@WUSTL_EM #EMConf: #FOAMed Supplement No. 15

 1. Kawaski's Disease and Other Pediatric Rashes
- Life in the Fast Lane covers Kawasaki's disease.  For a quick reference, you can also see ALiEM's Kawasaki PV card.  Peds EM Morsels also covered delayed diagnosis of  Kawasaki's disease in the post.
- WikiEM has some images of basic pediatric rashes.
- UMEM Educational Pearls breaks down rashes into those that involve the palms and soles, desquamate, and have a Nikolsky's sign (helps narrow differential).  I would add that asking if their is mucocutaneous involvement also helps narrow things down.

2. Neonatal Fever Not #FOAMed, but here are some links to the papers discussed by Indi Trehan during his talk:
     Who to tap?  Performance of Low - Risk Criteria in Evaluation of Young Infants with Fever. 
     If LP is indicated, how do you maximize your success?  Maximizing Infant Spinal Tap Success and Ultrasound Evaluation of Spinal Anatomy in Newborns
    Once the LP is done, what do you treat with?:  Listeria and Enterococcal Infections in Patients 28 days and Younger - Is Ampicillin still indicated?

For #FOAMed resources:
Emergency Medicine Cases addresses pediatric fever without a source.  
PEM Currents Podcast covered The Febrile Newborn.

3. Tumor Lysis Syndrome & Other Oncologic Emergencies
- Test yourself on Tumor Lysis Syndrome basics with this Life in the Fast Lane post.
- emdocs covers Oncologic Emergencies in these posts:  Oncologic Emergencies I and Oncologic Emergencies II.
- Not really #FOAMed, but a good review.  Emergency Medicine Clinics of North America covered "Management of Pediatric Tumor Lysis Syndrome in the Emergency Department".
- Check out this interesting case related to hyperleukocytosis from Life in the Fast Lane.
- UMEM Pearls covers management of hyperleukocytosis/blast crisis

4.Tracheostomy Complications
 - See the Life In the Fast Lane Tracheostomy page .
 -  Management of respiratory distress in the tracheostomy patient as covered by  emdocs and First 10 in EM.

5.  UTI treatment in the ED
- Blake Bruton recommends this article from Emergency Medicine News entitled "Urine Dipstick testing: Everything You Need to Know."
- Best Evidence Topic Reports covers the sensitivity (or lack thereof) of the bedside urine dipstick in ruling out UTI in patient's who presents with urinary symptoms.

Enjoy,
Maia (@maiadorsett)

@WUSTL_EM #EMConf: #FOAMed Supplement No. 14

Welcome to @WUSTL_EM #EMConf, the #FOAMed Edition. The purpose of this weekly column is to identify #FOAMed resources that reinforce and expand on the concepts/facts discussed during weekly conference. Please post additional resources as comments below or tweet to @WUSTL_EM.


1. Core Content - Eye Emergencies
Dr. Philip Chan @PhilChan86 provided high yield information on causes of vision loss, a topic covered in the always helpful Life in the Fast Lane. Afterwards, head over to Academic Life in EM and work through the AIR Series, HEENT module, covering topics like "The Red Eye" and ocular ultrasound.

2. The Man and the Machine
Dr. Sean Cavanaugh gave us an amazing lecture covering his approach to LVAD patients, and how to troubleshoot common problems.  Summary? #Treat_The_Pt_Then_The_Machine


For more, head over to ED ECMO and get the basics from a review article by Dr. Partyka.

Once you have an idea about how LVAD's work, learn how to troubleshoot managing the crashing LVAD patient. Head over to EM Crit for a podcast and then to the Maryland CC project for video lecture. 

3. Approach to chest xrays
The Resident Focker family gave us a practical approach to chest xrays. Summary? #Haveasystem.  

A quick pocket tool for reading chest xrays can be found at Life in the Fast Lane. If you are an intern and new to radiographs, perhaps start with an interactive learning tool by Dr. Lieberman

4. QI: Early Septic shock, Sedation troubleshooting
Dr. Oberle reviewed the topics of early sepsis management, and common ED sedation complications. 


Dr. Oberle commented on recent publications regarding the benefit of earlier antibiotics in sepsis, see last weeks. #FOAM supplement for reference. In addition,  EM Lit of Note is also questioning the survival benefit. 

