Sink Your Teeth Into this TIME SENSITIVE Topic!

http://www.dentaltraumaguide.org/permanent_avulsion_treatment.aspx

******PLEASE ALSO REVIEW VIA THE REX WEBSITE LIBRARY THE TOOTH AVULSION CHAPTER IN UPTODATE, WHICH HAS SUPERB PICTURES******

While we are obviously not dentists, facial and dental trauma are a part of urgent care practice. I will be the first to admit that a medical provider can quickly get lost in the dental terminology of dental concussion, subluxation, intrusion, extrusion, and avulsion. Here are the imperative points though:

• With a facial trauma, and a "knocked out tooth", in the mayhem of patient and understandable parent panic, don't lose sight of the forest for the (tooth) trees. In other words, make sure that the c-spine is alright, assess for loss of consciousness and intracranial injury risk factors that take precedence over the tooth, and do a quick body survey and history for potential child abuse.
• The most dreaded and time sensitive is a full tooth avulsion. These injuries, for PERMANENT TEETH, need care within 1 hour and if not placed in proper medium, the tooth and its essential periodontal ligament have a zero percent survival rate. 

      As such, our main focus is:
1. Is this a permanent tooth? Here is a basic guide:
-All teeth are primary for kids less than 5.
-Permanent incisors usually erupt around age 6-7. Note the frontal maxillary incisors are the 2 most commonly injured teeth.
- Mixed dentition occurs in ages 6-12. As such, this will be the "tough group."
-Most kids over 13 have all permanent teeth.

2. Is this an avulsion? Again, I suggest the UptoDate pictures, but in non dental language the tooth is totally knocked out at the gumline, the periodontal ligament is severed, and a fracture of the alveolar ridge may also be present. AVULSION NEEDS REIMPLANTATION AS SOON AS POSSIBLE. NOTE THAT FROM THE TRAUMA UNTIL REIMPLANTED AND SEEN BY A DENTIST, COLD MILK IS THE BEST TRANSPORT SOLUTION, OR IF THE CHILD IS OLD ENOUGH TO NOT ASPIRATE IT, INSIDE THE BUCCAL MUCOSA.
Per UptoDate, here is the basic-and doable-guide to reimplant the avulsed tooth and quickly being sent to the ER or dentist. Again, the 1 hour window applies to reimplantation, so you can make a big difference here...

• handle the tooth carefully by the CROWN and avoid the ligament
• remove debris by gentle rinsing with saline or tap water (again, milk is the preferred storage medium over saline for transport). DO NOT ATTEMPT TO STERILIZE OR SCRUB THE TOOTH, as you want to keep the periodontal microfibers.
• manually reimplant the tooth in the socket- see picutre 8 in up to date.
• keep the tooth in place by having the child bite down on a clean gauze or towel.
• see the dentist or pediatric ER as soon as possible.   

Again new things are always intimidating, but here is the cheat sheet summary:
1. SEE ALL DENTAL INJURIES ASAP IN THE CLINIC. 
2. IF A PARENT CALLS IN ROUTE, OR IF THE PATIENT HAS THE TOOTH IN HAND, PLACE IT IN COLD MILK OR THE BUCCAL MUCOSA. NO SCRUBBING.
3.IF A PERMANENT TOOTH, REIMPLANT IT TO MAINTAIN VIABILITY AND SEND TO THE DENTIST ASAP. 

 

Enter the Enterovirus D68

http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html?s_cid=cdc_homepage_whatsnew_001

Above is the link to the CDC website for enterovirus D68. Note that at least as of September 22, 2014 the CDC says it is not in North Carolina yet, but given its spread and proximity it is safe to say it is here and just undetected, or will be soon. A few salient urgent care points for this after reviewing the current information on EV-D68.

