SmilER 104: Pericoronitis and Dry Socket

This fourth and final installment in the SmilER series covers the diagnosis and management of 2 common dental conditions that present to the emergency department: pericoronitis and dry socket.

Author: Richard Ngo, DMD
Editors: Cameron Lee, DMD, MD; Andrew Eyre, MD, MS-HPEd
Series Editor: Chris Nash, MD

How well did you learn the material? Go to ALiEMU to take the multiple-choice quizzes to receive your badges and certificates.

Learning Objectives

  1. Understand diagnostic criteria of pericoronitis and alveolar osteitis (dry socket).
  2. Understand treatment modalities for patients with pericoronitis and alveolar osteitis (dry socket).
  3. Name some of the pharmacological adjuncts to aid in recovery.
  4. Review key points to include in discharge instructions.


Patients may present to the ED with pericoronitis, an inflammation of the gingival soft tissue overlying a mandibular third molar. This soft tissue is subject to trauma from the patient biting down and may lead to pericoronitis due to normal oral flora. Patients with compromised host defenses may more easily develop pericoronitis. Repeated trauma to the operculum, the soft tissue overlying a partially erupted tooth, may lead to increased swelling more easily subject to subsequent trauma—a vicious cycle leading to worsening pain and erythematous swelling. Food may also become entrapped under the soft tissue due to difficulty maintaining oral hygiene.

Pericoronitis is a clinical diagnosis and does not require imaging.

Treatment, discharge, and follow up

  1. Irrigation: In the emergency department and as an outpatient, irrigation of food debris under the operculum using chlorhexidine or normal saline can acutely reduce bacterial counts.
  2. Antibiotics: The patient can be prescribed penicillin, or clindamycin if allergic to penicillin. If not treated, pericoronitis may result in a localized soft tissue infection (see SmilER 103).

The patient should follow-up with an outpatient dentist to prevent recurrent infections. This typically involves the patient undergoing definitive treatment, that is, extraction of the offending tooth.


Dry socket, also known as alveolar osteitis, is moderate to severe pain experienced after dental extraction due to exposure of bony surfaces. The pain typically begins 3-5 days following a tooth extraction. Although the cause is unclear, it is thought to be related to fibrinolytic activity within the extraction socket, which leads to lysis of the developing blood clot. The subsequent exposure of bone leads to moderate to severe pain that may be dull and aching. This pain may radiate to the ipsilateral ear. Associated symptoms include a foul odor or taste. Although dry socket is rare (2%) following routine dental extractions, it is more commonly associated with extraction of the mandibular third molars.

Dry socket diagram

Dry socket illustration for exposed bone and nerve after a blood clot is dislodged

Treatment, discharge, and follow up

Treatment of a dry socket is relatively simple. The premise is to NOT dislodge any newly forming blood clot, which serves as a protective covering.

  1. Irrigate the socket with sterile saline
  2. Gently suction away the excess saline, but do not go too deep into the socket as to evacuate the developing blood clot. The area also should NOT be curetted, as this will often worsen and possibly dislodge beneficial blood clots.
  3. Insert a medicated dry socket dressing (iodoform gauze) into the socket. These may be available in your emergency department or, alternatively, can be obtained from the pharmacy or as a commercial preparation from a dental supply company. Ingredients in this dressing include: eugenol to help with pain, topical anesthetic such as benzocaine, and a carrying vehicle such as balsam of Peru. Upon application, the patient should experience immediate relief within 5 minutes. Unfortunately, many emergency departments do not stock dry socket paste or Dressol-X. An alternative is ribbon gauze or Gelfoam impregnated with eugenol, iodine, or oil of cloves.

The patient should follow-up with an outpatient dentist or oral surgeon within 2 days to have their dry socket dressing changed every other day for the next 3-5 days.


  1. Hupp J, Ellis E, Tucker M. Contemporary Oral and Maxillofacial Surgery. Elsevier; 2019. 
  2. Berman L, Blanco L, Cohen S. A Clinical Guide to Dental Traumatology. Mosby; 2006.
  3. Kademani Deepak. Atlas of Oral and Maxillofacial Surgery. Saunders; 2015.
By |2021-10-05T12:28:54-07:00Oct 6, 2021|ALiEMU, Dental, SmilER|

SAEM Clinical Image Series: Silver Scales

A 6-year-old otherwise healthy female presented to the emergency department (ED) with a rash across all four extremities. She has had seven months of pruritic, expanding lesions starting on her shins, now beginning to expand on her forearms. No history of allergies or irritant exposure. Due to Covid-19, she has been unable to see a provider before today’s ED visit.

Vitals: T 98.3°F; BP 96/72; HR 92; RR 24; O2 sat 100%

Skin: Numerous patchy red lesions scattered across bilateral upper and lower extremities with silver plaque accumulation. No nailbed involvement. No mucous membrane involvement.


Psoriasis vulgaris, plaque subtype, is a common dermatologic condition often seen in the outpatient setting. Plaques are most commonly noted on the knees, elbows, and lower back. The silvery plaques in characteristic locations are a hallmark of this diagnosis but are rarely seen to this extent. Unfortunately for this patient, this was the initial presentation due to the inability to access care during the COVID-19 pandemic.

Initial management is with high-potency topical corticosteroids. Systemic steroids should be avoided to prevent exacerbation or eruption of pustular psoriatic lesions. In this case, given the patient’s age and disease severity, she was seen in the ED by Dermatology and initiated on corticosteroid topical therapy. She was encouraged to establish care with rheumatology to be routinely screened for associated life-altering pathologies including psoriatic arthritis and uveitis.

