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Emergency Medicine > EENT > Flashcards

EENT Flashcards

1
Q

the pigmented part of the retina located in the very center

A

macula

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2
Q

perhaps the most important part of the eye.
the area of best visual acuity. It contains a large amount of cones—nerve cells that are photoreceptors with high acuity.

A

Fovea

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3
Q

Eye complaints should be categorized into one of the 4 categories

A
  1. Vision changes/loss
    - painful or painless
    - complete, partial, intermittent, persistent, floaters, flashing-lights, “curtain/vail”
  2. Change in appearance of the eye
  3. Eye pain/discomfort
    - aching, burning, throbbing, itching, FB sensation
  4. Trauma - mechanism of injury
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4
Q

chronic use of Ophthalmic drops can cause ___ and ____

A

chemical conjunctivitis
inflammatory changes to the cornea

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5
Q

These oral med can increase risk for glaucoma

A

dilating eye drops, TCA’s, MAOIs, antihistamines, antiparkinsonian drugs, antipsychotics, antispasmolytic agents

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6
Q

what surgicial hx component is important to consider

A

surgical hx focused on the eye

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7
Q

why is it important to ask about use of contacts or glasses?

A

contacts increase risk for bacterial corneal ulcers
lack of corrective lenses during exam will affect VA

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8
Q

usually the PE usually precedes treatment except for what type of injury?

A

chemical injuries require intervention prior to PE

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9
Q

what eye exam is performed first during the PE

A

Visual acuity and visual field by confrontation
- Use topical ophthalmic anesthetics if photophobia, pain or tearing interferes with exam
- VA should be assessed w/ corrective lens if available
- History of nystagmus?

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10
Q

If corrective lenses are unavailable VA should be assessed via ?

A

pinhole testing

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11
Q

If VA is worse than 20/200, what method do you use?

A

finger counting at 3 ft or hand motion perception at 1-2 ft

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12
Q

If pt is unable to detect hand motion when assessing VA, what is the last method you can use?

A

determine if light perception is present

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13
Q

If pinhole occluder is unavailable, what other method do you use?

A

use an 18 gauge needle to perforate a hole in an index card

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14
Q

Other eye exams to do during the PE

A
  1. EOM
    - impairment d/t muscle restriction, interrupted or decreased innervation, or trauma
  2. Pupils
    - size, shape, reactivity
    - assess for afferent pupillary defect
  3. Ocular adnexa: Eyebrows, eyelids, and lacrimal glands/ducts
    - assess for trauma, infection, dysfunction, deformity, crepitus, proptosis, eyelid FBs
  4. Conjunctiva, sclera, cornea, anterior chamber, iris, lens
    - inspect using a slit lamp (if available) provides a 3D view of the ocular structures
    - Fluorescein exam with Wood’s lamp
  5. Intraocular pressure
    - last d/t discomfort of exam
    - use anesthetic
  6. Fundoscopic exam
    - may require dilation - if so, perform last
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15
Q

normal ICP?

A

10-20 mmHg

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16
Q

What makes orbital cellulitis different from preseptal cellulitis?

A

Orbital
- fever, pain, eyelid swelling and erythema, decrease vision/diplopia, proptosis, ptosis, chemosis, pain with and limitation off EOM
- infection extending behind the orbital septum
- Life and vision threatening, inpatient IV therapy
- Often occurs as a complication of ethmoid or maxillary sinusitis

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17
Q

testing ICP is CI in what eye emergency?

A

globe rupture from blunt or penetrating trauma is suspected

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18
Q

where is the infection in periorbital cellulitis?

A

infection anterior to the orbital septum
generally benign, outpatient therapy
arises from sinusitis or contiguous infection due to local skin trauma, insect bite, or hordeolum.

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19
Q

REd flags for orbital involvement

A

chemosis, proptosis, increased IOP, decreased VA & pupillary response, pain with EOM

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20
Q

dx for orbital cellulitis

A

Orbital CT with contrast if concern for orbital involvement or in young children who are not able to cooperate fully with exam

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21
Q

complications of orbital cellulitis

A
  • orbital abscess
  • subperiosteal abscess
  • cavernous sinus thrombosis
  • frontal bone osteomyelitis
  • meningitis
  • subdural empyema
  • epidural abscess
  • brain abscess
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22
Q

management for periorbital cellulitis in non-toxic pts, adults and older children with mild symptoms

A
  • outpatient with oral Augmentin or Keflex
  • PCN allergy: clinda
  • hot compresses
  • f/u in 24-48 hrs with ophthalmology
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23
Q

management for periorbital cellulitis in young children and those with more severe presentation

A
  1. ADMIT, IV Rocephin / Unasyn + vanc
  2. PCN allergy: FQ + metronidazole / clinda
  3. ophthalmology consult
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24
Q

management for orbital cellulitis

A
  1. immediate ophthalmology consult
  2. admit for IV abx - IV ceftriaxone (Rocephin) OR ampicillin-sulbactam (Unasyn) PLUS vancomycin
  3. topical nasal decongestant
  4. lateral canthotomy - if increased IOP or optic neuropathy is present
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25
Q

what is a Hordeolum or Stye

A

acute infection of the eyelash follicle (external) or acute infection of the meibomian gland (internal)

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26
Q

acute, subacute, or chronic swelling caused by the obstruction of the meibomian gland

A

Chalazion

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27
Q

s/s of Hordeolum/Chalazion

A

pain, erythema, swelling

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28
Q

management for Hordeolum/Chalazion

A
  1. Warm, moist compresses for 10-15 minutes QID
  2. Erythromycin 0.5% ophthalmic oint BID for 7-10 days
  3. Do not manipulate the lesion
  4. Complication
    - cellulitis - use systemic antibiotics
    abscess - refer to ophthalmology for I&D
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29
Q
  1. Painless mucopurulent discharge with matting of the eyelids after sleep
  2. Conjunctiva is injected, occasional chemosis
  3. Cornea is clear without fluorescein uptake
  4. Rapid onset with severe purulent discharge - concern for GC/TC
A

