A 23-year-old male is in a bar fight. He only had "two beers" and was just standing there "minding my own business" when he was jumped by those infamous "two dudes" (how can those two dudes be in so many places at once!). He presents to you about 1 hour after the event with facial trauma. His vitals are normal and he is mentating well (with the exception of some impaired judgment secondary to the alcohol). His blood alcohol level is 150 mg/dL, showing that he is legally intoxicated. On examination, you notice that the patient has some epistaxis and a quite swollen nose. In addition, there is one avulsed tooth and one tooth that is displaced.
Question 1.8.1 The best way to transport an avulsed tooth is:
B) In the buccal mucosa after thorough washing with soap.
D) Wrapped in saline-soaked gauze.
Answer 1.8.1 The correct answer is "C." The best way to transport an avulsed tooth is (1) in a glass of milk, (2) in Hanks' balanced salt solution (good luck finding this when you need it!), or (3) in the buccal mucosa or under the tongue in a patient in whom the risk of aspiration is not a concern. "A" is incorrect because sterile water is hypotonic and may damage the tooth root decreasing the success rate of re-implantation. "B" is incorrect because washing the tooth with soap is not appropriate. Again, you want to maintain the viability of the root if possible. "D" is incorrect as well. If this is the only option available to you, it is better than nothing, but a glass of milk or under the buccal mucosa is preferred. "E" is acceptable only if you are a tooth fairy.
You call the dentist who is (of course) out of town. A dentist will not be available for at least 12 hours.
Question 1.8.2 Your best course of action at this point is:
A) Continue to keep the tooth viable in a glass of milk.
B) Continue to keep the tooth viable in the buccal mucosa.
C) Clean the tooth and keep it sterile and dry for re-implantation in 12 hours realizing that a bridge will probably be needed to hold the tooth in position.
D) Reinsert the tooth into the socket yourself.
Answer 1.8.2 The correct answer is "D." If there is going to be any delay in reimplantation by a dentist, the best course of action is to reinsert the tooth into the socket yourself. "A," "B," and "C" are all incorrect because they will reduce the rate of successful reimplantation.
Primary ("baby") teeth should not be reinserted into the socket! They ankylose to the bone preventing the eruption of the permanent tooth and cause a cosmetic deformity.
Any patient who is in the ED, says he only had three beers, and was "minding his own business" is probably not telling the truth on either account.
You now turn your attention to this patient's bloody nose and are trying to decide whether or not get an x-ray.
Question 1.8.3 The BEST timing for a radiograph of the nose is:
A) As soon as possible after the trauma once other injuries are stabilized and more important problems are addressed.
B) As soon as possible to assure that there are no bone fragments threatening the brain.
C) There is no need for a radiograph acutely. You can wait for 3 or 4 days.
D) There is never any indication for nasal radiographs.
Answer 1.8.3 The correct answer is "C." There is no need for radiographs acutely except in extraordinary circumstances. The reasons for a radiograph are to document a fracture and to assist in reduction. Because of swelling, it is difficult to get a good cosmetic result reducing a nasal fracture acutely. Thus, a radiograph is indicated in 3 to 4 days only if there is evidence of nasal deformity once swelling has resolved. If there is good cosmesis and the patient can breathe through his (they are almost always male) nose, a radiograph is unnecessary just to document a fracture. "A" and "B" are incorrect because, as noted earlier, there is no reason to do a radiograph at all unless there is evidence of deformity once the swelling is resolved. "D" is incorrect for the reasons noted earlier.
Question 1.8.4 You get the epistaxis stopped and examine the nasal mucosa. Which one of these is considered an emergency?
A) Closed nasal fracture.
C) Trauma to Kiesselbach plexus.
Answer 1.8.4 The correct answer is "B." A septal hematoma is considered an emergency. The problem is that the perichondrium, which supplies nutrition to the septum, is no longer in contact with the septum because of the intervening hematoma. Thus, the septal cartilage can necrose leading to a perforated septum. Septal hematomas should be drained acutely and the nose packed to keep the perichondrium in contact with the septal cartilage. "A" is incorrect (see previous question). "C" is incorrect. Kiesselbach plexus is in the anterior nose and is a venous plexus. Bleeding is easily controlled and generally is self-limited. "D," a deviated septum, may indicate an underlying fracture but in and of itself is not an emergency.
You continue to evaluate this patient and note that he has the loss of upward gaze in the right eye, the side on which he was hit. All of the other extraocular motions are intact.
Question 1.8.5 The most likely diagnosis in this patient is:
A) Blowout fracture with entrapment of the inferior rectus.
