FacebookRssXInstagramSoundCloud
Generic filters
Exact matches only

ALiEM AIR Series | Vascular 2021 Module

This image has an empty alt attribute; its file name is AIR-logo-2016-transparent-SAEM-CORD-586x650.jpg

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.

Take the AIR Vascular Quiz at ALiEMU

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

SiteArticleAuthorDateLabel
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.

By |2022-02-20T00:59:45-08:00Sep 26, 2021|Approved Instructional Resources (AIR series)|
Read More

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

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

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

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

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.

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.

Diet

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.

References

  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.

    ‌

SmilER Series

The purpose of the SmilER series on dental trauma and infection management is to teach fundamental principles, pearls, and pitfalls in the care for dental patients in the emergency department. As many as 1.5% of ED visits are dental-related¹ and many emergency physicians have expressed the need for more comprehensive training in the oral cavity. This series was created as an introductory guide on the management of patients who report to the ED with dental-related conditions.

All information has been expert peer-reviewed by an oral and maxillofacial surgeon.

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

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.

 

orbital compartment syndrome

 

Vitals: T 36.9°C; BP 181/119; HR 110

General: Alert and oriented; anxious; agitated

Ophthalmic:

OD:

  • 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

OS:

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

Non-contributory

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.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

 

 

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

Pre-Arrest Acidemia and the Effect of Sodium Bicarbonate on ROSC

Background

Sodium bicarbonate during a cardiac arrest is widely debated and used in many cases. In a 2018 PULMCrit post, Dr. Josh Farkas reviews much of the data and concludes that use of sodium bicarbonate is a “source of eternal disagreement.” A 2013 EMCrit article and podcast by Dr. Scott Weingart also details some of the controversy. The 2020 ACLS Guidelines state that routine use of sodium bicarbonate is not recommended in cardiac arrest [1]. Despite this recommendation, sodium bicarbonate is still often administered during resuscitations if a metabolic (or respiratory) acidosis is suspected or after a prolonged downtime. A recent study evaluated the effect of pre-arrest acid-base status on response to sodium bicarbonate and achievement of return of spontaneous circulation (ROSC) [2].

Evidence

This was a retrospective review of in-hospital cardiac arrests (IHCA) in patients with pre-arrest serum bicarbonate levels ≤21 mmol/L compared to >21 mmol/L. Pre-arrest bicarbonate levels were obtained <24 hours prior to the arrest. Similarly, post-arrest bicarb levels were obtained <24 hours following the arrest. Bicarbonate levels were recorded from basic chemistry panels rather than blood gases. All patients received a median sodium bicarbonate dose of 100 mEq. The groups were relatively well-matched, with the only major difference being the time to first bicarb administration was faster in the ‘acidotic’ group (6.9 vs. 9.2 minutes). Initial ECG rhythms were similar between the groups.

  • 102 patients in ‘acidotic’ group with a median pre-arrest bicarb level of 17 mmol/L
  • 123 patients in ‘non-acidotic’ group with a median pre-arrest bicarb level of 27 mmol/L
  • There was no difference in ROSC (53.9% vs 48.8%, p=0.44) or survival to discharge (8.8% vs 5.7%, p=0.36) between the acidotic group versus the nonacidotic group

Thoughts and Limitations

  • A meta-analysis found no difference in sustained ROSC or survival to discharge with sodium bicarbonate (Alshahrani 2021).
  • In the current study, prearrest bicarb levels could have resulted up to 24 hours prior to the arrest and the authors don’t comment on when exactly they were drawn. The timing limits the ability to know true acid-base status just prior to the arrest. And, that really limits applying this to out-of-hospital cardiac arrest where patients may have more significant acidemia if resuscitation is delayed.
  • A median bicarbonate concentration of 17 mmol/L isn’t really that low, relatively speaking, to indicate a potential impact from administering sodium bicarbonate.
  • Retrospective cardiac arrest studies are challenging. Many interventions happen around the same, making it impossible to connect any one of them with a specific outcome.
  • The study that would be more helpful is taking patients with metabolic/respiratory acidosis and giving have bicarb and the other placebo.

