EENT Emergencies Flashcards Preview

Emergency Medicine > EENT Emergencies > Flashcards

Flashcards in EENT Emergencies Deck (49):
1

Epistaxis
Common presenting complaint to EDs
1. Ideally, have patient in a straight up in what position?
2. What does this positioning do?
3. Prevents what?
4. May have to modify if patient appears to be what?

1. (90 °) sitting

2. Decreases nasal arterial pressures

3. aspiration

4. shocky

2

What is the significance of a Posterior bleed as opposed to an Anterior Bleed?

In posterior the bleeding can continue down the throat without the person knowing. These are more severe

Anterior are more common

3

Epistaxis
Hx questions? 5

1. One nare or both
2. Sensation of blood in the back of the throat
3. History of epistaxis, trauma, head/neck tumor, radiation or head/neck surgery
4. Family history of bleeding disorders
5. Anticoagulants, NSAIDS, or ASA?

4

Look for underlying cause of epistaxis
8

1. Nose picking
2. Dryness
3. Trauma
4 .Anticoagulation or ASA therapy
5. Bleeding diathesis
6. Foreign body
7. Allergies-nasal steroid use
8. ASA? & HTN?

5

Bleeding diathesis that may contribute the epistaxis?
6

1. Hematologic Disease
2. Polycythemia,
3. TTP,
4. von Willebrand Dz,
5. hemophilia,
6. Aplastic Anemia

6

Treatment for epistaxis

5

Step 1: Start with direct pressure

Step 2: If still bleeding after direct pressure

Step 3: Determine site of bleeding

Step 4: Cautery with silver nitrate stick

Step 5: Anterior Packing

7

tx for epistaxis:
Step 1: Start with direct pressure
1. Compress the nares between where?
2. Hold pressure for how long?
3. Patient to lean forward or sit upright at a ___ degree angle

4. How will this tx affect a posterior bleed?

1. the thumb and index finger or 2 tongue depressors taped together

2. 20 minutes

3. 90

4. This will have no effect on posterior bleeds

8

Treatment for epistaxis

Step 2: If still bleeding after direct pressure
1. Apply a what? 2
-Commercial preparation like?
-Or make your own by mixing by?

2. Place impregnated cotton balls in the nare X how long?

3. Remove cotton balls and evacuate clot. How? 2

1. topical anesthetic + vasconstrictor
-Afrin and cotton balls soaked in Lidocaine 2%
-2% Lidocaine and 1:1000 epinephrine and soaking cotton balls in this mixture

2. 10 min

3. (blowing or suction)

9

Treatment for Epistaxis
Step 3: Determine site of bleeding
1. You need what? 5
2. Many times the site is determined by age:
-Children?
-Adults?
-Older adults?

1.
-good illumination,
-a nasal speculum,
-suction,
-ENT chair (if available)
-PATIENCE!


2.
-Children – Often in anterior Kiesselbach’s area
-Adults – Generally just posterior to Kiesselbach’s area
-Older adults – Most difficult and often posterior

10

Treatment for epistaxis
Step 4: Cautery with silver nitrate stick
If still bleeding and can visualize the bleeding area?
3 steps

1. Apply pressure with the silver nitrate for 5-10 seconds
2. Cauterize a small area around the bleeder as well
3. Apply abx ointment to area
If this resolves the bleed then abx ointment X 7 days

11

Treatment for epistaxis
Step 5: Anterior Packing
Indicated if all measures up to this point have failed
1. Can use what? 2
2. Apply a what to the nare?
3. Apply what to the packing?
4. Insert along the _________ plane to the max depth

Foam polymers may need water to expand, some devices may require inflation


1. nasal tampons or nasal balloon catheters

2. topical anesthetic

3. surgial lubricant

4. horizontal

12

Treatment for epistaxis
Step 5: Anterior Packing
After Care? 4

After care:
1. Remove packing in 48-72 hours
2. Oral antibiotics required
3. Patient to remain upright (even sleep) for 48 h
4. No lifting and avoid laughing for 24 hours

13

Epistaxis
1. If still bleeding after packing consider this is a what?

2. Then?

3. What so we do with a septal hematoma?

4. What deformity can it cause?

1. posterior bleed
2. Consult ENT emergently

3. We drain it

4. saddle nose

14

Epistaxis
Posterior
1. What is ineffective?
2. Packing in a posterior pt?
3. What artery?

1. Direct pressure is ineffective

2. Nasal packs are uncomfortable to place
-Posterior packed patients are often admitted for observation

3. Sphenopalatine artery
ENT consult is warranted

15

Epistaxis: Posterior
Complications?

