HEENT Emergencies Flashcards
1
Q
What amount of those with head injury in the US have bleeding? What amount require intervention?
A
Bleeding: <10%
Intervention: <1%
2
Q
Mechanism hx for head injury?
A
Assault w object? fall from height? MVC? GSW? sports?
3
Q
LOC hx for head injury?
A
none, brief (<1min), prolonged, associated seizure ?
4
Q
Relevant factor hx for head injury?
A
Helmet? seat belt?
5
Q
Asscoaited sx hx for head injury?
A
N/V (# of projectile)? headache? soft tissue swelling (STS)/bruising? preceding event (syncope)?
6
Q
Misc hx for head injury?
A
Prior head injury? current anticoagulants? age? distracting injuries? ETOH/drug use?
7
Q
S/Sx of head injury?
A
Headache, confusion, light/sound sensitivity, fatigue/malaise, N/V
8
Q
What to assess in PE for head injury?
A
Mental status (GCS), distracting injuries
9
Q
What to inspect in PE for head injury?
A
Lacerations, foreign bodies, basilar skull fx (Battle sign, Raccoon eyes), hemotympanum, CSF leakage (clear rhinorrhea or otorrhea), facial bone injury, pupil size/reactivity
10
Q
What to palpate for in PE for head injury?
A
Depressed skull fractures, foreign bodies, soft tissue swelling (STS), C-spine
11
Q
What to focus on for neuro PE in head injury?
A
Gait, Rhomberg (balance), finger-to-nose, cognitive recall
12
Q
DDx for head injury?
A
Contusion (soft tissue and vertebral), concussion, skull fx w or w/o intracranial bleed
13
Q
How to begin work-up for head injury?
A
GCS (Glasgow coma scale) & clinical decision making
14
Q
GCS
A
15
Q
Clinical decision tools
A
16
Q
What is a concussion?
A
Head injury resulting in transient alteration of cognitive abilities, motor function, and/or level of consciousness
17
Q
What is a subarachnoid hemorrhage?
A
Tearing of pial vessels w/ subsequent tracking of blood in the subarachnoid space into the sulci and cisterns
18
Q
What is a subdural hematoma?
A
Shear through the bridging veins with blood tracking along brain under the dura
19
Q
What is an epidural hematoma?
A
Skull fracture leading to disruption of an artery & blood escapes from the artery, pushing the tightly adhered dura away from the calvarium
20
Q
What are cerebral contusions?
A
Areas of punctuate hemorrhages and cerebral edema usually d/t acceleration-deceleration injuries against the bony internal surfaces of the cranium
21
Q
If low risk, is workup for head injury necessary?
A
Not always, 3-4 hrs observation best
22
Q
When to check coags with head injury?
A
If on coumadin or if bleed present
23
Q
When to check CBC, chemistries, UA, tox-screen, ETOH, EKG, orthostatics for head injury?
A
If injury is secondary to another process
24
Q
What to consider if head injury with children or elderly?
A
Abuse
25
Are skull plain films helpful in the work-up of head injury?
No, of little value
26
What other injury to consider along with head injury?
C-spine
27
What is the Banyan Brain Trauma Indicator (new test) for head injury?
Measures levels of two brain proteins (ubiquitan C-terminal hydrolase & glial fibrillary acidic protein) that are released after brain injury
28
What is SyncThink (new test) for head injury?
Ocular tracker concussion test
29
Mainstay of tx for concussion?
Rest and time (avoid exercise, TV, gaming until sx resolved for 24 hrs)
After: gradual return to activity & stop if sx resume
30
Concussion screening tools most useful with baseline?
MACE, SCAT, King-Devick, ImPACT
31
Tx for ICB (intracranial bleed)?
Emergent neurosurgery consult for possible defompression, intubation if GCS <8, seizure prophylaxis w/ phenytoin (Dilantin), anticoag reversal
32
How to reverse Warfarin in cases of ICB?
Vitamin K, FFP
33
How to reverse Heparin/LMWH in cases of ICB?
Protamine
34
How to reverse ASA/clopidogrel in cases of ICB?
Platelets
35
Head injury pathway
36
What is post-concussive syndrome?
Sx complex that continues beyond the expected 7-10d recovery period (25-30% of mild TBI pts)
37
Who is post concussive syndrome more common in?
Those w/ negative perceptions about traumatic experience, pre-existing stress, anxiety, depression
38
Somatic sx of post concussive syndrome?
Headache, insomnia, dizziness, nausea, fatigue, light/noise sensitivity
39
Cognitive sx of post concussive syndrome?
Attention/concentration/memory problems
40
Affective sx of post concussive syndrome?
Irritability, anxiety, depression, emotional liability
41
Tx for post concussive syndrome?
Focused on sx: analgesics, antidepressants, cognitive therapy, counseling
42
<1% of those on warfarin that receive a head injury will develop what?
Delayed ICB
*consider prolonged ED observation for 23hhr, admit those w/ significant injury or neurologic abnormalities w/ normal initial CT (rpt CT if sx worsen)
43
What occurs in the complication of deterioration post-ICB?
