EENT emergencies Flashcards
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