Take-Home Points

  • When making a visual diagnosis of plaque psoriasis, evaluate for erythema, edema, or signs of superinfection.
  • Avoid systemic steroids given the risk of rash exacerbation, especially upon withdrawal.
  • Younger patients and those with more than 10% body surface area involvement should be evaluated by a dermatologist for initiation of topical corticosteroids and possible escalation to phototherapy, methotrexate, retinoids, or biologic agents.
  1. Menter A, Cordoro KM, Davis DMR, Kroshinsky D, Paller AS, Armstrong AW, Connor C, Elewski BE, Gelfand JM, Gordon KB, Gottlieb AB, Kaplan DH, Kavanaugh A, Kiselica M, Kivelevitch D, Korman NJ, Lebwohl M, Leonardi CL, Lichten J, Lim HW, Mehta NN, Parra SL, Pathy AL, Farley Prater EA, Rupani RN, Siegel M, Stoff B, Strober BE, Wong EB, Wu JJ, Hariharan V, Elmets CA. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients. J Am Acad Dermatol. 2020 Jan;82(1):161-201. doi: 10.1016/j.jaad.2019.08.049. Epub 2019 Nov 5. Erratum in: J Am Acad Dermatol. 2020 Mar;82(3):574. PMID: 31703821.




SmilER 103: Odontogenic Infections

This third module for the SmilER series covers the diagnosis and management of odontogenic infections seen in the emergency department (ED). What anatomical structures should be avoided? When is imaging necessary? What is the discharge plan?

Author: Richard Ngo, DMD
Editors: Cameron Lee, DMD, MD; Andrew Eyre, MD, MS-HPEd
Series Editor: Chris Nash, MD

How well did you learn the material? Go to ALiEMU to take the multiple-choice quizzes to receive your badges and certificates.

Learning Objectives

  1. Understand the major classifications and diagnostic criteria of odontogenic infections.
  2. Understand the indications and contraindications for computed tomographic (CT) imaging as well as incision and drainage (I&D).
    • List the materials that are required to perform an incision and drainage.
    • List some of the potential complications of incision and drainage.
  3. Name some of the pharmacological adjuncts to aid in recovery.
  4. Review key points to include in patient discharge instructions.
Diagram showing caries leading to abscess formation

Evolution of odontogenic infections, progressing from caries, pulp inflammation, to abscess formation

Odontogenic infections are infections that are dental in origin. Infections start as carious (cavitary) lesions of the dentition that spread through the pulpal tissue to develop an abscess, a purulent collection that begins at the tooth’s root. From here, the abscess may extend through the mandible or maxilla to other regions of the mouth, face, and the rest of the body through the fascial planes of the head and neck.

Diagram showing abscess formation around the roots of the maxillary incisors

(A) Periradicular (around the root) infection in a maxillary incisor with the root apex close to the facial aspect of the maxilla results in erosion of the facial cortex and an abscess in the vestibular space. (B) Maxillary incisor with the root apex closer to the palatal cortex, increasing the likelihood of palatal cortical erosion and palatal abscess. [1] 

Abscess vs Cellulitis

An abscess is a localized, fluctuant mass that can be palpated upon physical examination. In contrast, cellulitis is characterized by diffuse induration without purulence. In both cases, patients may be febrile and may exhibit erythema or warmth of the infected site. Abscesses benefit from incision and drainage treatment, while antibiotics alone are sufficient for cellulitis.

Incision and Drainage (I&D)

For abscesses, the most important therapeutic intervention is the I&D of purulent material. The technique and approach is similar to the I&D of skin and soft tissue abscesses in other parts of the body. For odontogenic infections, I&D also changes the previously anaerobic environment into an aerobic one, thus making it difficult for anaerobic microbes to survive. As with skin and soft tissue abscesses, antibiotic therapy is a necessary adjunct to proper drainage.

Buccal abscess

Buccal space abscess spontaneously draining through the skin of the cheek (path of least resistance) [1]


Fascial Planes

The head and neck regions have many fascial planes containing potential spaces by which pus or cellulitis from odontogenic infections may spread. Major anatomic groups include: the midface, cheek and lateral face, mandible and below, and pharyngeal and cervical areas. Once eroded through bone, an infection can express itself in various places depending on the the relationship of muscle attachments to the site of perforation. Regions beyond the local buccal and vestibular spaces of the oral cavity should be escalated to specialty care, given anatomy complexity and potential risk for airway compromise or irreversible damage to anatomic structures.

Masticator Space Abscess

One example of a deep space that may become infected and requires specialty consultation is the masticator space. The masticator space is a general term that includes the any of the following spaces:

  • Pterygomandibular space
  • Submasseteric space
  • Superficial temporal space
  • Deep temporal space

The boundaries of the masticator space consists of the muscles of mastication, which including the following:

  • Masseter muscle
  • Medial and lateral pterygoid muscles
  • Temporalis muscle

The superficial and deep temporal spaces are separated from each other by the temporalis muscle. The lateral pterygoid muscle divides the pterygomandibular space from the infratemporal portion of the deep temporal space. The zygomatic arch divides the submasseteric space from the superficial temporal space. Abscesses within any of the components of the masticator space will require surgical drainage in an operating room under general anesthesia and should not be attempted in the ED.

The above axial cross-section diagram marks other extraoral regions which require specialty consultation. The fascial planes of the head and neck region may serve as potential pathways for the spread of infection into deeper spaces. As an example, the retropharyngeal space (yellow area in diagram above) allows for the potentially dangerous extension of infection into the mediastinum.

Part 1: History

Proper diagnosis of odontogenic infection in the ED begins with a thorough medical and dental history (see the Oral Examination and Local Anesthesia course). Additionally, ask about the course and progression of the swelling, dysphagia, odynophagia, dyspnea, foul breath or taste, and any immunocompromising conditions.

Part 2: Examination

Suction, irrigate, and examine the oral cavity thoroughly. Palpate any intraoral or extraoral masses to assess fluctuance or induration. Also note the following:

  • Location of swelling and dental pain
  • Floor of mouth elevation or induration
  • Uvular deviation
  • Periorbital swelling
  • Orbital proptosis

Measure the maximal incisal opening by asking patients to open their mouths as wide as possible; this is the greatest distance between the incisal edge of the maxillary central incisor and the incisal edge of the mandibular central incisor. A normal adult mouth opening is between 30-40 mm. Trismus, or reduced mouth opening, should raise concern for a potential deep space infection.

Measuring the maximal incisal opening with a ruler, between the incisal edges of upper and lower central incisors.

Measuring the maximal incisal opening, between the incisal edges of upper and lower central incisors.