Progression of the ICB leading to hypoventilation/death
44
What disability can occur from head injuries?
Permanent neurologic or psychiatric deficits
(ex. CTE)
45
What is CTE?
Chronic traumatic encephalopathy- progressive disease secondary to repetitive trauma
46
What is a subconjunctival hemorrhage?
Collection of blood under conjunctiva from minor trauma, coughing, sneezing, etc
*no tx required
47
What is a hyphema?
Collection of blood in anterior chamber
48
Tx for hymphema?
Rest, head elevation, avoid ASA, optho follow up
49
Most common orbital fracture?
Orbital floor (blow-out fx)
50
Possible sx of orbital fracture?
Hyphema, ocular muscle entrapment, globe rupture
51
PE for orbital fracture?
Check EOMs, pupil shape
52
Tx for orbital fracture?
avoid nose blowing, etc.
Abx
Plastics or optho referral
53
Most corneal foreign bodies are ________
Superficial
54
Deformed pupil raises suspicion for what dx?
Corneal foreign body
55
PE for corneal foreign body?
Check under lids, document visual acuity PRIOR to meds
56
Procedure for corneal foreign body?
Anesthetic, fluorescein, blue light, cotton swab, 18gu needle, burr under slit lamp, irrigate
*rust ring needs to be removed
57
Tx for corneal foreign body?
Abx drops or ointment +/- cycloplegic, diclofenac, optho follow up
58
How will corneal laceration appear?
Similar to abrasion but with a raised border
59
How is a corneal laceration best visualized?
Under slit lamp
60
What may be present with corneal laceration?
Seidel sign (dye dilutes aqueous humor streams down eye w/ gravity)
61
Tx for corneal laceration?
Abx ointment/drops, optho referral for possible gluing, surg closure, or graft if large
62
What is actinic (UV) keratitis?
UV burns of the cornea secondary to welding, sunlamps, snow reflection
63
Which dx has diffuse punctate staining of fluorescein dye (usually bilaterally) on exam?
actinic (UV) keratitis
64
Delay of onset of sx with actinic (UV) keratitis?
6-12 hrs
65
Actinic (UV) keratitis usually resolves in what amount of time?
w/in 48 hrs
66
Tx for actinic (UV) keratitis?
Atropine sulfate (Isopto Atropine), cyclopentolate (Cyclogyl), Abx drops, analgesics
67
What kind of chemical eye injury is worse than acid?
Alkali
68
How to manage chemical injury to the eye?
Immediate copious irrigation w/ Morgan lens if available (*until pH of 7 obtained 5 min after stopping)
69
Tx for chemical injury to the eye?
Cycloplegics, analgesics, abx
-optho referral
70
When to worry about periocular erythema?
71
What is preseptal (periorbital) cellulitis?
Superficial infection around eye
72
What is septal (orbital) cellulitis?
Deep space infection involving orbital muscles
73
Cause of preseptal cellulitits?
Secondary to trauma or insect bite
74
Cause of septal cellulitis?
Secondary to sinusitis or surgery
75
Sx of preseptal cellulitis?
Superficial pain, lid edema, warmth, erythema, vision generally not affected
76
Sx of septal cellulitis?
Deep pain, proptosis, chemosis, opthalmoplegia, diplopia, decreased vision
77
Tx for preseptal cellulitis?
Clinda or Doxy alone
or
Bactrim + Amoxil PO
*close follow up
78
Tx for septal cellulitis?
Vanco + Ceftriaxone IV
*optho consult
79
What is an auricular (subchondral) hematoma aka cauliflower ear?
Collection of blood between cartilage and skin secondary to sheering trauma
80
Tx for auricular (subchondral) hematoma?
Needle aspiration or I&D w/in 7 days (sooner = better), compression bandage post drain, daily re-checks for expanding hematoma
81
Common ear foreign bodies?
Cerumen, insects, toys
82
Retrieval options for ear foreign bodies?
Alligator forceps, ear curette, irrigation, suction
83
What to do after extraction of ear foreign body?
Assess for additional retained material or soft tissue damage
84
What temp of water for ear irrigation?
Warm
85
What can be used as a cerumen softener?
Cerumenex, hydrogen peroxide, docusate (Colace)
86
What to use along with curette while extracting foreign bodies from the ear?
Otoscope
87
Hx/exam for nasal foreign body?
Witnessed event MC, sneezing, discomfort/pain, unilateral discharge, foul odor, epistaxis, mouth breathing, swelling
88
Ddx for nasal foreign body?
Polyp, malignancy, abscess
89
Work-up for nasal foreign body?
Thorough exam w/ good lighting
Imaging (CT/X-ray) if complicated
90
Options for removal of nasal foreign body?
Mouth to mouth, katz extractor, ear curette, suction, ENT consult
91
Complications of nasal foreign body?
May need sedation, infection (localized or toxic), bleeding, aspiration, necrosis (prolonged pressure, alkaline battery) w/ secondary synechia (scar band) resulting in obstruction
92
What to consider w/ nasal foreign bodies?
Abx/ ENT follow up
*but most require nothing further
93
Age distribution for epistaxis?
