Questions regarding imaging for patients with dental pain/infections.

[thegenius]

Odd, I am seeing more and more that ENT isn’t needling or cutting PTA. They are just giving antibiotics and follow up next week. They claim the literature reports 60-80% improve just with antibiotics. Anyone else seeing this?

Yes I have seen this. How do they define a "small" PTA?

Basically sounds like it requires imaging to get an accurate size.

It's basically impossible to get prompt ENT follow-up where I work for 90% of patients, so I would only do abx only if ENT can guarantee see in 24 hours.

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[deleted547339]

The latter. One dose rocephin and clinda both IV, one dose dex, 1 L NS too I think, home on PO clinda. Though it was a Kaiser study in SoCal so ENT f/u was guaranteed (not reality for most of us)

That’s dumb. IV and PO clinda have nearly 100% oral bioavailability. One dose of IV rocephin probably does nothing.

 

[Dr Mantis Toboggan]

That’s dumb. IV and PO clinda have nearly 100% oral bioavailability. One dose of IV rocephin probably does nothing.

only reason I can think is they wanted some parental abx still on board when the patients left?

 

[thegenius]

One dose of rocephin is as important as the next dose of rocephin and provides excellent coverage against Strep. I presume Clinda is for MRSA although MRSA has significant immunity to clinda depending on locale.

ceftriaxone is a good abx.

 

[Groove]

From this thread, all I can say is I'm glad I didn't pick the huge academic center for training. Getting a panorex on dental pain and calling OMFS sounds like a complete waste of time. Imaging a straight forward PTA is crazy. I've done a few this year. It's a very easy procedure that seems completely unnecessary to have ENT involved.

It's an easy procedure (usually) but it's time consuming. If I've got ENT available, I almost always give them first right of refusal. 85% of the time, they do it themselves either because they don't realize that I can do it (and don't ask me) or they want to bill for the procedure. Either way, it means I'm not tied down doing another procedure in the room and can see additional patients. I'm beyond poking my chest out and flaring my peacock feathers in the ED at this stage and am all about making my shift as easy as possible.

Now, in my current ED, I don't have reliable ENT coverage anymore and I'm not going to transfer one of these unless I have to...that's kind of embarrassing, so now I'm stuck doing them with more frequency but ah well... I do miss that 24/7 ENT coverage. They would jump all over these things.

If you're in an academic center, you've got it made as the ENT residents are all over these which would be totally fine by me. It's funny how procedures that used to be so exciting and fun to do as a resident are just seen as productivity decels to me now. Case in point, I used to get so amped up on trauma pt's and now just see them as massive time sinks with completely algorithmic management.

 

[deleted547339]

One dose of rocephin is as important as the next dose of rocephin and provides excellent coverage against Strep. I presume Clinda is for MRSA although MRSA has significant immunity to clinda depending on locale.

ceftriaxone is a good abx.

No, it’s not, That is a really dumb protocol - surprised their pharmacy group was ok with it. Cephalosporins are time dependent killing not concentration dependent without the appearance post antibiotic effect you may get with AGs - this is a good way to cause resistance.

 

[BoardingDoc]

No, it’s not, That is a really dumb protocol - surprised their pharmacy group was ok with it. Cephalosporins are time dependent killing not concentration dependent without the appearance post antibiotic effect you may get with AGs - this is a good way to cause resistance.

I agree about this being a fairly dumb protocol. There is no reason for a "single dose of IV antibiotics" in almost any case. IV abx are useful if -
1: The drug only exists as an IV formulation
2: The patient is unable to take PO
3: They are so sick that the med hitting their bloodstream immediately as opposed to over a couple of hours is likely to make a difference in their survival or overall outcome.

That said, while getting a single dose of any IV abx is unlikely to be helpful, it also probably isn't doing anything to increase the prevalence of resistant bugs, despite common myths to to contrary.