A crucial odontogenic infection-related physical exam finding includes blunting of the inferior border of the mandible at the body; this is significant facial swelling that prevents the provider from palpating the bony structures at the body of the mandible.

Mandibular Anatomy

Anatomy of the mandible. An important exam finding includes swelling of the soft tissues overlying the body of the mandible.

Part 3: Imaging

Computed tomography (CT) imaging is indicated if there is concern for an odontogenic infection involving a deep fascial space. Two physical exam findings help predict when CT imaging is warranted [2].

  1. Blunting of inferior border of the mandibular body
  2. Trismus, as determined by maximum incisal opening <25 mm
Algorithm to determine need for CT vs Radiographs

Algorithm to determine whether CT imaging for odontogenic infection is necessary

If CT is not indicated, a Panorex panoramic radiograph is sufficient.

It can be challenging to determine when a patient’s odontogenic infection warrants specialist consultation in the ED, operative treatment, or inpatient admission.

High risk odontogenic infections

The patient will require inpatient admission and likely operative treatment for these following conditions in the setting of an odontogenic infection:

  • Involvement of the airway or deeper fascial spaces
  • Rapid progression of the infection
  • Need for general anesthesia
  • Dehydration or the inability to take fluids orally
  • Trismus
  • Immunocompromised status
  • Lack of improvement on oral antibiotics

These patients should be monitored for progression of the infection, as cases may rapidly progress to life-threatening conditions. If the infection is evident on the skin, mark the edge of the erythematous regions of the infection to monitor spread.

Odontogenic infections which do NOT require specialty consultation

Intra-oral maxillary and mandibular vestibular and buccal space swellings are infections limited to relatively safe, low-risk areas. These abscesses are amenable to incision and drainage by the emergency physician under local anesthesia. These are fascial spaces that will not cause airway obstruction and generally do not require general anesthesia or extraoral incisions to achieve adequate drainage. In these cases, patients normally do not complain of trismus, difficulty breathing, or swallowing. CT imaging is usually unnecessary.

1. Vestibular Abscess

Vestibular abscesses are infections that spread through bone to buccal tissues when the apex of the involved tooth is within the confines of the buccinator muscle attachment. The infection remains between the oral mucosa and the nearby facial muscle.

2. Buccal Abscess

3. Buccal Space Abscess

The buccal space lies superficial to the buccinator muscle and deep to the overlying skin and subcutaneous tissue. In these cases, the involved tooth’s apex is either superior or inferior to the insertion of the buccinator muscle. This potential space may become involved via infection of maxillary or mandibular molars.

A) When the tooth root apex is within the confines of the attachment for the buccinator muscle (in red), a vestibular space abscess localized medial to the buccinator muscle results. 

B) When the tooth root apex is outside of the confines of the attachment for the buccinator muscle (in red), a buccal space abscess localized lateral to the buccinator muscle results.

Odontogenic infections which DO require specialty consultation

Progression of infections to deeper spaces beyond the vestibular and buccal spaces increases the severity of the infection and thus requires specialty consultation. Indications for specialty consultation include any of the following:

  • The spread of infection to potentially dangerous fascial spaces, potentially leading to airway compromise
  • Difficulty swallowing
  • Trismus
  • Systemic signs of infection, such as a toxic appearance, respiratory distress, or altered mental status

In these cases, CT imaging is usually needed to determine the location and extent of the infection.

What deep space areas are especially dangerous?

Dangerous fascial planes include infection which spread:

  • Beyond the alveolar process (such as to the submental, sublingual, or submandibular spaces)
  • To the palatal spaces (medial relative to the maxillary dentition)
  • To the masticator space involving the muscles of mastication
  • To the more posterior oropharyngeal/retropharyngeal spaces
  • To the superiorly-located sinuses or orbital spaces
  • To any nearby vital structures such as major nerves and arteries (mental, lingual, facial, and ophthalmic bundles).

When in doubt, CT imaging should be obtained to determine proximity to nearby vital structures. In more severe cases, odontogenic infections may potentially lead to but are not limited to cavernous sinus thrombosis, Ludwig’s angina (the bilateral involvement of the submandibular, sublingual, and submental spaces), sinusitis, brain abscess, or mediastinitis. These more severe cases often require airway management, CT imaging, IV antibiotics, or emergent I&D in the operating room by specialty surgical services.

Examples of High-Risk Cases

The following figures indicate common regions involved in odontogenic infections for which escalation of care with specialty consultation is recommended. These complex infections include: palatal space abscesses on the palate of the mouth medial to the maxillary dentition, sublingual and submandibular space abscesses inferior to the tongue and floor of mouth, and abscesses that extends superiorly to involve the sinuses or orbits. To reiterate, any abscess requiring an extra oral approach for management requires specialist consultation.

Abscesses in the Mandibular Premolar Region:

Abscesses located in the mandibular premolar region are located near the mental neurovascular bundle. Those that require I&D need a cautious approach to avoid this vital structure. These may be better served with 

Palatal Space Abscesses:

Found medial to the maxillary dentition. I&D should be escalated to specialty care to avoid damaging the greater and lesser palatine neurovascular bundles.

Sublingual Abscesses:The sublingual space lies between the oral mucosa and the mylohyoid muscle and can become infected from the mandibular premolar and first molar teeth. I&D should be escalated to specialty care as abscesses in this space are at high risk for rapid spread and airway compromise.

Submandibular Abscesses:

The submandibular space lies between the mylohyoid muscle and anterior layer of the deep cervical fascia, just deep to platysma muscle. It includes the lingual and inferior surfaces of the mandible below the mylohyoid muscle attachment. I&D should be escalated to specialty care as abscesses in this space are at high risk for rapid spread and airway compromise.

Potential risks for incision and drainage (I&D) should be discussed with the patient and informed consent obtained. These risks include but may not be limited to pain, bleeding, swelling, scarring, damage to adjacent anatomic structures, nerve damage, and the need for additional procedures.


