Pediatric emergency medicine trisk 809

Suggested Readings and Key References
Abramowicz S, Allareddy V, Lee MK, et al. Hospital-based emergency
department visits with pediatric burns: characteristics and outcomes.
Pediatr Emerg Care 2019. [Epub ahead of print]
American Burn Association. National Burn Repository. Available online at
. Accessed August
15, 2019.
Jamshidi R, Sato TT. Initial assessment and management of thermal burn
injuries in children. Pediatr Review 2013;34;395–404.
Jeschke MG, Herndon DN. Burns in children: standard and new treatments.
Lancet 2014;383:1168–1178.
Kraft R, Herndon DN, Al-Mousawi AM, et al. Burn size and survival
probability in paediatric patients in modern burn care: a prospective
observational cohort study. Lancet 2012;379(9820):1013–1021.
Palao R, Monge I, Ruiz M, et al. Chemical burns: pathophysiology and
treatment. Burns 2010;36(3):295–304.
Strobel AM, Fey R. Emergency care of pediatric burns. Emerg Med Clin
North Am 2018;36(2):441–458.
Thamm OC, Perbix W, Zinser MJ, et al. Early single-shot intravenous
steroids do not affect pulmonary complications and mortality in burned
or scalded patients. Burns 2013;39(5):935–941.
Tompkins RG. Survival of children with burn injuries. Lancet
2012;379(9820):983–984.
World
Health
Organization.
Burns.
Available
online
at
. Accessed August

15, 2019.


CHAPTER 105 ■ DENTAL TRAUMA
ZAMEERA FIDA, ISABELLE I. CHASE, BONNIE L. PADWA

GOALS OF EMERGENCY CARE
Proper diagnosis and management of traumatic dental injuries (TDIs) are
essential to improve prognosis. Identifying which injuries require immediate
referral to a dentist is important for emergency physicians. Since dental injuries
involve the head and neck, concomitant neurologic evaluation is an important
aspect of emergency care. Although the majority of injuries are the result of
accidents, the patient’s history must be carefully reviewed in the context of the
physical findings to determine if presenting injuries could be a result of
nonaccidental trauma, that is, abuse.
KEY POINTS
TDIs are common pediatric emergencies.
Neurologic assessment is an important part of management as injury
has been sustained in the head and neck region.
Jaw fractures, avulsed and displaced teeth, and dental fractures with
exposed nerves (pulp) require immediate referral to a specialist.
RELATED CHAPTERS
Resuscitation and Stabilization
A General Approach to the Ill or Injured Child: Chapter 7
Medical, Surgical, and Trauma Emergencies
Child Abuse/Assault: Chapter 87
ENT Trauma: Chapter 106
Facial Trauma: Chapter 107
Minor Trauma: Chapter 110
Dental Emergencies: Chapter 117

The Children’s Hospital of Philadelphia Clinical Pathway


ED Pathway for Dental Trauma or Infection
URL: />Authors: E. Szydlowski, MD; M. Herring, MD; K. Castelo, CRNP; B.
Pagliaro, RN; H. Giannakopoulos, DDS, MD; E. Hajishengallis, DDS,
PhD
Posted: August 2019

ASSESSMENT OF TRAUMATIC DENTAL EMERGENCIES
CLINICAL PEARLS AND PITFALLS
In patients with TDIs, carefully assess for associated injuries to the
CNS, cervical spine, orbits, and jaw.
Airway obstruction in the setting of facial trauma may be the result of an
aspirated tooth or blood in the oral cavity and pharynx.
Mucosal ecchymoses at the floor of the mouth or vestibular area are
highly suggestive of mandibular fractures.
Primary teeth in the process of exfoliation may be confused with TDI.
Be alert to the possibility of nonaccidental trauma (child abuse) if the
history is not consistent with the observed injuries.

Current Evidence
The most emergent concern in a child with dental trauma is to evaluate for
associated facial injuries and airway obstruction. Obstruction can result from
accumulation of blood in the oral cavity and pharynx. Alternatively, the etiology
may be a tooth aspirated by a child, or a fractured mandible causing the tongue to
fall backward against the posterior pharynx.
Beyond airway obstruction and life-threatening injuries, trauma to the jaw,
dentition, or soft tissues requires careful evaluation and treatment. Inadequate
recognition and management of these injuries can lead to suboptimal cosmetic

and functional outcomes.

Goals of Treatment
The care of pediatric patients with maxillofacial and dental trauma should follow
the basic tenets of emergency medicine, starting with evaluation and management


of airway, breathing, and circulation, as well as neurologic compromise. Once
stabilized, the emergency physician should perform a thorough extraoral and
intraoral examination to identify the presence of injury to the jaws, teeth, and
surrounding soft tissue. Identification of those injuries that require emergent care
from a dentist is imperative.

Clinical Considerations
Clinical Assessment
Children with facial injuries are usually frightened and apprehensive. The
examination should be organized to include inspection and palpation of extra- and
intraoral structures. Appropriate analgesia can facilitate the examination;
procedural sedation may be required in some cases.
Extraoral examination. The extraoral examination should start with evaluating
symmetry of the face in the anterior and profile views. The clinician should
carefully note the location and nature of any swollen or depressed structures, the
color and quality of the skin, and the presence of lacerations, hematomas,
ecchymoses, foreign bodies, or ulcerations. Evaluation of the temporomandibular
joints (TMJs) involves observation and gentle bilateral digital palpation while the
mouth is opened and closed. There should be equal movement on both sides
without major deviations. Mandibular deviation during function or limited mouth
opening may signify TMJ injury or condylar fracture. Range of motion should not
be forced because it may increase the extent of injury. The infraorbital rim should
be palpated to ensure it is continuous and intact all the way to the inner canthus of

the eye. Examination continues across the zygoma to the nose, palpating for
crepitus or mobility. The clinician should inspect for lip competency (the ability
of the lips to cover the teeth) because loss of competency may indicate
displacement of the teeth from trauma. Attention should focus on the mandible,
feeling along the posterior border of the ramus and moving anteriorly along the
body to the symphysis, palpating for any discontinuity, mobility, swellings, or
point tenderness. The child should be questioned and examined for any evidence
of paresthesia (numbness) of the lips, nose, and cheeks, which may indicate a
fracture through the bony foramen in which the nerve exits. Figure 105.1 shows
the main nerve supply to facial structures.