Is it time to stop counselling patients to “finish the course of antibiotics”?

www.ncbi.nlm.nih.gov

The antibiotic course has had its day

With little evidence that failing to complete a prescribed antibiotic course contributes to antibiotic resistance, it’s time for policy makers, educators, and doctors to drop this message, argue Martin Llewelyn and colleagues Antibiotics are vital to modern medicine and antibiotic resistance...

www.bmj.com

 

[deleted547339]

I agree about this being a fairly dumb protocol. There is no reason for a "single dose of IV antibiotics" in almost any case. IV abx are useful if -
1: The drug only exists as an IV formulation
2: The patient is unable to take PO
3: They are so sick that the med hitting their bloodstream immediately as opposed to over a couple of hours is likely to make a difference in their survival or overall outcome.

That said, while getting a single dose of any IV abx is unlikely to be helpful, it also probably isn't doing anything to increase the prevalence of resistant bugs, despite common myths to to contrary.

Is it time to stop counselling patients to “finish the course of antibiotics”?

www.ncbi.nlm.nih.gov

The antibiotic course has had its day

With little evidence that failing to complete a prescribed antibiotic course contributes to antibiotic resistance, it’s time for policy makers, educators, and doctors to drop this message, argue Martin Llewelyn and colleagues Antibiotics are vital to modern medicine and antibiotic resistance...

www.bmj.com

There’s a difference between a shorter yet still acceptable course vs. an unacceptable course. I attend in the icu as well. I always do as short a course as possible upstairs. For example, VAP treatment used to be 14 days, now it’s 7. Intrabdominal sepsis used to be a mess (but usually a long time), now it’s 4/5 days depending on how you count. There are scenerios when there is equivalent efficacy with equal or improved outcomes due to fewer side effects with shorter courses, but that’s not what we’re talking about. It’s pretty clear that when you develop clinical stability you should start peeling off abx. But what was proposed is an inadequate course for anything likely covered up by the fact that they’re doing a sufficient course of clinda. It’s like adding a 1c stamp to a letter with already adequate postage. You can say “look, the letter got there” but it was going to get there anyway and all you did was waste time and resources. (Do 1c stamps still exist?)

 

[BoardingDoc]

There’s a difference between a shorter yet still acceptable course vs. an unacceptable course. I attend in the icu as well. I always do as short a course as possible upstairs. For example, VAP treatment used to be 14 days, now it’s 7. Intrabdominal sepsis used to be a mess (but usually a long time), now it’s 4/5 days depending on how you count. There are scenerios when there is equivalent efficacy with equal or improved outcomes due to fewer side effects with shorter courses, but that’s not what we’re talking about. It’s pretty clear that when you develop clinical stability you should start peeling off abx. But what was proposed is an inadequate course for anything likely covered up by the fact that they’re doing a sufficient course of clinda. It’s like adding a 1c stamp to a letter with already adequate postage. You can say “look, the letter got there” but it was going to get there anyway and all you did was waste time and resources. (Do 1c stamps still exist?)

Agree with everything you just said. Also agree that 1 dose of a different category abx isn't going to be helpful. You didn't outright address it, but are you saying that you think that a single dose of IV CTX is contributing to bacterial resistance? My inference from the links that I posted above is that it likely does not.

 

[Apollyon]

(Do 1c stamps still exist?)

I think you are being rhetorical, but, absolutely. For example, the business reply mail franks are not open ended (the amount is set, not variable) so, sometimes, you will see one or more 1c stamps appended to make up the difference.

 

[Splenda88]

Strange! They admit all these PTA patients to the hospitalist/resident service in my hospital. I feel like my ED admits almost everyone.

 

[thegenius]

Such a waste of time, space and money in >90% cases.

 

[ERDude]

I find PTAs to be less time consuming than most lacs. And usually very satisfying for both the patient and the doc when you get a few cc's of pus out and they feel 100x better.

