Upper airway and Dental Conference Review

Thanks, Zac Schirm for writing up these reivews!

Conference Review:

HEENT: Upper airway obstructions, foreign body

Pediatric Airway Differences:

  • Larynx closer to C3-4 (vs. 4-5 adult) = more acute angle of visualization; airway appears more anterior
  • Proportionally larger tongue
  • Narrowest portion airway at level of cricoid (as opposed to vocal cords in adults)
  • Large occiput will force head into flexion; support shoulders to make neck neutral/extended
  • Obligate nasal breathing in infants; don’t compress nares when bag mask ventilating

Airway Management Tips:

  • Have a mental plan for how you would manage a can’t intubate, can’t oxygenate/ventilate scenario in all age groups
  • Age of safe cricothyrotomy is controversial – ranges from 5-12; avoid unless you can definitely feel a distinct cricothyroid membrane
  • Review cricothyrotomy procedure vidoes and make yourself comfortable with at least a couple techniques
  • Scott Weingart’s bare minimum supplies cric involves an 11 blade, bougie, 6.0ETT
  • Initial cut is vertical over membrane followed by horizontal cuts laterally to open membrane
  • Finger remains in trachea, bougie over finger to ensure proper placement; ETT over this. Done.
    • Note, a proper tracheostomy tube is preferable as it’s easier to secure to neck, although there are special ETT holders available as well
  • Percutaneous transtracheal ventilation is difficult to do well and you should have a plan
  • 14G or higher needle attached to 10cc syringe (there are special needles for this that have ‘memory’ and are less likely to kink) filled with a few cc’s water. Aspirate until air bubbles and plunger pulls back and stays back
  • Once catheter inserted there are a myriad of MacGyver-type setups to help, as well as professional solutions (Jet Ventilator)
    • common solution is to take a 3cc syringe and remove plunger; attach BVM adapter from a 7.0mm ETT and connect BVM; 3cc syringe will screw into catheter for tight seal (this is high pressure delivered into a small catheter)
  • Allow for very long expiratory phase as barotrauma is a common complication and lots of air needs to escape through a tiny catheter if the upper airway is completely occluded

Epiglottitis:

  • Common pathogens include H flu B, strep PNA, B hemolytic strep, staph including MRSA
  • Vaccines should help protect from H flu B and strep, and have decreased incidence
  • Airway management is your primary concern
  • In a patient with severe respiratory distress (drooling, stridor, tripod positioning) but who is still ventilating adequately, immediate OR transfer is indicated for definitive airway placement (e.g. ENT via nasal route with surgery at bedside if surgical airway needed)
  • Secure an airway prior to transfer if at all tenuous; Use your resources! ENT, anesthesia, etc.
  • Defer, as necessary, HEENT exams in distressed patients as you may worsen their obstructions
  • Lateral neck radiographs may show ‘thumb print’ sign (thickened epiglottis)
  • 3rd gen cephalosporin AND anti staph agent (clindamycin or vancomycin); vanc if severe sepsis or high clinda resistance area; 7-10 days treatment
  • If a vaccinated child develops H flu B or pneumoccocal epiglottitis despite completed vaccines, consider immunocompromise workup
  • Remember appropraite chemoprophylaxis guidelines for contacts of H flu B+ patients (usually household only w/ rifampin)

Stridor:

  • Chronicity of complaint and patient’s age can help you narrow your differential

 

Acute Onset Subacute Onset Chronic
Foreign Body Aspiration Croup Laryngomalacia
Thermal epiglottitis RPA Vocal cord dysfunction
Anaphylaxis PTA Vascular ring
  Epiglottitis Bronchogenic cyst
  Bacterial Tracheitis Etc.
  • Another way to stratify is by age!
Neonate/infant Infant/Toddler School age/adolescent All ages
Congenital d/o’s Croup, croup, croup PTA Anaphylaxis
  Foreign body aspiration Vocal cord dysfunction Bacterial Tracheitis
  Epiglottitis    
  • See previous week’s review for more detailed information on RPA, PTA, etc.

