EMS Protocol of the Week - Avulsed Tooth (Adult and Pediatric)

While EMS aren’t reimplanting extremities (yet), they ARE able to reimplant avulsed teeth! This week’s protocol goes over indications and contraindications, as well as how to best replace a tooth in a socket as a temporizing measure. Pay particular attention to the Key Points section, which also gives a refresher on appropriate storage media if implantation is impossible. 

Another short one this week, but nevertheless something to…chew on?

www.nycremsco.org or the protocol binder or honestly your cousin’s old book of puns for probably a lot of the same content.

Dave

POTD: Local Anesthetic Toxicity

Max amounts of local anesthetic:

 For a 70 kilogram, that means 35 mls of 1% Lidocaine, 49 mls of !% Lidocaine w/ epi, etc.

Mechanism of toxicity; sodium channel blockade effects block cardiac myocyte function and electrophysiology, resulting in arrhythmias. Intravascular absorption of LA also may travel to the CNS, causing its neurologic effects.

Symptoms: a prodrome of perioral numbness, tinnitus, agitation, dysarthria, and confusion. Followed by possible seizures and coma.

Cardiovascularly,  patients initially present with hypertension and tachycardia, which progresses to bradycardia and hypotension. This eventually progresses to ventricular arrhythmias and asystole.

The majority of adverse events occur within 1 minute of injection, but some cases may more than 1 hour after injection.

Bupivicaine’s higher toxicity is linked to its higher lipophilicity.

Toxicity is more common in this with hepatic and renal dysfunction, and those with heart disease and heart failure are at increased risk, as are those at the extremes of age, and in the ED setting are  most common in peripherals nerve blocks

Prevention:

Always aspirate before injection of local anesthetic.

 Treatment:

POTD: Anorectal symptoms in Men who have receptive-anal sex

Approach:

Should begin with a thorough examination of the external anus, evaluating for any lesions, fissures, or hemorrhoids.

If any abnormalities are discovered, or if the patient is complaining of rectal pain, bleeding, or purulent or bloody discharge, anoscopy and digital rectal exam is recommended.

Lidocaine ointment and may be used to facilitate examination if the patient is experiencing a great deal of pain

Infectious Etiologies:

Infectious proctitis:

Most often caused by gonorrhea

Symptoms are rectal pain, bleeding, +- purulent discharge, and can be associated with urgency or feelings of constipation. The external anal exam is normal, but the digital exam is noteworthy for diffuse tenderness.

STI testing is done through anal swabs for chlamydia and gonorrhea. If a visible lesion is present, swabbing the lesion for HSV PCR is indicated.

Diffuse ulcerations, systemic symptoms (fevers, chills), and lymphadenopathy should raise your suspicion for lymphogranuloma venereum (LGV), which is caused by Chlamydia trachomatis serovars L1, L2, and L3, have been reported in MSM.

If any ulcerations are present, it should raise suspicion for syphilis, HSV, or LGV.

An anal pap test may also be taken as MSM are at an increased risk of HPV related disorders, including anal warts/anal cancer

LGV:

Infection caused by specifically Gonorrhea L1, L2, and L3. In the Western world, it is most commonly found in HIV positive men who have sex with men.

Its pathogenesis is as follows:

Stage 1: 3-21 days after exposure: a painless blister or sore develops at the site of infection; most commonly the rectum, genitals, or mouth. This is commonly unnoticed. This develops into groups of blisters and can become more diffuse, spreading throughout the body. In rectal infection, proctitis can develop.

Stage 2: At 10-30 days, inflamed and swollen lymph glands appear in the groin, armpit, or neck. Anal infection can cause painful ulcerations, discharge, and bleeding. Systemic symptoms of fever or rash may develop.

Stage 3: if untreated, LGV can become more severe, causing general swelling of the lymph glands, swelling of the genitals, and severe ulcerations of the genitals, causing lasting damage, fibrosis, strictures, fistulas, and deformity.

Testing: Testing for chlamydia in the ER will rule out LGV. Further speciated chlamydial testing generally takes weeks to perform, and are not of particular use.

Treatment:

For all MSM patients with proctitis, treatment should be initiated for gonorrhea and chlamydial infections, with Ceftriaxone 500 mg IM and doxycycline 100 mg orally BID for 7 days.

For patients with ulcers, HSV treatments hould be initiated with valacyclovir 1g orally twice a day for 7-10 days.

For patients in whom you suspect LGV, doxycycline therapy should be extended to 3 weeks.

Anal warts:

MSM are at a higher risk of anal warts secondary to HPV, as seen below.

Treatment:

Prescriptions of Podofilox or imiquimod, which are patient applied creams in the case of immune modulators, can be given to the patient. Follow up with colorectal surgery should be given.