Bacterial Conjunctivitis

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30
Q

how to dx Bacterial Conjunctivitis

A
  1. Fluorescein exam to rule out herpetic dendrite, ulcer, abrasion
  2. C&S if purulence is severe
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31
Q

management for bacterial conjunctivitis

A
  1. Topical ophthalmic abx x 5-7 days
    - Trimethoprim–polymyxin B
    - Fluoroquinolone or tobramycin for contact wearers (Pseudomonas)
  2. Admit infants <30 d old and those with severe hyperacute onset
    - consult ophthalmology and start empiric IV abx to cover GC/TC
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32
Q
  1. mild-moderate watery discharge
  2. conjunctival injection, occasional chemosis, small subconjunctival hemorrhages and preauricular LAD
A

Viral Conjunctivitis

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33
Q

dx for Viral Conjunctivitis

A
  1. Fluorescein exam to r/o herpetic lesion
    - punctate fluorescein stain if complicated by keratoconjunctivitis
  2. Slit lamp - follicles (small, regular, translucent bumps) on the inferior palpebral conjunctiva
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34
Q

management for viral conjunctivitis

A
  1. Cool compresses
  2. Naphcon-A - topical antihistamine/decongestant
  3. Artificial tears 5-6 x/d
  4. Educated on contagiousness and self resolution after 1-3 wks
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35
Q
  1. watery discharge, redness, and intense itching
  2. erythematous swollen eyelids
  3. injected and edematous conjunctiva
    - papillae (irregular mounds of tissue with a central vascular tuft) on the inferior conjunctival fornix
A

Allergic Conjunctivitis

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36
Q

dx for Allergic Conjunctivitis

A

Fluorescein exam to r/o herpetic lesion

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37
Q

management for Allergic Conjunctivitis

A
  1. Cool compresses QID
  2. Naphcon-A - topical antihistamine/decongestant
  3. Artificial tears 5-6 x/d
  4. Refer to ophthalmology if severe or resistance to therapy
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38
Q

Inflammation of the anterior uveal tract (iris and ciliary body)

A

Iritis (Anterior Uveitis)

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39
Q

causes for Iritis (Anterior Uveitis)

A

usually result from corneal insult or conjunctivitis. May be idiopathic (50%) , or related to trauma, auto-immune, infections.

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40
Q

s/s of iritis

A
  1. unilateral or bilateral pain
  2. photophobia with consensual photophobia (hallmark)
  3. conjunctival injection/perilimbal flush
  4. miosis with poor reactivity
  5. diminished VA - due to clouding of aqueous humor
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41
Q

dx for iritis

A
  1. Slit-lamp
    - keratic precipitates (deposits of inflammatory cells on the corneal endothelium)
    - aqueous flare and cells in anterior chamber (from protein deposits)
  2. Hypopyon if severe presentation
  3. Fluorescein staining to rule out associated ulcer, abrasion, dendritic lesion
  4. Measure IOP (normal in most cases)
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42
Q

management for iritis

A
  1. cycloplegia (duration 2 to 4 days) for pain
    - Cyclogyl / cyclopentolate 1%
    - LA Homatropine 5% - agent of choice
  2. Topical steroids to suppress inflammation 1% prednisolone drops 1 drop QID
    - Often not part of treatment from the ED.
  3. refer to ophthalmology with in 24-48 hours
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43
Q

Avoid this steroids for iritis if there there these additional conditions:

A
  1. corneal abrasion
  2. infectious
  3. if IOP is elevated
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44
Q

An infection of the corneal stroma

A

Corneal Ulcer

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45
Q

Corneal Ulcer can be caused by what?

A
  1. bacterial, viral, fungal
  2. associated with trauma - contact lens wearers
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46
Q

s/s of corneal ulcer

A

pain, redness, tearing, photophobia, blurry vision

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47
Q

dx of corneal ulcer

A
  • Fluorescein - staining corneal defect with surrounding white hazy infiltrate, iritis and/or hypopyon
  • ulcer cx (performed by ophthalmologist in ED) by scraping lesion with sterile scalpel/needle
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48
Q

management for corneal ulcer

A
  1. Ophthalmic (topical) fluoroquinolone (ofloxacin/cipro)
    - tobramycin (cheaper alt)
  2. Topical cycloplegic for pain
  3. AVOID eye patching
  4. Consult ophthalmology if immunocomp
    - topical antifungal/antiviral in addition
    - NO topical steroids unless advised by ophthalmology
  5. If unable to see ophthalmology in ED - f/u in 12-24 hrs
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49
Q

An infection of the cornea and conjunctiva by HSV

A

Herpes Simplex Keratoconjunctivitis

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50
Q

s/s Herpes Simplex Keratoconjunctivitis

A
  1. Unilateral photophobia, pain, eye redness, diminished VA
  2. Preauricular LAD
  3. +/- vesicular eruption of eyelid, conjunctival injection, corneal hypoesthesia
    - Assess for corneal sensation prior to installation of anesthetics
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51
Q

Fluorescein staining shows uptake in classic pattern of dendritic lesion or geographic ulcer is diagnostic for what dx?