Want to be a master of the ED procedural sedation ? Start by using a Sedation checklist by EM Updates, then go on to watch the Sedation Trilogy  for sedation troubleshooting tips 

5.  Msk review: The foot part 1
Dr. Joy English gave us a nice introduction on foot injuries. Summary? #Useyourtools. Check out the The Ultrasound Site where they cover ultrasound diagnostics to potential foot and ankle injuries. 

The dude abides,

Louis Jamtgaard PGY-4
@Lgaard

@WUSTL_EM #EMConf: #FOAMed Supplement No. 13

Welcome to @WUSTL_EM #EMConf, the #FOAMed Edition. The purpose of this weekly column is to identify #FOAMed resources that reinforce and expand on the concepts/facts discussed during weekly conference. Please post additional resources as comments below or tweet to @WUSTL_EM.

1. Core Content - Eye Emergencies
-  EM Lyceum reviews topical anesthetics for corneal abrasions, timing of follow-up for patients with floaters, and the use of ultrasound to assess intraocular pressure in this post.
- Check out the Root Atlas, the "internet's best eye videos", for some instructional videos for procedures such as foreign body removal [this website really is awesome]. 

2. Sepsis in the Prehospital Arena
- One of our residents, Michael Willman, suggested this meta-analysis on affect of antibiotic timing on mortality in severe sepsis and septic shock.
- Consider reading this commentary by Alan Jones' group on the challenges of prehospital sepsis detection.
- See the July 2015 WashU Journal Club summary of studies evaluating early goal directed therapy for the treatment of severe sepsis and septic shock.
- Want to support research? Check out the Crowdfunding Page for development of the "Think Sepsis" tool at the University of Pittsburgh for prehospital sepsis recognition.

3. Neuro MRI protocols
-See this article regarding the increase in MRI exams performed through the emergency department
- Emergency Medicine Cases covers Low Back Pain Emergencies in the ED
- Our own blog covers the sensitivity of imaging studies for diagnosis of CSF shunt malfunction
- Review indications for critical and urgent MRI exams, as well as the correct exam for the indication:

4. Aortic Syndromes & Ultrasound
- Test yourself with Ultrasound Case of the Week #55 and #49.
- EM Curious Ultrasound Leadership Academy covers Aortic Ultrasound
- UMEM Education Pearls covers the suprasternal notch view for detecting aortic dissection.

5. Trauma Simulation -
- I've posted the link to Cliff Reid's talk on Making Things Happen many times, but I'm posting it again because if you haven't watch it yet, then do so now.
- Wash U EM Journal Club covered TXA in treatment traumatic hemorrhage, and the findings were nicely summarized in this article by our own Wes Watkins, Brian Cohn and Bill Dribben in epmonthly.
-ER Cast covers management of neurogenic shock.

Enjoy,
Maia (@maiadorsett)

The Times They Are A Changin': the "No Zone" Approach to Management of Penetrating Neck Trauma

Clinical Case: You're working a busy evening shift when a middle aged woman is brought in by EMS from the scene of a car accident.  She has a deep laceration to her anterior neck near the level of the cricoid cartilage from a glass shard.  She is neurologically intact, talking with a normal voice and is in no respiratory distress.  However, there is a continuous and brisk oozing of blood from the wound.

Clinical Question: What imaging is indicated in hemodynamically stable, neurologically intact patients with penetrating neck injuries?  What should the typical disposition be?

Literature Review:

Any neck wound that extends deep to the platysma is considered a penetrating neck wound, and it is estimated that they represent 5-10% of all trauma patients who arrive to the emergency department. Two common ways of anatomically dividing the neck include using the sternocleidomastoid to divide the neck into anterior and posterior triangles, or dividing the neck into three zones [1]:

In the event of penetrating injury to the neck, airway compromise should be immediately assessed, with early intubation for airway protection if there is any concern for expanding neck hematoma or concerns for airway injury.  An attempt can be made to orotracheally intubate (bougies have been suggested as excellent initial adjuncts [2]), but plans should be made to move to early cricothyroidotomy if the airway is unable to be secured from above. After securing the airway and establishing hemodynamic stability, the neck wound should be carefully inspected.  Injuries that breach the platysma may have caused significant underlying injury, and it is best to avoid probing these wounds at the bedside, as this could disrupt hemostasis.  Aside from risk of vascular disruption, patients with penetrating neck injuries warrant consideration of tracheal and esophageal compromise.  Signs of tracheal injury include air bubbling at the wound, hemoptysis, subcutaneous emphysema, and stridor.  Esophageal injuries can be initially be asymptomatic, and a missed injury can lead to neck space infection and mediastinitis [3].   Emergent surgical consultation is warranted, as patients with hemodynamic instability and/or "hard signs" of vascular or aerodigestive tract injury should go for emergent neck exploration [3].

