Predicting paediatric traumatic brain injuries

Cite this article as:
Dani Hall and Mieke Foster. Predicting paediatric traumatic brain injuries, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.30993

The biggest challenge in managing a child with a mild to moderate head injury is deciding whether to organise a CT scan or not. Balancing the risk of ionising radiation (and with it the small, but definite, risk of a future brain tumour or leukaemia) against the risk of missing a significant brain injury is mitigated to some extent by using a clinical decision rule, like the PECARN, CATCH or CHALICE rules. These rules are extremely sensitive with very few false negatives and excellent negative prediction values, meaning if you follow them, you’re unlikely to miss a clinically important brain injury (cTBI). Their problem is their specificity is low with plenty of false positives, meaning most of the children who have a scan won’t actually have a brain injury. (If you’d like a refresher on sensitivity, specificity, NPV and PPV in head injury decision rules, check out Damian’s critical appraisal talks in DFTB Essentials.)

Over the last 6 years, Australasia’s PREDICT network has been a publishing powerhouse on paediatric head injuries from their Australasian Paediatric Head Injury Research Study (APHIRST for short). In their cohort of 20,000 children the team have been able to tell us that of PECARN, CATCH and CHALICE, the PECARN rule has the highest sensitivity. They’ve also shown that planned observation leads to significantly lower CT rates, with no difference in missed cTBI. And probably most telling of all, they’ve told us  that, without using any rules, their clinicians are already very good at identifying children with a cTBI with a sensitivity almost as high as PECARN’s, but with a very low baseline CT rate.

Nonetheless, clinical decision rules do play their role. And so, when they asked their network what an ideal decision rule would tell them, their clinicians highlighted the gaps in the existing guidelines: What should we do with a child with a delayed presentation up to 72 hours after the head injury? What about a child with a bleeding disorder and a head injury? What about a child with a VP shunt and a head injury? Or an intoxicated child with a head injury? The list goes on.

And so, in true PREDICT style, they decided to develop their own guideline.

This week marks a landmark day for paediatric head injury management worldwide as PREDICT launch their guideline for mild to moderate head injuries in children. The risk criteria from the PECARN rule, the best performing prediction rule in the APHIRST study, play a central role, supported by an extensive literature search, including studies from PECARN and PREDICT on the risk associated with VP shunts and bleeding risks. PREDICT have pulled all the data into one comprehensive, evidence-based guideline for managing, what has previously been considered, some of the less clear-cut paediatric head injury presentations. Let’s explore the algorithm and run through a series of cases.

Babl FE, Tavender E, Dalziel S. On behalf of the Guideline Working Group for the Paediatric Research in Emergency Departments International Collaborative (PREDICT). Australian and New Zealand Guideline for Mild to Moderate Head injuries in Children – Algorithm (2021). PREDICT, Melbourne, Australia.

How was the guideline derived?

Building on the existing high-quality clinical decision rules, the PREDICT group conducted a systematic review of the literature to include more recently published evidence. To develop the new PREDICT guideline, they used a GRADE-ADOLOPMENT approach, adopting, adapting or developing new recommendations, which are labelled in the main guideline as ‘evidence-informed recommendations’, ‘consensus-based recommendations’ or ‘practice points’.

What does it say?

This guideline is here to tell us what to do with children with a mild or moderate head injury, with a GCS of 14 or 15, or a child with a GCS ≤ 13 with a normal CT scan. The ‘who to discharge, who to observe and who to scan’ part of the guideline is succinctly summarised with a two-page algorithm. Page 1 has an easy to follow flowchart, supplemented by footnotes and Appendix with modified guidance for special conditions on page 2.

Page 1
Page 2

The bottom line

What I like so much about this guideline is that it answers so many of our “what about the child with a head injury plus…?” questions. With the evidence-based recognition that senior clinicians who choose to observe rather than scan a child reduce the CT rate without increasing the number of missed cTBIs, this guideline also allows senior clinicians to make a risk assessment on a case by case basis, while remaining fluid enough to upgrade or downgrade a child’s risk if their clinical picture changes. Although designed for use in Australia and New Zealand, I can see it being immensely useful outside Australasia and am looking forward to putting its pearls of wisdom to use.