  1. Examine the oral cavity for any foreign material.
  2. Suction out any blood, saliva, and purulence.
  3. Irrigate the oral cavity with copious normal saline.
  4. Administer local anesthesia should be administered via a regional block and/or into the mucosa adjacent to the site of infection. Be careful not to pass the needle from infected to uninfected tissue to avoid the unintended inoculation of offending bacteria. Additional anesthesia may be required in the setting of infection. If the initial level of anesthesia is suboptimal, partially drain the abscess and irrigate to remove some of the pus. This can improve the acidic pH of the infection, allowing for additional local anesthetic to be more effective.
  5. Palpate the abscess to determine where the incision would obtain maximum drainage.
  6. Make a 1- to 2-cm incision perpendicular to the underlying bone at the height of fluctuance, while avoiding any major anatomical structures.
    • Maxillary vestibular abscesses: Placing the incision in a dependent (inferior) position prevents incomplete drainage. Upon evacuation of pus, a syringe can be used to collect cultures to be sent for sensitivity analysis. Submucosal spreading to break open any loculations with a curved hemostat should be performed. Finally, irrigate the surgical site copiously.
Maxillary Vestibular Abscess

For a maxillary vestibular abscess, an incision at a dependent, inferior position (green arrow) helps to prevent incomplete drainage from the pooling of the purulence on the inferior aspect of the abscess cavity. An incision at a non-dependent, superior position (red arrow) may lead to pooling of purulence and inadequate drainage.

I&D Technique

Incision and drainage technique for vestibular abscess. (A) Periapical infection of a mandibular premolar (note buccal cortical erosion superior to the buccinator muscle attachment). (B) Incision made into fluctuant swelling to the depth of the abscess cavity. (C) Curved hemostat used in opening motion in various directions to break loculations of purulence within the abscess cavity. (D) Optional: insertion of a Penrose drain (1 cm diameter) into the depth of the abscess cavity. (E) Optional: suturing of the drain with a single nonabsorbable suture (3-0 silk).

Oral Hygiene

Patients should be prescribed chlorhexidine 15 mL swish and spit, twice daily for 1 week.


Mixed aerobic and anaerobic bacteria cause most odontogenic infections. Antibiotics are an adjunct but not a replacement for incision and drainage in odontogenic abscess management. Antibiotics are particularly important for immunocompromised patients.

  1. Oral amoxicillin 500 mg TID for 3-7 days
  2. Alternative: Oral penicillin V potassium 500 mg QID for 3-7 days
  3. If first-line treatment fails: Either broaden the antibiotic therapy by adding oral metronidazole 500 mg TID for 7 days, or discontinue first-line treatment and prescribe oral amoxicillin 500 mg and clavulanate 125 mg (Augmentin) TID for 7 days.

 What if the patient has a penicillin allergy?

  • Inquire whether the patient has a history of anaphylaxis, angioedema, or hives with penicillin, ampicillin, or amoxicillin.
  • If the patient does not have any history of these severe allergic reactions, prescribe oral cephalexin 500 mg QID for 3-7 days.
  • If the patient does have such an allergic history, then prescribe oral azithromycin with a loading dose of 500 mg for one day, followed by 250 mg for an additional 4 days. An alternative to this would be oral clindamycin 300 mg QID for 3-7 days. If first-line treatment fails, then broaden antibiotic therapy to by adding oral metronidazole 500 mg TID for 7 days.

Pain Management

Postoperative pain can be managed with ibuprofen and/or acetaminophen. Peak swelling and inflammation is expected roughly 48 hours post-procedurally.


The patient must be instructed to follow up with an outpatient dentist as soon as possible to address the underlying cause of the infection. A root canal treatment or extraction of the offending tooth will likely be necessary to achieve source control of the infection. Failing this, the patient is likely to return to the ED with a recurring infection. Reasons for return to the hospital may include but are not limited to inadequate drainage with residual undrained loculations, spread of infection to deeper fascial planes, inappropriate antibiotic choice or dosage, or issues related to patient compliance.


  1. Hupp J, Ellis E, Tucker M. Contemporary Oral and Maxillofacial Surgery. Elsevier; 2019.
  2. Christensen BJ, Park EP, Suau S, Beran D, King BJ. Evidence-Based Clinical Criteria for Computed Tomography Imaging in Odontogenic Infections. J Oral Maxillofac Surg. 2019;77(2):299-306. PMID: 30347202
  3. Berman L, Blanco L, Cohen S. A Clinical Guide to Dental Traumatology. Mosby; 2006.
  4. Kademani D. Atlas of Oral and Maxillofacial Surgery. Saunders; 2015.
By |2021-09-29T16:19:43-07:00Sep 30, 2021|ALiEMU, Dental, SmilER|

ED Management of Cannabinoid Hyperemesis Syndrome: Breaking the Cycle

cannabis cannabinoid hyperemesis syndrome

What is cannabinoid hyperemesis syndrome?

Cannabinoid hyperemesis syndrome (CHS) is a condition in which patients who have been using cannabis or synthetic cannabinoids for a prolonged period of time develop a pattern of episodic, severe vomiting (usually accompanied by abdominal pain) interspersed with prolonged asymptomatic periods.

When should you consider cannabinoid hyperemesis syndrome as a diagnosis?

The diagnostic criteria for CHS require evidence of relief of symptoms with sustained cessation from cannabis, which makes them of limited utility in the Emergency Department (ED) [1]. However, a number of ED-based diagnostic criteria have been proposed with overlapping features [1,2]. There are 3 key components to assess for when making a presumed diagnosis:

  1. An episodic pattern of vomiting
    • Episodes of vomiting should last < 7 consecutive days
    • Asymptomatic periods often last > 1 month between episodes
  2. Prolonged cannabis use
    • Criteria vary: normally >1 time per week (often daily) for at least 1 year
    • Importantly, this is not an intoxication effect from a single large ingestion
  3. Exclusion of alternative diagnoses
    • Look for atypical features on history & exam including abnormal vital signs, diarrhea, focal abdominal pain, peritonitis, and jaundice
    • It is important to exclude pregnancy in all female patients
    • If a patient has never had an esophagogastroduodenoscopy (EGD), it is reasonable to refer newly diagnosed patients to gastroenterology for a non-emergent EGD to assess for a structural cause of the patient’s symptoms

What causes cannabinoid hyperemesis syndrome?