• Recall this is an enterovirus, which technically is the same grouping as polio. Recall that with these enteroviruses, while droplet spread is typical, a large amount of organism is shed in the stool.  As such, a valuable pearl for prevention in families is to remind family members to be especially diligent about washing hands (for at least 20 seconds) after diaper changes.
• Perspective is a key ally against the fear mongering in the news media. So far,  175 people in 27 states were confirmed to have EV-D68. Most of these patients were tested due to a need for hospitalization. For comparison, think how many children and adults are hospitalized in an average flu season.
• EV-D68 especially attacks babies, infants, children and teens. Most adult immune systems have already seen an immunologic plethora of enteroviral infections, and as such more immunity is present in older people. 
• MOST CRUCIAL POINT- FEVER, ESPECIALLY HIGH FEVERS, ARE NOT TYPICAL FOR EV-D68.  Almost subconsciously, like a pneumonia, one would expect respiratory severity to correlate with fever, but this is not the case. Yes, fever can cause tachypnea but EV-D6 can cause respiratory distress without fever.
• SECOND MOST CRUCIAL POINT: RESPIRATORY DISTRESS IS THE ATTACK MODE FOR THIS VIRUS. AS SUCH, IT IS IMMENSELY HELPFUL TO GAUGE THE CHILD'S RESPIRATORY STATUS BY SITTING AT THE BEDSIDE- SHIRT OFF (TO SEE ABDOMINAL BREATHING, NECK, AND RIB RETRACTIONS)- AND THEN TIME THE RESPIRATORY RATE FOR A FULL 30-60 SECONDS. USE A CLOCK, AS OTHERWISE YOU WILL STOP AT 15 SECONDS BECAUSE IT FEELS  LIKE 30 SECONDS.  This "old school" physical diagnosis pearl yields a veritable cornucopia of information. Plus, to the concerned parents this shows concern as this exam exudes thoroughness and an attention to detail. Try it- you will be amazed how a simple task can go so far. I have lost count of the number of times I thought a patient would need the hospital at triage, or conversely was unimpressed at triage, only to pull a "complete 180" after doing this maneuver. 

Obviously, much like Ebola, I suggest checking with the CDC website about every 2 weeks, especially as these are fluid epidemiological situations that are very much in the public mind. 

Nice Review that Will Raise Your Blood Pressure

http://reference.medscape.com/viewarticle/827504?src=wnl_edit_specol&uac=61764CK

Above is a link to a decent Medscape question/summary on hypertensive urgency and emergency, one of our Express Care bread and butter topics.
My only add on is to remember to thoroughly document your "end organ targets" in your note. For instance, don't forget to document your (undilated) fundoscopic exam. Get an urinalysis if you feel the need, or an EKG. Keep the end organ targets in mind to keep your documentation on target!

An Early Flu Guidance Tip

http://www.jwatch.org/fw108998/2014/06/27/cdc-panel-recommends-nasal-flu-vaccine-over-shot-kids?query=pfw

At the end of June 2014- for the 2014-2015 flu season, the CDC's Advisory Council on Immunization Practices (ACIP) formally voted that for healthy children ages 2-8, that the FluMist (the nasal flu vaccine that is attenuated- not killed like the shot) be the flu shot of choice for this age group. The reasoning was studies show much greater immunogenicity to the nasal spray as opposed to the shot.

While we do not give flu shots in this age at the Express Cares, this is a key guidance item to stay up to date on since we field many flu questions in our clinic.

Just to add to the controversy, the American Academy of Pediatrics disagrees with the ACIP, citing the higher cost of the FluMist and it's restriction to healthy kids, including excluding those with a history of asthma.

I think common sense here is to advocate as the first priority for all people over 6 months of age to simply get vaccinated. Then, for this age group and if accessibility is not an issue, one can show preference for the nasal vaccine. As always, www.cdc.gov and www.immunize.org are supreme, reliable resources for all vaccine information, and you can print out any VISs if needed.

A True Family Medicine-And Urgent Care Bible

I will admit I am a book junkie. and not the usual Kindle crap. I need to smell the book. Regardless of your proclivity to books, one that truly belongs on your bookshelf is:

The Color Atlas of Family Medicine- by Richard Usatine

This beautiful treatise was published in 2009, and its collection of photography and practical pearls is unrivaled. This vast collection clearly is the lifetime work of Dr. Usatine and only a fool would not try to gleam some of his hard won pearls.
The key feature of the book is how it mixes terse text with attached pictures to really cement your memory.
Use a bit of your Rex CME money to purchase this book. You will not regret it!

More Chest Pain Pearls

In urgent care, you can never have enough
http://www.jfponline.com/articles/editor-s-pick/article/chest-pain-tools-to-improve-your-in-office-evaluation/a48c14ba150da0e57563a48747c26535.html

chest pain pearls:

If the link goes down, then go to www.jfponline.com

The major take home point here is that for patients that you deem do not need the ER due to high GERD suspicion, consider at least 2 weeks of a PPI. I will admit, I tend to aim for 4-6 weeks of OTC meds, but the article points out a minimum of 2 weeks to judge efficacy.

