Rosen & Barkin's 5-Minute Emergency Medicine Consult (436 page)

• Significant displacement or associated dental trauma—open fractures require urgent specialty consultation for possible admission.
  
• The severity of associated trauma may indicate admission.
  
• Any patient with the potential for airway compromise should be admitted.
  
• An unreliable patient with nondisplaced fractures should be admitted for definitive fixation.
  
• In the pediatric population, if the mechanism of injury is not appropriate to the injuries seen, pediatric or child protective services consultation should be obtained.
  

Patients with nondisplaced, closed fractures may be discharged on analgesics and a soft diet.

Oral or maxillofacial surgeon within 2–3 days for uncomplicated fractures

• The most sensitive sign of a mandibular fracture is malocclusion.
  
• Failure to recognize that a gum laceration overlying a mandibular fracture represents an open fracture which requires antibiotics.
  
• Missing mandibular condyle fractures when only a panorex film is obtained – if there is condyle tenderness or malocclusion, obtain plain films or CT.
  
• Missing teeth must be accounted for, if not found, obtain a chest x-ray to rule out aspiration.
  
• A nonfractured mandible should be able to hold a tongue blade between the molars tightly enough to break it off. There should be no pain in attempting to rotate the tongue blade between the molars.
  

• Alpert B, Tiwana PS, Kushner GM. Management of comminuted fractures of the mandible.
  Oral Maxillofac Surg Clin North Am.
  2009;21(2):185–192.
  
• Ellis E 3rd. Management of fractures through the angle of the mandible.
  Oral Maxillofac Surg Clin North Am.
  2009;21(2):163–174.
  
• Koshy JC, Feldman EM, Chike-Obi CJ, et al. Pearls of mandibular trauma management.
  Semin Plast Surg.
  2010;24(4):357–374.
  
• Myall RW. Management of mandibular fractures in children.
  Oral Maxillofac Surg Clin North Am.
  2009;21(2):197–201.
  
• Perez R, Oeltjen JC, Thaller SR. A review of mandibular angle fractures.
  Craniomaxillofac Trauma Reconstr.
  2011;4(2):69–72.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Dental Trauma
  
• Facial Fractures
  

CODES

• 802.20 Closed fracture of mandible, unspecified site
  
• 802.21 Closed fracture of mandible, condylar process
  
• 802.25 Closed fracture of mandible, angle of jaw
  

BASICS

Marine envenomation refers to poisoning caused by sting or bite from a vertebrate or invertebrate marine species.

• Sponges:
  
  • Contain sharp spicules with irritants that cause pruritic dermatitis
    
• Coelenterates (Cnidaria jellyfish):
  
  • Contain stinging cells known as nematocysts on their tentacles
    
  • Fluid-filled cysts eject sharp, hollow thread-tube on contact.
    
  • Thread-tube penetrates skin and envenomates the victim.
    
  • Box jellyfish can kill within minutes
    
• Starfish:
  
  • Sharp, rigid spines are coated with slimy venom.
    
• Sea urchins:
  
  • Hollow, sharp spines filled with various toxins
    
• Sea cucumbers:
  
  • Hollow tentacles secrete holothurin, a liquid toxin.
    
• Cone shells:
  
  • Venom injected through dart-like, detachable tooth.
    
  • Active peptides interfere with neuromuscular transmission.
    
  • Presents with puncture wounds similar to wasp stings.
    
• Stingrays:
  
  • Most common cause of human marine envenomations.
    
  • Tapered spines attached to tail inject venom into victim.
    
• Scorpion fish:
  
  • Lionfish usually mild; stonefish can be life threatening.
    
  • Sharp spines along dorsum and pelvis of fish
    
  • Often stepped on inadvertently
    
  • Neurotoxic venom
    
• Catfish:
  
  • Dorsal and pectoral spines contain venom glands.
    
• Sea snakes:
  
  • Hollow fangs with associated venom glands
    
  • Highly neurotoxic venom blocks neuromuscular transmission.
    