There is no singular theory that fully explains CHS. Importantly, the pattern of illness does not correlate well with the amount of cannabis consumed acutely, suggesting it is not related to a direct effect of the delta-9-tetrahydrocannabinol (THC) or a withdrawal effect. There are two prevailing theories related to changes in neuro-signaling and receptor expression with chronic THC exposure:

Theory #1: Downregulation of the cannabinoid receptor type 1 (CB-1) receptor which occurs with chronic THC use causing dysregulation of the hypothalamic-pituitary-adrenal stress axis. This theory supports why medications that have sedative or anxiolytic properties, such as haloperidol and benzodiazepines, have reported efficacy.

Theory #2: Changes in central nervous system dopamine signaling pathways with chronic THC exposure leading to a hypersensitive emesis response to dopamine. This theory is less well supported but has been used to explain the beneficial effects of dopamine antagonists such as haloperidol, droperidol, and olanzapine.

How should we treat cannabinoid hyperemesis syndrome in the ED?

Ondansetron, Metoclopramide, and Antihistamines

Traditional antiemetics have had low rates of success in treating CHS based on reported cases (ondansetron = 1.75%, metoclopramide = 4.35%) [3]. Antihistamines such as dimenhydrinate, diphenhydramine, and meclizine have no studies supporting their use, and the limited case reports available suggest they are ineffective [3]. While cases of treatment failure are more likely to be published which contributes to a reporting bias, clinical experience supports that CHS often does not respond well to these antiemetics. These medications may still have a role as an adjunct for patients who are refractory to other treatments, but given the evidence available supporting other agents, they can no longer be recommended as first-line therapy. Drawbacks to using a “traditional antiemetics first” strategies include a delay to effective treatment, prolonged ED length of stay, and prolongation of the QT interval.


The HaVOC trial showed haloperidol was twice as effective as ondansetron at reducing nausea (change from baseline = -5.0 vs. -2.4) and abdominal pain (change from baseline = -4.3 vs. -2.1). Haloperidol also decreased rescue medication use (31% vs. 76%) and time from medication administration to ED discharge (3.1 hours vs. 5.6 hours) [4].

Lower doses of haloperidol were recommended (0.05 mg/kg) due to higher rates of adverse reactions with larger doses. Weight-band based dosing may be a more practical approach:

  • Haloperidol 2.5 mg IV for adults < 80 kg
  • Haloperidol 5 mg IV for adults > 80 kg


There is very limited evidence supporting olanzapine specifically in CHS (6 reported cases) [3]. However, olanzapine has strong evidence supporting its antiemetic properties in oncology literature [5,6]. Unlike haloperidol, olanzapine does not prolong the QT interval and it has much lower rates of extrapyramidal side effects. Therefore, olanzapine may be a reasonable substitution for haloperidol in the following cases: documented allergy to haloperidol, prolonged QT interval, or previous extrapyramidal effects with haloperidol.


While capsaicin is often discussed as a treatment [ALiEM trick of the trade], the evidence supporting its use is limited to a small case series and a small RCT with some significant limitations. The small RCT published in support of capsaicin had large baseline differences between the capsaicin and placebo groups. The placebo group was “more sick”, having higher baseline nausea which was not corrected for in the analysis [7].

The trial reported a significant reduction in nausea scores with capsaicin (60-minute nausea score: Placebo = 6.4 vs. Capsaicin = 3.2, p = 0.007) which looks impressive, but the change in nausea from baseline was much less substantial (change in nausea: Placebo = -2.1 vs. Capsaicin = -2.8). Overall, the evidence supporting capsaicin is limited, so its use should be a shared decision.


Lorazepam has no studies assessing its utility in CHS, but a summary of case reports suggests an efficacy of 58.3% in 19 patients [3]. Despite the lack of evidence, clinical experience has led to lorazepam being recommended as an adjunct in recent cyclic vomiting syndrome guidelines for patients who have an anxiety component to their presentation [8]. Since 40-50% of traditional cyclic vomiting syndrome patients were chronic cannabis users, it is reasonable to extrapolate these guidelines to CHS until more specific literature is published.

Overall Approach to Treatment

Based on the currently available research outlined above and clinical experience, the following is a reasonable approach to acute symptomatic management of CHS in the ED:

What should we be considering at the time of discharge?

Like other chronic episodic illnesses (eg. migraines) the long-term management of CHS can be conceptualized to have three components: avoidance of triggers, management of acute episodes, and episode prevention (prophylaxis).

Avoidance of Triggers

  • The only cure for CHS is the prolonged cessation of cannabis. It is important to emphasize that it may take 6 months of cannabis cessation before symptoms improve, and to recognize that the challenges in stopping cannabis use are often underestimated. Professional addictions support is encouraged.

Management of Acute Episodes

  • Medications at home to abort acute episodes are a logical management strategy and may be a safe option to reduce recurrent ED visits in some patients. This will depend on which medications work for the patient, their comorbidities, and the patient’s access to reliable follow-up.
  • There is no current evidence to guide outpatient treatment. Traditionally, many gastroenterologists have used a combination of sublingual lorazepam and ondansetron which may be reasonable if a patient has responded to these medications in the ED.
  • The use of oral haloperidol at home is currently being studied, but there are no good protocols published to guide practice.

Episode Prevention

  • There have been no studies on using medications to reduce the frequency of CHS episodes. However, amitriptyline is recommended as a first-line prophylactic treatment for adults with cyclic vomiting syndrome as it reduces subjective symptoms scores, episode frequency, and ED utilization [9,10].
  • Using amitriptyline for CHS would be considered experimental and amitriptyline has several well-recognized side effects, requires slow up-titrated, and necessitates close follow-up. It may be reasonable for a patient to discuss with their primary care provider.