Don't Lament Lemierre!

No article here, but I wanted to reiterate an entity that is gaining more recognition: Lemierre syndrome.
WHEN  do I consider this lethal entity? Awareness of this dangerous disease occurs anytime someone starts with pharyngitis and returns 3-6 days later with markedly worse fever and neck pain. Once again, beware of the bounceback!!!!! 

WHAT is Lemierre syndrome? Lemierre is a syndrome of bacterial infection that starts in the throat, then progresses. The #1 pathogen is Fusobacterium necrophorum, but Staph and Strep are also in the mix. The start is with a sore throat, then fevers of 102-105F, 4-5 days later. Then, while the sore throat may lessen, new neck pain, chills, dysphagia, and dyspnea develops, along with malaise and night sweats. Basically, an abscess is forming a suppurative thrombophlebitis of the IJV. The final death knell is usually lung involvement with septic pulmonary emboli.
In summary, the 4 classic Lemierre criteria are:

• recent oropharyngeal infection
• clinical or radiographic evidence of IJV thrombosis
• isolation of anaerobic pathogens
• evidence of at least one septic focus, often the lungs (this means watch out for pleuritic chest pain!)

WHAT do I do in the Express Care with a patient whom I think has Lemierre? Run like hell! No, just kidding.  Lemierre victims emergently need a CT with contrast of the neck and chest to first check the internal jugular vein, and second, to check for pulmonary emboli. Obviously EMS may be needed depending on the patient's appearance and respiratory status.

In summary, most of us when confronted with a "bounceback" sore throat with worse fever and neck pain will think mono, or perhaps even PTA. However, this 3rd option should be kept in your diagnostic acumen!

Making Your Suturing a "Cut" Above

http://www.jfponline.com/home/article/a-guide-to-better-wound-closures/da908f34dd436bab74e1fe982565ced9.html

The above link (if it goes down just search the article on www.jfponline.com) has some nice, classic tips on proper sewing for not just good, but great, outcomes. A few highlights, but again the article is encouraged:

• NEVER underestimate the importance of a well documented flushing of the wound. Again, avoid alcohol or anything that could harm the new, regenerating tissue. A solid rule is the old maxim, "don't put anything in a wound to clean it that you would not put in your eye!"
• Note the table on suggested suture removal times. In the real world, I have long railed against the "usual 7 days" for MOST wounds (ie- those from the neck down excluding the fast healing well vascularized face and scalp). I totally concur with the table in that the majority of our express care lacs need 10-14 days.
• The # 1 tip to go from good to great in sewing is this: EVERT the edges so dermis matches dermis. Many subtle tricks, ranging from deep, tension relieving mattress sutures to undermining the wound edges exist. The key is to aggressively utilize these tips consistently!

All is not So Well with the Wells Rule

http://www.bmj.com/content/348/bmj.g1340

At the link above, note that a recent metanalysis has detected that one cannot rely on the DVT Wells rule alone in 2 important circumstances- active cancer and a history of previous DVT/PE. The Wells rule had an unacceptable (higher than 2%) false negative rate for these 2 subgroups, and as such D-Dimer testing for rule out was needed despite the low risk Wells.

While this affects ER care more than express care, it does reinforce these 2 points:

• When assessing patients with respiratory complaints in the express care and you are tallying history to rule out DVT (and also PE), thoroughly respect and lend credence to active cancer or previous thrombotic history. 
• Again, always keep DVT/PE in the differential, and document as many points as possible against it if you do not send someone to the ER. Medicine will humble you through a PE or DVT.