Classically, management of hemodynamically stable patients with penetrating neck injuries was based on an anatomic "zone-based" approach mentioned above, with zone II injuries often going directly to surgical exploration and zone I and III injuries undergoing angiography, bronchoscopy, and esophagoscopy.  This approach was developed in the 1970’s, but it had several problems [4].  First, there may be poor correlation between the location of the neck wound and internal organ involvement, as there may be traversing of zones internally. Secondarily, the adoption of a mandatory-exploration policy lead to a high negative exploration rate (53% - 56%)[4,5].

With the rapid improvement and dissemination of the use of  CT over the past few decades, a “No Zone” management approach based on careful physical exam with CT angiography has been shown in surgical literature to decrease resource utilization and unnecessary surgical exploration, making the rigid zone approach less relevant [3].   Several studies have examined the sensitivity and specificity of CT angiography in stable patients with penetrating neck injury.  A study by Inaba et. al. prospectively evaluated an algorithm in which patients with "soft signs" of injury (venous oozing, non-expanding hematoma, minor hemoptysis, dysphonia, dysphagia, or small amount of subcutaneous emphysema) underwent an initial evaluation with CT-angiography and asymptomatic patients were observed [6].  Over a 31-month period, 453 patients with penetrating neck trauma were prospectively evaluated in their study.  186 of these patients had "soft signs" of clinical injury, and underwent CT angiography as their initial method of evaluation.  38.2% of these patients had an injury to zone II of the neck.  Using an aggregate gold standard of the final diagnosis at discharge which included operative exploration, catheter-based angiography, bronchoscopy, esophagogram and esophagoscopy results and clinical follow-up (duration not specified),  the sensitivity and specificity of CT Angiography for vascular or aerodigestive injury was 100% and 97.5 % respectively.  There were two patients who had false-positive findings of vascular injury (irregularities in the ICA) that were not present on follow-up with surgical exploration and/or angiography, and three patients had air tracking suspicious for aerodigestive tract injury that was not confirmed on follow-up imaging and endoscopic studies. 

As mentioned above, the "No Zone" approach combining clinical exam with imaging evaluation has the potential to decrease unnecessary neck exploration. A study by Osborn et. al. examined the rate of negative neck explorations in patients who were taken to the OR who did not have hard signs of injury.  They compared the rate of negative neck explorations amongst those patients who had a CT-A as part of their initial evaluation and those who did not, and found that CT angiography significantly reduced the negative neck exploration rate [7]:

Source: Osborn et al. (2008)

 In their review of penetrating neck trauma management, Shiroff at al. shared the algorithm below, comparing the traditional vs. "no zone" approach:

Image Source:  Reference 3

Take Home Points: Patients with penetrating neck trauma who are hemodynamically unstable or  display hard signs of vascular or aerodigestive should receive immediate surgical consultation with consideration for operative or invasive management.  As the traditional, anatomic approach to management of penetrating neck trauma is associated with a high rate of negative neck exploration, patients with soft signs of injury should be initially evaluated with CT angiography which has a high sensitivity for clinically-significant injury.

Submitted by Philip Chan, PGY-3
Edited by Maia Dorsett (@maiadorsett), PGY-4
Faculty reviewed by jason wagner (@TheTechDoc)

References
[1] Tintinalli’s Emergency Medicine, 7e.  Ch 257. 

