Pedo Core 13: Adewumi Emergency Protocols + Infections

Front 1

1) #1 thing to ask if a child comes into the ER?
2) 6 emergency conditions in children?
3) 7 steps in diagnostic strategy?

Back 1

1) Was there loss of consciousness?
2) Dental infections (most common), facial cellulitis from odotongenic infection (OI), dental/facial trauma, loose teeth/restorations, bleeding/pain following exts, medically compromised children
3) History (duration, intensity, previous therapy), med history, extra-oral/intrao-ral assessment, apporpriate radiographic views (daignostic and medicolegal reasons), temp, behavior assessment, plan of action

Front 2

1) 6 steps in evaluating trauma?

Back 2

1) Med history (check tetanus status and other immunization history)
2) Ask if LOC
3) When/where/how injury occurred
4) Previous trauma
5) Present malocclusion
6) All tooth fragments accounted for

Front 3

1) 4 things to look for in extra-oral exam
2) 5 things to assess during intra-oral exam
3) What does the PA radiograph assess?
4) Panorex?
5) Upper anterior occlusal?
6) Lateral skull
7) Soft tissue radiographs?

Back 3

1) Lacerations and abrasions, tooth fragments in soft tissue, difficulty in opening/closing, step deformity on closure
2) Lacteration of mucosal or gingival tissue, then assess the dentition for any fracture or displacement injury , extent of displacement injury, presence of mobility, abnormal occlusion
3) Open/closed apex
4) Developing dentition, mandibular or condylar fractures
5) Root fractures
6) Relationship to permanent successor
7) Tooth fragments

Front 4

1) Trauma in permanent teeth can affect what 2 things?
2) Most important thing to ask besides loss of consciousness if they have trauma?
3) How to tx avulsion in permanent teeth? (What to do with the socket, how to handle the tooth, how to deal w/ tooth if contaminated, what to do with alveolar fracture?)
4) If you don't replant on time, what happens?
5) How many teeth do you have to splint on either side?
6) Protocol, post-op instructions?
7) Immediate/long-term plan?

Back 4

1) Function, psychological reasons
2) Tetanus shot
3) History, reimplant ASAP (irrigate socket if clot is present, avoid curretting), handle tooth crown NOT the root. If contaminated, irrigate gently w/ saline. Use blunt instrument into the socket and reposition bone if alveolar fracture present
4) Get resorption
5) At least 1
6) Replant tooth with/without LA, place non-rigid splint, antibiotics, chlorhexidine, soft diet, reinforce OHI, review within 48 hours to check splint
7) Review within 7-10 days, pulp extripation and fill canal with non-setting CaOH, remove splint, endo referral for obturation

Front 5

1) 4 things to ask when getting a history of a dental infection?
2) 5 principles of treating an infection?
3) What 4 things should you look for in your extraoral exam?
4) What 3 things should you feel for in your extraoral exam?
5) What 3 things should you palpate for in your intraoral exam?
6) What will make diagnosis difficult?
7) What 4 things you have to consider in doing an emergency tx with children?

Back 5

1) Duration (any preceding tootache or other pain, how long has the patient had the swelling?), intensity (is it getting worse or radiating to other sites?) Any temperature changes? Previous therapy (analgesia, antibiotics)?
2) Remove source of infection (ext or endo tx), drain, prevent spread (use of antibiotics, oral or IV), restore function, maintain analgesia and adequate hydration
3) Presence of swelling and its size (mild/moderate/severe), extent of swelling (indicates spread), is spread localized or generalized, limited function?
4) Size of swelling, extent and limit of swelling including lymph nodes/midline, any rise in temperature
5) Consistency (fluctuant/firm/hard?), associated tenderness from teeth (look for carious teeth or deep restoration, OH), mobility/percussion
6) Several carious teeth
7) Child apprehension, parental anxiety, smaller structures, be gentle/firm/nice

Front 6

1) How to tx double tooth syndrome?
2) Main complication of exts and 4 ways to manage?
3) Remind parent and child about lip, cheek, and tongue biting for how many hours?