More Information on CA-MRSA

https://mail.rexhealth.com/owa/attachment.ashx?attach=1&id=RgAAAADl1XTUhfhQSbuUVKYGOBoABwBsXF%2b%2b5jagQ7x0ZqjK4HMvAAAGpllIAABpl1Wt0lmiTr42aFQwe7JSAAAzXUNZAAAJ&attid0=BAAAAAAA&attcnt=1

Attached above is (hopefully) the article from last month's NEJM on CA-MRSA. I encourage you all to review this article, and if you cannot, I will gladly send you the email link that lasts 30 days. A few summary points:

• The article readily admits that much is based on clinical experience, not evidence based medicine. 
• Like most CA-MRSA articles the article takes the "ivory tower" suggestion of solely relying on incision and drainage without antibiotics, but then lists the legion amount of caveats that indeed need antibiotics: multiple sites of infection, "rapid disease progression", associated cellulitis, signs of systemic illness, very young or advanced age, or face/hand/ genitalia abscesses. So, in the real lawyer infected world this means: "Everyone gets antibiotics." Note any first year lawyer can take the obtuse term "rapid disease progression" and contort it to a jury with a second grade health literacy level. ( FYI- national average is 4th grade.)
• I found most useful the evolving prevention tips. I have long been a fan of Hibiclens, and the article had some actual tips.

HIBICLENS/Prevention Tips

• Apply to all body parts from the neck down (stings the eyes,nose mouth), then rinse. Do this for 5 days.
• Remember that after you apply the Hibiclens in the shower and rinse, do not remove the protective layer by then applying soap, shampoo, etc. One female patient told me "So, you mean the Hibiclens is like conditioner...you apply it last and try to keep some in." Being bald, I told her it made sense in theory:).
• Also consider 2% mupirocin to the nares with a sterile cotton swab bid for 5 days. 

A "Laceration" to the Old Dogma

As people say, "these times are a changing!" One issue is the below cited study- now the second of 2 large studies in the last decade, to challenge the "1970-ish" dogma of either not closing or "loosely" closing wounds that present late. Please recall that a "late" presentation can often vary by body site and proximity to and amount of circulation, so a forehead laceration at 12 hours could still be considered by many to be "fresh" but the same laceration on the anterior leg in a diabetic smoker would very correctly be viewed as "late" at 12 hours. 

http://www.jwatch.org/na33434/2014/02/07/management-lacerations-dogma-changing

If you elect to close a "late" presenting wound, please remember the overall summary of the study:

• The study advocates that a late presentation is not a factor in infection rates. Rather, location (i.e. less blood supply) and co-morbidities play a larger role.
• Focus on the crucial mention that a key issue in infection prevention is through flushing. Recall the medical school surgical rotation maxim: "The solution to pollution is dilution!" I heartily recommend for medico-legal purposes in every suture case to document the amount of flush and diluent and method. For example say, "The wound was flushed with 250 cc of normal saline via Zero Wet apparatus."
• One unofficial laceration rule is that for every centimeter of laceration aim for a "minimum" of 100cc of flush. So a 3cm laceration needs a minimum of 300cc of flush.

Elderly Abdominal Pain-Know the Ischemia!

Elderly abdominal pain is always a conundrum. Even catastrophic, life threatening diagnoses can present with vague and mild symptoms. One confusing area-that has multiple variants- is the issue of ischemic intestinal disease.  In this realm of diseases, note that the ideal way to remember the presentations is to think about and thoroughly understand the source of the ischemia in the first place. Relating this physiologic origin to the clinical presentation in the clinic will assist your memory and recognition skills. Remember, the eyes cannot see what the mind does not know!

While I will explore the permutations of ischemic intestinal disease (IID) shortly, recall that all IID, regardless of etiology- has risk factors. Keep these in mind.

Risk Factors for Ischemic Intestinal Disease

• Atherosclerosis
• Recent MI
• Atrial fibrillation (be sure to listen to the pulse on your visit, as the a-fib could be new onset!)
• Dilated Cardiomyopathy
• Hypovolemia
• Valvular disease
• Advanced age
• Intra-abdominal malignancy (see thrombosis below)   

Now, let's review the variety of issues with IID.

Chronic Mesenteric Ischemia 

• Note the chronicity.
• Is an issue of low flow, not actual occlusion.
• Resembles intestinal angina, often see post prandial pain. Crampy and poorly localized.
• Phagophobia- actual weight loss because the angina is triggered by intestinal demand.
• "Classic patient"-Female over 60 with CV risk factors, past negative workup for cancer (due to weight loss), with several months of pain, and has been told she has irritable bowel syndrome (recall irritable bowel syndrome is usually a "young person's" disease!).
• 10% are guaiac postive, 60-80% have an abdominal bruit. 