A

Herpes Simplex Keratoconjunctivitis

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52
Q

management for Herpes Simplex Keratoconjunctivitis

A
  1. Infants < 30 d old - admit w/ urgent consult
  2. Eyelid - PO antiviral
  3. Conj - topical trifluridine w/ erythromycin ophthalmic
  4. Corneal - urgent consult
    - topical / oral antiviral per ophthalmology recommendation
    - ophthalmology f/u in 24-48 hours
  5. AVOID topical steroids
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53
Q

complications of herpes simplex keratoconjunctivitis

A

corneal scarring if not treated promptly

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54
Q

HZV involving the V1 division of the trigeminal nerve

A

Herpes Zoster Ophthalmicus

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55
Q
  1. Painful vesicular rash on erythematous base involving the upper eyelid and tip of the nose - Hutchinson sign
  2. Fever, malaise, HA
  3. Ocular involvement
    - Red eye, blurred vision, eye pain/photophobia
    - keratitis, anterior/posterior uveitis
  4. +/- Optic neuritis (unilateral pain or vision loss), elevated IOP
A

Herpes Zoster Ophthalmicus

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56
Q

dx for Herpes Zoster Ophthalmicus

A

Fluorescein stain - pseudodendrite (no epithelial erosion)

  • smaller in size, elevated w/o central ulceration, do not have terminal bulbs, and have relative lack of central staining (in comparison to true HSV dendrite)
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57
Q

management for Herpes Zoster Ophthalmicus

A
  1. Ophthalmology consult
  2. Severe - admit for IV acyclovir
  3. Skin
    - cool compresses
    - PO antivirals x 7-10 d (if rash present < 7 d)
    - topical bacitracin/erythromycin
  4. Ocular
    - erythromycin ophthalmic ointment
    - pain: cycloplegic, oral opiate, cool compresses
    - anterior uveitis (iritis) - topical steroids (only under direction of ophthalmology)
    — prednisolone acetate - absolute certainty of NO corneal lesions on slit-lamp prior to administration
  5. All < 40 y/o - work up for immunocomp state
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58
Q

Bleeding under the conjunctiva

A

Subconjunctival Hemorrhage

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59
Q

s/s of Subconjunctival Hemorrhage

A

bright red blood under the bulbar conjunctiva
hx of trauma; sneezing, coughing, vomiting, straining (Valsalva), hypertension, or can occur spontaneously

dx: clinical

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60
Q

management for subconjunctivial hemorrhage

A

Reassurance
educate that complete resolution may take 2-3 wks

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61
Q

Death of the corneal epithelial cells due to exposure to UV light

A

Ultraviolet Keratitis
Occurs when failure to use eye protection leads to exposure to arc welding, tanning bed lights or prolonged sun exposure

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62
Q

s/s of UV keratitis

A
  1. slow onset of FB sensation and mild photophobia, 6-12 hours after exposure, progressing to severe pain/photophobia
  2. blepharospasm, tearing, conjunctival infection
    - topical anesthetics (tetracaine) needed
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63
Q

dx for UV keratitis

A

Slit-lamp - diffuse punctate corneal edema, uptake of fluorescein - punctate corneal abrasions

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64
Q

management for UV keratitis

A
  1. +/-Eye patching
  2. cycloplegic, oral analgesics, topical abx
  3. Improvement after 24-36 hours of treatment
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65
Q

an insult/trauma to the cornea leading to a superficial or deep epithelial defect

A

Corneal Abrasion

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66
Q

s/s of Corneal Abrasion

A

tearing, photophobia, pain, blepharospasm
- topical anesthetic (proparacaine) is often needed to complete exam

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67
Q

dx for corneal abrasion

A

search for ocular FB
fluorescein stain with slit lamp

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68
Q

management for corneal abrasion

A
  1. ketorolac ophthalmic solution
    - oral opiate or cycloplegic if large abrasion or severe pain
  2. topical abx
    - erythromycin ointment or FQ/tobramycin if contact wearer
  3. f/u within 24-48 hrs with ophthalmology
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69
Q

Usually small piece of metal, wood, or plastic that becomes embedded superficially in the cornea

A

corneal FB
Need to determine cause of FB and the chance of a high-velocity globe penetration
Activities such as grinding, hammering metal on metal, operation of high speed machinery

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70
Q

s/s and dx for corneal FB

A
  1. Edema of the lids, conjunctiva, and cornea
  2. FB sensation, tearing, blurred vision, photophobia
  3. Evert lid to look for additional FBs
  4. Use slit lamp to look for less obvious corneal FB’s
  5. Hyphema/microhyphema suggest globe perforation
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71
Q

If FB is present in cornea for >24 hrs, what may be observed?

A

WBCs may migrate into cornea anterior chamber cause causing a white ring around the FB or a flare/cellular deposit respectively

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72
Q

For a corneal FB, Hyphema/microhyphema suggest globe perforation, how can you further assess?

A

Seidel test

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73
Q

what diagnostic do you order if suspected intraocular FB or globe rupture when dealing with a corneal FB

A

CT orbit

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74
Q

management for corneal FB

A
  1. Consult ophthalmology if hyphema noted
  2. Removal of FB
    - instill topical anesthetic to BL eyes
    - use 18-25-gauge needle, under slit lamp or other microscopic view to remove FB
    — remove rust ring if present unless pt can be seen by ophthalmology within 24 hrs
    - CI in uncooperative or intoxicated patients
  3. Resultant corneal abrasion - tx appropriately
  4. F/u with ophthalmology
  5. Update Td if appropriate
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75
Q

when managing a corneal FB when would you want a 24 hr f/u with ophthalmology?

A
  1. rust ring present
  2. FB is in central line of vision
  3. deep in corneal stroma
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76
Q

when managing a corneal FB when would you want a 48 hr f/u with ophthalmology?

A

if symptoms persist

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77
Q

how would you evaluate extent of injury with lid lacteration?

A
  1. lid margin
  2. full thickness
  3. underside of lid
  4. cornea/globe involvement
  5. nasolacrimal duct system
  6. loss of full lid movement (ptosis)

Td immunization status

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78
Q

when to consult oculoplastic surgeon for lid lacerations

A
  1. involving lid margin (>1mm)
  2. within 6-8 mm of medial canthus
  3. involving the lacrimal duct or sac
    - apply fluorescein into eye - if appearance into wound suspect canalicular involvement
  4. involving the inner surface of the lid
  5. associated with ptosis
  6. involving the tarsal plate
  7. involving the levator palpebrae muscle
79
Q

a lid laceration is observed to have
- a horizontal laceration with ptosis
- orbital fat is seen protruding through the laceration

what muscle is observed?