[2] Daniel, Y., de Regloix, S., & Kaiser, E. (2014). Use of a Gum Elastic Bougie in a Penetrating Neck Trauma. Prehospital and disaster medicine, 29(02), 212-213.
[3] Shiroff, A. M., Gale, S. C., Martin, N. D., Marchalik, D., Petrov, D., Ahmed, H. M., ... & Gracias, V. H. (2013). Penetrating neck trauma: a review of management strategies and discussion of the ‘No Zone’approach. The American Surgeon, 79(1), 23-29.
[4] Prichayudh, S., Choadrachata-anun, J., Sriussadaporn, S., Pak-art, R., Sriussadaporn, S., Kritayakirana, K., & Samorn, P. (2015). Selective management of penetrating neck injuries using “no zone” approach. Injury.
[5] Varghese, A. (2013). Penetrating neck injury: a case report and review of management. Indian Journal of Surgery, 75(1), 43-46.
[6] Inaba, K., Branco, B. C., Menaker, J., Scalea, T. M., Crane, S., DuBose, J. J., ... & Demetriades, D. (2012). Evaluation of multidetector computed tomography for penetrating neck injury: a prospective multicenter study. Journal of Trauma and Acute Care Surgery, 72(3), 576-584.

[7] Osborn, T. M., Bell, R. B., Qaisi, W., & Long, W. B. (2008). Computed tomographic angiography as an aid to clinical decision making in the selective management of penetrating injuries to the neck: a reduction in the need for operative exploration. Journal of Trauma and Acute Care Surgery, 64(6), 1466-1471.

Consultant Teachings No. 4: "I'm Dizzy"

 
Clinical Scenario: It’s 3 AM in the ED when a 70 year old male with a history of hypertension comes in complaining of dizziness. You spend 10 minutes trying to get him to describe his dizziness, getting various descriptions of “lightheaded”, “spinning”, “imbalanced”, with him eventually saying “I’m just dizzy doc!!!”. The dizziness was described as sudden onset and had been constant for an hour, but had spontaneously resolved on arrival to the ED. During the episode, he had difficulty standing and stated that it felt like he would fall if he "didn’t hold onto something". He also noted some mild nausea and diaphoresis. Finally, he complained of a headache, though he has a long history of similar headaches. His initial head CT showed no acute process. 

Clinical Question: How do you evaluate a patient with acute dizziness?

Discussion & Literature Review: 
Dizziness and vertigo make up about 4% of chief complaints in the emergency department (ED) [1]. This chief complaint can be caused by pathology in many different body systems, and that pathology can range from benign to acutely life-threatening. For patients presenting to an ED with dizziness, affected systems include otologic/vestibular (32.9%), cardiovascular (21.1%), respiratory (11.5%), and neurologic (11.2%) as the top four diagnostic groups [2].

Dizziness Conundrum: Despite dizziness being a relatively common complaint, it can be very challenging to work up and manage. Traditional teaching on the evaluation of dizziness is to rely heavily on the quality of the dizziness, whether it is “spinning”, “lightheaded” or other similar descriptors [3]. However, this has been shown to be an ineffective means of establishing a differential diagnosis and may lead to dangerous misdiagnosis. Emergency department physicians (including residents) have been specifically studied and found to demonstrate over-reliance on symptom quality leading to subsequent high-risk reasoning [4,5]. There is also evidence that patients with the two most common vestibular disorders (benign paroxysmal positional vertigo (BPPV) and acute peripheral vestibulopathy) are often managed sub-optimally both in terms of diagnostic testing and prescribed treatment in the ED [6]. These studies suggest an opportunity to improve the emergency management of dizzy patients. 

History is Everything In the Dizzy Patient: As in all of medicine, obtaining an accurate and useful history is the single most important step in establishing the diagnosis of a patient with dizziness. The quality of dizziness lacks specificity in ED patients; one study found that patients describe their dizziness in multiple ways if given multiple options, may change their description of the dizziness if asked again only 5-10 minutes after initial questioning, and answer open-ended questions with vague or circular answers [7]. 

As opposed to the quality of symptoms, patients have been found to more reliably answer questions about the timing and triggers of their dizziness. This had led to the formulation of the “timing and triggers” model of history taking in the evaluation of a dizzy patient [8]. The goal of history-taking in this model is to identify the patient as having one of four syndromic patterns of dizziness:

· acute, spontaneous, prolonged (also known as the acute vestibular syndrome) 
· episodic, positional 
· episodic, spontaneous 
· chronic unsteadiness [8]. 

When asking about timing, attempt to clarify whether the dizziness is sudden or gradual onset, episodic or continuous, the duration of symptoms, and the frequency of symptoms. If the symptoms are episodic, clarify how long each episode lasts (seconds, minutes, hours, days) and make sure to ask if they completely return to normal between episodes or if they have constant symptoms with exacerbations. When asking about triggers, it is important to define true triggers as opposed to exacerbating factors. A common exacerbating factor is any form head movement, which generally worsens all forms of acute vestibular dizziness, so does not often help establish a diagnosis. However, if specific movements (i.e. rolling over in bed or changing posture) trigger the dizziness, this can lead to a diagnosis.  