Case 1

Case 2

Case 3

Case 4

Case 5

Cases 6 and 7

Case 8

Cases 9 and 10

Case 11

Case 12

Case 13

Case 14

Case 15

References

 Babl FE, Tavender E, Dalziel S. On behalf of the Guideline Working Group for the Paediatric Research in Emergency Departments International Collaborative (PREDICT). Australian and New Zealand Guideline for Mild to Moderate Head injuries in Children – Algorithm (2020). PREDICT, Melbourne, Australia.

Babl FE et al. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. 2017. 389;10087:2393-2402. DOI: https://doi.org/10.1016/S0140-6736(17)30555-X

Babl FE et al. A prospective observational study to assess the diagnostic accuracy of clinical decision rules for children presenting to emergency departments after head injuries (protocol): the Australasian Paediatric Head Injury Rules Study (APHIRST). BMC Pediatr. 2014. 13;14:148. DOI: 10.1186/1471-2431-14-148

Singh S et al. The Effect of Patient Observation on Cranial Computed Tomography Rates in Children With Minor Head Trauma. Acad Emerg Med. 2020. 27:832–843. DOI: 10.1111/acem.13942

Borland M et al. Delayed Presentations to Emergency Departments of Children With Head Injury: A PREDICT Study. Ann Emerg Med. 2019. 74:1-10. DOI: 10.1016/j.annemergmed.2018.11.035

Concussion: Neha Raukar at DFTB19

Cite this article as:
Team DFTB. Concussion: Neha Raukar at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22181

After spending 12 years as the Director of the Division of Sports Medicine in the Department of Emergency Medicine at the Warren Alpert Medical School at Brown University, Dr. Raukar joined the Department of Emergency Medicine at the Mayo Clinic in 2018 as full-time faculty.

In this fascinating talk she explores what happens to those children we see every weekend in the emergency department. Whether it is a clash of elbow versus head on the footy oval or a punch to the face at karate practice or something as innocuous as a simple fall from the monkey bars we don’t give these head injuries the attention they deserve.

 

 

©Ian Summers

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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Head Injuries Module

Cite this article as:
Team DFTB. Head Injuries Module, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.27374
TopicHead injuries
AuthorChris Odedun
DurationUp to 2 hours
Equipment requiredNone
  • Basics (10 mins)
  • Main session: (2 x 15 minute) case discussions covering the key points and evidence
  • Advanced session: (2 x 20 minutes) case discussions covering grey areas, diagnostic dilemmas; advanced management and escalation
  • Sim scenario (30-60 mins)
  • Quiz (10 mins)
  • Infographic sharing (5 mins): 5 take home learning points

We also recommend printing/sharing a copy of your local guideline.

Basics of head injury assessment 

RCEMLearning module on head injury (September 2018)

Managing more serious head injuries 

OPENPediatrics “Introduction to Traumatic Brain Injury” (February 2016)

Neuroprotective strategies for severe traumatic brain injury (Paediatric FOAM)

DFTB “Traumatic Brain Injury” (2013)

Your department/region’s guideline for managing head injuries in children.

Head injuries form a wide spectrum of clinical presentations. At their most simple, they can be defined as any impact to the body, proximal to the cervical spine & neck, excluding trivial impact to the face. Practitioners seeing any patient with head injuries should devote time to understanding the primary injury – the mechanism, including its biomechanics. 

They should also aim to develop expertise at identifying the cohort of patients at risk of secondary injury, from deviations of ICP, blood pressure, CO2, O2 & glucose.

Head injuries are generally defined by conscious level (Glasgow Coma Score/GCS) post-injury.  Head injuries are a very common presentation for children to emergency departments. The vast majority are trivial or minor, requiring observation and/or discharge advice only.

Head injuries remain one of the most common causes of serious morbidity & mortality in children (and young adults). Practitioners need to become skilled at selecting the cohort who require imaging – which is well established as CT. This is the best modality commonly available to detect more serious injuries – typically contusions, intra/extra-cerebral bleeds & skull fractures. Practitioners should become familiar with clinical guidelines & decision-support resources (eg. NICE) to help guide which patients need imaging.

An even smaller proportion of these injured children will go on to require neurosurgical intervention. Here, the practitioner’s role is to mitigate secondary injury, as above – with neuroprotective strategies.

Lastly, practitioners should be aware of the possibility of non-accidental injury, especially with regard to drowsy or unconscious infants, and remember that they have a role in safeguarding all children presenting to the ED, regardless of reason for presentation.