1. Difficulty swallowing
2. Otitis media
3. Necrosis of the nasal mucosa

16

What is the most commonly fractured bone in the face?

Nasal fracture

17

Nasal fracture
1. Dx based on?
2. Nose will present how? 2
3. Look for? 3
4. Inspection with what is mandatory?
5. Manage how long?

1. Diagnosis usually based on physical exam
2. Nose usually edematous and tender
3. Look for
-displacement
-crepitus
-epistaxis
4. Inspection with a nasal speculum mandatory to rule out septal hematoma
5. Manage (closed reduction) 2-10 days post injury to allow for reduction of swelling

18

Septal hematomas occur secondary to trauma to the what?

anterior nasal septum

19

Septal hematomas occur secondary to trauma to the anterior nasal septum
1. Adults suspect one?
2. Children can occur with what?
3. Treatment? 2
4. Cartilage fracture: Formation of what?

1. Adults
-Suspect significant trauma and nasal fracture

2. Children
-Can occur with simple falls or minor altercations

3. Treatment
-Drain and pack
-Antibiotics (Augmentin) if abscess suspected IV Clindamycin and admission

4. Cartilage fracture
-Formation of bilateral hematomas

20

Complications that occur from untreated septal hematomas
3

1. Saddle nose deformity
2. Septal abscess
3. Septal perforation

21

Common Ear Complaints Encountered in EM
3

1. Otitis Externa
2. Otitis Media
3. Vertigo

22

External Otitis
1. AKA?
2. Signs and symptoms?
3. What must you visualize?
4. Whats the positive sign?
5. Tx? 3
6. Have to rule out what?
7. What bug?

External otitis
1. AKA “swimmer’s ear”
2.
-Edema,
-erythema of EAC with +/- exudate
3. MUST see TM (if not make sure you clean out ear so TM is visible)
4. Positive pinna tug
5. Treatment is generally
-application of wick and cortisporin otic;
-local heat,
-analgesia
6. MALIGNANT OE! -need referral to EENT and systemic abx for 6-8 weeks. Whole side of head will be swollen.
7. Pseudomonas
Otitis Media
You know this ad nauseum so just treat it!

23

Differentiate between a neurologic disorder vs. a disorder of the ear
Signs/Sx
1. Nystagmus
2. Hearing loss
3. Other neuro symptoms
4. Other symptoms
5. DDx (3 for CNS) (4 for Ear)

CNS
1. Usually absent
2. Rare
3. Present
4. Rare
5.
-Drug toxicity
-Cerebellar stroke
-Brain stem stroke

3. Ear
1. Horizontal
2. Usually present
3. Absent
4. N, V, sweating
5.
-Meniere’s
-Labrynthitis
-Acoustic neuroma
-Infectious

24

Vertigo
Ménière's disease:
1. What is it?
2. Presentation?
3. Usually what symtpom?
4. Tx?

1. Fluctuating, progressive, sensorineural deafness. Hydrops, FULLNESS in the ear!
2.
-Episodic*** characteristic definitive spells of vertigo lasting 20 minutes to 24 hours**
with
-no unconsciousness,
-vestibular nystagmus always present.
3. Usually tinnitus

25

Vertigo
Acute labyrinthitis
1. Recovery takes how long?
2. Describe the acute period?
3. Approximately how long?
4. How long may chronic compensation last?
5. May follow what?

1. Recovery generally takes from one to six weeks
2. An acute period, which may include severe vertigo and vomiting
3. Approximately two weeks of sub-acute symptoms and rapid recovery
4. Chronic compensation, which may last for months or years
5. Upper respiratory infection

26

Vertigo
1. What is BPV?
2. Tx?

1. Benign paroxysmal positional vertigo (BPPV) is a disorder arising in the inner ear. Its symptoms are repeated episodes of positional vertigo, that is, of a spinning sensation caused by changes in the position of the head. BPPV is the most common cause of the symptoms of vertigo.

2. Tx:
-Epley maneuver
-Antiemetic's (ondansetron-Zofran 4-24mg po/d)/ anticholinergics (meclizine 25mg po 1-4x/d)

27

Emergencies involving the Pharynx and Hypopharynx
5

1. Acute tonsillitis
2. Epiglottitis
3. Peritonsilar abscess
4. Croup
5. Ludwig’s Angina

28

Acute Tonsillitis
1. Signs and symptoms? 3
2. Difficult to differentiate etiology b/w?
3. Bacterial is usually caused by?
4. Rapid strep is helpful how?
5. Watch for atypicals like?
6. First line?

