Other ED procedures

Bleeding sockets

As the on-call DCT/SHO, you will undoubtedly receive calls where a patient has attended A&E complaining of post-extraction bleeding. Post-extraction bleeding can be categorized in a number of ways:
Time:
1) Primary – at the time of surgery
2) Reactionary – 2/3 hours post-operatively
3) Secondary – up to 2 weeks afterwards, almost always due to infection
Site:
1) Soft tissue
2) Bone
3) Vascular

Things to look out for

Gaining a thorough medical history is vital and you should be looking for anything which may predispose the patient to bleeding/hemorrhage:
1) Anticoagulant therapy – warfarin, NOACs
2) Clotting factor disorders – Von Willebrands, Vit. K deficiency, Haemophilia A&B
3) Platelet disorders – idiopathic thrombocytopenia purpura, drug induced

Equipment required

1) Gauze - lots of it!
2) Local anaesthetic
3) Suture kit
4) Haemostatic agents e.g. surgicel, tranexamic acid, silver nitrate
5) Cautery
6) Suction

Examination

1) Site
2) How much blood has the patient lost?
3) When was the extraction?
4) Check observations – blood pressure, heart rate etc.
5) Are the surrounding soft tissues intact? Look for inadvertent lacerations

Treatment

1) Roll the gauze up, place the gauze directly over the socket and ask the patient to bite down on it. Ensure the gauze is thick enough so when the patient is biting down on it, firm pressure is being applied to the socket
2) If this proves ineffective, administer lidocaine with adrenaline around and inside the socket as infiltrations
3) Tranexamic soaked gauze can be applied to the socket and asking the patient to bite down for 20-30 minutes
4) Failing this, surgicel can be placed in the socket with college tweezers. The surgicel dressing can be secured in place using sutures. It is recommended to use 3-0/4-0 vicryl rapide, a simple interrupted or horizontal mattress suture can be placed.
5) If you determine the bleed to be vascular in nature, cautery is recommended if other measures have failed [1].

When to escalate

If after having attempted local measures, the patient is still bleeding, contact your registrar/senior. At this stage, it would also be worth taking blood for a clotting screen.

Dry Socket

As a GDP dry sockets are something you will come across relatively frequently. It refers to a post-extraction socket where some or all of the alveolar bone in the socket is exposed. This is often due to the blood clot being lost or failing to form post-extraction.
There are a variety of risk factors for developing a dry socket e.g. difficult tooth extraction, immunocompromised patient, smoking, history of dry socket, poor oral hygiene and they are more likely to occur in mandibular teeth.

Signs and symptoms

1) Severe pain 3-7 days post-extraction
2) Bad taste and/or halitosis
3) Erythema of surrounding tissues
4) Socket devoid of a blood clot
5) Debris, grey slough in socket
6) Visible exposed bone

Treatment

1) Gather equipment – local anaesthetic, basic dental kit (mirror, tweezers), saline in a syringe, alveogyl (eugenol impregnated alveolar dressing)
2) Administer local anaesthetic around and inside the socket
3) Thoroughly irrigate the socket to remove any debris/food
4) Pack the socket with Alveogyl
5) Prescribe/advise patient on pain relief
6) Explain to the patient they should be reviewed by their own dentist in the next 3-5 days

If patients are presenting with persisting dry socket there may be an underlying cause which should be investigated.

TMJ Dislocation

TMJ dislocations attending the emergency departments necessitate relocation by OMFS urgently. Dislocations can be acute or chronic. Generally the TMJ is relocated however if it is chronic, the patient should be followed up and investigated.
On examination, the patient will have an open mouth. Sometimes it is worth obtaining a radiograph e.g. OPG to confirm dislocation if you are unsure.
It’s wise to ask a senior for help if you have never done this before. In terms of how to relocate the mandible:
1) Administer analgesia (occasionally patients require sedation)
2) Sit the patient upright
3) Stand in front of the patient and ask a colleague to support the patients head
4) Wrap your thumbs in gauze and place them along the mandibular molars. Use your remaining fingers to hold the mandible extra-orally
5) Use a downwards and back motion to relocate the condyle. You should feel a ‘pop’
6) Prescribe analgesia, advise on a soft diet for 72 hours and to refrain from yawning
7) Follow-up on an outpatient clinic if necessary
If you are unable to relocate the condyle, contact your senior

References