If PTA likely based on hx/exam:
- IV, fluids, abx, steroids, pain meds
- After that's all going, have RN/EMT get all the supplies at bedside (topical lido spray, DL blade for patient to hold to depress tongue and provide light, +/- also inject lido, 5cc syringe with 18g needle to aspirate, suction)
- Procedure at that point is < 5 minutes in-and-out unless not going as expected
- D/C probably 80% of these home, ~20% are sick or miserable enough I admit but rare they get a 2nd procedure in hospital
- I don't do bedside US on these and I only get CT if they have really bad trismus such that I can't even see the back of the throat or something else is funky

 

[thegenius]

I find PTAs to be less time consuming than most lacs. And usually very satisfying for both the patient and the doc when you get a few cc's of pus out and they feel 100x better.

If PTA likely based on hx/exam:
- IV, fluids, abx, steroids, pain meds
- After that's all going, have RN/EMT get all the supplies at bedside (topical lido spray, DL blade for patient to hold to depress tongue and provide light, +/- also inject lido, 5cc syringe with 18g needle to aspirate, suction)
- Procedure at that point is < 5 minutes in-and-out unless not going as expected
- D/C probably 80% of these home, ~20% are sick or miserable enough I admit but rare they get a 2nd procedure in hospital
- I don't do bedside US on these and I only get CT if they have really bad trismus such that I can't even see the back of the throat or something else is funky

sounds reasonable
does the mac blade get in the way? I've never tried that. Sounds kind of nice and the lighting at my place suxs.

 

[ERDude]

sounds reasonable
does the mac blade get in the way? I've never tried that. Sounds kind of nice and the lighting at my place suxs.

Yeah it works pretty well to give exposure and also gives the patient something to focus on/occupy their hands which is nice.

The lighting is adequate but I usually still wear a headlamp.

I generously topicalize the back of tongue and OP and then have the patient hold the laryngoscope handle and then kind of help them inch it back along their tongue until it's in good position. Blade doesn't get in the way if you get it back there and the patient is also exerting a little downward pressure.

 

[Fox800]

I like the lidocaine neb idea.

i’ve never had much luck with the needle aspiration, even when I cut off the guard over an 18 gauge needle. Any tips? Should I be using a smaller syringe (5 mL) or cutting off a smaller guard? the past few times I’ll stab and stab and I don’t get anything.

 

[RustedFox]

I wouldn't trust a patient to hold a laryngoscope blade themselves in this manner.

 

[ERDude]

I like the lidocaine neb idea.

i’ve never had much luck with the needle aspiration, even when I cut off the guard over an 18 gauge needle. Any tips? Should I be using a smaller syringe (5 mL) or cutting off a smaller guard? the past few times I’ll stab and stab and I don’t get anything.

I actually don't use a neb i just use the pump action lidocaine bottle thing (but I'm sure a neb would work well also).

I find 3cc or 5cc syringe are easier to maneuver and not obstruct view. I sometimes probe gently with a long q-tip to see where it's most fluctuant otherwise I just poke superior and/or where it looks to be most prominent. I cut the plastic cap to expose about at least 1.5-2cm of needle, 1cm doesn't seem like enough to work with. If I don't get pus after 2-3 pokes at most I stop and just tell the patient it's more likely phlegmon or developing abscess and that things should get better with abx/steroids.

I wouldn't trust a patient to hold a laryngoscope blade themselves in this manner.

They are just holding a laryngoscope with MAC blade upside down on top of their tongue...what would you be concerned might happen?

 

[RustedFox]

They are just holding a laryngoscope with MAC blade upside down on top of their tongue...what would you be concerned might happen?

Fair question.

- that they could freak-out at any point and in their spazz-fit, they hurt themselves with the laryngoscope blade (laceration, tooth fracture, etc).

I admit; after I posted my above post, I asked myself the same question - and was then immediately left with the unsettling but undeniable realization that, no matter what, patients are complete idiots.

 

[deleted547339]

Agree with everything you just said. Also agree that 1 dose of a different category abx isn't going to be helpful. You didn't outright address it, but are you saying that you think that a single dose of IV CTX is contributing to bacterial resistance? My inference from the links that I posted above is that it likely does not.

Certainly can’t help prevent antibiotic resistance.

 

[Renaissance Man]

Except that it's not.

Except it is for most non-cancer related or ischemic complaints like sore throat/trismus.