Back 6

1) If loose, encourage pt to wiggle. If firm, ext
2) Hemorrhage - 1) Allow adequate time and pressure w/ gauze pack. 2) Gelfoam, surgicel may enhance clot formation. 3) Sutures with resorbable 3'0 vicryl suture. 4) Stimate or amicar mouthwash (antifibrinolytic) - in pts who have prolonged bleeding
3) 3-5 hours

Front 7

1) 3 causes of OI in children?
2) 5 clinical features of OI?
3) How do infections spread in children vs. adults, and what is a major concern?
4) Most dental pulp infection in children drain ____. Why?
5) When does cellulitis occur?
6) Is a "gum boil" superficial or deep drainage?
7) Definition of cellulitis? 3 ways it's classified?
8) Look at picture of spaces, identify: retropharyngeal space, lateral pharyngeal space, masseteric space, pterygomandibular space, sublingual space, submandibular space, submental space, prevertebral space
9) 6 compartments that allow the spread of OI?

Back 7

1) Carious teeth, traumatized teeth, perio disease
2) PLS Feel Me: Pain (localized or generalized), Local redness on affected side of the face, Swelling (cellulitis or abscess formation), Fever (temp elevation >104), Malaise => anorexia, nausea, fatigue, sweating, dehydration
3) Spread more rapidly, dehydration is major concern
4) Superficially. Root of primary teeth usually resorb in response to extended pulpal inflammation, roots are shorter, and posterior primary teeth frequently have accessory canals in the floor of the pulp chamber, which encourages superficial drainage.
5) When deep drainage into the tissues occurs
6) Superficial
7) An infection of the cellular adipose tissue located in aponeurotic spaces. Classified by location, severity, and evolution
8) Superficial spaces between facial skin and facial bones (orbital, infratemporal), FOM, masticator space, paraphyarngeal space, parotid space, paratonsillar space

Front 8

Direction of infection spread if it's from:

1) Lower primary molars
2) Upper primary molars
3) Upper incisors and canines
4) Lower incisors and canines

Back 8

1) Buccal space, sublingual space, submandibular space
2) Buccal space, infra-orbital, infratemporal fossa, pterygopalatine fossa
3) Superficial, canine space (rarely)
4) Superficial, submental

Front 9

1) What is upper cellulitis caused by? Where does swelling occur? Complications are serious/not serious
2) Lower facial celluitis? What is a clinical problem it can lead to?
3) 6 sections you can partition a face into to analyze OIs?

Back 9

1) Infection from maxillary teeth. Infraorbital, maxillary, nasal regions, can extend to frontal and periorbital tissues. Serious
2) Infection from mandibular teeth - swelling is around mandible, cheek, FOM, extends to submental/sublingual, very dangerous. Trismus => dehydration, not eating
3) Frontal, infraorbital, maxillary, buccal, submandibular, sublingual

Front 10

1) Diagnostic strategy for OIs? (6 steps)
2) 5 questions you should ask for the history?
3) 4 things to look for in extra-oral exam?
4) What 3 things should you feel for extra-orally?
5) What things should you touch for intra-orally? What can make diagnosis difficult?
6) How should your extraoral/intraoral exam compare?

Back 10

1) Hx (duration/intensity/previous therapy), extraoral assessment (evidence of spread of infection, presence of abscess or cellulitis), intra-oral assessment, appropriate radiographs, TEMP, current behavior
2) Duration (any preceding toothache, other pain, how long has the swelling been there?), intensity (is the pain or swelling getting worse?), med history? any temp changes? previous therapy (analgesia, antibiotics?)
3) 1) Presence of swelling and size, 2) extent of swelling, 3) is spread localized or generalized, 4) limited function?
4) 1) Size of swelling, 2) extent/limit of swelling (including lymph nodes, midline), 3) any rise in temp
5) 1) Consistency (fluctant, firm, hard?) 2) Associated tenderness from teeth/look for carious teeth or deep restorations, OH 3) Mobility, percussion. If several carious teeth diagnosis may be difficult
6) Should compliment each other

Front 11

1) 5 types of radiographs?
2) 4 principles of tx?