A

levator palpebrae muscle

Consult oculoplastic surgeon

80
Q

management for lid lacteration

A
  1. If lid edge margin < 1mm - do not suture - heals spontaneously
  2. Repair superficial lacerations not meeting criteria for oculoplastics
    - repair using soft, absorbable or nonabsorbable 6-0 or 7-0 suture (small suture material)
  3. Oral cephalexin (Keflex) and erythromycin ophth ointment
  4. Cold compresses
  5. DC pending f/u with ophthalmology in 24 hours
81
Q

presentation of Globe Rupture

A
  1. Hx of high speed FBy or penetrating injury - hammering or grinding without eye protection
  2. PE
    - severe subconjunctival hemorrhage
    - shallow or deep anterior chamber (when compared to unaffected eye)
    - hyphema
    - teardrop-shaped pupil
    - limited EOM
    - extrusion of globe contents
    - reduction in VA
    - (+) Seidel test - may be negative if penetrating wound has sealed

Once dx is suspected remainder of exam is suspended

82
Q

diagnotics for globe rupture

A

CT scan of orbit
confirms dx and presence of FB

83
Q

management for globe rupture

A
  1. Apply eye shield, keep upright and NPO
  2. IV broad spectrum antibiotics with antiemetic
    - IV vanc + ceftazidime
    — FQ if PCN/ceph allergy
    - IV ondansetron (Zofran)
    - avoid increase in IOP
  3. Update Td (if indicated)
  4. Emergent ophthalmology consult
84
Q

how to inspect/assess a blunt eye trauma, and why?

A

Use eyelid speculum/retractor or bent paperclip - using fingers will increase IOP further worsening a globe injury

85
Q

PE components for blunt eye trauma

A
  1. Assess VA, pupil, anterior chamber, globe
  2. If globe appears intact perform complete eye exam:
    - inspect for proptosis
    - assess EOM
    - palpate orbital rim
    - assess sensation of inferior orbital nerve
    — below the eye and ipsilateral side of nose
    - slit-lamp with fluorescein
    — assess for abrasions, lacerations, FB, hyphema, iritis, and lens dislocation
    - If globe still appears intact assess IOP
86
Q

complications of blunt eye trauma

A
  1. Ruptured globe
  2. Postseptal hemorrhage
  3. Hyphema
  4. Orbital blowout fracture
87
Q

postseptal hemorrhage complication ater a blunt eye trauma occurs most frequently in patients on ?

A

anticoagulants

88
Q

after a blunt eye trauma, the pt is now experiencing restriction of upward or lateral gaze, paresthesia along the infraorbital nerve route, subcutaneous emphysema

what is this compliation?

A

Orbital blowout fracture
results in entrapment of the inferior rectus muscle

89
Q

indications for CT facial bones w/o contrast for blunt eye trauma

A
  1. suspected postseptal hemorrhage
  2. hyphema
  3. orbital blow out fracture
  4. step off of orbital rim
  5. concern for globe rupture not fully evident on PE
  6. intraocular FB
90
Q

management and disposition for blunt eye trauma

A
  1. DC home with f/u to ophthalmology w/n 48 hrs if normal VA (compared to baseline) and nml ocular anatomy with full function
  2. Tx traumatic iritis (no corneal injury) - prednisolone acetate + cycloplegic (after consultation with ophthalmology)
  3. Emergent consult ophthalmology
    - indications: globe rupture, postseptal hemorrhage, hyphema, orbital blow-out fracture, intraocular FB
91
Q

First thing of action for chemical oxular injury?

A

Intervention prior to history/PE - Eye irrigation immediately (at the scene of the incident if possible)

92
Q

irrigation procedure for chemical ocular injury

A
  1. Apply topical anesthetic
  2. Attach NS or LR to a Morgans lens
  3. Check pH after 2 L of irrigation have occured
    - Wait 5-10 minutes before checking pH
    - Use pH paper in lower cul-de-sac
    - Irrigation continues until the pH returns to 7.4 for 30 minutes
  4. Once pH returns to normal inspect fornices and everted eyes
    - sweep with moistened cotton-tipped applicator to ensure there are no residual particles
93
Q

when do you do a PE for chemical ocular injury? what do you do for w/u?

A

After successful irrigation

  • Slit lamp - assess for necrosis, corneal defects, assess everted lids
  • IOP
94
Q

management and disposition for chemical ocular injury

A
  1. Cycloplegic, opioid pain meds
  2. Erythromycin ophthalmic ointment
  3. Update Td

Disposition: If discharged - f/u with ophthalmology within 24 hours is needed

95
Q

6 indications for emergent opthalmology consult for chemical ocular injury?

A
  1. increased IOP
  2. pronounced chemosis
  3. conjunctival blanching
  4. epithelial defect
  5. corneal edema
  6. opacification exposure to hydrofluoric acid, lye or concrete
96
Q

____ angle, also called closed angle or Acute angle closure glaucoma

A

narrow angle

Open Angle = Chronic glaucoma

97
Q

an area of tissue in the eye located around the base of the cornea, near the ciliary body, and is responsible for draining the aqueous humor from the eye via the anterior chamber (the chamber on the front of the eye covered by the cornea).

A

trabecular meshwork

98
Q

A group of eye diseases characterized by neuropathy to the optic nerve, with or without elevation in intraocular pressure

99
Q

Second leading cause of blindness ww next to cataracts

100
Q

what happens to the optic disk on ophthalmologic examination is seen with glaucoma?