DIAGNOSIS

• Sponges:
  
  • Itching and burning a few hours after contact
    
  • Local joint swelling and soft tissue edema
    
  • Fever
    
  • Malaise
    
  • Dizziness
    
  • Nausea
    
  • Muscle cramps
    
  • In severe cases, desquamation in 10 days to 2 mo
    
• Coelenterates (Cnidaria jellyfish):
  
  • Mild envenomation:
    
    • Immediate stinging sensation
      
    • Pruritus
      
    • Paresthesia, burning sensation
      
    • Throbbing
      
    • Blistering/local edema/wheal formation
      
  • Moderate/severe:
    
    • Neurologic: Ataxia, paralysis, delirium, seizures
      
    • Cardiovascular: Anaphylaxis, hemolysis, hypotension, dysrhythmias
      
    • Respiratory: Bronchospasm, laryngeal edema, pulmonary edema, respiratory failure
      
    • Musculoskeletal: Muscle cramps or spasm, arthralgias
      
    • Gastrointestinal: Nausea, vomiting, diarrhea, dysphagia, hypersalivation/thirst
      
    • Ophthalmologic: Conjunctivitis, corneal ulcers, elevated intraocular pressure
      
• Echinodermata:
  
  • Starfish:
    
    • Immediate pain
      
    • Bleeding
      
    • Mild edema
      
    • Paresthesias, nausea, vomiting if severe
      
  • Sea urchins:
    
    • Intense pain and severe local muscle aches
      
    • Nausea, vomiting
      
    • Paresthesias, hypotension, or respiratory distress with multiple stings
      
  • Sea cucumbers:
    
    • Mild contact dermatitis
      
    • Corneal and conjunctival involvement: Severe reactions can lead to blindness.
      
• Mollusks:
  
  • Cone shells:
    
    • Puncture wounds similar to wasp stings
      
    • Sharp burning and stinging
      
    • Paresthesias indicate severe envenomation.
      
    • Can evolve into muscular paralysis and respiratory failure, dysphagia, syncope, disseminated intravascular coagulation
      
• Stingrays:
  
  • Puncture wounds or jagged lacerations
    
  • Local, intense pain, edema, bleeding; necrosis if severe
    
  • Nausea, vomiting, diarrhea
    
  • Diaphoresis
    
  • Headache
    
  • Tachycardia
    
  • Seizures
    
  • Paralysis
    
  • Hypotension
    
  • Dysrhythmias
    
• Scorpion fish:
  
  • Intense local pain for 6–12 hr
    
  • Erythema may progress to cellulitis.
    
  • Headache
    
  • Nausea, vomiting, diarrhea
    
  • Pallor
    
  • Delirium
    
  • Seizures
    
  • Fever
    
  • Hypertension
    
• Catfish:
  
  • Local pain, ischemic appearance progressing to erythema
    
  • Swelling, bleeding, and edema
    
  • Local muscle spasms
    
  • Diaphoresis
    
  • Neuropathy, fasciculations, weakness, syncope
    
• Sea snakes:
  
  • Bite initially causes very little pain.
    
  • Pin-like pairs of fang marks
    
  • Onset from 5 min to 6 hr
    
  • Muscle pain, lower extremity paralysis, arthralgias
    
  • Trismus, blurred vision, dysphagia, drowsiness
    
  • Severe signs include:
    
    • Ascending paralysis
      
    • Aspiration
      
    • Coma
      
    • Renal and liver failure
      
  • If untreated, 25% mortality
    

• Time of envenomation
  
• Body part envenomated
  
• Activity when envenomated (scuba diving, swimming, surfing, fishing, boating, pet care)
  
• Type of water (salt water, fresh water, aquarium)
  
• Geographic location (resort, international, remote, local, aquarium, zoo, pet store)
  
• Onset of symptoms, pain
  
• Mental status changes
  
• Near drowning