Back 11

1) Periapical, pano, upper occlusal, lateral skull, CT scan
2) Remove source of infection (ext or RCT), institute drainage (I/D), prevent spread (antibiotics oral or IV), restore function, maintain analgesia and adequate hydration (oral vs IV)

Front 12

ANTIBIOTICS:

1) 6 questions you have to ask yourself if you're considering antibiotics?
2) 4 reasons antibiotics NOT indicated?
3) Times when you consider IV before oral antibiotics

Back 12

1) How serious? Drainage? Healthy or immunocompromised? Cellulitis present or likely? Limited function? Localized or early-onset periodontitis?
2) 1) Chronic well localized abscess in a healthy child 2) Resolved by ext or RCT 3) Fistula with superficial drainage 4) The above with NO facial swelling
3) Failure of initial tx, limited function (e.g. mouth opening, <10 mm), high/persistent fever (>104 F), cellulitis that can potentially compromise airway, risk of dehydration (limited eating, drinking), dyspnea/dysphagia/dysphonia, immunocompromised patients

Front 13

1) Aerobic flora?
2) Anaerobic?
3) Who are narrow spectrum antibiotics effective against?
4) Bactericidal vs. bacteriostatic mode of action?

Back 13

1) Streptococci (viridians), Staphylococcus, Corynbacterium spp
2) Peptostreptococci (gram + cocci), Prevotella/prophyromonas gingivalis, bacteroides species (gram - rods), fusobacterium (gram -)
3) Gram positive/gram negative
4) Bacterial wall synthesis (survival), interfere with protein synthesis or folate metabolism (growth) q

Front 14

Penicillin V - first choice:

1) Pediatric dose
2) Spectrum
3) Mode of action
4) Side effects

Back 14

1) 50 mg/kg
2) Narrow (gram + only)
3) Bacteriocidal
4) Penicillinase resistance, cross-allergenicity

Front 15

Amoxicillin:

1) Pediatric dose
2) Spectrum
3) Mode of action
4) Side effects

Back 15

1) 50 mg/kg
2) Broad (gram -)
3) Bacteriocidal
4) Allergy, resistance, less GI upset

Front 16

Ampicillin

1) Pediatric dose
2) Spectrum
3) Mode of action
4) Side effects

Back 16

1) 50 mg/kg (IV)
2) Broad
3) Bactericidal
4) More GI upset than amoxicillin, Rash

Front 17

Augmentin

1) Pediatric dose
2) Spectrum
3) Mode of action
4) Side effects

Back 17

1) 50 + 6.25 mg/kg, or 50 + 5 mg/kg (IV)
2) Broad
3) Bacteriocidal
4) Inhibits beta lactamase organisms. Expensive

Front 18

Clindamycin:

1) Who is this good for?
1) Pediatric dose
2) Spectrum
3) Mode of action
4) Side effects

Back 18

1) Penicillin allergy & SBE
2) 20 mg/kg (300 mg in four doses), 15 mg/kg (IV)
3) Narrow (most gram + anaerobic)
4) Bacteriostatic
5) Causes GI problems, pseudomonas colitis

Front 19

Erythromycin/azithromycin:

1) Who is this good for?
1) Pediatric dose
2) Spectrum
3) Mode of action
4) Side effects

Back 19

1) Penicillin allergy
1) 15 mg/kg (<60 lbs, 125 mg 6 hourly, >60 lbs 250 mg 6 hourly)
2) Similar to penicillin but wider
3) Bacteriostatic, bacteriocidal in high concentration
4) Resistance, GI problems, Steven's Johnson syndrome