101
Q

An obstruction of aqueous humor outflow - results from the lens or the peripheral iris blocking the trabecular meshwork

A

Acute Angle Closure Glaucoma

102
Q

Acute Angle Closure Glaucoma
Usually follows a history of an event that lead to pupillary dilation:

(4)

A
  1. exposure to dark room (movie theater)
  2. reading
  3. use of dilating agents, inhaled anticholinergics
  4. use of cocaine
103
Q

Hx:
* sudden onset
* eye pain or frontal/supraorbital HA
* rarely painless monocular vision loss
* blurred vision colored halos around lights, N/V

A

Acute Angle Closure Glaucoma

104
Q

PE:
1. fixed midposition pupil
1. hazy cornea
1. conjunctival injection
1. Increased IOP - may exceed 60-80 mmHg (normal 10-20 mmHg)
- affected eye is very firm to palpation
- use tonometry to confirm

A

Acute Angle Closure Glaucoma

105
Q

DDX for Angle closure Glaucoma

A
  1. Iritis
  2. Trauma
  3. Hyphema
  4. Subconjunctival hemorrhage
  5. Corneal abrasion
  6. Infectious keratitis
    1.
106
Q

management for Acute Angle Closure Glaucoma

A
  1. Immediate ophthalmologic consult
  2. supine
  3. Pharm
    - acetazolamide IV - if IOP > 50 mmHg, severe vision loss or unable to tolerate PO therapy
    - timolol/apraclonidine - wait 1 min between each drop
    - mannitol IV - if IOP >40 mmHg after 30 mins after mannitol
    - pilocaprine - induces mitosis but isn’t effective until IOP is < 50 mmHg
107
Q

gold standard for Angle closure Glaucoma diagnosis?

A

Gonioscopy - Views the iridocorneal angle

108
Q

definitive tx for Acute Angle Closure Glaucoma

A

Laser peripheral iridotomy

109
Q
  1. Inflammation along optic nerve
  2. Vision loss is often painless (can be painful with EOM)
    - Reduction in color vision MC affected
    - Mild loss of VA up to complete loss of light perception
A

Optic Neuritis (ON)

110
Q

PE + managment for optic neuritis

A
  1. VA including a Red desaturation test - affected eye will often perceive the object as pink or a lighter red
  2. (+) afferent pupillary defect
  3. Funduscopic:
    - swollen and edematous optic disk = anterior ON
    - nml optic disk = retrobulbar ON

Management: Emergent consult with ophthalmology and neurology

111
Q

Sudden painless monocular vision loss
hx of amaurosis fugax (transient vision loss)

A

Central Retinal Artery Occlusion

112
Q

PE for Central Retinal Artery Occlusion

A
  1. (+) afferent pupillary defect
  2. Fundoscopy - compare R to L
    - retina will infarct and become pale, less transparent, and edematous
    - macula remains red - “cherry red spot”
    - Segmented arterioles - “boxcarring”
113
Q

management and prognosis for CRAO

A
  • Management - Emergent ophthalmology and neurology consult
  • Prognosis - Permanent vision loss will occur 4 hours after onset
114
Q

Sudden painless monocular vision loss
vision loss is variable ranging from vague blurring to rapid loss

A

Central Retinal Vein Occlusion

115
Q

PE and management for Central Retinal Vein Occlusion

A
  1. (+) afferent pupillary defect
  2. Fundoscopy - compare R to L
    - optic disc edema, diffuse retinal hemorrhages “blood-and-thunder fundus”

Management: Ophthalmology consult with a follow-up in 12-24 hours

116
Q

Sudden onset of painless monocular vision changes
“floaters”, “flashes of light”, dark veil/curtain

A

Retinal Detachment

117
Q

PE/work-up/management for retinal detachment

A

PE:
- ocular exam nml other than VA and visual fields by confrontation
- fundoscopy nml - majority of detachments occur in peripheral retina (not visualized on fundoscopy)

Work-up: Bedside US

Management: Urgent consult (w/i 24 hours) with ophthalmology for a dilated eye exam

118
Q
  • pruritus, otalgia, and tenderness of the external ear - worse with mastication/movement of the auricle
  • otorrhea and decreased hearing in more severe presentations
  • Erythema and edema of the external auditory canal, spreading to the tragus and auricle
  • Clear - purulent discharge with crusting of the external canal
  • Severe cases - complete occlusion of the auditory canal, periauricular edema/erythema, LAD
A

Otitis Externa

119
Q

management for OE

A
  1. Analgesics - Tylenol/Motrin
  2. Cleansing of the external canal - gentle irrigation using hydrogen peroxide 1:1 with warm saline or water and gentle suction under direct visualization
  3. Otic drops
    - acetic acid/hydrocortisone (CI in perforated TM or if unable to visual TM)
    - ofloxacin (Floxin) or ciprofloxacin/hydrocortisone (Cipro HC)
    — avoid Cipro if suspected/confirmed TM perforation
    — ofloxacin safe for TM perforations
  4. Ear wick - Indicated if swelling is severe and prevents full application of otic drop
120
Q
  • Red flags: elderly, DM immunocompromised pts
  • Persistent sx despite standard therapy (2-3 wks)
  • Severe otalgia and edema; granulation tissue on floor of EAC possible
  • Assess CN’s - VII is usually first to be affected
A

Malignant Otitis Externa

121
Q

diagnostics and management for Malignant Otitis Externa

A
  1. Dx: CT head w/ contrast = “bone erosion”
  2. Tx:
    - Urgent ENT consult
    - IV abx - tobramycin + piperacillin; ceftriaxone; cipro
    - Pain - IV opiate is usually needed
    - Admission with ENT consult
122
Q

Infection of the inner ear

123
Q
  1. Hx
    - otalgia
    - +/- fever, otorrhea, hearing loss
  2. Physical Exam
    - TM erythema, yellow/white exudate behind intact TM or in canal if TM is perforated
    - Retracted or bulging with impaired mobility

dx?

124
Q

management & disposition for OM

A

Oral abx

  1. Amoxicillin - DOC
    - Alt - cefdinir, zithromycin limited efficacy against H. flu and S. pneumo.
    - Recent Abx use or recurrent OM - Augmentin or cefdinir
  2. Analgesics - Tylenol/Motrin

Disposition - home to f/u with PCP in 3-5 day

125
Q

MCC organisms of OM

A
  1. S. Pneumoniae
  2. H. Influenzae
  3. M Catarrhalis
  4. S. Pyogenes
  5. S. Aureus
  6. as well as respiratory viruses.
126
Q

dx and management Acute Mastoiditis

A
  1. Diagnosis
    - CT head w/ contrast confirms
    - mastoid “clouding” early in disease; loss of bony septae of the mastoid air cells, destruction/irregularity of the mastoid cortex, periosteal thickening
  2. Management - EM ENT consult, IV vancomycin and ceftriaxone, Admission
127
Q

A complication of OM in which the infection spreads to the mastoid cells

A

Acute Mastoiditis

128
Q
  1. History
    - otalgia, fever, postauricular pain and swelling
  2. Physical Exam
    - PE findings same as OM
    - protrusion of the auricle with loss of postauricular crease
    - postauricular erythema, swelling and tenderness

what is this dx?

