HEENT Emergencies Flashcards
What amount of those with head injury in the US have bleeding? What amount require intervention?
Bleeding: <10%
Intervention: <1%
Mechanism hx for head injury?
Assault w object? fall from height? MVC? GSW? sports?
LOC hx for head injury?
none, brief (<1min), prolonged, associated seizure ?
Relevant factor hx for head injury?
Helmet? seat belt?
Asscoaited sx hx for head injury?
N/V (# of projectile)? headache? soft tissue swelling (STS)/bruising? preceding event (syncope)?
Misc hx for head injury?
Prior head injury? current anticoagulants? age? distracting injuries? ETOH/drug use?
S/Sx of head injury?
Headache, confusion, light/sound sensitivity, fatigue/malaise, N/V
What to assess in PE for head injury?
Mental status (GCS), distracting injuries
What to inspect in PE for head injury?
Lacerations, foreign bodies, basilar skull fx (Battle sign, Raccoon eyes), hemotympanum, CSF leakage (clear rhinorrhea or otorrhea), facial bone injury, pupil size/reactivity
What to palpate for in PE for head injury?
Depressed skull fractures, foreign bodies, soft tissue swelling (STS), C-spine
What to focus on for neuro PE in head injury?
Gait, Rhomberg (balance), finger-to-nose, cognitive recall
DDx for head injury?
Contusion (soft tissue and vertebral), concussion, skull fx w or w/o intracranial bleed
How to begin work-up for head injury?
GCS (Glasgow coma scale) & clinical decision making
GCS
Clinical decision tools
What is a concussion?
Head injury resulting in transient alteration of cognitive abilities, motor function, and/or level of consciousness
What is a subarachnoid hemorrhage?
Tearing of pial vessels w/ subsequent tracking of blood in the subarachnoid space into the sulci and cisterns
What is a subdural hematoma?
Shear through the bridging veins with blood tracking along brain under the dura
What is an epidural hematoma?
Skull fracture leading to disruption of an artery & blood escapes from the artery, pushing the tightly adhered dura away from the calvarium
What are cerebral contusions?
Areas of punctuate hemorrhages and cerebral edema usually d/t acceleration-deceleration injuries against the bony internal surfaces of the cranium
If low risk, is workup for head injury necessary?
Not always, 3-4 hrs observation best
When to check coags with head injury?
If on coumadin or if bleed present
When to check CBC, chemistries, UA, tox-screen, ETOH, EKG, orthostatics for head injury?
If injury is secondary to another process
What to consider if head injury with children or elderly?
Abuse
Are skull plain films helpful in the work-up of head injury?
No, of little value
What other injury to consider along with head injury?
C-spine
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
What is SyncThink (new test) for head injury?
Ocular tracker concussion test
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
Concussion screening tools most useful with baseline?
MACE, SCAT, King-Devick, ImPACT
Tx for ICB (intracranial bleed)?
Emergent neurosurgery consult for possible defompression, intubation if GCS <8, seizure prophylaxis w/ phenytoin (Dilantin), anticoag reversal
How to reverse Warfarin in cases of ICB?
Vitamin K, FFP
How to reverse Heparin/LMWH in cases of ICB?
Protamine
How to reverse ASA/clopidogrel in cases of ICB?
Platelets
Head injury pathway
What is post-concussive syndrome?
Sx complex that continues beyond the expected 7-10d recovery period (25-30% of mild TBI pts)
Who is post concussive syndrome more common in?
Those w/ negative perceptions about traumatic experience, pre-existing stress, anxiety, depression
Somatic sx of post concussive syndrome?
Headache, insomnia, dizziness, nausea, fatigue, light/noise sensitivity
Cognitive sx of post concussive syndrome?
Attention/concentration/memory problems
Affective sx of post concussive syndrome?
Irritability, anxiety, depression, emotional liability
Tx for post concussive syndrome?
Focused on sx: analgesics, antidepressants, cognitive therapy, counseling
<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)
What occurs in the complication of deterioration post-ICB?
Progression of the ICB leading to hypoventilation/death
What disability can occur from head injuries?
Permanent neurologic or psychiatric deficits
(ex. CTE)
What is CTE?
Chronic traumatic encephalopathy- progressive disease secondary to repetitive trauma
What is a subconjunctival hemorrhage?
Collection of blood under conjunctiva from minor trauma, coughing, sneezing, etc
*no tx required
What is a hyphema?
Collection of blood in anterior chamber
Tx for hymphema?
Rest, head elevation, avoid ASA, optho follow up
Most common orbital fracture?
Orbital floor (blow-out fx)
Possible sx of orbital fracture?
Hyphema, ocular muscle entrapment, globe rupture
PE for orbital fracture?
Check EOMs, pupil shape
Tx for orbital fracture?
avoid nose blowing, etc.