NICE clinical guideline CG176 – head injury: assessment & early management esp. 1.3 & 1.4.9, 10, 11 + this review of the 2014 changes to indications for CT and more [Tessa Davis, Anna Ings (BMJ)]

NICE clinical guideline CG176 – head injury: assessment & early management esp. 1.3 & 1.4.9, 10, 11 + this review of the 2014 changes to indications for CT and more [Tessa Davis, Anna Ings (BMJ)]

CT imaging became the imaging modality of choice during the 2000s/2010s in developed economies.  Since then, access to CT has generally widened, and become ubiquitous. Key to this in the UK has been the development of guidance by NICE, in 2014, with updates since – it guides management of head injury in children and adults.  A trio of cohort studies looking at outcomes of children with head injury were key to the development of the paediatric part of this guideline – please see references. Included below is a flowchart guiding CT use in children courtesy of NICE.

CHALICE (UK/2006) – highly sensitive but significantly less specific rule developed in the UK, later incorporated into the NICE guidance

PECARN (US/2009) – cohort study looking to identify low-risk group of paediatric patients who could safely not be imaged
CATCH (Canada/2010) – prospective multicentre cohort study from Canada looking to establish features for medium & high-risk for clinically significant traumatic brain injury

A 6 year old girl is brought in by ambulance to the ED you work in. She was playing on a climbing frame and fell off the top onto concrete, onto her head. Handover states that she was briefly knocked unconscious, then returned to a GCS = 15, but has become more drowsy en route to hospital.

On your initial assessment, there is a large swelling to the left side of her scalp and forehead, and there appears to be some blood leaking from her left ear. Her GCS is 12 (E3V4M5) but the rest of her vital signs are within normal limits.

Outline your management steps.

How soon do you want this child to have CT imaging?

The scan shows an extradural haematoma. How can you direct your team to prevent secondary brain injury?

  • This child needs immediate CT imaging of the head and their cervical spine – they are ideally managed by a trauma team, where the primary survey should ensure detection of any other injuries. If as likely, the cervical spine cannot be cleared clinically, they will need immobilisation until this is completed. A written report from an appropriate radiologist will ideally be available within 60mins of the scan.
  • Significant CT findings (see ‘Basics’) will need urgent discussion with a neurosurgeon, to determine if the child needs emergency surgery. If not, a clear management plan – who will monitor the child, and where? will need to be agreed.
  • This child may require intubation, for airway, oxygenation & ventilatory control, or for secondary transfer. Tranexamic acid may be used. Attention should be paid to pain management, and neuroprotective initiatives should be put in place (control of ICP, blood pressure, CO2, O2 & glucose – see the referenced paediatric FOAM article which provides a good summary of clinical management) 

You see a 20 month old boy in your ED, who was playing with his 6 year old cousin when he ran into an opening door at home. He cried immediately, and vomited around 10 minutes later. 

Having been brought into the ED, which is 20 minutes from his home, he has vomited twice more. There was no LOC or seizure activity, and other than looking nauseated he appears to be behaving normally.

To scan or not to scan?

What guidance do the parents/nursing staff looking after this child in the ED need?

How long will you observe for, and what if the child vomits again?

  • This child can probably be safely observed without immediate CT scanning – this management approach would be supported by NICE (see sections 1.4.9 and 1.4.10).
  • This case will hopefully provoke discussion about what constitutes a ‘vomit’, and whether there are any other plausible causes of vomiting, other than the injury itself. 
  • Learners could discuss what local provision they have for more extended observation of a child.
  •  Discussion of provision of verbal + written advice would also be pertinent.

A 9 month old child presents after rolling off a bed onto the floor. You see a 7cm swelling on his occiput. In the trauma call, he is held in mum’s arms and is crying.

You are unsure over how to proceed – the child definitely needs CT imaging, but how should we ensure they keep still?

  • Recap of CT guidance – “For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head”
  • Options for CT sedation: benzodiazepines vs. diamorphine/opiates vs. ketamine vs. intubation & ventilation – given a significant CT finding is possible. This would be a good opportunity to mention the 2020 revisions to RCEM ketamine sedation guidance (with associated DFTB commentary)

An 8 year old girl is brought in by her dad. She clashed heads with another player at basketball two days previously, and did not initially seek medical advice as she was ‘fine’. She had to leave school early today because she had trouble seeing the board & teacher, and felt sick. There are no focal neurological findings but there is a bruise on the parietal part of the scalp on the right, and you cannot feel the scalp.