A

Acute Mastoiditis

129
Q

A complication of OM characterized by bullae formation on the TM and deep external auditory canal.

A

Bullous Myringitis

130
Q
  1. History
    - severe otalgia, intermittent otorrhea due to ruptured bullae
    - hearing loss (reversible)
  2. Physical exam
    - intact bullae along the TM and EAC - blood filled, serous, serosanguineous
    - middle ear effusion

dx? tx?

A

Bullous Myringitis
same as OM

131
Q

Accumulation of blood between the skin and the cartilage of the auricle due to blunt trauma

132
Q

presentation and tx for hematoma?

A
  • Swelling, pain and ecchymosis of the auricle
  • Consult ENT: Immediate I&D with evacuation of the hematoma followed by compressive dressing to prevent reaccumulation
  • If left untreated: scarring with deformity leading to cauliflower ear
133
Q

H&P of FB in ear

A
  1. History - insertion of FB in ear, visualization of FB in ear, sensation of movement in ear, ear pain or loss of hearing
  2. Physical Exam
    - FB is visualized on otoscopic exam
    - look for signs of TM perforation and infection
134
Q

management for FB in ear

A
  1. immobilize live insects with lidocaine 2% solution before removal
  2. FB removal
    - use forceps or hooked probe under direct visualization or suction
    - irrigation with warm water or saline for small objects (non-organic objects) - organic objects may absorb liquid and swell
  3. Consult ENT if TM perforation is present or if object cannot be removed
135
Q
  • History of barotrauma, blunt/penetrating/acoustic trauma, lightning strikes (rarely)
  • Sudden onset of pain and hearing loss
  • +/- bloody otorrhea, vertigo, tinnitus
  • rupture of TM, ensure full visualization of TM and canal

what dx

A

Tympanic Membrane Perforation

136
Q

management for Tympanic Membrane Perforation

A
  1. Most TM ruptures will heal spontaneously
  2. Uncomplicated TM perforations can be discharged home
    - blunt or noise trauma that are isolated injuries
    - ENT f/u 7-10 day f/u is acceptable
  3. Penetrating TM ruptures - f/u with ENT in 24 hrs
  4. Otic antibiotics are needed only if foreign material remains in canal or middle ear
137
Q

2 classifications for epistaxis

A

anterior or posterior

  1. Anterior bleed - visualized on external exam
  2. Posterior bleed - unable to directly visualize bleed, blood from bilat nares or in posterior pharynx, failure to control with anterior packing
  3. Use nasal speculum to attempt visualization of bleed
138
Q

which epistaxis is happens MC at the sphenopalatine artery and Kiesselbach plexus?

A
  • anterior - kiesselbach
  • posterior - sphenopalatine
139
Q

management for epistaxis

A
  1. If severe bleed/hemodynamic instability - type and crossmatch blood
    - MC in posterior bleed and pts taking anticoagulants
  2. Place in “sniffing” position - lean forward, neck in neutral position, nose straight
  3. Direct pressure application
  4. Chemical cauterization - anterior sites only
  5. Thrombogenic Foams And Gels
  6. nasal packing
140
Q

how to perform direct pressure application for epistaxis

A
  1. evacuate all clots via nose blow
  2. apply intranasal vasoconstrictor
    - oxymetazoline 0.05% or phenylephrine 0.25% - 2 sprays/nostril
  3. pinch nose for 10-15 minutes without disturbing pressure
    - hands-free tongue depressor device
141
Q

how to do chemical cauterization for epistaxis

A

anterior sites only

  1. Utilize after 2 attempts at direct pressure have failed AND the bleeding vessel is visualized
  2. Anesthetize the nasal mucosa with 3 cotton swabs soaked in 1:1 mixture of 0.05% oxymetazoline and 4% lidocaine
  3. Silver nitrate stick directly on bleeding vessel
  4. CI - active hemorrhage, bilat bleeding, recent cauterization (within last 4-6 wks)

Electrocautery is only performed by ENT

142
Q

epistaxis - management utilized if chemical cautery fails

A

Thrombogenic Foams And Gels

  1. Gelfoam and Surgicel (oxidized cellulose)
    - apply directly to visualized bleeding mucosa
  2. FloSeal (hemostatic gelatin matrix mixed with human thrombin)
    - inject mixture directly into bleeding nare, filling the nare completely
    - FloSeal will begin to break down after 3-5 days and provides complete healing in apps 8 wks
143
Q

indications for nasal packing for epistaxis

A

failure of chemical cautery, gel/foam not available, posterior epistaxis suspected

144
Q

3 types of nasal packing

A

epistaxis balloon, tampon/sponge, ribbon packing

145
Q

what is the epistaxis balloon (rapid rhino)?

A
  • easier to use and more comfortable for patient than other packing options
  • fabric is coated with cellulose, promoting platelet aggregation
146
Q

what are nasal tampons/sponges for epistaxis and their management?