Bottom Line

  • In this cohort of IHCA patients, sodium bicarbonate administration did not improve the chances of ROSC or survival to hospital discharge, irrespective of pre-arrest acid-base status. In other words, attempting to correct ‘acidosis’ does not seem to change rate of ROSC.
  • Sodium bicarbonate use in cardiac arrest should be targeted (e.g., hyperkalemia with metabolic acidosis, sodium channel blockade secondary to an overdose).

Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.

References

  1. Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: adult basic and advanced life support: 2020 american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020;142(16_suppl_2):S366-S468. doi: 10.1161/CIR.0000000000000916. PMID: 33081529.
  2. Mclean H, Wells L, Marler J. The effect of prearrest acid-base status on response to sodium bicarbonate and achievement of return of spontaneous circulation. Ann Pharmacother. Published online August 5, 2021:10600280211038392. doi: 10.1177/10600280211038393. PMID: 34353142.
By |2021-10-09T09:23:40-07:00Sep 18, 2021|Cardiovascular, Critical Care/ Resus, EM Pharmacy Pearls|
Read More

SmilER 101: Oral Exam and Regional Anesthesia in Dental Care

The purpose of the SmilER series on dental trauma and infection management is to teach fundamental principles, pearls, and pitfalls in the care for dental patients in the emergency department. As many as 1.5% of ED visits are dental-related¹ and many emergency physicians have expressed the need for more comprehensive training in the oral cavity. This series was created as an introductory guide on the management of patients who report to the ED with dental-related conditions. The first module teaches the oral examination and demonstrates how to provide anesthesia in the oral cavity.

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

Learning Objectives

  1. Review basic anatomy of the oral cavity.
  2. Understand how to perform a basic oral examination.
  3. Learn to perform basic regional anesthesia to each region of the oral cavity.

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

Adult

The typical adult oral cavity contains 32 teeth split into 4 sections, with each quadrant containing 2 incisors, 1 canine, 1 premolars, and 3 molars. The universal numbering system labels dentition with numbers from 1 through 32 starting with the right maxillary third molar. When assessing the oral cavity for avulsed or damaged dentition, it is essential to note some individuals may have congenitally missing teeth or may have had dentition extracted in the past due to various reasons. Premolars can be found anterior to the molars, and they are smaller in width.

Adult Dental Anatomy Chart

Permanent dentition named and numbered (modified from Shutterstock)

Pediatric

Whereas adults have 32 teeth, pediatric patients have 20 primary teeth, labeled A through T. Pre-adolescents have mixed dentition, consisting of both deciduous (“baby” or “primary”) dentition and succedaneous (“permanent”) dentition. Most pediatric patients will have lost all of their primary teeth by 12 years of age.

Tooth Anatomy

Each tooth follows the same overall anatomical structure, as seen in the diagram below. However, the shape, number of roots, function, and other attributes vary from tooth to tooth. When referencing dentition, coronal is the portion of the tooth towards the crown. On the other hand, apical (as in apex) is the portion of the tooth towards the root.

A thorough oral examination is essential in the ED assessment of patients with dental complaints. When assessing the oral cavity for avulsed or damaged dentition, it is essential to note that some individuals may have congenitally missing teeth or may have had dentition extracted in the past. Obtaining a thorough dental history and oral examination may help to alleviate any potential confusion regarding special anatomical considerations. Note findings such as absence of teeth, poor/damaged dentition, supernumerary teeth, extracted teeth, and tori.

This diagram reveals the eight regions of the oral cavity that the provider should examine carefully. Manual manipulation of the tongue is easier when gauze is used to obtain a steadier grip. A tongue depressor is recommended for examination of the posterior oropharynx.

Oral Tori

Oral tori are uncommon but normal variants of bone found along the palate or lingual aspect of the mandible. They are bony structures in the hard palate or the mandible, as shown below. It is important to know that these structures exist so as to avoid being unnecessarily alarmed.

Photo and CT Scan of a Torus Palatinus

Torus seen on the hard palate [exam, CT image]

Maxillary Tori photo and a CT scan demonstrating the same

Maxillary tori [exam, CT image]

Notably, tori differentiate themselves from cancers and abscesses in a few ways.

  1. Tori are typically bony to the touch as they arise from bone. In contrast, abscesses and soft tissue cancers are more fluctuant and/or softer than bone.
  2. Tori are typically symmetrical from side to side.
  3. Tori are typically asymptomatic.