People freak out over giving 10 of morphine will not look twice giving 1 mg of diluadid.

I actually don't/won't give Dilaudid for anything except cancer pain, and certainly don't freak out about what others do...btw the equivalent of 10 mg of Morphine would be a 1.5 mg slug of Dilaudid IV. No worries, just a 50% exaggeration to get your point across though.

 

[Brigade4Radiant]

Except it is for most non-cancer related or ischemic complaints like sore throat/trismus.



I actually don't/won't give Dilaudid for anything except cancer pain, and certainly don't freak out about what others do...btw the equivalent of 10 mg of Morphine would be a 1.5 mg slug of Dilaudid IV. No worries, just a 50% exaggeration to get your point across though.

1.5 of the diluadid doesn’t really cause that much Issues compared to one of diluadid since it’s at synthetic opiate and you have less histamine release so you don’t have the blood pressure affects of morphine. Also depending how big the person.

Also yeah you can order 1.5 of Dilaudid for a patient and a nurse really won’t blink twice from it that’s entire point.

Epicwon’t issue any warnings for giving 2 of diluadid

 

[GenericWhiteGuy]

I like the lidocaine neb idea.

i’ve never had much luck with the needle aspiration, even when I cut off the guard over an 18 gauge needle. Any tips? Should I be using a smaller syringe (5 mL) or cutting off a smaller guard? the past few times I’ll stab and stab and I don’t get anything.

The approach I found works best is to make sure you are approaching from the other side; Right side PTA, your plane of approach starts over the left canine towards the right peritonsilar space. I found if you started on the right side and went straight back over the right side molars much harder to find the abscess.

 

[GenericWhiteGuy]

They are just holding a laryngoscope with MAC blade upside down on top of their tongue...what would you be concerned might happen?

I actually use a disposable speculum with a light source by taking the top piece off and having them hold it down to suppress the tongue. In my experience, less of a gag reflex than the MAC blade and the lip of the speculum will catch and pool some of the pus and blood.

 

[deleted547339]

Except it is for most non-cancer related or ischemic complaints like sore throat/trismus.



I actually don't/won't give Dilaudid for anything except cancer pain, and certainly don't freak out about what others do...btw the equivalent of 10 mg of Morphine would be a 1.5 mg slug of Dilaudid IV. No worries, just a 50% exaggeration to get your point across though.

Not exactly. Hydromorphone is equipotent to between 7–10mg of morphine. I don’t think it’s that cut and dry.

And that’s silly to only give hydromorphone for cancer pain.

 

[Birdstrike]

What in the world is an oral radiologist

I'm not exactly sure what and "oral radiologist" is, but I'm pretty sure he's gonna lose his license soon.

 

[Renaissance Man]

1.5 of the diluadid doesn’t really cause that much Issues compared to one of diluadid since it’s at synthetic opiate and you have less histamine release so you don’t have the blood pressure affects of morphine. Also depending how big the person.

Epicwon’t issue any warnings for giving 2 of diluadid

You are really saying that 1.5 mg of Dilaudid is no different in its potential for side effects than 1 mg of Dilaudid...really?

Also EPIC flags any dose ordered over 1 mg in my hospital system.

Not exactly. Hydromorphone is equipotent to between 7–10mg of morphine. I don’t think it’s that cut and dry.

Source? - especially the 1:10 conversion you are quoting? Seems like mostly agreed upon ~1:5, which is backed up in literature. Of course it isn't cut and dry, it is research about levels of subjective pain.

https://www.jpsmjournal.com/action/showPdf?pii=S0885-3924%2801%2900294-9

 

[thegenius]

If someone is in terrible pain and it's obviously why they are in terrible pain (i.e. they are not malingering)
I have no problem giving 6-10 mg morphine or 1-2 dilaudid. I probably wouldn't give 2 dilaudid upfront to a naive patient, but it also depends on what I'm treating. Someone in a major car wreck with a broken pelvis and rib fractures, why are we dicking around with 6 mg morphine? What the hell is our problem? We should be giving them 100 fentanyl up front within 5 minutes of eval and titrating thereafter.