A
  1. Available sizes
    - 5 cm length for anterior packing
    - 10 cm length for posterior packing
  2. Coat tampon with water-soluble antibiotic ointment
  3. Gently insert along nasal floor
  4. Irrigate tampon (while in proper place) with 5 ml of NS if it has not expanded within 30 seconds of placement
  5. Tape drawstring to face to secure
  6. Remove in 2-3 days
147
Q

last packing resort, most uncomfortable for patient and most difficult to insert

epistaxis

A

Ribbon gauze

148
Q

Posterior packing alternative for epistaxis

A
  1. 14-French foley catheter
  2. Anesthetize the nares with oxymetazoline and lidocaine (as discussed previously)
  3. Cut tip of catheter just beyond balloon if sensitive gag reflex
  4. Lubricate distal ⅓ of foley with lidocaine gel
  5. Advance foley along nasal cavity floor until the end is visualized in posterior oropharynx
  6. Inflate balloon with 7 ml of air and pull back until it becomes lodged in the choanal arch
    - DO NOT use saline to inflate tube as this could cause aspiration if rupture occurs
    - if balloon doesn’t lodge deflate balloon and insert again adding 10 ml of air - avoid using > 10 ml air due to risk of necrosis
  7. Secure catheter to face with tape
149
Q

complications for epistaxis

A

vasovagal syncope, dislodgement of packing, recurrent bleeding, sinusitis, toxic shock syndrome - more likely with posterior nasal packing

150
Q

epistaxis - Admit and consult ENT if:

A

Posterior packing is required or anterior epistaxis is uncontrolled

151
Q

epistaxis - Prophylactic abx recommended if ?
what abx?

A
  • packing will be present >48 hours
  • augmentin
  • PCN allergy: cephalosporin or Bactrim
152
Q

follow-up and pt ed for epistaxis

A
  • Follow up - All packing must be removed in 2-3 days by ENT or ED - 2 days is most ideal
  • pt ed - Avoid NSAIDs for 3-4 days
153
Q
  • fever, odynophagia, petechial or vesicular lesions along soft palate and tonsils
  • cough, rhinorrhea, nasal congestion

which type of pharyngitis

A

viral pharyngitis

154
Q
  • fever, headache, sore throat, odynophagia,
  • tonsillar exudates/erythema, cervical LAD

which type of pharyngitis

A

bacterial pharyngitis

155
Q

Centor Criteria?

A
  • tonsillar exudates
  • tender anterior cervical adenopathy
  • absence of cough
  • fever
156
Q

DDx to consider for pharyngitis/tonsillitis

A

mononucleosis, influenza, acute URI

157
Q

If 2 or more Centor criteria are met, perform ?

A

rapid strep test

  • McIsaac scoring system or modified Centor Criteria, includes age.
  • Younger than 15 adds a point, older than 15 but younger that 45 0 point, and
  • Older than 45 is a negative risk factor -1 point
158
Q

Ulcers for pharyngitis/tonsillitis are almost always ____!!!

159
Q

Palatal Petechiae is caused by what pathogen?

A

GABHS
Strep pyogenes

160
Q

tx for Pharyngitis/Tonsillitis

A
  1. Non-bacterial: supportive - antipyretics, analgesics, IV fluids if dehydrated
  2. Bacterial: Single dose of PCN G 1.2 million U IM / amoxicillin 500 mg BID x 10d
    - PCN allergy (rash) - Cephalexin / Cefdinir / Cephalosporins
    - anaphylaxis - Azithromycin / clinda
161
Q
  1. HX
    - Fever, malaise, sore throat, odynophagia, dysphagia, “hot potato” voice, otalgia, +/- trismus
  2. PE
    - Unilateral tonsillar enlargement
    - Palatal and uvula edema
    - Contralateral deflection of uvula
    - Tender ipsilateral anterior lymphadenopathy
    - Drooling
    - Dehydration
A

Peritonsillar Abscess

162
Q

Pt ed for pharyngitis/tonsillitis

A
  1. Tell pt change toothbrush after 24 hours
  2. Not contagious any longer after 24 hours of treatment
  3. Strep will “go away” on it’s own without antibiotics
    - However, a patient will remain contagious for 2-3 weeks after symptoms abate
163
Q

Peritonsillar Abscess

A

a collection of purulent material between the tonsillar capsule, the superior constrictor, and palatopharyngeus muscle

164
Q

DDx peritonsillar abscess

A

peritonsillar cellulitis, mononucleosis, retropharyngeal abscess, HSV tonsillitis, neoplasm, internal carotid aneurysm

165
Q

Dx peritonsillar abscess

A
  1. Imaging is often not needed due to classic presentation of disease allowing for confident clinical diagnosis
  2. Intraoral US - confirms presence of abscess when differentiating between cellulitis and abscess
  3. CT scan w/ contrast of the neck (not C-spine)
166
Q

management for peritonsillar abscess

A
  1. Needle aspiration or I&D (consult ENT if necessary)
  2. Non-toxic + successful drainage + can tolerate PO = DC w/ PO abx
    - PCN VK + metronidazole x 10 d
    - allergy: clinda + metronidazole
  3. Toxic pts - sepsis workup, IV pip-taz
167
Q

a collection of pus in the space anterior to the prevertebral fascia that extends from the base of the skull to the tracheal bifurcation

A

Retropharyngeal Abscess

168
Q
  1. History
    - look for source: recent intraoral procedure, trauma, foreign bodies (fishbone/pencil), or extension from odontogenic infection
    - sore throat, dysphagia, neck pain/torticollis
    - stridor in children
  2. Physical Exam
    - muffled voice
    - cervical adenopathy
    - respiratory distress

dx?

A

Retropharyngeal Abscess

169
Q

dx Retropharyngeal Abscess and its findings?

A
  1. lateral soft tissue neck x-ray
    - thickening and protrusion of the retropharyngeal wall
  2. CT neck w/ IV contrast - GOLD STANDARD
    - use if high suspicion and XR not definitive
    - early: nonsuppurative edema, mild fat stranding, linear fluid, minimal mass effect
    - later: necrotic nodes with central low attenuation and ring enhancement
170
Q

management for retropharyngeal abscess

A
  1. Prepare for emergent airway placement
  2. Urgent ENT consult for surgical intervention and admission
  3. IV fluids, NPO
  4. IV clinda / cefoxitin
    - Alt: pip-taz / Unasyn
171
Q

An inflammatory condition of the epiglottis, most often infectious in nature

A

Epiglottitis

172
Q
  1. 1-2 day progressive dysphagia, odynophagia and dyspnea
  2. +/- drooling, inspiratory stridor, fever
  3. sx worse when supine, improved when upright
    - upright, leaning forward, neck extended with mouth open
  4. tachycardia
  5. cervical adenopathy
  6. tenderness of anterior neck with gentle palpation of the larynx and upper trachea

dx?

