pharmacological techniques, the strongest evidence to date supports the use of chlorpromazine 25 to 50 mg administered intravenously, with a second dose within 2 to 4 hours intravenously or intramuscularly

Sources:

Uptodate

Palliative Care Medicine Information Service

Life In The Fast Lane

Drug Rashes

• Unsurprisingly key in diagnosis is a good history.

• Most commonly caused by antibiotics.

• 90% are morbilliform: widespread erythematous macules or papules

• Common timeframe is 1-2 weeks after starting drug (however some can take up to three weeks).

Rash Presenting Symptoms Onset After Drug Causes Treatment Erythema Multiforme Target like lesions symmetric on trunk and extremities (generally distributed acrally) Mucous membrane involvement in multiforme major.

3-14 days HSV primarily; also NSAIDS, sulfa drugs, antibiotics, anti-epileptics. Stop offending agent. Drug Rash with Eosinophilia and Systemic Symptoms Syndrome (DRESS)

Fever and rash. Must be organ involvement: hapatic (60-80%), renal, lung. 2-8 weeks Anticonvulsants and allopurinol, additionally sulfa medications, antibiotics, CCB, NSAIDs, and anti-retrovirals (LFTs and BMP should be trended). Topical corticosteroids for rash. Systemic corticosteroids (for interstitial lung disease or nephritis); supportive care/withdrawl of causative agent for organ involvement

Stevens-Johnsons

Sydrome

Blisters with mucous membrane involvement

SJS involves less than 10% of the skin surface.

+Nikolsy

4-28 days Allopurinol, sulfa drugs, anti-epileptics, nevirapine and oxicam NSAIDs Range from observation to ICU level care (consider burn unit for approaching >30% BSA)

IV-IG and systemic corticosteroids are controversial.

Stop drug. Supportive.

Toxic Epidermal Necrolysis Similar to above, however involves >30% of skin.

4-28 days Same as above, however >80% are due to drug. Same as above. Burn Unit/ ICU setting. Serum Sickness-Like Reaction* Rash: urticarial polycyclic wheals on trunk, limbs, face. Fever. Arthralgias in >2/3 patients. 1-2 weeks Penicillin, amoxicillin, cefaclor, bactrim Stop drug. Supportive

Note: True sereum sickness-- protein antigen from a nonhuman species (antitoxin for snake bites, rabies).