Bimodal: 2-10 y/o and >50 y/o
94
Hx/causes of epistaxis?
Trauma, dry air/nasal O2, FB, structural abnormality (mass, telangtasia), drugs (blood thinners, steroid nasal spray, street drugs), bleeding disorders (if infant w/ unexplained bleeding), allergic rhibitis, HTN (?)
95
Is most epistaxis anterior or posterior?
Anterior (>90%) MC in Kiesselbach plexus
96
Work-up for epistaxis?
Most need nothing, Labs (CBC, bleeding panel) if warranted
97
Exam for epistaxis?
Get supplies (ready to treat), pt sitting up in gown, good light, evaluate pharynx for any bleeding, check sptal wall (hematoma), clear nose (blow nose, suction)
98
1st line tx for epistaxis?
Pressure
99
Procedures for pressure w/ epistaxis?
Vasolene gauze, merocele, silver nitrate, rapid rhino, epistat, foley (for posterior)
100
Patients with a disposition for epistaxis should be seen by who?
Emergent ENT consult
101
Complications of epistaxis?
Poor control of bleed, unrecognized posterior bleed, obstruction, BP control, Bleeding disorders (need to reverse cause)
102
Discharge of patient with epistaxis?
Recommend 15 min constant pressure if bleeding reoccurs
Humidifier/saline
If packing: follow up w/ ENT in 3-5d
+/- Abx
103
How to stop bleeds from hemophelia?
DDAVP, Factor VIII, IX, FFP
104
How to stop bleeds from thrombocytopenia/alcohol/anti-platelet meds?
Platelets
105
Most suspected nasal bone fxs require what?
No tx
106
What is needed if deformity is noted with nasal bone fx?
X-ray
107
Displaced/depressed nasal fxs need what?
ENT or plastics follow up in 5-7d if cosmetics/function concern
108
Always check for what with a nasal fx?
Septal wall hematoma
109
What does a septal wall hematoma usually require?
Drainage, ENT follow up
110
Complications of untreated septal hematoma?
Necrosis (disrupted blood supply leading to septal perf)
111
Dental fracture class Ellis I?
Through enamel only
*non tender, no color change
*non emergent follow up
112
Dental fracture Ellis II?
Enamel and dentin
*tender, yellow layer
113
Tx for Ellis II dental fx?
Ca+ hydroxide paste, dental referral, may need possible root canal
+/- Abx
114
Dental fracture Ellis III?
Enamel, dentin, and pulp
*tender, small dot of red visible
115
Tx for Ellis III dental fx?
Ca+ paste, follow up w/in 24hr
+/- Abx
116
What is subluxation?
Mobile angulation of tooth
117
What us luxation?
Displaced angulation of tooth
118
Tx for subluxation/luxation?
If loose or unstable --> Coe-Pak compound to splint, follow up w/ dentist
119
What is intrusion?
Tooth that is pushed up into gum (suspect when abnormal spacing, alignment, or blood at gum)
*most stable
120
What is avulsion?
Missing tooth (where is it??)
121
What can occur as a result of intrusion?
Neurovascular compromise
122
How to manage avulsion?
Milk or tooth saver X up to 12hrs and re-implant ASAP
*emergent oral surgery follow up
123
What to use to splint traumatized teeth?
N-butyl-2-cyanocrylate tissue adhesive and skin closure strips
124
Where is a lower dental block inserted?
Coronoid notch (alveolar nerves)
*angle near first and second premolar on opposite side
125
Imaging for mandible fx?
Xray, panorex, or CT
126
When is a mandible fx considered open?
If intraoral lac present
127
What should you be concerned about w/ mandible fx?
Inferior alveolar nerve, parotid duct, or dental involvement
128
Management of mandible fx?
Oral surgery follow up and Abx if open fx
129
Classification for maxilla fx?
Le Fort Classification, at level of: teeth (I) , nasal bones (II), orbits (III)
130
Is unstable maxilla fx, check for what?
CSF rhinorrhea or ocular involvement
131
Common ingested foreign bodies in children? adults?
Children: coins
Adults: food impaction (meat)
132
What may be useful in determining location if metal foreign body ingested?
X-ray
133
Where are esophageal coins usually found? What about tracheal coins? (FB ingestion)
-Esophageal: coronal plane (round on PA)
-Tracheal: Sagittal plane (flat on PA)
134
If vomiting shortly after drinking post-FB ingestion, what does this indicate?
Blockage
*requires endoscopy
135
What may work for FB ingestion by decreasing LES pressure?
Glucagon
136
What is important to know with ingested substance emergencies?
Intentional/accident (child protective or psych may be needed)? What type and amount?
137
What to do (if indicated) for ingested substance emergency?
Endoscopy and laryngoscopy
138
Severity of sx with ingested substance emergency usually correlates with ____________
degree of damage
139
Rx for ingested substance emergency?
NPO, IV fluids, PPI, analgesics
**AVOID LAVAGE
140
Complications of ingested substance emergency?
Perf with mediastinitis, pneumonitis, bleeding, esophageal-tracheal fistula, strictures, inc. risk of squamous carcinoma