A

epiglottis

173
Q

Lateral soft tissue neck XR shows obliteration of the vallecula - “thumbprint” sign

dx?
What is the gold standard for confirming?

A

epiglottis

Transnasal fiberoptic laryngoscopy - risk of airway obstruction during exam

174
Q

management for epiglottis

A
  1. Emergent ENT consult and admission
  2. Prepare for emergent airway placement
    - Place on cardiopulmonary monitors
    - Do not leave pt unattended
    - Pt should remain upright
  3. Humidified oxygen, IV fluids
  4. IV cefotaxime + vanc
    - Severe PCN allergy: rsp FQ
  5. IV methylprednisolone 125 mg - reduce inflammation and edema
175
Q

Extension of a dental abscess into a surrounding structure or deep neck space

A

Odontogenic Abscess

176
Q

where can Odontogenic Abscesses occur? (3)

A

retropharyngeal, parapharyngeal spaces, floor of mouth

177
Q
  1. hx of dental pain/abscess
  2. erythema edema of the labia or buccal gingiva, intraoral or dento-cutaneous fistula (tooth abscess)
  3. trismus, fever, edema of the upper neck/floor of mouth, displacement of the tongue, airway compromise (Ludwig’s angina)
  4. sore throat, dysphagia, dyspnea (retro-parapharyngeal abscess)

dx? w/u?

A

Odontogenic Abscess

  • superficial infection - bedside US to confirm
  • deep - CT neck with IV contrast
178
Q

2 complications with Odontogenic Abscess

A
  1. Ludwig’s angina
  2. Necrotizing infection
179
Q

cellulitis of the sublingual and submaxillary space

which odontogenic abscess complication? tx?

A

Ludwig’s angina
rapidly progressive - obtain definitive airway early in presentation

180
Q

toxic appearing with hemodynamic instability, skin discoloration, crepitus of the subcutaneous tissue, fever, confusion

which odontogenic abscess complication?
tx?

A

Necrotizing infection
requires immediate surgical fasciotomy

181
Q

management for odontogenic abscess

A
  1. Non-toxic with superficial (dental abscess)
    - PCN VK / amoxicillin PO
    — allergy - clinda
  2. Toxic, deep infection, complication of odontogenic infections
    - Urgent ENT consult and admission
    - IV fluids, NPO
    - IV unasyn + clinda + cipro
182
Q

swallowed FB are a concern particularly in who?

A

kids, mental illness, prisoners

183
Q

MC food that becomes lodged in esophagus

184
Q
  1. Clinical Presentation
    - Children: refusal or inability to eat, vomiting, gagging and choking, stridor, neck or throat pain, and drooling
    - Adults: retrosternal pain (upper ⅓ of esophagus), dysphagia, vomiting, choking, coughing, aspiration if attempting to “wash down” in esophagus
  2. Physical Exam
    - Assess airway, nasopharynx, oropharynx, neck and chest

which dx

A

swallowed FB

185
Q

dx swallowed FB

A
  1. “FB film” - chest and abdomen
    - will only reveal radiopaque objects
  2. CT chest without contrast
    - will shows non-radiopaque objects
    - provide information on perforation and signs of infection
186
Q

how will swallowed coins look on XR

A
  • circular face on AP/PA if in esophagus
  • circular face on lateral view if in trachea
187
Q

tx for swallowed FB

A
  1. Assess for airway compromise and risk of aspiration
    - complete esophageal obstruction leads to pooling of secretions and aspiration
  2. Determine need for urgent endoscopy
    - do not delay endoscopy for further imaging
188
Q

7 circumstances warranting urgent endoscopy for esophageal FB

A
  1. ingestion of sharp or elongated objects (toothpicks, aluminum soda can tabs)
  2. ingestion of multiple FB
  3. ingestion of button batteries
  4. evidence of perforation
  5. coin at the level of the cricophargyngeus muscle in kid
  6. airway comp
  7. presence of FB for >24 h
189
Q

management/disposition for swallowed FB

A
  1. Expectant therapy: if object is past pylorus and meets no “red flags” for obstruction
    - serial x-rays (if radiopaque) until complete passage
  2. Distal esophageal objects
    - IV glucagon, 1-2 mg in adults, may relax the lower sphincter and allow passage of the object
  3. Successful endoscopy without complications: discharge home
190
Q

management for food impaction

A
  1. complete esophageal obstruction requires emergency endoscopy
  2. partial obstruction: treat expectantly with f/u in 12-24 hours to ensure passage
    - if passage hasn’t occurred endoscopy is needed
191
Q

management for coin ingestion? alt procedure?

A
  1. coins in the esophagus should be removed
  2. endoscopy is procedure of choice
    - alt: foley catheter performed under fluoroscopy by experienced provider
192
Q

management for swallowed sharp objects

A
  1. if in esophagus, stomach or duodenum - immediate endoscopy
  2. if distal to duodenum and is asx - daily xrays until passage
  3. if passage doesn’t occur within 3 d - consult surgery
  4. consult surgery immediately if s/s of perforation
    - pain, emesis, fever, GI bleed
193
Q

special considerations with swallowed button battery and its management

A
  1. True emergency requiring prompt removal if found in the esophagus
    - battery will lead to rapid mucosal injury and necrosis
    - perforation within 6 hrs of ingestion
  2. passed esophagus - f/u in 24 hrs for repeat exam
  3. Repeat XR at 48 hrs to ensure passage through pylorus
  4. Complete passage takes 48-72 hours for most patients
194
Q

management for narcotic ingestion (body packers)

A
  1. commonly ingested inside a condom - can hold up to 5 grams of narcotics
  2. rupture of 1 pack = fetal
  3. endoscopy CI d/t risk of rupture
  4. visible with plain film
  5. admit for observation until packet reaches rectum

Emergency Medicine (20 decks)

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