Examination Tools and Tips: On physical examination, general medical and neurologic screening exams are important. Focal abnormalities on these exams may suggest a diagnosis (i.e. unilateral weakness or ataxia may suggest stroke, new cardiac murmur may suggest myocardial infarction or aortic dissection). However, there are specific physical exam maneuvers that can also be performed. The most commonly employed is the Dix-Hallpike maneuver to evaluate for benign paroxysmal positional vertigo (BPPV). This should be employed only if the patient describes episodic dizziness. The Dix-Hallpike maneuver will worsen the already-present spontaneous nystagmus during the acute vestibular syndrome, but this should not be taken as a positive test. The other test an ED provider should be familiar with is the HINTS-Plus exam [9]. This is a three step test of skew deviation, nystagmus, and head impulse testing (video links to a positive head impulse test, which suggests a peripheral etiology) combined with an assessment for unilateral hearing loss. This test is concerning for a central etiology with the presence of skew deviation, direction changing or vertical nystagmus, a negative head impulse test, and/or new unilateral hearing loss. In the evaluation of the acute vestibular syndrome, this bedside test is more accurate in the acute setting than MRI for diagnosing a posterior circulation stroke. Another physical exam pearl is that some patients can suppress nystagmus with visual fixation, so removing fixation can bring out their nystagmus. An easy way to do this is to turn off the lights and use your ophthalmoscope, which will block fixation and give you a magnified view of the eye for easier visualization of the nystagmus.

Summary and differential diagnosis: Once a patient’s complaints have been characterized by history as one of the four syndromic patterns discussed above, the differential diagnosis is much more limited. The physical examination assesses for specific diagnoses, which then guides further workup and treatment.

Source: Newman-Toker, D. E., Symptoms and signs of neuro-otologic disorders, Continuum (Minneap Minn), 2012, 18(5 Neuro-otology):1016-1040.

Submitted by Alex Dietz, Neurology PGY-4
Faculty Reviewed by Peter Panagos
Everyday EBM Editor: Maia Dorsett, PGY-4

References
[1] Saber Tehrani, A. S., Coughlan, D., Hsieh, Y. H., Mantokoudis, G., Korley, F. K., Kerber, K. A., Frick, K. D., et al., Rising annual costs of dizziness presentations to U.S. emergency departments, Acad Emerg Med, 2013, 20(7):689-696.
[2] Newman-Toker, D. E., Hsieh, Y. H., Camargo, C. A., Pelletier, A. J., Butchy, G. T. and Edlow, J. A., Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample, Mayo Clin Proc, 2008, 83(7):765-775.
[3] Kerber, K. A. and Newman-Toker, D. E., Misdiagnosing Dizzy Patients: Common Pitfalls in Clinical Practice, Neurol Clin, 2015, 33(3):565-575.
[4] Newman-Toker, D. E., Charted records of dizzy patients suggest emergency physicians emphasize symptom quality in diagnostic assessment, Ann Emerg Med, 2007, 50(2):204-205.
[5] Stanton, V. A., Hsieh, Y. H., Camargo, C. A., Edlow, J. A., Lovett, P. B., Lovett, P., Goldstein, J. N., et al., Overreliance on symptom quality in diagnosing dizziness: results of a multicenter survey of emergency physicians, Mayo Clin Proc, 2007, 82(11):1319-1328.
[6] Newman-Toker, D. E., Camargo, C. A., Hsieh, Y. H., Pelletier, A. J. and Edlow, J. A., Disconnect between charted vestibular diagnoses and emergency department management decisions: a cross-sectional analysis from a nationally representative sample, Acad Emerg Med, 2009, 16(10):970-977.
[7]Newman-Toker, D. E., Cannon, L. M., Stofferahn, M. E., Rothman, R. E., Hsieh, Y. H. and Zee, D. S., Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting, Mayo Clin Proc, 2007, 82(11):1329-1340.
[8] Newman-Toker, D. E., Symptoms and signs of neuro-otologic disorders, Continuum (Minneap Minn), 2012, 18(5 Neuro-otology):1016-1040.
[9] Saber Tehrani, A. S., Kattah, J. C., Mantokoudis, G., Pula, J. H., Nair, D., Blitz, A., Ying, S., et al., Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms, Neurology, 2014, 83(2):169-173.
 