If there are no side effects from 6 mg morphine, i doubt there will be any from 10 mg morphine.
Similarly logic for dilaudid.

We regularly under treat pain in the ED and it's a shame.

 

[Splenda88]

If someone is in terrible pain and it's obviously why they are in terrible pain (i.e. they are not malingering)
I have no problem giving 6-10 mg morphine or 1-2 dilaudid. I probably wouldn't give 2 dilaudid upfront to a naive patient, but it also depends on what I'm treating. Someone in a major car wreck with a broken pelvis and rib fractures, why are we dicking around with 6 mg morphine? What the hell is our problem? We should be giving them 100 fentanyl up front within 5 minutes of eval and titrating thereafter.

If there are no side effects from 6 mg morphine, i doubt there will be any from 10 mg morphine.
Similarly logic for dilaudid.

We regularly under treat pain in the ED and it's a shame.

It's not only in the ED... It also happens on the floor (Internal Medicine). I am arguably the most liberal resident in my class. Being liberal means giving 4 mg of morphine Q6 PRN to someone who is in pain from Crohn's flare...

 

[bravotwozero]

It's not only in the ED... It also happens on the floor (Internal Medicine). I am arguably the most liberal resident in my class. Being liberal means giving 4 mg of morphine Q6 PRN to someone who is in pain from Crohn's flare...

Welcome to the era of the opioid abuse epidemic. The pendulum is now in the other direction, a long way from when it was in the direction of 'we've got more pain meds than you have pain'. Couple that with known narco seekers, and some peer-reviewed disasters where the patient wouldn't stop screaming until he got narcs till he zonked, people are going to get real testy with narcs.

 

[deleted109597]

That’s dumb. IV and PO clinda have nearly 100% oral bioavailability. One dose of IV rocephin probably does nothing.

Sadly, the IDSA still recommends it for pyelo. It's madness I tell you.

If you're giving a single dose of something, give Pen G. Or, you know, nothing.
I do love how the dentists tell us that the analgesic simply won't work unless the infection is being treated with antibiotics. I'd love to see the study they're basing this on.

Oh, and OP? If I had a dental clinic that could read panorex, I would just send the patient over there.

 

[WheezyBaby]

People freak out over giving 10 of morphine will not look twice giving 1 mg of diluadid.

If someone is in terrible pain and it's obviously why they are in terrible pain (i.e. they are not malingering)
I have no problem giving 6-10 mg morphine or 1-2 dilaudid. I probably wouldn't give 2 dilaudid upfront to a naive patient, but it also depends on what I'm treating. Someone in a major car wreck with a broken pelvis and rib fractures, why are we dicking around with 6 mg morphine? What the hell is our problem? We should be giving them 100 fentanyl up front within 5 minutes of eval and titrating thereafter.

If there are no side effects from 6 mg morphine, i doubt there will be any from 10 mg morphine.
Similarly logic for dilaudid.

We regularly under treat pain in the ED and it's a shame.

My practice is in line with genius. 10/2 is a lot of opioid to give up front to a naive patient and I see very little reason to do so outside of situations on the extreme end of the spectrum. There's very little upside to loading it up front like that with a class of meds that's so easily titrated to effect. I also agree about it being silly to withhold dilaudid for cancer patients. I use substantially more dilaudid and fent than morphine. Less histaminergic and less worry about renal impairment. Typically cap initial dosing for naive patients at 1 / 50 for dilaudid / fentanyl and reassess in a timely manner for repeat dosing. If they're tolerant typically double that

 

[Old_Mil]

Cheers from the dental side of the world. I'm an oral radiology resident and I am trying to gauge how imaging is handled in your EDs for patients that present with dental pain/infection. First of, I want to say its unfortunate that this burden often falls on you. At my university it is all too common for patients with tooth pain/infections to be seen in the ED. That being said, my questions are:

1) What are your imaging protocols for patients with dental issues?

Protocol: some screening to make sure this isn’t something serious like an MI or deep space infection, shot of ketorolac, Rx for antibiotics, see your dentist, discharge.