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Diff areas of epistaxis?

- Keisselbach's plexus: anterior
- sphenopalatine plexus: posterior


How should pt be sitting w/ epistaxis? Why?

- should be sitting straight up - 90 degrees:
-this decreases nasal arterial pressures
-prevents aspiration
-may have to modify if pt appears shocky


Sig of posterior bleed as opposed to anterior bleed?

- distinguish b/t the 2: posterior won't stop bleeding, anterior should be able to visualize
- if packing and cauterization isn't working: most likely a posterior bleed
- posterior is more serious


Hx questions to ask pt w/ epistaxis?

- one nare or both
- sensation of blood in back of throat
- hx of epistaxis, trauma, head/neck tumor, radiation or head/neck surgery
- family hx of bleeding disorders
- anticoag, NSAIDs, ASA?


Underlying causes of epistaxis?

- nose picking
- dryness
- trauma
- anticoag or ASA therapy
- bleeding diathesis: heme (polycythemia, TTP, VW dz, hemophilia, aplastic anemia)
- FB
- allergies: nasal steroid use
- ASA? and HTN?


Tx of epistaxis - step 1?

step 1: start w/ direct pressure:
- compress nares b/t thumb and index finger or 2 tongue depressors taped together - for 20 minutes, have pt lead forward or sit upright
**this will have to effect on posterior bleeds


Step 2 tx of epistaxis?

if still bleeding after direct pressure:
- apply a topical anesthetic+vasoconstrictor
- commercial prep like Afrin and cotton balls soaked in lidocaine 2%
- or make own by mixing 2% lidocaine and 1:1000 epi and soaking cotton balls in mixture
- place impregnated cotton balls in nare x 10 min
- remove cotton ball and evacuate clot (blowing or suction)


Step 3 tx of epistaxis?

determine site of bleeding:
- you need good light, nasal speculum, suction, ENT chair and patience
- many times site is determined by age:
-kids - kiesselbach's area - anterior
-adults - generally posterior to kiesselbachs area
-older adults - most difficult and often posterior


Step 4 tx of epistaxis?

cautery w/ silver nitrate stick:
- if still bleeding and can visualize the bleeding area
- apply pressure w/ silver nitrate for 5-10 sec
- cauterize small area around bleeder as well
- apply abx oitment to area
- if this resolves the bleed then abx ointment for 7 days


Step 5 tx for epistaxis?

anterior packing:
- indicated if all measures up to this pt have failed
- can use nasal tampons or nasal balloon catheters
- apply topical anesthetic to nare
- apply surgical lubricant to packing
- insert along horizontal plane to max depth
- foam polymers may need water to expand, some devices may reqr inflation
- after care:
remove packing in 48-72 hrs, oral abx reqd, pt to remain upright (even sleeping) for 48 hrs, no lifting and avoid laughing for 24 hrs


if bleeding still exists after packing and cauterization what should you suspect?

- posterior bleed
- consult ENT emergently


Tx of posterior epistaxis?

- direct pressure is ineffective, nasal packs are uncomfortable to place, posterior packed pts are often admitted for observation
- ENT consult is warranted


Complications of posterior epistaxis?

- difficulty swallowing
- otitis media
- necrosis of nasal mucosa, TSS


Nasal fx: how is dx made? Management?

- MC fx bone in face
- dx based on Physical :
nose usually edematous and tender, look for displacement, crepitus, epistaxis
- inspection w/ nasal speculum mandatory to r/o septal hematoma
- mangagement: closed reduction - 2-10 days post injury to allow for reduction of swelling


Complications secondary to nasal fx?

- septal hematoma - complications -cause necrosis, perf septum - untx can lead to saddle nose
- infection
- obstructed airway from septal deviation
- tx: drain hematoma


When you see septal hematoma what should you suspect as etiology? tx? Tip off that it is a cartilage fx?

- adults: sig trauma and nasal fx
- kids: can occur w/ simple falls or minor altercations
- tx:
drain and pack, abx (augmentin) if abscess suspected - IV clinda and admission
- cartilage fx: tip off - formation of bilateral hematoma - ENT referral


Complications that occur from untx septal hematoma?

- saddle nose deformity
- septal abscess
- septal perf


Presentation of external otitis?