1. Signs and symptoms:
-Fever,
-exudate,
-adenopathy common

2. Difficult to differentiate viral versus Strep

3. Bacterial is usually caused by Strep (group A)

4. Rapid strep is helpful for cases that you suspect may be viral otherwise just treat

5. Watch for atypical, resistant infection (i.e.- GC pharyngitis)

6. Oral PCN
-alt: amoxicillin

29

Epiglottitis
1. What is it?
2. Signs? 2
3. Management?
4. What will you see on X-ray?

1. Infection/inflammation of epiglottis and surrounding soft tissue
2.
-Tripod Posture
-Thumb print sign
3. Usually seen in children
If you suspect – STOP – DO NOT EXAMINE; obtain soft-tissue lateral of neck and call ENT/Pediatrics

4.
-Inflamed epiglottis
-swollen aryepiglottic folds

30

Peritonsillar Abscess
-Signs? 8
-Imaging?
-Management?

1. Severe pain,
2. hoarseness,
3. “hot potato voice”,
4. drooling,
5. dysphagia
6. Cervical lymphadenopathy,
7. fever
8. Soft palate bulging and uvula deviating AWAY

1. CT of neck

1.
-Call ENT to evaluate and take to the OR for an I&D;
-Usually Strep; Start IV antibiotics
-Draining of abscess is the treatment
-After drainage, High dose abx

31

Which oral antibiotics for post drainage on a peritonsilar abscess? 3

1. PCN ,
2. Augmentin or
3. Clindamycin for PCN allergic patients

32

Centor criteria for pharyngitis
4

1. Tonsilar exudates
2. Tender cervical LA
3. Fever or hx of
4. No cough

The more you have the more it is likely to be bacterial

33

What’s the difference between peritonsillar abscess and acute tonsillitis?

Uvula deviated- usually no exudates = abscess

Tonsilitis = inflamed with exudates

34

Croup (Laryngotrachealbronchitis)
1. Airway infection usually caused by?
2. Most common in kids of what age?
3. cough like?
4. Tx?
5. What is usually effective for decreasing swelling of the airway?

6. WARNING: They usually have other viral symptoms; therefore be VERY CAREFUL to not miss a what?

1. Parainfluenza virus
2. 3 months – 3 years

3. Hoarse, barking cough

4. Racemic epi and call pediatrician

5. Dexamethasone

6. inhaled FOB

35

Ludwigs angina
1. What is it?
2. Most often in which pts?
3. Can be life threatening: why? 3

4. Signs and symptoms? 7

5. Tx?

1. Cellulitis of the sublingual and submandibular areas that is usually caused by normal mouth flora
2. Most often in patients with poor dental hygiene or after dental procedures
3. Can be life threatening:
-Airway obstruction,
-sepsis, or
-extension of infection into mediastinum

4.
-Submandibular pain,
-swelling,
-trismus
-dysphagia
-Sublingual and submandibular tissues markedly swollen with “woody appearance”
-Tongue is pushed superiorly and posteriorly
-Ant/Lat neck swollen/indurated- “Bull’s Neck”

5. ABX and I&D

36

Dental Emergencies
1. Generally, patients present with?
2. ED tx?
3. They may need what?
4. What may you learn to do?

1. Generally, patients present with acute dental pain
2. Little, if any, ED treatment available other than analgesia
3. They may need antibiotics
4. If given the opportunity, learn to do apical dental blocks

37

Eye Emergencies
7

1. Acute angle closure glaucoma
2. Central retinal artery occulsion
3. Orbital cellulitis
4. Retinal detachment
5. Conjunctivitis
6. Foreign bodies
7. Corneal abrasions

38

Eye Emergencies
Ocular Conditions Requiring Immediate Rx
4

1. Acute angle-closure glaucoma
2. Occlusion of Central Retinal Artery (CRAO)
3. Orbital Cellulitis
4. Retinal Detachment

39

Acute Angle Closure Glaucoma
1. What is it?
2. What does it lead to?
3. Symptoms? 5
4. The affected eye will look like what? 4

1. Sudden increase in IOP due to blockage of outflow channels by iris root
2. Increase in IOP leads to intraocular venous insufficiency with ischemia to retina/optic nerve
3.
-Severe pain,
-halos around lights,
-blurred vision,
-photophobia, and
-N&V

4. Affected
-eye is red,
-nonreactive midrange (often irregular) pupil,
-hazy cornea,
-shallow anterior chamber angle

OPHTH EMERGENCY – CALL IMMEDIATELY!