  • Need for detailed history-taking around the delay in presentation – actively look for any safeguarding concerns
  • Should we have an altered threshold for CT imaging when presentation is delayed? This DFTB post is a useful summary of a paper relating to this cohort of patients – finding of a nonfrontal scalp haematoma or strong suspicion of a basal skull fracture were significantly associated with a clinically significant brain injury.

A 15 year old girl re-attends 10 days after being knocked unconscious for 10-15 seconds while jumping for a header playing football. She passed a pitchside concussion test and continued to play, but was substituted after saying she felt dizzy, and was seen in an ED. A CT scan was performed – which showed no bleed, contusion or fracture. 

She says she found it hard to concentrate on schoolwork for a week afterwards, but this is now normal. She wants to know exactly when she can go back to playing as she has an important match in 3 days.

What do you do?

  • Concussion describes the symptoms & abnormal function experienced by patients after a head injury, without any evidence of macroscopic brain injury. Its management is commonly misunderstood and poorly explained to patients and carers.
  • Management focuses on cognitive rest, avoidance of activities that trigger symptoms, and graduated return to cognitive activity & education.
  • Return to sport should also be graduated, with trial of light activity, and avoidance of sport with a risk of head impact until the patient has been reviewed by a clinician.
  • There is a significant risk of secondary concussion if sport/normal activity is returned to too soon after the initial injury 

Some excellent resources from:

You see a 4 year old with a head injury. All of the following are an indication for urgent CT imaging except:

A: GCS<14

B: Sign of a basal skull fracture

C: Focal neurology on examination

D: Post-traumatic seizure

E: Loss of consciousness for a few seconds

The correct answer is E.

NICE guidelines mention all of the above as indications for immediate CT except for LoC – if brief this is not an indication. If more prolonged (>5min), this would mandate observation in the ED for at least 4h after the time of injury.

In an intubated child with an extradural haematoma causing mass effect, the following are important considerations in managing intracranial pressure:

A: Managing untreated pain

B: Using RR or tidal volume to control pCO2

C: Keeping O2 saturations 94-98%

D: Keeping blood glucose tightly controlled between 4-8

E: Removing any constrictive neck devices (tube ties, cervical collars etc)

The correct answer is D.

Evidence for tight glycaemic control has been superseded by the risks associated with hypoglycaemia for the injured brain. Prevention of hyperglycaemia would be a more sensible aim. All of the other answers would minimise increases in intracranial pressure, including aiming for a low-normal pCO2.

When managing children with head injuries, which of the following statements are true?

A: If the mechanism of injury is dangerous, the cervical spine should be CT imaged along with the head.

B: It is good practice to discuss management of delayed presentations with a senior before discharge

C: 3 vomits in 10 mins constitutes separate ‘episodes’ of vomiting.

D: CT imaging is essential in those with haemophilia.

E: Intranasal diamorphine can be used to manage pain and keep a child still for scanning.

The correct answers are A, B, and E.

If the child’s head is being imaged with CT, best practice would be to extend to the cervical spine if concern exists regarding injury. Teams should use judgement of the mechanism, presence of abnormal neurology and GCS to help make this decision). 

Evidence would suggest that presentation >24h after a head injury is associated with more significant findings, thus the threshold for scanning may need to be altered. 

Clinical judgement needs to be exercised with regard to vomiting. NICE refers to a vomit being a ‘single discrete episode’ but does not explicitly define timing. Our practice would suggest significant time for recovery should be allowed between episodes eg. 20mins.

Diamorphine is a good analgesic for young children and its sedative effects can be harnessed when attempting to safely CT in mild agitation – although other options are more safe if airway protection is required.

Congenital bleeding diatheses such as haemophilia require a lower threshold for imaging, and would need urgent supplementation of clotting factors – but very minor trauma to the head may still be managed without CT.