- aka swimmers ear: pseudomonas
- edema, erythema of EAC w/ +/- exudate
- must see TM (if not make sure you clean out ear so TM is visible - make sure not perf)
- positive pinna tug
- tx is generally application of wick and cortisporin otic, local heat, analgesia
- have to r/o malignant otitis externa (goes intracranially - osteomyelitis) - need systemic tx: really painful, cellulitis


CNS origin of vertigo?

- nystagmus: usually absent
- hearing loss: rare
- other neuro sxs: present
- other sxs: rare
- DDx:
drug toxicity
cerebellar stroke
brain stem stroke

- do neuro exam to diff from ear origin


Ear origin - vertigo?

- nystagmus: horizontal
- hearing loss: usually present
- other neuro sxs: absent
- other sxs: N/V, sweating
- DDx:
acoustic neuroma


What is meniere's disease?

- fluctuating, progressive, sensorineural deafness
- episodic, characteristic definitive spells of vertigo lasting 20 min to 24 hrs w/ no unconscious, vestibular nystagmus always present
- usually tinnitus

***tinnitus and hearing problems, episodic nystagmus
tx: diuretics, low Na diet


What is acute labyrinthitis? Recovery time?

- infection in labyrinth (usually viral, may follow URI)
- recovery generally takes 1-6 wks
- an acute period, which may include severe vertigo and vomiting
- approx 2 wks of sub acute sxs and rapid recovery
-chronic compensation: may last for months - yrs


What is BPV?

- otoliths out of place
- perform epley maneuver to move them back
- also give antiemetics (zofran, anticholinergics - meclizine)


Characteristics of acute tonsilitis? Tx?

- signs and sxs: fever, beefy red tonsils w/ exudate, adenopathy common
- r/o peritonsilar abscess (uvula deviation)
- difficult to diff viral vs strep
- bacterial is usually caused by strep
- rapid strep helpful for cases that you suspect may be viral otherwise just tx
- watch for atypical resistant infection: GC pharyngitis
- sx tx, fluids, rest, ibuprofen for pain and swelling, steroid burst pack - if pts can't swallow
- for strep - PCN, amoxicillin, cephalexin, azithro


Centor criteria - more likely to be bacterial?

- need abx if 3 or more +:
- tonsillar exudates
- tender cervical LA
- fever or hx of
- no cough


What is epiglottitis? presentation?

- infection/inflammation of epiglottitis and surrounding soft tissue
- present w/: hot potato voice, stridor, tripod or sniffing position, drooling
- x ray: thumb print sign
- pathogens: H flu, strep pneumo, staph, M cat
- usually seen in kids
- if you suspect - stop and don't examine - obtain soft tissue lateral neck xray and call ENT/peds
- tx w/ rocephin, if concern for MRSA add vanco or clindamycin, MRSA - will look more toxic, more systemic sxs


Presentation of peritonsillar abscess? Dx, tx?

- severe pain, hoarseness, hot potato voice, drooling, dysphagia, cervical lymphadenopathy, fever, sfot palate bulging and uvula deviating away
- CT of neck is dx Test of choice
- call ENT to eval and take to OR for I and D, usually strep- start IV abx
- drain abscess is tx
- after drainage: high dose PCN, augmentin, or clindamycin for PCN allergic pts


Characteristics of croup?

- airway infection caused by virus (parainfluenza, RSV, influenza A, B)
- MC in kids 3 m- 3 years
- hoarse, barking cough
- tx: racemic epi and call pediatrician
- dexamethasone is usually effective for decreasing swelling of airway
warning: they usually have other viral sxs: so be careful to not miss inhaled FOB


What is ludwig's angina?

- cellulitis of sublingual and submandibular areas that is usually caused by normal mouth flora
- most often in pts w/ poor dental hygiene or after dental procedures
- can be life threatenign: airway obstruction, sepsis, or extension of infection into mediastinum
- submandibular pain, swelling, trismus, and dysphagia
- sublingual and submandibular tissues markedly swollen w/ woody appearance (tense)
- tongue is pushed superiorly and posteriorly
- ant/lat neck swollen and indurated: bull's neck
- tx: refer - surgery: drain and abx


Dental emergencies - management?

- pts will present w/ acute dental pain
- only ED tx really available is analgesia, and abx
- can do apical dental blocks
- know who to refer to


Ocular conditions that reqr immediate rx?

