Rosen & Barkin's 5-Minute Emergency Medicine Consult (200 page)

• Admission for other associated injuries
  
• Suspected child or elder abuse and those with no available safe environment
  

All hemodynamically stable patients with dental injury without associated traumatic injury

• Ellis III injuries: Immediate dental referral
  
• Loose, displaced, or missing teeth
  
• Document recommendations and arrangements for dental follow-up care
  

All patients with avulsions and Ellis II and III injuries should see dentist within 24 hr

• Avulsed teeth should never be transported in a dry medium or in tap water
  
• Occlusion is the best guide to proper tooth position after reimplantation
  
• Warn patients with dental trauma of risks of tooth resorption, color change, potential tooth loss, and/or need for future root canal
  

• Andreasen JO, Lauridsen E, Gerds TA, et al. Dental Trauma Guide: A source of evidence-based treatment guidelines for dental trauma.
  Dent Traumatol.
  2012;28:345–350.
  
• Diangelis AJ, Andreasen JO, Ebeleseder KA, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth.
  Dent Traumatol
  . 2012;28:2–12.
  
• Wolfson AB, Hendey GW, Ling LJ, et al., eds.
  Harwood Nuss’ Clinical Practice of Emergency Medicine
  . 5th ed. Philadelphia, PA: Lippincott; 2010.
  

See Also (Topic, Algorithm, Electronic Media Element)

Tooth Pain

CODES

• 525.8 Other specified disorders of the teeth and supporting structures
  
• 525.11 Loss of teeth due to trauma
  
• 873.63 Open wound of tooth (broken) (fractured) (due to trauma), without mention of complication
  

BASICS

Major depression:

• Depressed mood and associated signs and symptoms lasting more than 2 wk
  
• Significant morbidity and mortality, including risk of suicide
  
• Often coexists with other medical illness
  

• Biologic illness associated with derangements in several neurotransmitter systems including serotonin, norepinephrine, and dopamine
  
• Contributing factors:
  
  • Genetic predisposition
    
  • Medical illness
    
  • Medication effects
    
  • Psychosocial stress: Depression may follow adverse life event, trauma, loss of important relationship, or life role
    
• Higher prevalence in women. (Woman make more suicide attempts; men are more likely to complete suicide successfully)
  

DIAGNOSIS

• 5 or more symptoms for at least 2 wk. (One of the symptoms must be depressed mood or loss of interest or pleasure):
  
  • Depressed mood
    
  • Diminished interest or pleasure
    
  • Change in appetite, weight loss/gain
    
  • Sleep disturbance
    
  • Fatigue or loss of energy
    
  • Diminished concentration
    
  • Feeling of worthlessness or guilt
    
  • Recurrent thoughts of death or suicide
    
  • Psychomotor agitation or retardation
    
• Subtypes: Psychotic features, melancholic, catatonic, atypical, postpartum, seasonal
  
• May be anxious/agitated or withdrawn
  
• Associated somatic complaints:
  
  • Weakness, malaise
    
  • Weight loss
    
  • Headache, back pain
    

• Time course, acuity, stressors
  
• Review depressive symptoms (see above)
  
• Past medical history
  
• Past psychiatric history
  
• Medications (prescribed and over-the-counter)
  
• Substance use
  
• Family history
  
• Social and occupational history; losses, transitions, trauma, and other major life events
  
• Safety assessment:
  
  • Suicide risk
    
  • Risk of violence to others
    
  • Assess ability to care for self, nutrition
    
• Collateral from family or outpatient providers
  
• Cultural and language differences may complicate evaluation; use interpreter when appropriate
  

• Vital signs
  
• Neurologic exam:
  
  • Motor exam: Station, gait, strength, tone, abnormal movements
    
  • Cognitive exam: Orientation, attention, memory, language, executive function
    
• Mental status exam: Affect and mood, thought form and content
  

• Depression may be difficult to diagnose in children and adolescents. Indicators of major depression in children may include:
  
  • Changes in school, home, and social functioning
    
  • Changes in sleep
    
  • Social withdrawal
    
  • Somatic complaints
    
• Consult with a child psychiatrist
  

• Identify signs and symptoms of major depression (see “Signs and Symptoms”)
  
• Use history and physical exam to guide further workup
  
• Rule-out associated or coexisting psychiatric and medical conditions, substance use
  
• Safety assessment
  

• 1st line:
  
  • CBC; chemistries including electrolytes, BUN/creatinine, glucose, calcium, liver function tests
    
  • Urinalysis
    
  • Serum and urine toxicology screen
    
  • Thyroid function tests
    
  • B
    ₁₂
    and folate
    
• 2nd line, guided by history and initial findings:
  
  • HIV testing
    
  • RPR
    
  • ESR/CRP/ANA
    

• Brain imaging: Recommended for atypical presentation or if focal neurologic findings
  
• MRI brain preferred over CT for detecting tumors, cerebrovascular accident, white matter changes
  

• Psychiatric illnesses:
  
  • Dysthymic disorder
    
  • Adjustment disorder
    
  • Bipolar disorder
    
  • Anxiety disorders, including acute stress reactions, PTSD
    
  • Schizophrenia, schizoaffective disorder
    
  • Personality disorder
    
  • Eating disorder
    
  • Substance-induced mood disorder
    
• Medical conditions that may cause or mimic depression:
  
  • Drug induced:
    
    • Antihypertensives
      
    • Oral contraceptives
      
    • Steroids
      
    • Sedative-hypnotics
      
    • Opioids
      
    • Psychostimulants (in withdrawal phase)
      
    • β-Blockers
      
    • Metoclopramide
      
  • Endocrine disorders:
    
    • Hypothyroidism
      
    • Adrenal insufficiency
      
    • Diabetes mellitus
      
    • Postpartum, perimenopausal, and premenstrual syndromes
      
  • Tumors:
    
    • Pancreatic
      
    • Lung
      
    • Brain
      
  • Neurologic disorders:
    
    • Dementia (early phase or frontal type)
      
    • Epilepsy
      
    • Parkinson disease
      
    • Multiple sclerosis
      
    • Huntington disease
      
    • Stroke
      
    • Head trauma; subdural hematoma
      
    • Normal pressure hydrocephalus
      
  • Infections:
    
    • Hepatitis
      
    • HIV
      
    • Mononucleosis
      
  • Nutritional disorders:
    
    • Folate deficiency
      
    • Pellagra
      
    • Vitamin B
      ₁₂
      deficiency
      
  • Electrolyte disturbances
    
  • End-stage renal, hepatic, pulmonary, and cardiovascular diseases
    
  • Obstructive sleep apnea
    
  • Chronic pain syndromes
    

TREATMENT