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Emergency Med Exam 2 > EENT Emergencies > Flashcards

EENT Emergencies Flashcards

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1
Q

Corneal Abrasion

A

*Most common eye injury
*Corneal epithelium is scraped or
compromised

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2
Q

Corneal Abrasion presentation

A

*Symptoms unilateral
*Foreign body sensation
*Eye pain
*Inability to open eye
*Photophobia
*Excessive tearing

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3
Q

Corneal Abrasion diagnosis

A

*No obvious laceration on initial exam
*Assess visual acuity
*Instill topical anesthetic
*Fluorescein & Wood’s lamp
*Slit lamp examination if no obvious
abrasion
*If penetrating injury suspected
*CT or MRI
*If ulcer suspected, obtain cultures
prior to antibiotics

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4
Q

Corneal Abrasion treatment

A

*Prophylactic topical antibiotics until patient is
asymptomatic
*Ciprofloxacin, tobramycin, trimethoprim/polymyxin B
*Pain relief
*Oral narcotic
*Topical NSAID
*Diclofenac (Voltaren) or ketorolac (Acular)
*Long-acting cycloplegic agent can provide significant relief for
photophobia and blepharospasm
* Cyclopentolate
* Contraindicated in narrow-angle glaucoma

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5
Q

T/F Small abrasions can be managed
outpatient

A

T

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6
Q

Abrasions from contacts=_____

A

pseudomonas

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7
Q

Abrasions from _____ r=fungal

A

vegetable matte

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8
Q

Corneal Foreign Body presentation

A

*Red eye
*Pain
*Foreign body sensation
*Photophobia
*Tearing

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9
Q

Corneal Foreign Body exam

A

*Visual acuity may be decreased
*Conjunctival injection
*Visible foreign body
*Epithelial defect that stains with
fluorescein
*Rust ring
*Anterior chamber cell/flare

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10
Q

Corneal Foreign Body diagnosis

A

*Exclude intraocular foreign body
*Orbital CT
*B-scan ultrasound
*Ultrasound biomicroscopy (UBM)
*If metallic object suspected,
consider x-ray as initial study
Slit lamp
*Full-dilatation examination by an
ophthalmologist

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11
Q

Corneal Foreign Body treatment

A

*Remove foreign body
*Ophthalmologist consult
*Infectious corneal infiltrates/ulcers generally require
scrapings for smears and cultures
*Topical antibiotics
*Polymyxin B sulfate-trimethoprim, ofloxacin, tobramycin,
ciprofloxacin
*Antibiotics containing steroids are contraindicated
*Topical cycloplegic (cyclopentolate) for pain and
photophobia

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12
Q

*Do NOT patch if any of the following are present:

A

*A chance of a perforation of the globe exists
*A corneal infiltrate is present
*A chance of a retained intraocular foreign body is possible

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13
Q

Acute Angle-Closure Glaucoma risk factors

A
  • Family history
    *Age over 60 years
    *Hyperopia
  • Female
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14
Q

Acute Angle-Closure Glaucoma presentation

A

*Rapid diagnosis, immediate intervention, and referral can have
profound effects on patient outcome and morbidity
*At least 2 of the following:
*Ocular pain
*Nausea/vomiting
*History of intermittent blurring of vision with halos
*AND at least 3 of the following:
*IOP greater than 21 mm Hg
*Conjunctival injection
*Corneal epithelial edema
*Mid-dilated nonreactive pupil
*Shallower chamber in the presence of occlusion
*Periorbital pain
*Ipsilateral headache with boring pain
*Nausea and vomiting
*Visual deficits
*Halos around objects

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15
Q

Acute Angle-Closure Glaucoma examination

A

*Cornea and scleral injection, ciliary flush
*Visual acuity, visual fields, fundoscopic
exam, ocular motility
*Pain on eye movement, a mid-dilated fixed
pupil, and a firm globe

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16
Q

Acute Angle-Closure Glaucoma diagnosis

A

*IOP via tonometry
*Slit-lamp
*Corneal edema, irregular pupil shape,
synechiae(adhesions), segmental iris
atrophy
*Gonioscopy
*Allows visualization of the angle

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17
Q

*IOP should be checked ____ minutes
after administering drops for Acute Angle-Closure Glaucoma

