Day 4 Leaderboard

Things are tight at the top of the #PEMTwitterTriviaContest Leaderboard.

Tied for first place are:

@paulbunchmd

@MarlinaLovett

Not too far behind are @GreggKottyan, @Bedingaj, @ziggy7652, and @dbailey4

If you're not participating - what are you waiting for? @PEMTweets continues this weekend with 'Mom' related questions, that will make you 'fussy' if you miss out on the learning.

The 'tooth' about dental injuries

Dislodged/Luxated Teeth

Intrusion: Tooth impacted into the alveolar socket

Extrusion: Tooth vertically dislodged from the socket

Lingual luxation: Displcement of the tooth towards the tongue

Labial luxation: Tooth is displaced toward the lips

Lateral luxations: occur within the plane of the tooth

Luxations of primary teeth are treated by extraction. Permanent teeth are immediately treated if malocclusion or significant mobility is present. It consists of repositioning and splinting.

Intrusion injuries are generally followed up by a dentist within 48 hours. Permanent teeth will generally re-erupt within 6 weeks. Intrusions <3mm have a good prognosis, those >6mm have a poor outcome secondary to inflammatory root resorption.

Avulsed teeth

teeth that have been knocked completely out of the socket. The best storage media in order of preference are milk, saliva, and saline. Hank's Solution (Save-a-Tooth) can preserve the fragile periodontal ligament for 24 hours. the major risk of not preserving a tooth is that it will dry out. Ideal re-implantation  with 90% survivability occurs within 90 minutes. Survival decreases 1% every minute thereafter, with very few teeth surviving after being out >2 hours.

Primary teeth should never be re-implanted, as there is a risk of interfering with the eruption of a permanent tooth, as well as ankylosis (fusion of the tooth with the alveolar bone) occurring.

Tooth Fractures

Class I:Chips or fractures in the outer enamel layer only
Class II: Fractures into the dentin layer
Class III: Fractures into the pulp of the tooth
Class IV: Fractures onto the root often vertical fractures

When to consult dentistry

Immediate

• Avulsed permanent teeth
• Luxation injuries with malocculsion or significant mobility
• Root fractures with crown displacement
• Alveolar ridge fractures (socket)

Within 48 hours

• Tooth fractures (Class II and III)
• Tooth subluxation
• Tooth intrusion
• Luxation without malocclusion or significant mobility

Non-urgent follow-up (1 week)

• Tooth concussion
• Class I tooth fracture

Peritonsillar abscesses

Symptoms start approximately within a week (2-8days) before abscess formation

• Progressively worsening, unilateral sore throat and odynophagia
• persistent pain
• fever, malaise, headache
• hot potato voice
• tender cervical lymphadenopathy
• referred ipsilateral ear pain
• halitosis
• trismus

Exam findings

• Redness and edema in the tonsillar area of the affected side
• The uvula may be displaced towards the unaffected side

Etiology

• Strep, Staph, and Nontypeable H. flu

Management

• I&D + antibiotics

See this video for a PTA I&D: http://www.youtube.com/watch?v=h9Ap2X7xqQo

What have we learned today?

#PEMTweetsID Q10: What is the most common cause of a temperature >38 C in infants age 1-3 months presenting to the ED?
Viral syndrome at 54% is far and away the #1 cause

#PEMTweetsID Q11: When fever rises about what temperature (centigrade) does the risk of bacteremia increase four fold?
40 C has a risk of 38%, <40 the risk is only 8.8% as noted in http://www.ncbi.nlm.nih.gov/pubmed/15874809

#PEMTweetsID Q12: What is the most common cause of bacterial sepsis in newborns?Group B strep

#PEMTweetsID Q13: How do the bacteria that cause preseptal vs orbital cellulitis differ?Preseptal is usually secondary to extension from local skin infections or direct trauma. Spread form the ethmoid sinus can occur. Staph and Strep species predominate. Treat with MRSA coverage.


Orbital cellulitis extends most typically from the sinuses (75%) S pneumo and Moraxella. These patients need IV therapy - Ceftriaxone or Cefotaxime.

#PEMTweetsID Q14: What is ophthalmia neonatorum?neonatal conjunctivitis occurring in the first month. It can be concerning for gonorrhea, chlamydia, HSV and other bacterial organisms.Gonorrhea usually occurs 24-48 hours after birth whereas chlamydia starts slower within the first 3 weeks.

#PEMTweetsID Q15: A 2 year old with high fever, difficulty swallowing, who won’t look up with the following XRay likely has what? This is a classic XRay for a retropharyngeal cellulitis or abscess. The prevertebral space is greater than one half the width of the vertebral body. Current evidence suggests that most of these kids can be initially treated with IV antibiotics, even if a phlegmon or early abscess is present.

Standings as the sun rises on day #2

As we head into Day 2 of the Pediatric Emergency Medicine Twitter Trivia Contest we have a tight race at the top. Remember, that even though only the first person to answer gets the point - I'll do my best to respond to every post and give feedback on the answer. My primary aim is that you learn stuff. Basically, on day 1 I was impressed by your collective smarts!

1st @paulbunchmd 4 points
2nd @MarlinaLovett & @GreggKottyan 3 points

Bacteremia - She ain't what she used to be

Interesting article from Pediatrics this past March looking at the epidemiology of sepsis in newborns.

http://pediatrics.aappublications.org/content/129/3/e590.abstract


The investigators conducted a retrospective review of over 160,000 full term infants that had a blood culture drawn. Only 2% were positive (93/4255), with 247 positive cultures being due to contaminants. The incidence rate in this study was 0.57 per 1000 live births. 


Pathogen #1 was E coli (56%), and 98% of these infections were UTIs. GBS was second, and S aureus was third. Listeria and meningococcemia were left out in the cold (no cases of either).


Does this change your practice?


How would you alter your discussion with families about fever in the neonate after reading this study?


Are there any limitations to the methodology that are noteworthy?

Categories of shock and physiology overview

There are four main categories of shock:


Hypovolemic

• #1 cause worldwide
• Deficiency in intravascular volume
• Gastroenteritis, hemorrhage, increased urine output (DKA), 3^rd space losses, burns

Distributive

• Inappropriate distribution of blood volume into the tissues
• Septic, Anaphylactic, Spinal (Neurogenic)

Cardiogenic

• Myocardial (pump) dysfunction
• Congenital heart disease, myocarditis, arrhythmias

Obstructive

• Physical obstruction to blood flow

Remember: The overall goal of treating shock is to prevent end-organ injury and halt the progression to cardiopulmonary failure and cardiac arrest!

Contest Rules

The rules of the Pediatric Emergency Medicine Trivia Contest are simple. I'll post questions multiple times a day to the @PEMTweets Twitter feed. Each is worth 1 point unless otherwise specified. Answer the question by 'Replying' to the original tweet. You can use whatever resources you see fit to find the answer. 


Look for me to Reply regarding an answer, and if it is correct - that question is closed. First one to answer it right gets the point(s).


I'll keep a log of correct answers, and post the updated leader board on this website.


Don't worry if you miss a question - more will be tweeted soon enough. The 'themes' will be denoted by a hash-tag (#) - #PEMTweetsSample is an example. You can search for these hash-tags on twitter. Essentially, it's a way of indexing content. You'll know that we're on to a new theme once the hash-tag changes.


Please let me know if you have any questions, and good luck!