Transcript Dental and Opthalmologic Emergencies

Morehouse Pediatrics EM Lecture Series
November 23,2009
Taryn R Taylor, MD
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Epidemiology
Tooth Eruption & Shedding Schedule
Clinical Evaluation
Dental Concussion & Subluxation
Avulsion Injuries
Tooth Displacement
Tooth Fractures
Dental Abscesses
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Epidemiology
◦ 30% of children experience dental injuries
◦ Peak period of trauma to primary teeth is 18 to 40
months of age
◦ Trauma to permanent teeth
 School aged boys suffer trauma twice as frequently as
girls
 Upper (maxillary) central incisors are most frequently
injured
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Tooth Eruption & Shedding Schedule
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Clinical Evaluation
◦ Medical History
 Assess need for SBE prophylaxis
 Determine if child has a bleeding disorder or is
immunocompromised
 Record current medications and medication allergies
 Obtain history of previous surgeries
 Determine if tetanus immunization is up to date
 Determine if child lost consciousness due to injury
◦ Dental History
 How the injury occurred: provides info regarding severity
 When injury occurred: prognosis for injured tooth worsens
with every minute of delay in treatment
 Where injury occurred: helps determine whether tetanus
prophylaxis is warranted
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Clinical Evaluation
◦ Physical Examination
 General assessment includes review of vital signs,
evaluation of potential head and cervical spine injury
as well as ocular damage
 Extra oral evaluation
 Palpate mandibular condyles, maxilla, zygoma & TMJ
 Anterior open bite, malocclusion or limited mandibular
opening suggests condylar fractures or dislocation
 Note extra oral lacerations, bruises or swelling
 Lacerations must be inspected for foreign bodies i.e. gravel
or tooth fragments & be debrided if foreign body present
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Physical Exam cont.
◦ Intra oral evaluation
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Remove all clots and debris
Palpate alveolus to detect fractures
Have patient clench teeth to detect dental occlusion
Examine each tooth for damage or mobility
Examine labial mucosa, maxillary frenulum, gingival
tissues and tongue for bruising or lacerations
 Lacerations must be cleaned & explored for presence of
foreign body
 Frenulum will heal without long term consequences
 Most tongue lacerations will heal on their own, unless
tissue edges are not self-approximating
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Dental Concussion & Subluxation
◦ Concussion: Mild injury to periodontal ligament without
tooth mobility or displacement
◦ Subluxation: Significant injury to periodontal ligament
resulting in some tooth mobility
◦ These injuries may result in tooth discoloration
◦ Initial management
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Tylenol as needed for pain
Ice as needed for swelling
Soft diet
Follow up with dentist
◦ Dental office management
 Radiographs of primary tooth to evaluate for root fracture
 Splinting of permanent tooth if extremely mobile
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Avulsion Injuries
◦ Occurs when a tooth is completely displaced from the
dental socket
◦ Radiographs may be necessary if tooth cannot be found
◦ Primary Teeth
 Not reimplanted, as the risk of injury to developing
permanent tooth bud is high
◦ Permanent Teeth
 Best way to preserve an avulsed tooth is to replace it in its
socket as quickly as possible
 Periodontal ligament is protective layer surrounding the root,
which suffers irreversible damage if allowed to dry
 Do not touch root of tooth, handle by crown only
 Rinse only if there is dirt covering it, don’t scrub or scrape tooth
 Gently dislodge any clots, & reintroduce tooth into the dental
socket slowly
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Avulsion Injuries cont.
◦ Post Reimplantation care
 Dental consult immediately for splinting & tooth
stabilization
 10 day course of prophylactic penicillin
 Tetanus vaccination if wound is dirty or vaccination
requires updating
 Chlorhexidine gluconate rinses, oral hygiene & soft
diet instructions
 Analgesics for pain control
 Dental follow up within one week
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Tooth Displacement
◦ Luxation: Displacement of tooth in any direction,
while remaining in the socket
 Lateral luxation is usually associated with fracture of
alveolar bone
 Primary teeth: analgesia, proper dental hygiene,
prompt dentist follow
 Permanent teeth: gently reposition tooth, additional
care similar to primary teeth
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Tooth Displacement
◦ Extrusion: tooth is only partially removed from
socket
 Care similar to other luxation injuries
◦ Intrusion: tooth is impacted into alveolar bone with
associated fracture
 Intrusions of up to 3 mm have excellent prognosis
 Care similar to other luxation injuries
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Tooth Fractures
◦ Crown fractures are described by Ellis Classification
 Ellis class I: involves enamel only, rarely painful, cosmetic
implications only
 Ellis class II: involves enamel as well as dentin
 Sensitivity to cold air & fluids
 Emergency treatment aimed at protecting the pulp by applying
calcium hydroxide product
 Dentist follow up in 48 hours
 Ellis class III: dental pulp involved, often appears red
 Exposure of nerve endings causes extreme pain
 Exposure of pulp will lead to pulpal necrosis from bacterial
infection if left untreated
 Emergency treatment aimed at protecting the pulp by applying
calcium hydroxide product
 Dentist follow up within 24 hours
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Dental Abscess
◦ Results when inflammation of the pulp is left
untreated
◦ Pain, tenderness, red, swollen gingiva with areas of
fluctuance
◦ Complications include localized cellulitis, fistula
formation
◦ Emergency management includes pain control and
oral penicillin
◦ Prompt dental follow-up
◦ Emergent ENT consultation for patients requiring
incision and drainage due to severe pain or with