  1. Venkatesan T, Levinthal DJ, Li BUK, et al. Role of chronic cannabis use: cyclic vomiting syndrome vs cannabinoid hyperemesis syndrome. Neurogastroenterology & Motility. 2019 Jun;31(Suppl 2):e13606.
  2. Sorensen CJ, DeSanto K, Borgelt L, Phillips KT. Cannabinoid hyperemesis syndrome: diagnosis, pathophysiology, and treatment – a systematic review. Journal of Medical Toxicology. 2017;13:71-87.
  3. Richards JR, Gordon BK, Danielson AR, Moulin AK. Pharmacologic treatment of cannabinoid hyperemesis syndrome: a systematic review. Pharmacotherapy. 2017;37(6):725-34.
  4. Ruberto AJ, Sivilotti ML, Forrester S, et al. Intravenous haloperidol versus ondansetron for cannabis hyperemesis syndrome (HaVOC): a randomized, controlled trial. Annals of Emergency Medicine. 202 Nov;S0196-0644(20)30666-1.
  5. Hashimoto H, Abe M, Tokuyama O, Mizutani H, Uchitomi Y, Yamaguchi T, Hoshina Y, Sakata Y, Takahashi TY, Nakashima K, Nakao M, et al. Olanzapine 5 mg plus standard antiemetic therapy for the prevention of chemotherapy-induced nausea and vomiting (J-FORCE): a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Oncology. 2020;21:242-49.
  6. Naravi RM, Qin R, Ruddy KJ, et al. Olanzapine for the prevention of chemotherapy-induced nausea and vomiting. New England Journal of Medicine. 2016 Jul;375(2):134-42.
  7. Dean DJ, Sabagha N, Rose K, et al. A pilot trial of topical capsaicin cream for treatment of cannabinoid hyperemesis syndrome. Academic Emergency Medicine. 2020;27:1166-72.
  8. Venkatesan T, Levinthal DJ, Tarbell SE, et al. Guidelines on management of cyclic vomiting syndrome in adults by the American neurogastroenterology and motility society and the cyclic vomiting syndrome association. Neurogastroenterology & Motility. 2019;31(Supp 2):e13604.
  9. Hejazi RA, Reddymasu SC, Namin F, et al. Efficacy of tricyclic antidepressant therapy in adults with cyclic vomiting syndrome: a two year follow up study. Journal of Clinical Gastroenterology. 2010;44:18-21.
  10. Namin F, Patel J, Lin Z, et al. Clinical, psychiatric and manometric profile of cyclic vomiting syndrome in adults and response to tricyclic therapy. Neurogastroenterology & Motility. 2007;19:196-202.

ALiEM AIR Series | Vascular 2021 Module

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Welcome to the AIR Vascular Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to vascular emergencies in the Emergency Department. 9 blog posts met our standard of online excellence and were curated and approved for residency training by the AIR Series Board. We identified 3 AIR and 6 Honorable Mentions. We recommend programs give 4.5 hours (about 30 minutes per article) of III credit for this module.

AIR Stamp of Approval and Honorable Mentions


In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Interested in taking the Vascular quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.


Highlighted Quality Posts: Vascular Emergencies

EMDocsBlunt CVISimon Sarkisian, DO and Zach Sletten, MD4 Jan 2021AIR
EMDocsCVTTony Spadaro, MD and Kevin Scott, MD21 Sep 2020AIR
EMDocsAortic DissectionDrew Long, MD17 Aug 2020AIR
EMDocsDifficult Vascular AccessRichard Cunningham, MD and Geoffrey Comp, DO27 Jan 2021HM
PedsEM morselsTraumatic Vertebral Artery DissectionSean Fox, MD16 Apr 2021HM
PedsEM morselsBlunt CVISean Fox, MD15 Jan 2021HM
Rebel EMRebel Core: Superficial Venous ThrombosisAnand Swaminathan, MD24 Feb 2021HM
Rebel EMRebel Core: AAAAnand Swaminathan, MD10 Feb 2021HM
Rebel EMBlunt CVISalim Rezaie, MD28 Dec 2020HM

(AIR = Approved Instructional Resource; HM = Honorable Mention)

If you have any questions or comments on the AIR series, or this AIR module, please contact us! More in-depth information regarding the Social Media Index.

Thank you to the Society of Academic Emergency Medicine (SAEM) and the Council of EM Residency Directors (CORD) for jointly sponsoring the AIR Series! We are thrilled to partner with both on shaping the future of medical education.

SmilER 102: Dental Trauma

This second module for the SmilER series covers the management of common dental trauma cases seen in the emergency department (ED). What should you do with the various types of dental fractures and avulsions, how do you manage them in the ED, and what sort of follow-up should the patient receive?

Author: Richard Ngo, DMD
Editors: Cameron Lee, DMD, MD; Andrew Eyre, MD, MS-HPEd
Series Editor: Chris Nash, MD

How well did you learn the material? Go to ALiEMU to take the multiple-choice quizzes to receive your badges and certificates.

Learning Objectives

  1. Understand the major classifications and diagnostic criteria of dental traumatology for adult patients.
  2. Understand reimplantation of avulsed teeth, as well as splinting for adult dental-related trauma.
    • List the materials that are required to place a dental splint.
    • List some of the potential complications of splinting.
    • Understand imaging required for dental-related trauma cases.
  3. Name some of the pharmacological adjuncts to aid in recovery.
  4. Review key points to include in patient discharge instructions after dental trauma.

Part 1: History

Proper diagnosis of dental trauma in the ED begins with a thorough medical and dental history (see the Oral Examination and Local Anesthesia course).

Part 2: Examination

  • Suction and irrigate the oral cavity thoroughly.
  • Maintain the patient’s airway while assessing and removing potential aspiration risks, including significantly loose or displaced dentition.
  • Identify all fracture fragments, since they may be lodged into soft tissues or intruded into alveolar bone.
  • Hemorrhage control can be achieved with gauze and direct pressure. Escalate care to specialists if you are unable to achieve hemostasis.
  • Assess the parotid and sublingual ducts for possible lacerations. Trauma to these areas could potentially lead to sialadenitis (salivary gland inflammation).
  • Poor occlusion (bite) may be indicative of mandibular or maxillary fractures.

