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Trick of the Trade: Dental Avulsion and Subluxation

ToothAvulsionIt’s a Friday evening shift in the “minor area” of your ED and a young woman who had imbibed a little too much alcohol comes in with an avulsion of her first left upper incisor after falling and striking her face against the ground.  She’s crying because of the event but is otherwise unscathed.  At this point it’s time to take care of the avulsion.  What to do?

 

Close up repair 4


Trick of the Trade

Dermabond (2-octyl cyanoacrylate) and N95 Nasal Bridge Technique

Although originally described for dental avulsions, I have also used this technique to stabilize subluxations. This is temporizing fix until the patient can get to the dentist for a definitive repair. Below is a description of the technique.

  1. Lightly rinse tooth with saline solution.
  2. Rinse socket with 20-40 mL of saline solution and then pat dry with a surgical sponge.
  3. Gently reimplant tooth into a satisfactory anatomic position.
  4. Pat tooth dry and apply 2-octyl cyanoacrylate (2-OCA) to the mesial and distal edges of the tooth, thereby adhering it to the adjacent teeth. In this case of a left central incisor avulsion, “mesial” means right edge and “distal” means left edge in dental speak.
  5. Use the pliable metal nasal bridge from an N95 respirator mask as a splint. Cut it to the appropriate size. Be sure to round the edges to avoid injury.
  6. Secure the replanted tooth by applying 2-OCA to the inner aspect of the splint and buccal surface of the target and one/both adjacent teeth.
  7. Hold the splint under pressure for about 1 minute.
  8. Confirm stability.

In addition, remember to start the patient on prophylactic antibiotics. Penicillin is a reasonable choice. Keep a liquid diet and see a dentist, as soon as possible.

Warnings

  • Children: Avulsed primary teeth should not be replanted. Also ensure they will not be at aspiration risk.
  • Warn the patient that if they feel that the dental splint is loosening, simply remove it.

Special thanks to our amazing residents Dr. Mike Hickey for his assistance with the case report and Dr. Warren Cheung for providing one of the images.

Below are other images where we have successfully used this technique in our ED.
Close up repair 3
Close up repair 2
Reference
  • Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011 Apr;57(4):375–7.

 

By |2021-09-04T09:55:04-07:00Jan 17, 2012|Dental, Tricks of the Trade|
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Paucis Verbis card: Interpretation of intraosseous blood

IO needles intraosseous labs

There is a growing number of normal volunteers who agree to get an intraosseous (IO) needle placed. Just search Intraosseous Needle on Youtube. Often you can draw blood out of the needle. How do you interpret the lab values? Are they the same as your peripheral blood draw? Should we even send the blood to the lab?

In a 2010 article in Archives of Pathology and Laboratory Medicine, peripheral IV blood from 10 volunteers was compared to blood drawn twice from a single IO line in the humerus. After discarding the first 2 mL of IO blood, the first IO sample was drawn (4 mL). Then a second IO sample was drawn (4 mL), which is equivalent to a sample with the first 6 mL discarded.

Interesting, not all IO labs correlated with IV labs. The good news is that a few critical ones do show correlation: creatitine, glucose, and hematocrit.

PV Card: Interpreting Labs from the IO Line


Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Thanks to Dr. Michael McGonigal at Trauma Professional’s Blog for posting about this.

Reference

  1. Miller L, Philbeck T, Montez D, Spadaccini C. A new study of intraosseous blood for laboratory analysis. Arch Pathol Lab Med. 2010;134(9):1253-1260. [PubMed]
By |2021-10-11T15:23:29-07:00Jan 13, 2012|ALiEM Cards, Heme-Oncology|
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Trick of the Trade: A removable guidewire


GuidewireCentralLineAn essential skill of any innovative troubleshooter in the Emergency Department is the ability to recognize when one piece of equipment may be used elsewhere. For instance, what’s your go-to approach when looking for a spare guidewire? Let’s say you are trying to salvage an ultrasound-guided basilic vein IV catheterization.

Here’s where I go for guidewires:

  • Central line kits
  • Pneumothorax pigtail kits
  • Seldinger-based cricothyrotomy kits

(more…)

By |2016-11-11T18:51:26-08:00Jan 10, 2012|Tricks of the Trade|
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Paucis Verbis: Serotonin syndrome

Synapses serotonin syndrome

Background

Serotonin syndrome is caused by the excess of serotonin and presents classically as:

  • Altered mental status
  • Autonomic instability
  • Neuromuscular hyperactivity

Fortunately, there’s a nice algorithm (Hunter’s decision rule) which helps you decide whether it is serotonin syndrome or not. I also include a table, which I adapted from a New England Journal of Medicine review article, which helps you to differentiate it from its mimickers, such as anticholinergic syndrome, neuroleptic malignant syndrome, and malignant hyperthermia.

PV Card: Serotonin Syndrome


Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.

A video to remind you what clonus looks like:

Thanks to Dr. Steve MacDade (Univ of Florida, Jacksonville EM resident) for the idea!

References

  1. Boyer E, Shannon M. The serotonin syndrome. N Engl J Med. 2005;352(11):1112-1120. [PubMed]
  2. Ables A, Nagubilli R. Prevention, recognition, and management of serotonin syndrome. Am Fam Physician. 2010;81(9):1139-1142. [PubMed]
By |2021-10-11T15:32:25-07:00Jan 6, 2012|ALiEM Cards, Tox & Medications|
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