Conference Notes 08/30/23

Emergency Management of Dentition and Midface

Dentoalveolar trauma can include fractures, avulsions, displacement of teeth
An avulsed tooth is only viable within one hour, however, even outside of this window it is still worth replacing the tooth. In some cases, they may then get a root canal with dentistry
Alveolar fractures need timely treatment or risk poor cosmetic outcome and infection
Most oral abscesses can be drained in the ED with close dental follow-up
The need to obtain CT is dependent on the full clinical picture. If pt has significant RFs for deep space infection or cancer, it may warrant a face CT
Trismus sometimes can be confused with guarding due to pain. Can be worthwhile to provide analgesia and reassess
Buccal and canine space infections can present with significant facial swelling. These should be assessed with CT, drainage should occur from within the oral cavity near the involved tooth, not through the skin of the face
Radiology reads will frequently indicate Ludwig’s, however, this is often overread. True Ludwig’s is a surgical emergency. Can cause significant airway compromise
As a general approach to anesthetic for oral abscesses, should first infiltrate around the abscess, then can attempt direct injection
Inferior alveolar N blocks can be challenging due to surrounding vessels as well as the parotid gland that can be inadvertently damaged

Anti-Arrhythmics

Among the sodium channel blockers, they are divided into IA, IB and IC. Procainamide is the common IA, Lidocaine is a IB and Flecanide is IC
Class II antiarrhythmics are the beta blockers
Class III antiarrhythmics are K channel blockers. Amiodarone is the most common example
Class IV antiarrhythmics are the Ca channel blockers
Beta-blockers and calcium channel blockers should be used with caution in the setting of CHF exacerbation given their negative inotropic effects
Amiodarone has both rate and rhythm-control properties
Ibutilide and procainamide are the safest medications to give in the setting of WPW
Dr Huecker: Can also consider adding magnesium to any of the aforementioned therapies

Infective Endocarditis

Defined by the Modified Duke Criteria
Most commonly caused by Staph species
Don’t forget about pseudomonal coverage in those with prosthetic valves
Valves are at high risk of infection given their lack of robust vasculature as well as the turbulent flow around them
IE cases are increasing due to both increased IVDU as well as increased prosthetics being placed
The average age of IE is now >65. Majority will require surgical intervention
Recall Osler nodes, Janeway lesions, splinter hemorrhages, Roth spots/ conjunctival petechiae
IVDU leads to right-sided IE
When IE is diagnosed don’t forget to get blood cx from 3 separate sites
Empirically give Vancomycin. Add on pseudomonal coverage if pt has a prosthetic valve
The biggest RF for IE is prior IE
Undomiciled patients are at increased risk of IE due to Bartonella species given flea exposure

Ultrasound in the Unstable Patient

CXR sensitivity for edema/ effusions is low
Ultrasound has good sensitivity in confirming ETT placement
Palpating pulses during ACLS has poor sensitivity/ specificity, another area where ultrasound can be helpful, in addition to checking for reversible causes of a patient’s arrest
Ultrasound can be used to find the CO plus the SVR, which together can be very valuable information when resuscitating an undifferentiated shock/ SOA/ hypotensive patient

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