Adult Emergency Medicine: HAP9

Showing posts with label HAP9. Show all posts

Sunday, 25 May 2014

Dental Blocks

It's on our syllabus that we should be able to do dental nerve blocks - and I suppose we should all be happy to at least give it a try. There are lots of potential dental nerve blocks that can be used. The Oxford Handbook only mentions two of them, so I'm only going to cover those two.

Infraorbital Nerve Block

- Supplies the skin and mucous membrane of the cheek, upper lip, lower eyelid and side of the nose.
- Emerges from the infraorbital foramen (0.5cm below the infraorbital magin and vertically below the pupil).
- Insert the needle into the buccogingival fold between the first and second premolars and direct it up towards the infraorbital foramen.

Mental Nerve Block

- Sensation to the lower lip and the chin
- Emerges from the mental foramen, which is palpable on the mandible on a line between the first and second premolar teeth.
- Block at mental foramen with 1-2ml of LA
- Intraoral or extraoral approach

http://www.emergpa.net/wp/wp-content/uploads/Emergency-Dental-Handbook.pdf

http://www.ncemi.org/cse/cse0420.htm

TMJ Dislocation

Identification
- 90% of cases are bilateral
- Most common cause is excessive mouth opening
- Anterior dislocations are most common.
- Posterior, lateral and superior dislocations are associated with a fracture.

Preparation
- Protect your thumbs with gauze rolls around each thumb.

- Adequate analgesia
- Consider intra-articular lignocaine
- X-ray to confirm reducation and no fracture. May not be necessary if pain settled completely.

Procedure
Massage masseter muscles
Apply rotational force on the mandibular ramus

After Relocation Advice
- Keep jaw closed for next 24hours
- Head bandage if chronic
- Soft diet

References
http://academiclifeinem.com/trick-of-the-trade-massaging-a-mandibular-dislocation-back-in/
http://academiclifeinem.com/trick-of-the-trade-protecting-your-thumbs-in-mandible-relocations/
http://academiclifeinem.com/trick-of-the-trade-stabilizing-mandibular-relocations/
http://crashingpatient.com/medical-surgical/oral-medicine-and-dentistry.htm/
http://academiclifeinem.com/trick-of-the-trade-temperomandibular-tmj-dislocation/
http://www.enlightenme.org/knowledge-bank/cempaedia/mandibular-and-temporomandibular-joint-injuries
http://emedicine.medscape.com/article/149318-overview

Tuesday, 20 May 2014

Dental Fractures

The first step is to have a look at the tooth and work out what tooth it is.

Then have a look and try and work out what is wrong with it. See what it looks like. See if it's sore. See if it wobbles.

Concussed
- no obvious displacement. Tender to touch.
- not wobbly.
- soft food for a week

Subluxation
- Increased mobility and pain
- Some associated bleeding
- Increased mobility
- Soft food, clean carefully, chlorhexidine mouthwash.

Extrusion
- Partial displacement of the tooth out of its socket
- Partial or total separation of the peridontal ligament resulting in loosening and displacement of the tooth.
- Tooth appears elongated
- If <3mm in an immature developing tooth, needs careful repositioning.

Intrusion
- May or may not intersect the secondary tooth bud.
- May penetrate into the nasal cavity.
- Often associated with alveolar fracture.
- Needs repositioning and careful advice.

Avulsion
- Empty socket
- Do not replace
- Consider x-ray to check not aspirated. Soft food for a week.

In adults
- Wash briefly
- Reposition
- Bite on a hankerchieft to hold it in position
- Glass of milk for storage.
- Flexible splint for two weeks

Infraction
Crack - No follow up needed

Enamel Fracture
Smooth sharp edges

Alveolar Fracture
Manual repositioning + stabilising of the segment
Monitor
Soft diet

Tooth Fractures
These need things done to them. You can catagorise them using the Ellis staging system. I'm going to refer them all to max fax/ a dentist.

Post Extraction Problems

Bleeding - rolled up piece of gauze in the socket for 10min. May need horizontal matress suture - use lidocaine + adrenaline.

Dry socket pain - if bone exposed. Typically 3- 8 days later. Irrigate with warm saline, oral antibiotics, analgesia and dentist.

http://www.annemergmed.com/article/S0196-0644%2809%2901141-X/abstract
http://emin5.com/2014/04/07/dental-fractures/
http://www.dentaltraumaguide.org/Permanent_Alveolar_fracture_Description.aspx

Monday, 12 May 2014

Dental Emergencies

Incisors grow at 6 - 10months

Canine 16 - 20months

Molars 10 - 24months

Secondary incisors grow at 7 -8 years

Canine + pre-molars at 11- 13years

Molars 6 - 25years

Abscess

Likely to be streptococcus or staph aureus.
In history ask when it started, whether antibiotics used, about presence of systemic features, and immunocompromised.

Not all patients need antibiotics - give if systemically unwell, high risk or likely complications.

Amoxicillin or metronidazole - either works.

Admit if systemically unwell, antibiotics no help, rapid spread, dysphagia or dysphonia, immunocompromise or GA needed.

Vincent's Angina

Acute necrotising ulcerative gingivitis or trench mouth

Causes pseudo-membranous infection.
Needs chlorhexidine mouthwash with metronidazole or amoxicillin.
Dental review ASAP.

Ludwig' s Angina - submandibular abscess

Mostly affects males, between 20 -60 years old
Peri-apical abscess of the 2nd or 3rd molar penetrates the inner cortex of the mandible and gains access to the area inferior of mylohyoid. The infection tracks posteriorly so the sublingual space is involved.
The tongue is forced upwards and backwards.
It causes fever, pain, drooling, trismus, dysphagia, submandibular mass and dyspnoea.

Hot potato voice.

Lemierre syndrome

Thrombophlebitis of the jugular veins with distant sepsis of oropharyngeal infection (pharyngitis / tonsilitis +/- peri tonsillar abscess). Caused by an anaerobic gram-negative bacillus.
Patients present unwell, trismus and pain behind the angle of the jaw.

USS shows thrombophlebitis of the internal jugular vein which is often the first hard evidence to suggest Lemierre's.