A

30-60

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18
Q

Orbital Cellulitis

A

*Infection of the soft tissues of the
orbit posterior to the orbital
septum
*10% of cases result in vision loss
*Recent facial trauma or surgery,
dental work, or infection
elsewhere in the body are risk
factors
Periorbital cellulitis- skin of the
eyelid and tissue around the eye

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19
Q

Orbital Cellulitis presentation

A

*Fever, malaise, and a history of
recent sinusitis or URI
*Conjunctival chemosis
*Decreased vision
*Pain on eye movement
*Headache
*Lid edema
*Rhinorrhea

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20
Q

Orbital Cellulitis exam

A

*Ophthalmoplegia
*Dyschromatopsia and relative afferent pupillary defect
*Slit Lamp, elevated IOP
*Orbital pain and tenderness (present early)
*Dark red discoloration of the eyelids, chemosis, hyperemia of the
conjunctiva, and resistance to retropulsion of the globe may be present
*Purulent nasal discharge may be present

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21
Q

Orbital Cellulitis diagnosis

A

*CBC c diff, blood cultures prior to
antibiotics, cultures
*High-resolution contrast CT scan of the
orbit with axial and coronal views
*Rule out peridural and parenchymal brain
abscess formation
*MRI
*Lumbar puncture if cerebral or
meningeal signs develop

22
Q

Orbital Cellulitis treatment

A

*Admit for inpatient care until afebrile x 48 hours and clearly improved
* Broad-spectrum IV antibiotics should be started immediately
* Vancomycin + Ceftriaxone and Metronidazole
*Canthotomy and cantholysis- orbital compartment syndrome
*Surgical drainage
*Periorbital maybe more mild, and oral antibiotics could be used
*Fungal infection requires IV antifungal therapy along with surgery
*Ophthalmology and ENT consults, possibly infectious disease

23
Q

Orbital Blowout Fracture

A

*Force of blow → backward
displacement of eyeball → intraorbital
hydraulic pressure increases
→fracture in the weakest point of the
orbital wall
* A high-velocity object that impacts
the globe and upper eyelid transmits
kinetic energy to the periocular
structures

24
Q

Orbital Blowout Fracture presentation

A

*Facial trauma
*Decreased visual acuity
*Periorbital ecchymosis and edema
*Hypesthesia extending through the
region of the maxillary nerve
*Diplopia
*Decreased extraocular movement

25
Q

Orbital Blowout Fracture diagnosis

A

*Maxillofacial CT scan

26
Q

Orbital Blowout Fracture treatment

A

*Systemic antibiotic and no blowing
the nose
*Reassess in 1 week
*Patients who present without significant enophthalmos (2
mm or more), a lack of marked hypo-ophthalmos, absence
of an entrapped muscle or tissue, a fracture less than 50%
of the floor, or a lack of diplopia may not need surgery

27
Q

Cardinal sign of ocular inflammation

A

*Conjunctivitis
*Blepharitis
*Canaliculitis
*Keratitis
*Dacryocystitis
*Scleritis
*Episcleritis
*Corneal Injury
*Iritis
*Dry eye syndrome
*Glaucoma
*Subconjunctival hemorrhage

28
Q

Red flags with red eye presentation

A

*Decreased visual acuity
*Severe, deep eye pain
*Ciliary flush
* A pattern of injection in which the redness is most pronounced
in a ring at the limbus
*Photophobia
*Severe foreign body sensation that prevents the eye from staying
open
*Corneal opacity
*Fixed pupil
*Severe headache with nausea

29
Q

Peritonsillar Abscess (PTA)

A

*Form between the tonsil and
capsule
*Usually progress from tonsillitis →
cellulitis → abscess formation
*Weber glands
*Mean age is 20-30 years

30
Q

Peritonsillar Abscess presentation

A
  • Symptoms usually begin 3-5 days prior
    to evaluation
  • Fever
  • Malaise
    *Headache
    *Neck pain
  • Throat pain markedly more severe on
    the affected side and occasionally
    referred to the ipsilateral ear
    *Dysphagia
  • Change in voice
    *Otalgia
    *Odynophagia
31
Q