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Dental trauma

Cite this article as:
Orla Kelly. Dental trauma, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20931

One of the many perks of practising in the Emergency Department is the knowledge and experience of managing multiple different types of presentations and injuries involving all parts of human anatomy. This is true except for one small yet crucial part that medicine has historically handed over to another speciality – dentists. However, even though we may have limited experience with the oral cavity and its bony growths, we can still provide appropriate initial management in the Emergency Department.

Evie’s six. She was playing tag with friends, giggling as she twisted and skipped away from being caught. A boy playing football appeared out of nowhere. Evie collided with him and landed face down on the playground floor. One of Evie’s teeth was broken. Evie’s school nurse carefully put the fragment in a glass of milk. Panicked on receiving a phone call from the school, Evie’s mum collected her and brought her straight to your ED. You check Evie over for signs of a head injury. Thankfully all seems ok in this department. Her tongue looks fine with no lacerations. But her tooth is definitely fractured and you’re not sure what to do.

Anatomy

Teeth are divided into the crown (exterior) and root (embedded in the alveolar bone). The tooth is covered in enamel protecting the dentin in which the pulp with the neurovascular supply to the tooth is located. They are held in alveolar bone sockets by the periodontal ligament, a connective tissue covering the root, which forms the socket wall.

You look carefully at Evie’s fractured tooth.  You can see an outer white layer, the enamel, surrounding a slightly creamier inner layer, the dentin. Right in the centre of this, you glimpse a pink, vascular layer. This must be the pulp. So Evie has a fracture of her tooth right through the enamel, dentin and into the pulp. But is it an adult or baby tooth?

Baby teeth are called deciduous teeth (although you’ll also hear them called primary and milk teeth). There are 20 deciduous teeth, which start erupting at approximately 6 months of age (although this is very variable – you’ll see many one year olds who still give you a winning gummy smile).

When the child’s about 6 or 7, these deciduous teeth will start falling out, much to the delight of the tooth fairy, making way for the adult, permanent teeth of which there are 28-32 in total.

Which tooth is which?

Don’t confuse your central and lateral incisors from your canines, premolars or molars. Although dentists use a numbering and lettering system, this differs from country to country so, to avoid confusion, it’s easiest to use each tooth’s descriptive term as follows:

Differentiating between whether a tooth is deciduous or permanent is important as it drastically affects management. The patient’s age and a careful history will often make it clear, however, if not teeth can be differentiated according to their characteristics. Deciduous teeth are smaller, white and often with flat smooth edges. Permanent teeth are larger, creamier in colour and can have uneven edges if newly erupted.

deciduous versus permanent tooth characteristics

Image from Royal College of Emergency Medicine

Evie’s fractured tooth is her front right incisor. All of Evie’s teeth are white with smooth edges.  Wide-eyed, Evie tells you that the tooth fairy hasn’t visited her yet as she hasn’t lost any of her baby teeth. You check the surrounding teeth. None are wobbly and Evie’s mum is sure the others look they same as they did this morning when Evie went to school.

Epidemiology

Traumatic dental injuries are common amongst small and school-age children with 25% experiencing dental trauma. In the preschool age data shows one-third of children suffer trauma to the deciduous dentition, and one-quarter of children and a third of adults have suffered trauma to permanent teeth. Despite the oral cavity comprising 1% of total anatomy, traumatic dental injuries account for 5% of injuries.

Management

Other injuries should be examined, including mandibular or facial bone fractures. Assess for malocclusion of the jaw, bony tenderness along mandible and facial bones and sensory disturbance or numbness. The inferior alveolar nerve (a branch of the mandibular division of the trigeminal nerve) supplies sensory innervation to the mandibular teeth and via the mental branch to the lower lip and chin. It is often implicated in mandibular fractures, and as such sensory disturbance in these regions should prompt close examination of the mandible. Don’t forget the possibility of a significant head injury. In the case of avulsion, if the tooth can’t be located and there are clues in the history such as choking or coughing, consider ordering a chest x-ray to check it hasn’t been aspirated.

The clinical importance of traumatic injury to deciduous teeth is the impact on the underlying permanent tooth. The apex of the injured deciduous tooth root is in close proximity to the permanent tooth germ, thereby increasing the possibility of injury. Malformation, impaction, eruption disturbance and discolouration are all possible sequelae to injury. As such, management of injuries to deciduous teeth differs to that of permanent teeth as demonstrated below.

Dental injuries fall broadly into five categories: fractures, luxations and subluxations, avulsions and concussions.