40

Occlusion of Central Retinal Artery (CRAO)
1. Most common etiology?
2. Retina is completely without blood and will die in how long?
3. Classic presentation? 4
4. What will the retinal exam look like? 4

1. Most commonly embolic in origin (carotid artery plaque or endocardial vegatation)
2. will die in 30-60 minutes
3.
-Sudden,
-painless,
-unilateral vision loss usually in
-an older patient

4.
-Pallor of the optic disc,
-edema of the retina,
-cherry-red fovea,
-“boxcar” segmentation of the retinal veins

Ophthamological emergency – Call ophthalmologist IMMEDIATELY!

41

Orbital Cellulitis
1. Acute infections of the orbital tissues; usually which bugs?
2. Starts where?
3. Usually a hx of? 2
4. Signs and symptoms?3
5. Disk margins will look?
6. Labs?
7. Imaging?

8. Tx?

1. Acute infections of the orbital tissues; usually
-Strep pneumoniae,
-Staph aureus, or
-H. influenza
2. Starts in the ethmoid sinus and the infection spreads into the subperiosteal lining of the orbit through the ethmoid bone.
3. Usually a history of sinusitis or trauma to orbital area
4.
-Periorbital edema,
-some degree of exophthalmos,
-limitation in cardinal fields of gaze/painful EOM

5. Disk margins may be blurred,
6. WBC is elevated and fever is probably present
7. CT scan will confirm
Ophthalmology urgency

8. IV abx and referral and admission

42

Retinal Detachment
1. What is it?
2. More common in who? 2
3. Signs and symptoms? 2
4. IOP levels?
5. How will the retina itself look?
6. Management? 3

1. Actual separation of neurosensory layer from the retinal pigment epithelium

May become bilateral in 25%; 2. More common in
-older patients and
-those who are myopic

3.
-Painless DECREASE in vision with flashes of light and sparks;
-May be described as curtain dropping

4. IOP is normal or low
5. Detached retina appears gray with white folds
6.
-Admit,
-bilateral patch, and
-ophthamology consult urgently

43

Bacterial Conjunctivitis
1. Tx?

2. for contract wearers
-What are we treating?
-What are the abx to use?

3. What other education do they need?

1. Treatment
Non contact wearers
-Polymyxin

2. Contract wearers
-pseudomonas
-Cipro

3. Dont wear your contacts for

44

Treatment of bacterial conjunctivitis
1. Noncontact wearers? 2
2. Contact wearers? 2

1. Non-contact lens wearers
-Erythromycin
-Trimethoprim-polymyxin
2. Contact lens wearers
-Ofloxacin
-Ciprofloxacin

45

Treatment of Viral and allergic Conjunctivitis
1. Viral?
2. Allergic? 2

Viral
1. Antihistamine/decongestant drops
Allergic
1. Antihistamine/decongestant drops
2. Mast cell stabilizer/antihistamine drops

46

Foreign Body
1. Symptoms? 4
2. Dx? 2
3. R/O?
4. Tx? 3

Take a careful history
1. Symptoms:
-pain,
-tearing,
-redness,
-corneal abrasion
2. Diagnosis:
-slit lamp or
-Fluoroscein stain

3. Rule out intraocular foreign body

4. Treatment
-Removal,
-topical antibiotics,
-may need oral pain meds

47

Corneal Abrasion
1. Symptoms?
2. Dx?
3. Beware of what?
4. Tx?

1. Symptoms
-Eye pain,
-photophobia

2. Diagnosis
-Fluoroscein stain

3. Beware of
-white infiltrates or
-dendritic lesions
this could be Infection or herpes

5. Treatment
-Topical antibiotics

-PO pain meds for a day

48

Which are the topical abx that you would treat corneal abrasion with? 3

-Cipro,
-Erythromycin,
-Polytrim

49

Pearls For Eye Emergencies
1. Visual acuity in glaucoma?
2. Photophobia is present with what and not present with what?
3. What strongly suggests photophobia?
4. What is a steamy cornea suggestive of?
5. Pupil constricted or dialated in iritis?
6. in acute glaucoma?
7. IOP in iritis is?
8. In which disorders is there no pupillary light reflex?

1. The vision in acute glaucoma is markedly blurred
2. Photophobia with iritis is severe while it is absent in conjunctivitis and acute glaucoma
3. Circumcorneal ciliary injection strongly suggests iritis
4. A “steamy cornea” is suggestive of acute glaucoma
5. The pupil in iritis is constricted while in
6. acute glaucoma is mid-dilated, fixed and irregular
7. IOP in iritis is normal
8. There is NO pupillary light response with acute glaucoma and it is poor with iritis.