- acute angle closure glaucoma
- occlusion of central retinal artery (CRAO)
- orbital cellulitis
- retinal detachment

- always test visual acuity first and document this!


Presentation of acute angle closure glaucoma?

- sudden increase in IOP due to blockage of outflow channels by iris root
- increase in IOP leads to intraocular venous insufficiency w/ ischemia to retina/optic nerve
- severe pain, halos around lights, blurred vision, photophobia, and N/V
- affected eye is red, nonreactive midrange (often irregular) pupil, hazy cornea, shallow anterior chamber angle
- ophtho Emergency!!! call ASAP


Presentation of CRAO?

- MC embolic in origin (carotid artery plaque or endocardial vegetation)
- retina is completely w/o blood and will die in 30-60 min
- sudden, painless, unilateral vision loss usually in older pt
- pallor of optic disc, edema of retina, cherry red fovea, boxcar segmentation of retinal veins
- ophtho emergency: call ASAP


Cause of orbital cellulitis? Spread? Hx? Presentation? Tx?

- acute infections of orbital tissues: usually Strep pneumo, staph, or H flu
- starts in ethmoid sinus and infection spreads into subperiosteal lining of orbit through ehtmoid bone
- usually hx of sinusitis or trauma to orbital area
- periorbital edema, some degree of exophthalmos, limitation in cardinal fields of gaze
- EOMs will be painful, red flag: can't open eye lid
- disk margins may be blurred, WBC is elevated and fever is probably present
- CT scan will confrim
- Ophtho urgency!


Characteristics of retinal detachment? Fundoscopic findings?

- actual separation of neurosensory layer from retinal pigment epithelium
- may become bilateral in 25%, more common in older pts and those who are myopic
- painless decrease in vision w/ flashes of light and sparks, may be described as curtain dropping
- may have floaters or flashing lights that precede vision loss
- IOP is normal or low
- detached retina appears gray w/ white folds
- admit, bilateral patch, and ophtho consult urgently


Presentation of viral conjunctivitis?

- itching: minimal
- hyperemia: generalized
- tearing: profuse
- exudation: minimal
- preauricular adenopathy: common
- in stained scrapings and exudates: monocytes
- assoc sore throat and fever: occasionally


Presentation of bacterial conjunctivitis?

- itching: minimal
- hyperemia: generalized
- tearing: moderate
- exudation: profuse
- preauricular adenopathy: uncommon
- in stained scrapings and exudates: bacteria, PMNs
- assoc sore throat and fever: occasionally


Presentation of chlamydial conjunctivitis?

- itching: minimal
- hyperemia: generalized
- tearing: moderate
- exudation: profuse
- preauricular adenopathy: common only in inclusion conjunctivitis
- in stained scrapings and exudates: PMNs, plasma cells inclusion bodies
- assoc sore throat and fever: never


Presentation of allergic conjunctivitis?

- itching: severe
- hyperemia: generalized
- tearing: moderate
- exudation: minimal
- preauricular adenopathy: none
- in stained scrapings and exudates: eosinophils
- assoc sore throat and fever: never


Tx of bacterial conjunctivitis?

- non contact wearers:
- contact wearers (worried about ulcer - pseudomonas):


Tx of viral and allergic conjunctivitis?

- viral:
antihistamine/decongestant drops
- allergic:
antihistamine/decongestant drops
mast cell stabilizer/antihistamine drops


Sxs of fb? Dx, tx?

- take careful hx
- sxs: pain, tearing, redness, corneal abrasion
- dx:
slit lamp or fluoroscein stain
- r/o intraocular FB
- tx: removal, topical abx, may need oral pain meds


Corneal abrasion:
sxs, dx, tx?

- get good hx
- sxs: eye pain, photophobia
- dx: fluoroscein stain
- beware of white infiltrates or dendritic lesions: infection or herpes
- tx:
topical abx (cipro, erythromycin, polytrim)
- PO pain meds for a day


Vision in acute glaucoma? Presentation?

- markedly blurred
- can have photophobia
- steamy cornea
- pupil is mid-dilated, fixed and irregular
- NO pupillary light response


Presentation of iritis?

- severe photophobia
- circumcorneal ciliary injection
- pupil is constricted while in acute glaucoma it is mid-dilated
- IOP is normal
- poor pupillary light response
- tx with paralytic