Nasal Foreign Body

  • Toys, food, paper, beads, insects
  • Most common presentation is asymptomatic, but w/ history of insertion
  • mucopurulent d/c, foul odor, epistaxis also possible (<20%)
  • Diagnostics
  • Often a strong history and direct visualization enough
  • If unclear history, severe symptoms may consider xray vs. CT to determine object type and number
  • Treatment
  • button batteries and magnets must come out, otherwise this is elective
  • small children may need restraint either physical (taco roll) or chemical (ketamine)
  • if occlusive object, attempt positive pressure ventilation through mouth while occluding opposite nare
  • to visualize object, use vasocontrictor (oxymetalozine) plsu anesthetic (nebulized lidocaine) – except with button batteries
  • your tools here include alligator foreceps, suction for rounded objects, right angle hook, cyanoacrylates, or small balloons inserted distal to object
  • ENT may be necessary if unable to remove (penetrating, posterior, chronic with large inflammation)
  • Complications
  • aspiration of FB, infection, necrosis and perforation, epistaxis

Airway foreign body

  • Kids aged 1-3, adults w/ neuro disorders, intox, dentures
  • Peanuts most common in kids, hot dogs adults
  • Tend to lodge in: right lung (60%), left lung (23%), trachea/carina (13%), larynx (3%)
  • Presentation
  • ‘classic triad’= cough, wheeze, diminished breath sounds (57%)
  • cough most common
  • MONOPHONIC wheeze or DECREASED air entry REGIONALLY
  • Diagnosis/Treatment
  • Unstable patient (complete obstruction)
    • TO TO BLS
      • <1 yr alternative chest/back blows per BLS protocols, then direct inspection
      • >1 yr abd thrusts
    • Not working?
      • Direct laryngoscopy and magill forceps
    • Not working?
      • Above cords?
        • Crich/needle insufflation
      • Below cords?
        • Intubate to mainstem bronchus, pull back tube, ventilate L lung
      • Stable
        • Xrays help – inspiratory/expiratory to show air trapping (or decubitus films in infants)
        • UTD algorithm from here:

*CXR and algorithm from uptodate.com

Conference Review:

Dental Emergencies

Images from uptodate.com and Hudsonvilledental.com

 

Tooth Anatomy

Pain Control

  • Topical anesthetics
  • Benzocaine (6-20%)
  • Lidocaine (2-5%)
  • Gels placed w/ cotton tip
  • Benzocaine needs a few minutes, lido several more to act
  • Injectables
  • Bupivicaine – good for longer pain control
    • 6-8 hours complete, several hours partial
  • Lidocaine shorter acting for lac/tongue repair
  • Carpules will help with stability and aspiration
  • Supraperiosteal Injection
  • 1-2.5cc at APEX of tooth anesthetized (3-4mm deep)
  • Withdraw slightly if bone contact (avoid periosteum)
  • Inferior Alveolar Infection
  • Find coronoid notch, inject just posterior to this from angle starting over contralateral premolars 1-3cc
  • Anesthetizes retromolar region to midline, lower lip and chin, floor of mouth and tongue (ant. 2/3)
  • Midline teeth will have some controlateral crossover and may require supraperiosteal injection as well
  • Infraorbital nerve block
  • palpate infraorbital rim, feel notch; draw line from midline pupil, through notch and approximately 5-10mm inferior to this is infraorbital foramen
  • needle inserted vertically, about 5mm lateral to 2nd premolar on ipsilateral side – usually 15mm deep – 1cc injection
  • against, some crossover at midline

 

Dental Fractures

  • Classification
  • Ellis I, II, III (enamel only, enamel/dentin, enamel/dentin/pulp)
  • Enamel is white, dentin in yellow, pulp is pink/red
  • This system not used by dentists; just describe it to them
  • Treatment
  • Ellis I
    • can sad w/ emery board/rotary disc
    • counsel patient on rare possibilities or color change, pulp necrosis
  • Ellis II
    • need dentist w/i 24 hours as higher incidence pulp necrosis
    • cover dentin w/ ca hydroxide (other other paste)
      • helps pain and reduced infection risk
      • apple to dry tooth, foil not necessary if prompt f/u obtained
    • soft foods homegoing
    • antibiotics are controversial
  • Ellis III
    • TRUE DENTAL EMERGENCY
    • contact dentist if available at facility
    • can cover as above after discuss w/ dentistry, or if none available and you have arranged EMERGENT dental follow up
    • abx controversial
    • liquid diet only