Front 20

Cefadroxil - 1st generation

1) Pediatric dose
2) Spectrum
3) Mode of action
4) Side effects

Back 20

1) 50 mg/kg (125-250 mg 6 hourly)
2) Broad spectrum (less anaerobic)
3) Bactericidal
4) Cross-sensitivity w/ penicillin

Front 21

Cefotaxime - 3rd generation

1) Pediatric dose
2) Spectrum
3) Mode of action
4) Side effects

Back 21

1) 50 mg/kg
2) Broad spectrum
3) Highly potent bactericidal
4) Resistant to a wide range of beta lactamases

Front 22

Tetracycline

1) Pediatric dose
2) Spectrum
3) Mode of action
4) Side effects

Back 22

1) 15 mg/kg
2) Broad
3) Bacteriostatic
40 Tooth discoloration <8 yrs

Front 23

Metronidazole

1) Pediatric dose
2) Spectrum
3) Mode of action
4) Side effects

Back 23

1) 15 mg/kg
2) Narrow (anaerobic and protozoal infections)
3) Bactericidal
4) Nausea, diarrhea, bad with alcohol

Front 24

1) 4 times you should do a culture and sensitivity?

Back 24

1) Pt fails to respond within 48 hrs
2) Spread of infection to fascial spaces
3) Immunocompromised patients
4) Previous hx of endocarditis

Front 25

1) Major complications of OIs?
2) Main things that need to be done with a significant OI?
3) 3 differential diagnosis of OIs?

Back 25

1) **Brain abscess, cavernous sinus thrombosis, ludwig's angina**, dehydration, bacteremia, septicemia, external ear infections, necrotizing fasciitis, mediastinitis, orbital infection, loss of function, days off from school, loss of earnings for parents
2) Immediate referral to pediatric dentist or oral surgeon, child may require hospitalization
3) Primary herpetic gingivostomatitis, staph aureus, cat-scratch disease

Front 26

PRIMARY HERPETIC GINGIVOSTOMATITIS:

1) Most common in what age?
2) What causes it?
3) Symptoms?
4) Main clinical signs?
5) How to tx?
6) How long does it last?
7) What to prescribe?
8) Risk of?

Back 26

1) <4 years
2) Viral infection (HSV-1)
3) Flu-like symptoms, painful and inflamed vesicles that lead to ulcerations on perioral region (gingiva/lips/anterior tongue), keratinized and non-keratinized mucosa
4) Excessive drooling, halitosis, sore throat
5) Early dx, topical anesthetics, antibacterial rinses, oral analgesics, OHI
6) Self limiting, 10-14 days
7) Acyclovir (15 mg/kg) or 200 mg/5 ml 5x/day for 10 days
8) Dehydration

Front 27

Staph auerues:

1) Associated with what kind of infections?
2) Causes infections how?
3) Cause of what major infection? Where do these infections start?

Back 27

1) Skin and sinus
2) By releasing enterotoxins and super antigens into bloodstream
3) MRSA - methicillin-resistant staph aureus - major cause of hospital acquired (nosocomial) infections. Indwelling medical devices or surgical wounds

Front 28

Cat-Scratch disease:

1) What is it?
2) When does it appear?
3) Signs/symptoms?
4) Who carries it more, kittens or adult cats?
5) Organisms?
6) Resolution?

Back 28

1) Benign disease found in kids
2) 1-2 weeks following a cat scratch
3) Begins as small pustule @ site of scratch => painful swelling of local lymph nodes => extensive parotid and submandibular enlargement, and in severe cases, fever/malaise/anorexia
4) Kittens >> cats
5) Bartonella henselae/Bartonella clarridgeiae (gram - bacteria)
6) Spontaneous resolution within a month (with/without tx), immunocompromised pts may take longer