Part 3: Imaging

A chest x-ray should be obtained if there is concern for aspiration. Panoramic imaging is helpful to visualize the dentition and also should be assessed for mandibular fractures. For all cases requiring intervention, the provider should obtain pre- and post-procedural imaging.

The traditionally-taught Ellis classification system is falling out of favor. More recently, fractures of both primary and permanent teeth are classified as either uncomplicated or complicated fractures. A fracture is defined as complicated if it involves the pulp.

Tooth fracture classification (modified from [1])

Uncomplicated enamel fractures are fractures in the tooth that do not extend to the dental pulp. These fractures tend to be asymptomatic and do not require urgent attention. This may include infractions, also known as craze lines. An infraction is an incomplete fracture through the enamel. It is asymptomatic and does not require further treatment. In general, uncomplicated fractures of only the enamel simply require observation and follow-up with an outpatient dentist.

Uncomplicated Fractures of the Enamel-Dentin

Simple uncomplicated fractures can extend into the enamel and/or dentin, but avoid penetration to the pulp. Patients can be advised to keep tooth fragments for potential re-bonding as a temporary restoration at an outpatient dental clinic. If a tooth fragment is brought into the ED, it may be re-bonded as a temporary measure. This can be completed in the hospital by consulting the OMFS or dental services. Alternatively, this can be completed by a dentist in the outpatient setting.

Enamel-Dentin-Pulp Fractures

Enamel-dentin-pulp fractures in the tooth that result in the exposure of dental pulp to the oral cavity. Patients often complain of significant pain or sensitivity. These cases require either root canal treatment or extraction of the offending tooth by an outpatient dentist. If this is not properly performed, the patient is likely to return to the ED with an infection or worsened dental pain. If calcium hydroxide is available, this can be applied to the surface of the pulpal exposure. These patients should follow-up with an outside dentist, preferably within 1 week following discharge from the emergency department.

Complicated Dental Fracture

Complicated dental fracture involving the pulp and an uncomplicated fracture through just the enamel in the same tooth. 

Root Fractures

Root fractures are complicated fractures of the tooth root. Patients often have pain and tenderness upon percussion of the offending tooth. The coronal segment may be mobile/displaced, in which case a splint is recommended for at least 4 weeks.

If the tooth is non-mobile (fracture likely in the apical third of the root), no immediate treatment is necessary. Of note, it is possible to have a root fracture even if the visible, manipulable portion of the tooth is not mobile. An outpatient dentist must thoroughly evaluate these patients with proper imaging equipment (e.g., periapical radiographs) that are typically not available in emergency departments.

These patients should follow-up with an outside dentist, preferably within 1 week following discharge from the emergency department.

Alveolar Fractures

Alveolar fractures are complicated and involve the bone surrounding the dentition, also known as the alveolus. The hallmark of this injury is that upon manipulating a single tooth, an entire segment of teeth and bone will move simultaneously. Patients may also present with concurrent fracture or luxation injuries. OMFS consultation is recommended for these cases, because a complex arch bar placement is often necessary for proper stabilization and treatment.

Displacement classifications include concussion, subluxation, luxation, intrusion, and avulsion. Cases involving avulsion are time-sensitive and require urgent attention for the best prognosis.


Concussion is an injury to tooth-supporting structures without displacement or mobility of the tooth. These teeth exhibit pain to percussion. Concussed teeth generally do not require emergency treatment unless the tooth becomes dark or black; these patients should follow up with an outpatient dentist for potential root canal treatment.


Subluxation is mobility of a tooth without significant displacement of the tooth from its original position. These cases involve injury to the tooth-supporting structures, which result in abnormal loosening without displacement. These teeth, if permanent ones, should be placed in a dental splint for at 2 two weeks.


Intrusion involves movement toward the root (superiorly for maxillary teeth and inferiorly for mandibular teeth). OMFS consultation is highly recommended for cases involving intrusion, as complex surgical manipulation and re-positioning may be required. Of all types of luxation injuries, intrusions are the most likely to require long-term treatment by dental specialists.

Lateral Luxation/Extrusion

Lateral luxation involves displacement of the tooth from its original position (usually anteriorly or posteriorly), and extrusion is displacement from the sock in the coronal direction. These teeth, if permanent ones, should be repositioned and placed in a dental splint for at least 2 weeks.

Lateral Luxation Diagram

Eccentric displacement of the tooth seen in lateral luxation. Displacement of the tooth anteriorly or posteriorly is often associated with alveolar wall fractures. 


Avulsion is the complete displacement of the tooth out from its original socket in the alveolar bone. If the patient arrives with an avulsed tooth, it is important to ask the patient how long the tooth has been avulsed. If the patient cannot be seen immediately, the avulsed tooth or teeth should be placed in saline, milk, or water (in that ordered preference).

The physician should avoid handling or wiping the root (handle by the crown only) to maintain the vitality of periodontal ligament cells and maximize chances for successful re-implantation and re-integration of the tooth.

If the tooth has been out of the socket for more than 20 minutes:

  1. Place it into saline for 30 minutes. This appears to reduce the incidence of ankylosis by improving the survivability of the cells on the root of the tooth.
  2. Then soak it in a doxycycline solution (1 mg/20 mL saline) for 5 minutes. The doxycycline helps to inhibit bacterial growth in the pulp, which reduces chances for revascularization.
  3. Attempt re-implantation. The tooth can be replanted slowly with slight, careful digital pressure.
  4. Place a dental splint.

Possible complications of re-implanted avulsed dentition include enamel hypoplasia, hypocalcification, crown/root dilaceration, and eruption pattern disruption. Long-term prognosis is negatively correlated with the length of time that the tooth has been avulsed from its socket. Once out of the socket for over an hour, it becomes unlikely that the tooth will re-integrate to the bone without complications.

Although many emergency departments do not have access to typical dental supplies, providers who do have access to these supplies should follow instructions as described below. For those who do not, you might consider having your department invest in these supplies.


  • Curing light
  • Etching material
  • Bonding material
  • Flowable composite
  • Stainless steel wire
  • Wire cutters

Splinting Steps

  1. Etching
  2. Priming/bonding
  3. Curing of flowable composite to hold the dental wire in place

Screenshots from Dundee Dental School YouTube video (shown below).

