EENT emergencies Flashcards
1
Q
Diff areas of epistaxis?
A
- Keisselbach’s plexus: anterior
- sphenopalatine plexus: posterior
2
Q
How should pt be sitting w/ epistaxis? Why?
A
- should be sitting straight up - 90 degrees:
- this decreases nasal arterial pressures
- prevents aspiration
- may have to modify if pt appears shocky
3
Q
Sig of posterior bleed as opposed to anterior bleed?
A
- 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
4
Q
Hx questions to ask pt w/ epistaxis?
A
- 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?
5
Q
Underlying causes of epistaxis?
A
- 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?
6
Q
Tx of epistaxis - step 1?
A
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
7
Q
Step 2 tx of epistaxis?
A
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)
8
Q
Step 3 tx of epistaxis?
A
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
9
Q
Step 4 tx of epistaxis?
A
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
10
Q
Step 5 tx for epistaxis?
A
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
11
Q
if bleeding still exists after packing and cauterization what should you suspect?
A
- posterior bleed
- consult ENT emergently
12
Q
Tx of posterior epistaxis?
A
- direct pressure is ineffective, nasal packs are uncomfortable to place, posterior packed pts are often admitted for observation
- ENT consult is warranted
13
Q
Complications of posterior epistaxis?
A
- difficulty swallowing
- otitis media
- necrosis of nasal mucosa, TSS
14
Q
Nasal fx: how is dx made? Management?
A
- 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
15
Q
Complications secondary to nasal fx?
A
- septal hematoma - complications -cause necrosis, perf septum - untx can lead to saddle nose
- infection
- obstructed airway from septal deviation
- tx: drain hematoma
16
Q
When you see septal hematoma what should you suspect as etiology? tx? Tip off that it is a cartilage fx?
A
- 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
17
Q
Complications that occur from untx septal hematoma?
A
- saddle nose deformity
- septal abscess
- septal perf
18
Q
Presentation of external otitis?
A
- 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
19
Q
CNS origin of vertigo?
A
- 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
20
Q
Ear origin - vertigo?
A
- nystagmus: horizontal
- hearing loss: usually present
- other neuro sxs: absent
- other sxs: N/V, sweating
- DDx:
menieres
labrynthitis
acoustic neuroma
infectious
21
Q
What is meniere’s disease?
A
- 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
22
Q
What is acute labyrinthitis? Recovery time?
A
- 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
23
Q
What is BPV?
A
- otoliths out of place
- perform epley maneuver to move them back
- also give antiemetics (zofran, anticholinergics - meclizine)
24
Q
Characteristics of acute tonsilitis? Tx?
A
- 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
25
Q
Centor criteria - more likely to be bacterial?
A
- need abx if 3 or more +:
- tonsillar exudates
- tender cervical LA
- fever or hx of
- no cough
26
Q
What is epiglottitis? presentation?
A
- 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
27
Q
Presentation of peritonsillar abscess? Dx, tx?
A
- 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
28
Q
Characteristics of croup?
A
- 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
29
Q
What is ludwig’s angina?
A
- 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
30
Q
Dental emergencies - management?
A
- 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
31
Q
Ocular conditions that reqr immediate rx?
A
- acute angle closure glaucoma
- occlusion of central retinal artery (CRAO)
- orbital cellulitis
- retinal detachment
- always test visual acuity first and document this!
32
Q
Presentation of acute angle closure glaucoma?
A
- 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
33
Q
Presentation of CRAO?
A
- 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
34
Q
Cause of orbital cellulitis? Spread? Hx? Presentation? Tx?
A
- 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!
35
Q
Characteristics of retinal detachment? Fundoscopic findings?
A
- 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
36
Q
Presentation of viral conjunctivitis?
A
- itching: minimal
- hyperemia: generalized
- tearing: profuse
- exudation: minimal
- preauricular adenopathy: common
- in stained scrapings and exudates: monocytes
- assoc sore throat and fever: occasionally
37
Q
Presentation of bacterial conjunctivitis?
A
- itching: minimal
- hyperemia: generalized
- tearing: moderate
- exudation: profuse
- preauricular adenopathy: uncommon
- in stained scrapings and exudates: bacteria, PMNs
- assoc sore throat and fever: occasionally
38
Q
Presentation of chlamydial conjunctivitis?
A
- 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
39
Q
Presentation of allergic conjunctivitis?
A
- itching: severe
- hyperemia: generalized
- tearing: moderate
- exudation: minimal
- preauricular adenopathy: none
- in stained scrapings and exudates: eosinophils
- assoc sore throat and fever: never
40
Q
Tx of bacterial conjunctivitis?
A
- non contact wearers: erythromycin trimethoprim-polymyxin - contact wearers (worried about ulcer - pseudomonas): ofloxacin ciprofloxacin
41
Q
Tx of viral and allergic conjunctivitis?
A
- viral: antihistamine/decongestant drops - allergic: antihistamine/decongestant drops mast cell stabilizer/antihistamine drops
42
Q
Sxs of fb? Dx, tx?
A
- 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
43
Q
Corneal abrasion:
sxs, dx, tx?
A
- 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
44
Q
Vision in acute glaucoma? Presentation?
A
- markedly blurred
- can have photophobia
- steamy cornea
- pupil is mid-dilated, fixed and irregular
- NO pupillary light response
45
Q
Presentation of iritis?
A
- 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