Subluxation – the tooth is tender and is mobile

Extrusion – the tooth is almost pulled from the socket so appears longer and is very wobbly

Intrusion – the tooth is impacted into the alveolar bone

Avulsion – the tooth is not in the socket but in the hand

Concussion – just like receiving a bump on the head, the tooth is tender to touch or tapping but does not move

In all cases definitive management and follow up must be performed by dentists, as soon as possible, to prevent complications such as necrosis of the tooth’s pulp and unnecessary patient discomfort.  There are, however, a few things we can do in the ED.

Tips and tricks in the ED: investigations you might consider

  • Chest x-ray: to check a lost tooth hasn’t been aspirated if the history is suggestive of an inhaled foreign body
  • Soft tissue x-ray: to check the soft tissue of the cheek and lips to find a lost toothy fragment if there is soft tissue swelling or a palpable embedded fragment.
  • Orthopantomogram: useful when there’s doubt as to whether a traumatised tooth is deciduous or permanent or whether a tooth that only has a very small portion visible in the mouth has intruded or is fractured.

You carefully check the inside of Evie’s mouth. There are no lacerations of her cheeks, lips or tongue and the small piece of tooth Evie gingivally hands to you looks like the missing piece of her fractured incisor.  You’re satisfied there are no missing fragments of tooth so document there is no need for an x-ray to hunt down any dental foreign bodies.

Fractures

Dental fractures can be classified as enamel; enamel-dentin and enamel-dentin-pulp fractures. The root can also fracture as can the alveolar bone socket.

Enamel fractures just require the smoothing and sanding down of sharp edges.

Enamel-dentin fractures  should be sealed if possible and should be followed up in 3-4 weeks.

Enamel-dentin-pulp fractures are the most serious of the three. If the pulp cavity is not capped off with something like calcium hydroxide paste then apical periodontitis and failure of root maturation may occur. The alternative is just to remove the tooth and be done with it – not a viable option in the case of permanent teeth. There is no evidence that prophylactic antibiotics need to be given in these dental fractures.

Management of deciduous tooth and permanent tooth fractures varies slightly (it’s all to do with whether the tooth fairy is ready for this bit of tooth or not).

Fractured deciduous teeth: the fragment is unsuitable for replacement (the tooth fairy *may* decide it’s worthy of a coin so wrap it in a tissue and give it back to the child). Tell the carer to take their child for dental review so the portion of tooth that remains in situ can be sealed.

Fractured permanent teeth: the broken fragment may be bonded to the tooth if available – this one’s not for the tooth fairy just yet.  Store the tooth in milk or saline and advise the child attends a dentist as soon as possible.

Root fractures: Look for bleeding from the gingival sulcus – this might be the only clue that root of the tooth is fractured. If the fragment is displaced, reposition it, bind it with a temporary splint in the ED as soon as possible, and refer to the dentist as soon as possible for assessment for formal splinting.

Alveolar fractures: Alveolar fractures are fractures of the bony socket. They may extend into the mandible – a segment or multiple teeth may be mobile and there may be problems with jaw occlusion. Both will require urgent dental intervention for splinting.  Any displaced segment should be repositioned as soon as possible.  Discuss with the on-call dental or maxillo-facial team as this is likely to require general anaesthetic.

Luxations 

Extrusions: the tooth is almost pulled from the socket so appears longer and is very wobbly.  Management of these again depends on whether the tooth is deciduous or permanent.

Extruded deciduous teeth: treatment depends on the age of the child and severity of the injury. If the extrusion is minor (less than 3mm), it can be repositioned and temporarily splinted in ED. But if it is a major extrusion (more than 3mm), a fully formed deciduous tooth can be extracted with some local anaesthetic and piece of dry gauze or needle holder if the child is able to tolerate this. This tooth will then be ready for the tooth fairy.

Extruded permanent teeth: reposition the tooth if it is obviously elongated, place a temporary splint and advise dental review for permanent splinting. Don’t pull it out.

Intrusions: the tooth is impacted into the alveolar bone.