Cut Wire to Length

1. Cut the wire and contour it to fit the dental arch

Etch the teeth

2. Etch the surfaces to be bonded with flowable composite to create the proper porosity necessary for bonding. After 30 second, the teeth should be irrigated thoroughly with saline.

Apply bonding agent

3. Apply bonding agent to the previously etched surfaces

Cure the bonding agent

4. Cure the bonding agent for 30 seconds. The chemical reaction within the bonding agent is initiated by blue light. Be sure not to look directly into the light as it can damage the retina.

Position the composite and wire in the desired location

5. Apply the flowable composite to the mobile tooth and at least 2 adjacent teeth flanking the mobile tooth. Make sure you splint the teeth their ideal location (where it looks most natural). Cure for 30 seconds to finalize the splint. A post-procedure panoramic radiograph should be obtained if available at your institution. 

Video Summary of Splinting Steps

Not every hospital has access to high-quality dental equipment, and your emergency department may not have the necessary supplies to create a composite and wire splint. In that case, you’re still in luck! Check out this ALiEM Trick of the Trade by Dr. Hans Rosenberg and published in Annals of Emergency Medicine about using equipment that you will have in your ED to fashion a temporary splint. All you need are an N95 mask and tissue glue adhesive.

Close up repair dental avulsion

Dentist Follow-Up Care

Following splinting of dental trauma, the dentition may or may not be salvageable in the long term. However, the patient must follow-up with a dentist as soon as possible for a more thorough dental examination and long-term care. Although dentition may appear to be stable on physical examination and imaging in the ED, providers should inform patients of the possibility that dental fractures may not be visible without more thorough imaging at an outpatient dental clinic, ideally within a 2-week timeframe or sooner.

Pain Management

Regarding postoperative pain management, ibuprofen can be prescribed in combination with acetaminophen. The patient will experience peak swelling and inflammation roughly 48 hours after the procedure. The patient should be instructed to ice the area to minimize swelling without wetting the splint for the first 24 hours following discharge.

Oral Hygiene

Chlorhexidine 0.12% 15 mL can be used to rinse the mouth twice daily for 1 week. Using chlorhexidine for longer than this is not recommended as staining of the dentition may occur.


The patient should be placed on a soft diet and avoid chewing in the area of the splint until further instruction by their dentist.

No Antibiotics

Antibiotics are not generally recommended following dental trauma except for avulsion injuries.


  1. Hupp J, Ellis E, Tucker M. Contemporary Oral and Maxillofacial Surgery. Elsevier; 2019.
  2. Berman L, Blanco L, Cohen S. A Clinical Guide to Dental Traumatology. Mosby; 2006.
  3. Kademani D, Tiwana P. Atlas of Oral and Maxillofacial Surgery. Saunders; 2015.
  4. Dundee Dental School. Composite and Wire Splint. Part1: Placement. YouTube; 2018.

By |2021-09-21T16:48:06-07:00Sep 22, 2021|ALiEMU, Dental, SmilER|

SAEM Clinical Image Series: Traumatic Swollen Eye

A 53-year-old caucasian male with a history of alcohol and amphetamine abuse presents to the Emergency Department via ambulance immediately after sustaining a fist-blow injury to the right eye. The patient denies loss of consciousness and complains of eye pain with the inability to see.

Vitals: T 36.9°C; BP 181/119; HR 110

General: Alert and oriented; anxious; agitated



  • Visual acuity – no light perception
  • Pupil 4mm, irregular shape, and fixed
  • Extraocular movement – none
  • Proptotic; Conjunctival prolapse; Subconjunctival hemorrhage
  • Anterior chamber hyphema
  • IOP 55 mmHg


  • Visual acuity – 20/20
  • Pupil 3mm round and reactive
  • Extraocular movement – intact
  • IOP 12 mmHg


A lateral canthotomy and cantholysis.

This procedure is easily performed at the bedside in the ED and the transected lateral canthal tendon and inferior/superior crus can be repaired during the repair of the presenting injury. Patients report improvements in pain and sometimes vision in as little as 10 minutes after the procedure.

A CT should be ordered after performing a lateral canthotomy and cantholysis to minimize the complications associated with elevated retrobulbar pressure including ischemia and permanent loss of vision. This photograph depicts a patient who presented to the ED suffering from the effects of orbital compartment syndrome (OCS) after being punched in the eye. OCS can develop from as little as 7mL of fluid accumulation in the retro-orbital space and can rapidly lead to permanent blindness if ischemia is present for more than 100 minutes. Symptoms of OCS requiring immediate lateral canthotomy and cantholysis include: proptosis, increased intraocular pressure, Marcus-Gunn pupil, decreased acuity, or restricted ocular movements. Importantly, OCS is a clinical diagnosis, and treatment of this condition should not be delayed for further testing or diagnostic workup. While treatment may not result in the return of vision, there are many case reports of patients regaining full or partial vision up to two hours after the onset of symptoms.

Take-Home Points

  • Don’t delay! Quick action can save your patient’s vision.
  • Signs of OCS requiring immediate bedside surgical intervention include:
    • Proptosis
    • Increased intraocular pressure
    • Marcus-Gunn pupil
    • Decreased visual acuity
    • Restricted ocular movements
  1. Rowh AD, Ufberg JW, Chan TC, Vilke GM, Harrigan RA. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med. 2015 Mar;48(3):325-30. doi: 10.1016/j.jemermed.2014.11.002. Epub 2014 Dec 16. PMID: 25524455.
  2. Jaksha AF,Justin GA, Davies BW, Ryan DS, Weichel ED, Colyer MH. Lateral Canthotomy and Cantholysis in Operations Iraqi Freedom and Enduring Freedom: 2001-2011. Ophthalmic Plast Reconstr Surg. 2019 Jan/Feb;35(1):62-66. doi: 10.1097/IOP.0000000000001168. PMID: 29979268.



By |2021-09-08T11:14:28-07:00Sep 20, 2021|Ophthalmology, SAEM Clinical Images|
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