Title Image source: wikipedia.

@WUSTL_EM #EMConf: #FOAMed Supplement No. 12

Welcome to @WUSTL_EM #EMConf, the #FOAMed Edition. The purpose of this weekly column is to identify #FOAMed resources that reinforce and expand on the concepts/facts discussed during weekly conference. Please post additional resources as comments below or tweet to @WUSTL_EM.


1. Evaluation of Pediatric Abdominal Pain
- Don't Forget the Bubbles had this post on the differential diagnosis for obstruction in the pediatric population.
- Our own EM Journal club covered non-operative management of pediatric appendicitis.
- St. Emlyn's covers the spectrum of pediatric emesis 
- FOAMcast covers pediatric GI emergencies.
- Test your pediatric X-ray prowess with this series of cases of obstruction vs. ileus.

2. Interesting Case Conference - Rocky Mountain Spotted Fever
- A good review on the Emergent Diagnosis of the Unknown Rash, including the deadly causes.
- Crashing Patient covers Tick-Born Illnesses

3. Neonatal Sepsis
- PEM blog reviews the evidence surrounding procalcitonin as a marker of serious bacterial infection in the febrile newborn and you can listen to a podcast about the febrile newborn.

4. Intraparenchymal Hemorrhage - EM Lyceum provides this comprehensive review on emergency management of ICH.

5. Pelvic Inflammatory Disease
- New England Journal of Medicine published this recent review on Pelvic Inflammatory Disease.
- EM Lyceum covers the history & physical exam findings, diagnostic workup & management of PID.

Enjoy,
Maia Dorsett (@maiadorsett)

On Broken Teeth: Emergency Management of Dental Fractures

Clinical Scenario: One evening in the ED, a teenage boy is brought in by his mother for dental trauma after an altercation at school.  The boy reports that he was pushed to the ground in the scuffle, hitting face first into the concrete. On exam, pinkish-red material was visible at base of what remains of his frontal incisors.  It's been awhile since you took care of dental trauma and you decide to read more about it. 

Clinical Question: What are the different layers of teeth and how do they impact severity of dental injury? What are the risk factors for dental injury? How are dental fractures graded and what steps should the ED physician take to protect remaining tooth fragments? 

Source: wikipedia.org

Review: Traumatic dental injuries (TDI) are a common occurrence in both children and adults. Approximately 1 in 3 adults sustain dental trauma during their lifetime, the majority which occur in childhood. A wide variety of risk factors have been described in the literature. These include patient specific factors like ADHD, epilepsy, cerebral palsy, propensity for risk-taking behavior, and anatomic factors like over-jet (the horizontal distance between posterior surface of the maxillary incisors and the anterior surface of the mandibular incisors) and inadequate lip coverage. In a review of rates of TDI in epileptic patients, over half had suffered TDI, many with multiple injuries. Environmental factors include poor socioeconomic status, living in an overcrowded environment and poor road safety [1]. Etiologies of TDI are broad with the most common mechanism of injury being falls. Adolescents and adults are more likely to sustain TDI through organized sporting activities, traffic accidents and violent means including fighting and assault.  In children, dental fractures can be a presentation of non-accidental trauma, and therefore a complete a full physical exam, including skin exam, should be performed. 

With regard to anatomy, primary dentition consists of 20 teeth – 8 incisors, 4 canines and 8 molars, classically lettered A – T. The permanent dentition includes 28 to 32 teeth – 8 incisors, 4 canines, 8 premolars and 8 - 12 molars. The 32 permanent teeth are numbered from right to left on top and left to right on the bottom [2].

With regard to anatomy of the individual teeth, from the inside out a tooth is composed of pulp, dentin and enamel [2]. The visible portion of the tooth is referred to as the crown and consists all three layers. As the tooth extends underneath the gum line, the enamel portion thins and the dentin and pulp extend in to the alveolar bone covered by a thin layer of cementum. The apex of the tooth is the entry point of the neurovascular bundle supplying each tooth. Finally,  the periodontal ligament is a collagenous strructure that extends from the alveolar bone to the cementum surrounding the root of the tooth.