Intruded deciduous teeth: because the growing maxilla/mandible is relatively demineralised compared to that of an adult, when a toddler falls flat on their face they are more likely to push the tooth into the soft bone (intrusive luxation) than to fracture the jaw. Management of the intruded tooth depends on the direction and degree of intrusion as well as the presence or absence of an underlying alveolar fracture. Because the intruded teeth – most commonly the incisors –  follow the line of the roots. i.e. in a labial direction – they are pushed away from the waiting secondary dentition. A watchful waiting approach, in a case series by Altun et al.  found that 78% re-erupted, 15% partially erupted and only 7% remained impacted. The majority re-erupted within 6 months. If they intrude towards the underlying. No formal treatment is needed in the ED but the child should be seen urgently by a dentist because, if the tooth intrudes towards the underlying permanent teeth then they should be removed to avoid permanent disfigurement.

Intruded permanent teeth: no formal treatment is needed in the ED but dental follow-up within 24 hours is advised for repositioning and splinting, to assess for fractures and assessment of pulp necrosis.

Lateral luxations: the tooth is angulated sideways.

Reposition digitally if possible and place a temporary splint. The tooth can sometimes be lodged in a bony lock and as such will need forceps repositioning – one for our dental colleagues.  If there is occlusal interference, whereby the displaced tooth impacts on the child’s ability to chew, discuss to on-call dental or maxillo-facial colleagues.

Concussions

Parents may not be aware of the inciting trauma but become concerned when they notice a grey discolouration of the tooth. There may be underlying pulp necrosis but this may be asymptomatic. As the damage is only cosmetic no real treatment is needed, other than regular follow up to ensure that osteitis is detected early.

Avulsions

Avulsed deciduous teeth: avulsed deciduous teeth are not to be re-implanted. Doing so can cause damage to the development and eruption of permanent teeth. Determine the location of the avulsed tooth (particularly that it has not been aspirated), check for other injuries, and refer to a dentist for follow up. Check the child’s tetanus status. And don’t forget to give the tooth back to the child for the tooth fairy.

Avulsed permanent teeth: avulsion of a permanent tooth is a dental emergency and requires prompt action. Successful re-implantation is the goal and as such the tooth should be digitally reimplanted as soon as possible. Do not grasp the tooth by the root as this will disrupt periodontal cells, rather hold by the crown and irrigate with either milk or saline (a cannula attached to a syringe is a useful tool for this endeavour).  Ensure the socket is clean of debris – irrigate the socket with saline to remove any blood clots (this allows revascularisation of the reimplanted tooth). Reposition the tooth by using adjacent dentition as a guide and hold in place by advising the patient to bite down gently on a soft medium such as handkerchief or rolled up gauze. Splint the tooth in place.

The ‘dry time’ of the tooth – the time outside of the socket – and the appropriate medium is one of the key indicators for successful re-implantation. The periodontal cells are no longer viable after 60 minutes so teeth that have not been reimplanted within an hour of avulsion are likely to fail.9 If a tooth cannot be immediately re-implanted, then it should be stored in either milk or normal saline. Storage in the mouth such as in the cheek or under the tongue is possible, however in a paediatric population the risk of swallowing is high, so a liquid external medium is preferable.

Reimplanting avulsed permanent teeth is one of the times antibiotics should be prescribed. Make sure you’ve checked the child is up to date with their tetanus vaccination; if they’re not, vaccinate in ED.

Tips and tricks in the ED: splinting teeth

A temporary splint to secure a tooth until the child can get to a dentist can be made in the ED with skin glue and either steri-strips or the foil from a suture pack.  But remember, don’t reimplant an avulsed deciduous tooth as you may damage the developing permanent tooth. Save this tooth for the tooth fairy!  Only reimplant and splint avulsed permanent teeth or fragments of teeth that may be suitable for permanent splinting.

Image from: Academic Life in Emergency Medicine

  1. Hold the tooth by the crown (not the root) and lightly rinse the tooth with saline.
  2. Rinse the socket with 20-40 mL of saline solution and then pat dry with gauze.
  3. Gently reimplant tooth into a satisfactory anatomic position.
  4. Pat the tooth dry and apply skin glue to the edges of the tooth to adhere it to the adjacent teeth.
  5. Use either layers of steristrips or foil from a suture pack as a splint. NB if using foil, cut it to the appropriate size and round the edges to avoid injury.
  6. Secure the replanted tooth by applying skin glue to the inner aspect of the splint and outer surface of the target and one/both adjacent teeth.
  7. Hold the splint under pressure for about 1 minute.
  8. Confirm stability.