Peritonsillar Abscess exam

A
  • Mild/moderate distress
  • Fever
  • Tachycardia
  • Dehydration
  • Drooling, salivation, trouble handling oral
    secretions
  • Trismus resulting from pain from
    inflammation and spasm of masticator
    muscles
  • Hot potato/muffled voice
  • Rancid or fetor breath
  • Cervical lymphadenitis in the anterior
    chain
  • Asymmetric tonsillar hypertrophy
  • Localized fluctuance
  • Inferior and medial displacement of the
    tonsil
  • Contralateral deviation of the uvula
  • Erythema of the tonsil
  • Exudates on the tonsil
32
Q

Peritonsillar Abscess diagnosis

A

*Testing is not necessary in
straightforward cases
*If questionable diagnosis
*CT scan

33
Q

Peritonsillar Abscess treatment

A

*Pay close attention to the patient’s airway
*If the patient’s airway is compromised, immediate endotracheal intubation is indicated
*Fluid resuscitation
*Pain medication
*Oral steroids
*Empiric antibiotics
*Clindamycin, Omnicef, or Augmentin
*Can cause sepsis or carotid artery erosion if left untreated

34
Q

Peritonsillar Abscess I&D prep

A
  • Refer to ENT if needed
  • The patient should be sitting upright in an examination chair
  • Spray the tonsil and ipsilateral soft palate with benzocaine (eg,
    Cetacaine)
    *Using an 18-gauge needle on a 10-mL syringe, draw up approximately
    6-10 mL of lidocaine 1% with epinephrine
  • Change to a 27-ga needle (preferably a long needle)
    *Inject the mucosa overlying the fluctuant area with local anesthetic
35
Q

Medications for peritonsillar abscess

A

Clindamycin TID, Percocet, Medrol, tetracaine lollipops

36
Q

Epiglottitis

A

*Acute inflammation in the supraglottic region
of the oropharynx with inflammation of the
epiglottis, vallecula, arytenoids, and
aryepiglottic folds
*Haemophilus influenzae (25%)
*Noninfectious causes
*Reaction to chemotherapy
*Thermal (crack cocaine, throat burns in bottle
fed infants)
*Caustic insults

37
Q

Epiglottitis presentation

A

*Onset and progression of symptoms of
epiglottitis is rapid
*Sore throat (95%)
*Odynophagia/dysphagia (95%)
*Muffled voice (54%) - “Hot potato
voice”
*Adults may have preceding URI
symptoms

38
Q

Epiglottitis exam

A
  • Tripod position - Sitting up on hands, with the tongue out and the head
    forward
  • Drooling/inability to handle secretions
  • Stridor: A late finding indicating advanced airway obstruction
  • Muffled voice (54%)
  • Cervical adenopathy
  • Fever
  • Hypoxia
  • Respiratory distress
  • Severe pain on gentle palpation over the larynx or hyoid bone
  • Mild cough
  • Irritability
  • Tachycardia
  • Toxic appearance of patient
39
Q

Epiglottitis diagnosis

A

*Direct visualization of the epiglottis
*Nasopharyngoscopy/laryngoscopy = ENT
*Cherry red epiglottis
*The airway should be secured or
should be readily securable if
endoscopy is performed
*Lateral neck soft-tissue radiographs
*Avoid radiography for patients in
distress until the airway is secure
*Swollen epiglottis (thumb sign)

40
Q

Epiglottitis treatment

A
  • DO NOT ATTEMPT DIRECT VISUALIZATION OF THE EPIGLOTTIS
  • Reflex laryngospasm
  • Airway management is the most urgent consideration
  • Signs and symptoms associated with a need for intubation include respiratory
    distress, airway compromise on examination, stridor, inability to swallow,
    drooling, sitting erect, and deterioration within 8-12 hours
  • When in doubt, securing the airway is the safest approach
  • 18.1% require airway management
  • Patients without signs of airway compromise may be managed without
    immediate airway intervention by close monitoring in the intensive care unit
    (ICU)
  • Avoid therapy such as sedation, inhalers, or racemic epinephrine
  • Close contacts of patients in whom Haemophilus influenzae type b is isolated
    should receive rifampin prophylaxis (20 mg/kg; not to exceed 600 mg/d for 4
    d)
41
Q