B) Blowout fracture with dysfunction of the superior rectus.
C) Injury to cranial nerve III, which controls the superior AND inferior rectus muscles.
D) Volitional refusal to perform upward gaze on the right side in this intoxicated patient.
Answer 1.8.5 The correct answer is "A." The most likely diagnosis is blowout fracture with entrapment of the inferior rectus. The force of a blow to the globe is transmitted to the inferior orbital wall, which is the weakest point in the orbit. This can cause entrapment of the contents of the inferior orbit, including the inferior rectus, causing an inability to perform upward gaze. Due to disconjugate gaze, patients with entrapment of the inferior rectus muscle from a blowout fracture may complain of diplopia. "B" is incorrect because a blowout fracture generally refers to the inferior orbital wall, which would not entrap the superior rectus. In addition, patients with an entrapped superior rectus would have difficulty with downward gaze. "C" is incorrect because it is unlikely that being hit in the face would cause an injury to CN III. In addition, a CN III lesion would affect all extraocular muscles except for the lateral rectus (CN VI) and the superior oblique (CN IV). "D" is incorrect because it is impossible to move the eyes independently of one another unless you are a chameleon or particularly talented.
Note that a blowout fracture may be a good thing. Having the fracture allows pressures to equilibrate and prevents orbital compartment syndrome (proptosis, visual loss, etc.). Proptosis with visual loss is a surgical emergency mandating an immediate lateral canthotomy (easy to do….check YouTube).
The patient has had a long night of partying, and it is 3:00 AM Saturday morning when you call your consultant about the blowout fracture. The consultant is not happy and refuses to see the patient acutely. He wants you to send him to the office in 3 days (Tuesday morning).
Question 1.8.6 Your response is:
A) To call another consultant; a blowout fracture should be attended to immediately.
B) Do nothing; evaluation in 2 to 3 days for a blowout fracture, even with inferior rectus entrapment, is appropriate.
C) Start steroids to reduce muscle edema to facilitate the spontaneous release of the entrapped muscle.
D) Start antibiotics and hospitalize the patient so that he can be seen in the morning when the consultant makes rounds.
E) Stick pins in a voodoo doll of your consultant.
Answer 1.8.6 The correct answer is "B." While blowout fractures with muscle entrapment require close follow-up, there is no need to intervene acutely. In fact, a decision to operate may be delayed for up to 14 days. If the entrapment spontaneously resolves when the swelling goes down (not uncommon) and there is no diplopia or other complicating symptoms, surgery is not needed. The other answers are all incorrect because acute intervention is not required in this patient. "E," however, may be of some benefit… depending on your voodoo skills.
Caveat to the above: In the pediatric population, immediate surgical repair should be undertaken in trapdoor fractures. A trapdoor fracture is one in which there is significant entrapment of the inferior rectus muscle. If the muscle is left entrapped in the pediatric population, restriction and fibrosis may occur, so immediate evaluation by a surgeon is warranted. Oral steroids at a dose of 1 mg/kg may decrease edema in the first 7 days limiting ultimate fibrosis. In patients with significant sinus disease, antibiotics may be considered, usually a penicillin or cephalosporin.
The patient mentioned above has a "friend" who was also in the altercation. He, too, was just "minding his business"—like everyone in the bar—until there was a gentleman's disagreement that could only be resolved with a broken bottle. He has a simple laceration of the chin, which you repair. This patient has a blood alcohol level of 150 mg/dL (the legal limit in most states is 80 mg/dL). Since he is intoxicated, the nurses are reluctant to allow the patient to leave because of liability issues. He seems initially very cooperative and competent. However, the nurse manager reminds you of the legal issues. The patient is getting more agitated; he wants to go home.
Question 1.8.7 Your response is:
A) Sedate the patient with haloperidol and observe him until sober.
B) Sedate the patient with a benzodiazepine and observe him until sober.
C) Call the police to remove this patient from your ED.
D) Use restraints on the patient and observe him until sober, as sedative drugs may prolong time in the ED.
E) Let the patient leave the ED with a competent adult.
Answer 1.8.7 The correct answer is "E." The patient was initially cooperative and competent. Competence is not based on a blood alcohol level but rather on your judgment of the patient's ability to make rational decisions. We allow patients on narcotics to make decisions about their own care all of the time despite having narcotics on board. There are patients who will have capacity and are safe at a blood alcohol of 200 mg/dL and others who may be impaired at 80 mg/dL. So, judge capacity individually.
Objectives: Did you learn to…
Treat acute dental trauma?
Diagnose and manage nasal and periorbital trauma?
Care for the intoxicated patient with minor trauma?