Local anesthesia is necessary before splint placement, incision and drainage, or any other procedure which involves significant and painful dental manipulation. It may also be used for temporary relief of substantial pain. Note that this is not a long-term solution but simply a temporary measure to bridge a patient to an outpatient dental appointment. In these cases, bupivacaine is recommended due to its longer half-life. The maximum dosage of local anesthetics should be calculated prior to administration (MDcalc).

With appropriate dosing and administration, you shouldn’t have to worry about toxicity, but you can read more about local anesthetic systemic toxicity (LAST) to be extra prepared.

Supraperiosteal Block

Anesthesia of the maxillary dentition is achieved through supraperiosteal (“local”) infiltration of lidocaine. tThe maxilla is more porous than the mandible, allowing easier penetration of the bone and anesthesia of the dentition.

1. Anterior Maxilla

Administration of local anesthesia to the anterior maxillary dentition can be particularly painful for patients given the extensive neural anatomy of the nose. Thus, it is essential to begin laterally and work in a stepwise fashion medially. Additionally, one can consider topical anesthesia with viscous lidocaine or benzocaine before using the needle.

2. Posterior Maxilla

For posterior maxillary teeth, use a short needle to minimize the risk for developing a hematoma. Taut retraction of the lip and the attached mucosa provides tension which makes needle penetration easier. Additionally, retraction activates proprioceptive fibers, which helps distract the patient from the pain of needle insertion.

Supraperiosteal Block: Site of local anesthetic deposition for infiltration technique to anesthetize regions of the maxilla. Source: NYSORA.COM

Technique

  1. Aim for the tooth apex and advance the needle while maintaining a needle position parallel to the long axis of the tooth.
  2. Penetrate the mucogingival junction with the bevel pointing towards the bone.
  3. Make contact with bone.
  4. Aspirate.
  5. Inject 1-2 cc of anesthetic.

Inferior Alveolar Nerve Block

The inferior alveolar nerve (IAN) is a branch of the mandibular nerve (V3 of the trigeminal nerve). Anesthesia of this nerve will result in anesthesia of the ipsilateral mandibular teeth to the midline, as well as the skin and mucous membranes of the lower lip, skin of the chin, and the labial gingiva of the anterior teeth. The goal is to inject local anesthetic in the region of the IAN before it enters the mandibular foramen at the medial aspect of the mandible.

Landmark Anatomy

The following figures help to clarify major anatomical landmarks for the IAN block:

IAN Landmarks

Inferior Alveolar Nerve Block: Pay attention to the site of entrance of the alveolar nerve into the mandible, and note the coronoid notch as an important landmark.

Inferior Alveolar Nerve Block Landmarks

Inferior Alveolar Nerve Block: The pterygomandibular raphe is a useful landmark to guide the intraoral injection point. When the patient’s mouth is held as wide as possible, the raphe tenses and becomes a visible reference line. The injection point (labeled with an X above) should be just lateral to the line so that the needle does not penetrate the raphe itself. An optional pre-step is to apply topical anesthesia with viscous lidocaine or benzocaine at the planned injection site prior injection.

Technique

  1. Place the thumb in the ipsilateral coronoid notch and visualize a line extending from the thumb back to the pterygomandibular raphe (roughly two-thirds up the finger nail).
  2. Keep the needle parallel to the occlusal plane with the bevel positioned away from the bone.
  3. Enter with the syringe oriented on the contralateral mandibular premolars.
  4. Insert the needle 1 cm above the occlusal plane and 3-5 mm lateral of the pterygomandibular raphe.
  5. Advance the needle 20-25 mm to sound bone.
  6. Retract 1-2 mm.
  7. Aspirate.
  8. Inject 75% of the total dose in this region.
  9. While removing the needle, inject the remaining 25% dose to anesthetize the lingual nerve. The total amount injected will be approximately 1-2 cc of anesthetic.
  10. Ensure adequate anesthesia by testing the patient for any acute pain upon manipulation. Keep in mind that it may take up to 5 minutes for the block to take effect following administration.

Of note, given its proximity to the IAN, the lingual nerve is also sometimes anesthetized during this block. This leads to anesthesia of the anterior two thirds of the tongue, the lingual gingiva, and the mucosa of the floor of the mouth.