Dental follow-up

All patients will need to see a dentist for definitive management and follow up, with the degree of urgency depending on the nature of injury. If in doubt do not hesitate to contact on-call services out of hours, particularly for avulsions. Patients should be advised to avoid contact sports or other high impact activities, only eat a soft diet, brush with a soft toothbrush and use a chlorhexidine (0.1%) mouth rinse twice daily for a week.

After giving Evie a sticker for being so brave, you solemnly wrap the fragment of her tooth in gauze and hand it to her.  You tell Evie’s mum that as the fractured tooth is a deciduous tooth, and the fracture luckily doesn’t extend into the root, the fragment isn’t suitable for reimplantation.  The tooth will need formal sealing though so you advise her to see her dentist as soon as possible. She phones and gets an appointment for later that afternoon. You advise her to keep Evie away from the toffees. That night, after receiving her second sticker from dentist, Evie carefully places the wrapped piece of tooth under her pillow. The following morning she’s delighted to find she’s had her first visit from the tooth fairy, who has left a shining Euro coin and a little note in beautiful, but tiny calligraphy that simply says, “Thank you”.

Pearls of wisdom

  • The emergency management of dental trauma in the ED is limited, however can have drastic positive implications if done correctly.
  • Avulsed primary teeth are for the tooth fairy, even if their sacrifice was premature.
  • Avulsed permanent teeth should be resuscitated within 60 minutes – store in milk, hold by crown, wash root and socket with saline and replace and splint ASAP
  • Things that look like they’re not in the right place – attempt replacement (permanent teeth only!)
  • Check and document sensation of the lower lip and chin – disruption of the mental nerve suggests mandibular trauma
  • Antibiotic cover when reimplanting avulsed teeth or in immunocompromised children
  • Tetanus tetanus tetanus
  • Head injury head injury head injury

 

How much does the tooth fairy leave?

Andy Tagg has explored this issue before as it’s an incredibly important one for any clinician working with children to have insight into.  As Andy says,

“The Tooth Fairy is not just an awful film starring Dwayne ‘The Rock” Johnson (it scored a grand 18% on Rotten Tomatoes) but a tall tale that has only been around for about 90 years. Before she (?he) flitted into our children’s bedrooms slipping shiny coins and more under pillows, parents told stories of La Petite Souris (in France) or Ratóncito Pérez (in Spain). This creature would sneak in like a rodent Indiana Jones swiping his shiny enamel treasure and replacing with a slightly weightier monetary equivalent.”

Andy ran a Twitter poll in 2017 to find out just how much La Petite Souris would have to leave behind. For children in Australia the almost unanimous vote came out in favour of a shiny two dollar coin (unless it was a first tooth then some recommended five dollars). For our international readers, at the time of first print, that worked out as £1.19 or US$1.52.

References

Altun C et al. Traumatic intrusion of primary teeth and its effects on the permanent successors: a clinical follow-up study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 107(4): 493-8

Andersson L et al.  International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumato 2012; 28: 88-96

Andersson, L. Epidemiology of Traumatic Dental Injuries. Pediatric Dentistry, Volume 35, Number 2, March/April 2013, pp. 102-105(4)

Boffano P, Roccia F, Gallesio C, Karagozoglu K, Forouzanfar T. Inferior alveolar nerve injuries associated with mandibular fractures at risk: a two-center retrospective study. Craniomaxillofac Trauma Reconstr. 2014;7(4):280–283. doi:10.1055/s-0034-1375169

Brajdić D, Virag M, Uglešić V, Aljinović-Ratković N, Zajc I, Macan D. Evaluation of sensitivity of teeth after mandibular fractures. Int J Oral Maxillofac Surg. 2011;40(3):266–270

Colak I, Markovic D, Petrovic B, Peric T, Milenkovic A. A Retrospective Study of Intrusive Injuries in Primary Dentition. Dent Traumatol 2009;25: 605-10

DiAngelis A 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

Glendor U. Epidemiology of traumatic dental injuries – a 12 year review of the literature. Dent Traumatol 2008;24: 603–11.

Holan G, Ram D. Sequelae and prognosis of intruded primary incisors: a retrospective study. Pediatr Dent 1999;21:242–7.

Malmgren B et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dent Traumatol 2012; 28: 174-182