extension of infection into deeper tissues
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Landmarks of the eye
Different types of eye injuries
Emergency care for eye injuries
Orbital Cellulitis
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The globe of the eye, or eyeball is a sphere
approximately 1” in diameter
Five most important landmarks of the eye:
◦ Sclera- the “white” of the eye
◦ Cornea- clear, front portion of the eye that covers
the pupil
◦ Pupil- opening in which light enters
◦ Iris-colored portion of the eye
◦ Retina- back of the eye
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Ocular trauma is the leading cause of
noncongenital unilateral blindness in children
younger than 20
Most eye trauma occurs during sports
activities
Clinical Assessment
◦ Mechanism: blunt or sharp object, foreign body
present
◦ Symptoms: pain, photophobia, eye movements,
visual acuity
◦ Exam: Pupil size, shape, reaction to light: orbital
rims, floor, extra ocular motion
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Eye injuries are usually not life-threatening
Time is of the essence in your treatment
Six different types of eye injuries:
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Foreign object in the eye
Corneal Abrasions
Lid injury
Injury to the globe
Injury to the orbits
Chemical burn to the eye
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Extra ocular Foreign Objects
◦ Dust, dirt, sand or fine pieces of metal can be
blown into the eye & lodged on conjunctiva or
cornea
 Signs & Symptoms
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Pain, foreign body sensation
Excessive tearing
Reddening of conjunctiva
Decreased visual acuity
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Extra ocular Foreign Body
◦ Flush eye for at least 20
minutes
◦ If object cannot be flushed,
attempt to remove
◦ Evaluate for possible corneal
abrasion
To remove object:
Pull down lower lid while
patient looks up, or evert
upper lid while patient looks
down
Remove object with sterile
gauze
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Corneal Abrasions
◦ Most common eye injury in all ages
◦ Scraping away of the corneal surface, caused by:
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Injury
Blowing dust, sand, debris
Extended contact lens wear
Ocular foreign bodies, embedded under an eyelid
◦ Signs and symptoms
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Red, irritated eye
Foreign body sensation
Increased tearing
Photophobia
Fluorescein uptake under Woods lamp
◦ Treatment
 Polytrim antibiotic ointment or gtts
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Eyelid Lacerations
◦ Control bleeding with LIGHT pressure
◦ Ocular injury should always be suspected
◦ Lids should be everted and conjunctival surface
examined
◦ Orbital CT if suspected ocular penetration
◦ Laceration repair with 6-0 nonabsorbable suture
◦ Optho referral for repair:
 Lacerations involving nasolacrimal duct
 Full thickness lacerations
 Eyelid margin lacerations
◦ Lacerations from animal or human bites require
tetanus prophylaxis
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Injuries to Globe
◦ Subconjunctival Hemorrhage
 Blood between conjunctiva & sclera, stops at cornea
 Not an emergency
 Heals like any other bruise
◦ Hyphema
 Accumulation of blood in the anterior chamber
 Complications include inflammation and increased IOP
 Patients with sickle cell disease or trait & thalassemia are
at risk for central retinal artery and optic nerve damage
 Patients are at risk for rebleeding 3-5 days after initial
injury
 Initial treatment: bed rest, elevation of head of bed 30
degrees, optho referral
 Hyphemas > 50% should be admitted
 Avoid aspirin & NSAIDS
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Injuries to Globe
◦ Globe Rupture
 Can occur after significant laceration of cornea or
sclera due to sharp objects, or blunt trauma
 Visual loss, bloody chemosis, soft globe
 Protective shield should be placed over the eye
AVOIDING direct pressure on globe
 Broad-spectrum IV antibiotics against skin flora &
tetanus prophylaxis should be administered
 Analgesics, sedatives and antiemetics to decrease IOP
from vomiting
 Immediate ophthalmologic consultation required
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Orbital Fractures
◦ “Blowout” Fracture
 Following blunt trauma, eye is pushed through floor of
orbit, causing fracture of orbital wall
 Trapping of intraocular muscle prevents movement of
eye away from fracture site
 Facial asymmetry, sunken eye, paralysis of upwards
gaze, double vision
◦ Orbital roof fractures
 Occur mostly in children under 5 years
 Possibility of communication between orbit &
intracranial cavity
 Pulsating proptosis
◦ CT scan with immediate ophthalmologic
consultation
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Chemical Burns
◦ Represent a DIRE emergency
◦ Permanent damage can occur within seconds
◦ Burning and tissue damage will continue to occur as
long as substance is left in eye
◦ Signs and Symptoms
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Irritated, swollen eyelids
Redness of the eye
Blurred/diminished vision
Irritated, burned skin around the eyes
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Chemical Burns
◦ Emergency Care
Immediately begin irrigation with NS or LR
Continuously irrigate for a minimum of 20 minutes
Remove contact lenses-may trap chemicals
Wash your hands afterward to prevent contamination
to yourself
 Contact Poison Control Center for further information
 Referral to ophthalmologist
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Orbital Cellulitis
◦ An infection of the orbit itself, which occurs
 As a complication of sinusitis with extension of the
infection to the orbit
 Secondary to penetrating trauma
 As an extension of a nearby facial infection
◦ Signs & Symptoms
 Erythema, edema, induration and tenderness to peri
orbital tissues
 Decreased eye movement
 Proptosis, chemosis, decreased visual acuity and
papilledema
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Orbital cellulitis
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CT scan of orbit
Prompt treatment with IV antibiotics
Inpatient admission for frequent monitoring
Ophthalmologic consultation
Questions?