Adjunctive Blocks

  1. Mandibular Incisors: The IAN block is typically sufficient to anesthetize the ipsilateral mandibular dentition and soft tissues. However it can somestimes under-anesthetize the mandibular incisors, If this occurs, we recommend adjunctive supraperiosteal blocks, as noted in the previous section. Note that supraperiosteal blocks, while useful in the maxilla, will not reliably attain complete anesthesia of the mandibular dentition as the mandible is less porous.
  2. Lips: The mental block is useful for the soft tissues of the lip anteriorly

Peer Reviewed

All information has been expert peer-reviewed by an oral and maxillofacial surgeon. 

Reference

  1. Hupp J, Ellis E, Tucker M. Contemporary Oral and Maxillofacial Surgery. Elsevier; 2019.
  2. Kademani D, Tiwana P. Atlas of Oral and Maxillofacial Surgery. Saunders; 2015.

By |2021-09-15T06:17:56-07:00Sep 15, 2021|ALiEMU, Dental, SmilER|
Read More

SAEM Clinical Image Series: Pediatric Penis Swelling

penile swelling

A 3-year-old healthy uncircumcised male presents to the Emergency Department with five days of penis swelling and pain. Five days prior, his father noted that the patient’s foreskin appeared stuck behind the head of the penis. The patient was seen at an urgent care facility four days prior and was given an antifungal cream for presumed balanitis, however, this did not resolve the patient’s symptoms. Since that time, the penis has been getting progressively more swollen and painful. The patient has not experienced the inability to urinate, decreased urine output, penile discharge, other penile lesions, fever, chills, abdominal pain, nausea, vomiting, testicular pain, or testicular swelling.

 

 

Vitals: Within normal limits

General: Alert, anxious

Genitourinary: Penile swelling, erythema, and tenderness to palpation

Non-contributory

Paraphimosis is a medical emergency due to the risk of tissue necrosis. A preputial or phimotic ring – a circumferential band of tissue – caught behind the glans causes swelling of penile tissue.

In the evaluation of painful penile swelling, the first step is to determine whether the patient is circumcised or not through a review of the medical record or discussion with the patient’s family. In an uncircumcised male, the critical next step is to assess for an entrapped and retracted foreskin (paraphimosis). Visualization of the glans penis and the urethral meatus as in this case demonstrates that the foreskin is retracted. Additionally, visualization of the glans penis and urethral meatus makes a scarred and unretractable foreskin (pathologic paraphimosis) unlikely to be the primary diagnosis. The differential diagnosis also includes hair tourniquet syndrome, chigger bites, and inflammation of the glans and foreskin (balanitis and balanoposthitis).

Take-Home Points

  • In any male presenting with penile pain, it is critical to first ascertain his circumcision status. In an uncircumcised male, visualizing the glans and urethral meatus demonstrates that the foreskin is retracted.
  • Paraphimosis is a medical emergency caused by an entrapped, retracted foreskin.

  1. Bragg BN, Kong EL, Leslie SW. Paraphimosis. 2021 May 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29083645.
  2. 2. Simonis K, Rink M. Paraphimosis. In: Urology at a Glance. Springer Berlin Heidelberg; 2014:361-364. doi:10.1007/978-3-642-54859-8_65

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

 

 

 

By |2021-09-13T10:34:13-07:00Sep 13, 2021|Genitourinary, Pediatrics, SAEM Clinical Images|
Read More

EMRad: Can’t Miss Adult Traumatic Hip and Pelvis Injuries

 

Have you ever been working a shift at 3 AM and wondered, “Am I missing something? I’ll just splint and instruct the patient to follow up with their PCP in 1 week.” This is a reasonable approach, especially if you’re concerned there could be a fracture. But we can do better. Enter the “Can’t Miss” series: a series organized by body part that will help identify injuries that ideally should not be missed. This list is not meant to be a comprehensive review of each body part, but rather to highlight and improve your sensitivity for these potentially catastrophic injuries. We’ve already covered the adult elbow, wrist, shoulder, ankle/foot, and knee. Now: the hip.

 

(more…)

By |2021-09-01T17:23:13-07:00Sep 3, 2021|Orthopedic, Radiology, SplintER, Trauma|
Read More
Go to Top