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Trick of the Trade: Dental Avulsion and Subluxation

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

 

Close up repair 4


Trick of the Trade

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

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

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

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

Warnings

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

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

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

 

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

IO needles intraosseous labs

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

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

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

PV Card: Interpreting Labs from the IO Line


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

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

Reference

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

Synapses serotonin syndrome

Background

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

  • Altered mental status
  • Autonomic instability
  • Neuromuscular hyperactivity

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

PV Card: Serotonin Syndrome


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

A video to remind you what clonus looks like:

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

References

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

Dizziness HINTS exam acute vestibular examWhat is your diagnostic approach to the acutely vertiginous patient?

The bottom-line question is: Is the cause peripheral or central in etiology?

In this great 2011 systematic review article in CMAJ on Acute Vestibular Syndrome (AVS), the authors review how (un)predictive elements of the history and physical exam are. By definition of AVS, symptoms must be continuous for at least 24 hours and have no focal neurologic deficits.

Frighteningly, the authors report many of the signs and symptoms (type of dizziness, hearing loss, patterns of nystagmus, Hallpike-Dix) are not as predictive as we classically are taught!

The take home point is to learn and incorporate the 3-part HINTS exam into your diagnostic approach (see bottom box on card). It is reported to be as good as a diffusion-weighted MRI for diagnosing a posterior stroke. The steps are:

  1. Do the horizontal head impulse test. (Normal = central cause)
  2. Check for directionally-alternating nystagmus movement on left and right gaze.
  3. Do the alternate cover test.

PV Card: Acute Vestibular Syndrome vs Stroke | The HINTS Exam


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

There is a helpful 10-minute video showing normal and abnormal HINT findings:

  • Head impulse testing
  • Nystagmus testing
  • Testing of skew

VIDEO LINK: http://emcrit.org/misc/posterior-stroke-video/

Thanks to Dr. Brian Resler (UCSF-SFGH EM resident) for giving me the heads up about this at Followup Conference!

Reference

  1. Tarnutzer A, Berkowitz A, Robinson K, Hsieh Y, Newman-Toker D. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011;183(9):E571-92. [PubMed]
By |2021-10-11T15:40:21-07:00Dec 2, 2011|ALiEM Cards, Neurology|
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Paucis Verbis: aVR Lead on ECG

ECG leads aVR lead

What lead is the most overlooked on the ECG?

 Answer: aVR Lead

This lead can provide some unique insight into 5 different conditions:

  1. Acute MI
  2. Pericarditis
  3. Tricyclic antidepressant (TCA) and TCA-like overdose
  4. AVRT in narrow complex tachycardias
  5. Differentiating VT from SVT with aberrancy in wide complex tachycardias by using the Vereckei criteria (possibly better than Brugada criteria)

PV Card: The aVR Lead on ECG


Adapted from [1-4]
Go to ALiEM (PV) Cards for more resources.

See also:

References

  1. Williamson K, Mattu A, Plautz C, Binder A, Brady W. Electrocardiographic applications of lead aVR. Am J Emerg Med. 2006;24(7):864-874. [PubMed]
  2. Vereckei A, Duray G, Szénási G, Altemose G, Miller J. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm. 2008;5(1):89-98. [PubMed]
  3. Kireyev D, Arkhipov M, Zador S, Paris J, Boden W. Clinical utility of aVR-The neglected electrocardiographic lead. Ann Noninvasive Electrocardiol. 2010;15(2):175-180. [PubMed]
  4. Riera A, Ferreira C, Ferreira F, et al. Clinical value of lead aVR. Ann Noninvasive Electrocardiol. 2011;16(3):295-302. [PubMed]
By |2021-10-11T15:47:33-07:00Nov 18, 2011|ALiEM Cards, Cardiovascular, ECG|
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