Image source: Tintinalli, JE et al: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7^th Ed via Accessmedicine.com

The primary traumatic dental injury classifications are concussion, subluxation, extrusion, luxation, intrusion, avulsion and fracture [3].  Examination of a TDI should include visual inspection, percussion testing, manual evaluation of tooth mobility and consideration for radiographic imaging to evaluate for associated alveolar bone injury and widening of the periodontal ligament space. Sensitivity testing (cold testing) is often less useful at the time of injury due to transient lack of pulpal response.   

Dental fractures aka "broken teeth" require different management based on the extent of the injury.  The Ellis classification, which subdivides dental fractures into three classes of injury,  is useful for ED providers because it determines emergent care of the dental fracture [4]: 
              -    Ellis I fractures involve only the enamel.  They typically require no emergency treatment. If sharp edges are present, those can be smoothed for patient comfort. Dentist follow up can be at the patient’s convenience.
              -    Ellis II fractures involve the dentin but not the pulp  and  can be identified on exam by the creamy yellow color of dentin compared to the whiter, harder enamel.  These fractures require more urgent care.  Because dentin is a microtubular structure, Ellis II fractures threaten the integrity of the pulp and can lead to contamination of the pulp by oral flora . After recognizing an Ellis II fracture, the ED provider should anesthetize, clean and dry the tooth (Peridex can be used to sterilize the tooth) and seal the exposed dentin, which can be done with dental cement . Urgent dental follow up in the next 24 hours is recommended. Patients will require frequent visits and radiographs.
              -   Ellis III fractures are full thickness and expose the pulp.  They can be identified by visualization of the pink-red pulp as well as bleeding from the pulp on cleaning of the tooth. Like Ellis II injuries, the pulp is at risk with these injuries but at a greater extent given the direct exposure of pulp to the oral environment. Ellis class III injuries require a two step sealing procedure. After anesthetizing, cleaning and drying the tooth, bleeding should be controlled with careful direct pressure. The first sealant layer is a calcium hydroxide base. On top of this base, the same dental cement coverage is applied. Like Ellis II injuries, Ellis III injuries require urgent dental follow up preferably within 24 hours.   

For children with injuries to primary teeth, pulp exposure is more often encountered given the relatively larger size of the pulp. The same approach to different fracture types are recommended for children. Children will often require a pulpotomy to better protect the pulp from infection, but this requires more specialized tools and can be performed by the dentist in rapid follow up.

Because dental fractures can have associated injuries, it is important to examine for associated intraoral lacerations, tooth subluxation or avulsion. Subluxations and avulsions may require repositioning of the tooth and splinting to adjacent teeth with zinc oxide based dressings like Coe-Pak  [little trick of the trade: since the applications of dental splints requires teeth to be dry, cut off the end of oxygen tubing and attach to the air or oxygen on the wall to blow air onto the teeth and dry them prior to application of an adhesive dental splint]. 

With all of these injuries, patients should be discharged with oral analgesics, a soft diet and urgent dental follow-up. Generally, topical anesthetics should be avoided. Routine use of systemic antibiotics has not demonstrated benefit, but patient specific factors, associated injuries and co-morbidities should be considered [5].    
  
Take-Home Points:  Dental fracture management depends on the Ellis classification. Anything more than an Ellis I fracture requires some degree of a protective coating applied in the ED and referral to urgent dental follow up.  Always examine patients thoroughly for other associated injuries and watch for NAT. 

Submitted by Sara Manning (@EM_SaraM), PGY-4
Faculty Reviewed by Rob Poirier

Everyday EBM Editor: Maia Dorsett (@maiadorsett)  

In case you were thinking that "Broken Teeth" would be a good name for a band, it's already taken.  Thank you google.  

References:
1. Glendor, U, “Aetiology and risk factors related to traumatic dental injuries a review of the literature.” 2009. Dental Traumatology. Vol 25: 19 – 31. 
2. Tintinalli, JE et al, : Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th Ed via Accessmedicine.com 
3. Dentaltraumaguide.org
4.DiAngelis et al, “International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth.” 2012 Dental Traumatology. Vol 28: 2 – 12. 
5. ANDREASEN, J. O., STORGÅRD JENSEN, S. I. M. O. N., & SAE‐LIM, V. A. R. A. W. A. N. (2006). The role of antibiotics in preventing healing complications after traumatic dental injuries: a literature review. Endodontic Topics, 14(1), 80-92.

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