 

Alveolar Fracture

  • Treatment is rigid splinting by oral surgery
  • You must identify the injury and severity
  • large and mobile or open fracture? Emergency
  • small and stable? 48-72 hours follow up ok

 

Luxation, subluxation, intrusion, avulsion

  • Subluxation – mobile, non displaced
  • Minimally mobile – leave ablone
  • Grossly mobile – can splint with coepak or self cure composite
    • soft diet, dental f/u 24 hours
  • Luxation – displaced partially or completely (i.e. avulsion)
  • splint and follow up
  • Intrusion – forced apically into bone (***can look like avulsion *** caution young padowan)
  • often stable, but require 24 hour dental follow up due to infection risk
  • Avulsion
  • DENTAL EMERGENCY!
  • Let’s play… where’s the tooth??
    • If you aren’t shown a whole tooth and/or history is unclear, consider intrusion and/or aspiration
    • cxr, panorex can help you here
  • Primary tooth?
    • Who cares! DO NOT reimplant – can cause problems
  • Permanent?
    • In 60 minutes or less periodontal ligament will dry out
      • Place in milk or save-a-tooth (hank’s balanced salt solution)
        • will preserve 8-12 hours
      • Saline if NOTHING else available
      • Saliva > H20
    • Reimplantation in field is o.k.
    • BEST case reimplantation:
      • frazier suction to gently remove clot → gently irrigate tooth and socket → hold tooth by crown → firm but gently pressure to place in socket → splint if mobile → tetanus UTD → soft diet home

 

Bleeding

  • Usually controlled with saline/hydrogen peroxide rinses and pressure
  • ED steps
  • Direct pressure AFTER removing excess clot w/ suction and gentle irrigation
    • Can use gauze roll soaked in epinephrine covered w/ 2×2’s
  • No dice? Infiltrate with lido and epi until blanching occurs – repeat bite/gauze
  • No dice? Gelfoam, surgicel, avitene, instat and gently close surrounding gingiva with slik suture – repeat bite/gauze
  • No dice? Consider systemic disorders and their reversal agents (coagulopathy, platelet d/o)

 

Alveolar Osteitis

  • Dry socket pain; is local inflammation of alveolar bone
  • Common after tooth extraction 2-4 days ago
  • history is classically smoking, drinking from straw
  • Irrigate socket and suction debris, then fill socket with dry socket paste or gauze w/ eugenol
  • antibiotics generally not indicated

 

Dentoalveolar Infections

  • Pulpitis
  • Usually from cavity eroding through, sometimes trauma/instrumentation
  • Periapical abscess
  • If drainage from pulpitis blocked can spread to periapical space
  • This hurts and can spread to deep structures
  • If there is localized, visible swelling/tenderness/fluctuance this requires I&D
  • Dental literature does not support antibiotics for pulpitis or localized periapical abscess but this is fairly common practice in emergency medicine
  • Can treat w/ nerve block and/or oral analgesics
  • Periodontal Disease
  • Infection of gingiva, periodontal ligament, and alveolar bone
  • Red, inflamed gums that bleed easily; usually doesn’t hurt so this is an uncommon ED complaint
  • If abscess forms, needs drainage, then saline or chlorhexidine rinses
  • ANUG (aka vincent’s angina or trench mouth)
  • Acute necrotizing ulcerative gingivitis
    • SEVERE pain helps distinguish from chronic periodontitis
    • bad breath, blunting of interdental papilla, necrotic slough of gingiva
  • Needs debridement (from their dentist, urgently), chlorhexidine rinses and abx (pcn or flagyl for 7-10 days)
  • Pericoronitis
  • Inflammation over erupting teeth may trap bacteria (especially molars)
  • Easily spreads to deeper spaces
  • Usually have trismus 2/2 irritation of masseter or pterygoid muscles
  • Need to detect deeper spread if at all suspected – CT best
  • Any evidence of advanced infection – IV abx, urgent drainage
  • Localized?
    • Saline rinses and oral abx – dental f/u in 24-48 hours
  • With all of these infections, be on the lookout for deep space infections
  • Maxillary extension of periapical abscess to cavernous sinus
  • Mandibular periapical extension can go to submandibular space – ludwig’s
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