Dental abscess

A

*Bacteria from the tooth can extend
into the gums, the cheek, the throat,
the tissues beneath the tongue, or
even into the jaw or facial bones
*Pus often collects at the site of the
infection as the immune system tries
to keep the infection from spreading
*Can result in death if it spreads to the
brain, causes septicemia, or if
swelling obstructs the airway
*A gum or gingival abscess is the
result of infection or trauma to
the surface of the gum tissue
*Periodontal abscesses are the
result of an infection that has
moved deeper into gum areas
*Periapical abscess refers to a
tooth with an infection of the
dental pulp

42
Q

Dental abscess presentation

A

*Pain, swelling, redness
*One or more teeth will be very
sensitive to pressure
*Nausea/vomiting
*Fever/chills
*Difficulty swallowing
*Difficulty opening mouth
*Difficulty breathing
*Dehydration

43
Q

Dental abscess exam

A

*Swelling
*Warmth
*Erythema
*Fluctuant mass
*Extends toward the buccal
side of the gum and to the
gingival-buccal reflection
*Parulis
*Trismus
*Necrotizing fasciitis
*Teeth
*Most frequently the lower third
molar, followed by other lower
posterior teeth
*Increased mobility
*Tenderness with percussion
*Extrusion

44
Q

Dental abscess diagnosis

A

*No labs indicated for uncomplicated abscess
*If accompanying cellulitis
*Leukocytosis with neutrophil predominance
*Aerobic and anaerobic blood cultures prior to IV antibiotics
*Panorex dental x-rays- not done in the ER
*Lateral and neck x-rays
*CT scan
*Needle aspiration
*1-2 drops

45
Q

Dental abscess treatment

A

Treatment
*Assess the airway and secure if necessary
*Cultures
*Antibiotic
*Oral vs. IV
*Hydration
*Pain management
*I & D
*F/u discharge referrals
*Uncomplicated → dentist
*Complicated → maxillofacial oral surgeon/ENT

46
Q

Epistaxis risk factors

A

*Rhinotillexis/mucophagy
*Dry climate
*Supplemental oxygen
*Nasal anatomy
*Trauma
*Coagulopathy
*Foreign body
*Iatrogenic
*Infection

47
Q

Epistaxis presentation

A

*Anterior
* 90% of bleeds occur anteriorly
* Capillary or venous bleeds
* Patients present with a constant ooze or
intermittent bleeding that resolves quickly
* Posterior
* Often of arterial origin
* Branches of the sphenopalatine artery
* Associated with atherosclerotic disease and
hypertension
* Patients present with profuse bleeding

48
Q

Epistaxis treatment

A

Labs and imaging usually not required
Treatment of anterior epistaxis
* Direct pressure continuously for 15 minutes
* Sitting position
* Slightly leaning forward
* Topical nasal decongestants
* Topical 4% cocaine
* Silver nitrate
* Surgicel
* ENT referral if recurrent or
persistent

49
Q

Treatment of posterior epistaxis

A
  • ENT ER consult
  • Rigid nasal endoscopy
  • Cauterize
  • Rapid Rhino
    *Antibiotic
  • F/u with ENT 3-4 days later
50
Q

BPPV presentation

A

*Begins suddenly upon waking
*Severe spinning
*Episodes are brief, less than 1-2 minutes
*Triggered by sudden head movement,
often unilateral
*Lag period
*May have no symptoms between
episodes
*“Mentally foggy”
*Exam usually WNL

51
Q

BPPV diagnosis

A

*Dix Hallpike
*Classic rotatory nystagmus with latency and limited duration
*In classic posterior canal BPPV, the top pole of the eyes rotates
toward the undermost (affected) ear
*Imaging typically not indicated in uncomplicated BPPV that
resolves with treatment

52
Q

BPPV treatment

A
  • Rehydration
    *Observation
  • Benign and can resolve
    spontaneously
  • Medication to suppress the
    vestibular system
  • Diazepam, meclizine
  • Canalith repositioning (Epley
    maneuver)
  • Vestibular rehabilitation
  • Patient education
  • Most cases resolve within 6 weeks
  • Recurrence rate of 15-20%

Emergency Med Exam 2 (4 decks)

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