Acute Mesenteric Ischemia

• Is the usual pain out of proportion to exam.
• Usually involves the superior mesenteric artery (SMA)
• Can be embolic (clot forms in heart from a-fib, then breaks off and lodges in the SMA), or can be thrombotic (just like cardiac angina can occlude to the point of a MI, the above chronic mesenteric ischemia can progress to total occlusion and become an acute "intestinal heart attack" via thrombosis).  
• Triggers for the thrombosis can be infection or abdomen trauma. 
• Classic triad is 1.formal "acute abdomen pain", with 2.cardiac disease and 3.acute GI emptying (forceful nausea, vomiting and bowel evacuation).
• Mortality is 70-90%. Translation- if this elderly acute abdomen is missed the lawyers will come calling!
• Recall pain out of proportion to exam---the patient is writhing!

Mesenteric VENOUS Thrombosis

• is 5% of the acute ischemias, but can present in a sub-acute manner
• I predict this is the one most unknown/overlooked.
• Cardinal feature is that the patient has an underlying hypercoaguable state. Remember one of the above risk factors is "abdominal malignancy".
• Involves superior mesenteric vein
• 50% of these cases have a family history of venousthromboembolism!
• Usually mid abdomen, colicky pain and unlike the arterial acute ischemias, patient often waits over 48 hours to present.
• Key risk factors: family history of VTE, female, smoker, birth control pills, recent abdomen trauma/MVA, other risk factors for VTE like malignancy.
• over 50% have heme pos stool.
• IN SUMMARY THIS IS A DVT OF THE INTESTINE. SO RISK FACTOR ASSESSSMENT IS IMPERATIVE.

NON- occlusive Mesenteric Ischemia (NOMI) 

• This is basically secondary intestinal ischemia from a primary inciting insult, such as MI, CHF, sepsis, or shock.
• Insidious onset of hours to days, and 25% lack abdomen pain, and rather have a quiet, distended abdomen without rebound.
• Often can occur post cardiac surgery or dialysis.
• Attacks the aged (over 70) with severe atherosclerosis ( dialysis, legion stents, etc.)
• Physiologically is hypoperfusion to watershed areas of splenic flexure and distal sigmoid.
• Key here is not to ignore the "rotting intestine" as you focus on the primary insult.

 Respect elderly abdomen pain, as it can hurt the patient and the medical provider severely!

( Summary source: "General Surgery, Part II The Acute Abdomen" Lecture by Americo D. Fraboni, MD for AAFP Board Review Manual, 2013 edition. Published by American Academy of Family Physicians)

Otitis Media 2- A Challenging Picture Primer

http://www.medscape.com/viewarticle/813360?src=wnl_edit_specol&uac=61764CK

In this second article on the omnipotent OM, take the Medscape quiz above on OM. The picture review is a nice reminder of effusions versus infection versus normal ears. The article speaks for itself. Try it....you'll be a better clinician for it!

A Pearl On Otitis Media that Actually Helps

http://www.medscape.com/viewarticle/814301?src=wnl_edit_specol&uac=61764CK

Above is a Medscape article from the CDC regarding how to safely fine tune your antibiotics (both when to use and doses). Note if the link is wonky, I highly suggest you simply register with Medscape as they keep a useful urgent care pearl about every 6 weeks, at least based on casual following.
     Now before you roll your eyes about "another article about how antibiotics are the Satan and Apocalypse of otitis media" let me say I do have empathy for the medical provider who is tired of being the "conscience of the world". We all know the real world scenario that the government CDC "suits"-who have no patient contact- miss. Your typical urgent care otitis media is a single mom who has been told to "go home and pound sand" by their pediatrician once or even twice. Tired due to 3 nights of lost sleep and about to get fired from her job due to poor performance and not enough sick days, she demandingly comes into urgent care on Day 3 to 5 of the infection. As such, this article has some pearls on use and indications.
     My favorite was tip #3, where it honed in on the proper duration of antibiotic therapy to lessen the amount of resistance. For children 2 or younger with "severe infections" use a 10 day therapy. For pediatric patients 2-5 years old, aim for 7 days. Lastly, for children 6 years old or more, squeeze by with a 5-7 day duration of therapy.
     The fact that OM is still the #1 reason for pediatric antibiotics in this country proves the discord from the academics and society. Use the tips to soothe parents and minimize the chance of antibiotic harm.