Abx
Plastics or optho referral
Most corneal foreign bodies are ________
Superficial
Deformed pupil raises suspicion for what dx?
Corneal foreign body
PE for corneal foreign body?
Check under lids, document visual acuity PRIOR to meds
Procedure for corneal foreign body?
Anesthetic, fluorescein, blue light, cotton swab, 18gu needle, burr under slit lamp, irrigate
*rust ring needs to be removed
Tx for corneal foreign body?
Abx drops or ointment +/- cycloplegic, diclofenac, optho follow up
How will corneal laceration appear?
Similar to abrasion but with a raised border
How is a corneal laceration best visualized?
Under slit lamp
What may be present with corneal laceration?
Seidel sign (dye dilutes aqueous humor streams down eye w/ gravity)
Tx for corneal laceration?
Abx ointment/drops, optho referral for possible gluing, surg closure, or graft if large
What is actinic (UV) keratitis?
UV burns of the cornea secondary to welding, sunlamps, snow reflection
Which dx has diffuse punctate staining of fluorescein dye (usually bilaterally) on exam?
actinic (UV) keratitis
Delay of onset of sx with actinic (UV) keratitis?
6-12 hrs
Actinic (UV) keratitis usually resolves in what amount of time?
w/in 48 hrs
Tx for actinic (UV) keratitis?
Atropine sulfate (Isopto Atropine), cyclopentolate (Cyclogyl), Abx drops, analgesics
What kind of chemical eye injury is worse than acid?
Alkali
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)
Tx for chemical injury to the eye?
Cycloplegics, analgesics, abx
-optho referral
When to worry about periocular erythema?
What is preseptal (periorbital) cellulitis?
Superficial infection around eye
What is septal (orbital) cellulitis?
Deep space infection involving orbital muscles
Cause of preseptal cellulitits?
Secondary to trauma or insect bite
Cause of septal cellulitis?
Secondary to sinusitis or surgery
Sx of preseptal cellulitis?
Superficial pain, lid edema, warmth, erythema, vision generally not affected
Sx of septal cellulitis?
Deep pain, proptosis, chemosis, opthalmoplegia, diplopia, decreased vision
Tx for preseptal cellulitis?
Clinda or Doxy alone
or
Bactrim + Amoxil PO
*close follow up
Tx for septal cellulitis?
Vanco + Ceftriaxone IV
*optho consult
What is an auricular (subchondral) hematoma aka cauliflower ear?
Collection of blood between cartilage and skin secondary to sheering trauma
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
Common ear foreign bodies?
Cerumen, insects, toys
Retrieval options for ear foreign bodies?
Alligator forceps, ear curette, irrigation, suction
What to do after extraction of ear foreign body?
Assess for additional retained material or soft tissue damage
What temp of water for ear irrigation?
Warm
What can be used as a cerumen softener?
Cerumenex, hydrogen peroxide, docusate (Colace)
What to use along with curette while extracting foreign bodies from the ear?
Otoscope
Hx/exam for nasal foreign body?
Witnessed event MC, sneezing, discomfort/pain, unilateral discharge, foul odor, epistaxis, mouth breathing, swelling
Ddx for nasal foreign body?
Polyp, malignancy, abscess
Work-up for nasal foreign body?
Thorough exam w/ good lighting
Imaging (CT/X-ray) if complicated
Options for removal of nasal foreign body?
Mouth to mouth, katz extractor, ear curette, suction, ENT consult
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
What to consider w/ nasal foreign bodies?
Abx/ ENT follow up
*but most require nothing further
Age distribution for epistaxis?
Bimodal: 2-10 y/o and >50 y/o
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 (?)
Is most epistaxis anterior or posterior?
Anterior (>90%) MC in Kiesselbach plexus
Work-up for epistaxis?
Most need nothing, Labs (CBC, bleeding panel) if warranted
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)
1st line tx for epistaxis?
Pressure
Procedures for pressure w/ epistaxis?
Vasolene gauze, merocele, silver nitrate, rapid rhino, epistat, foley (for posterior)
Patients with a disposition for epistaxis should be seen by who?
Emergent ENT consult
Complications of epistaxis?
Poor control of bleed, unrecognized posterior bleed, obstruction, BP control, Bleeding disorders (need to reverse cause)
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
How to stop bleeds from hemophelia?
DDAVP, Factor VIII, IX, FFP
How to stop bleeds from thrombocytopenia/alcohol/anti-platelet meds?
Platelets
Most suspected nasal bone fxs require what?
No tx
What is needed if deformity is noted with nasal bone fx?
X-ray
Displaced/depressed nasal fxs need what?
ENT or plastics follow up in 5-7d if cosmetics/function concern
Always check for what with a nasal fx?
Septal wall hematoma
What does a septal wall hematoma usually require?
Drainage, ENT follow up
Complications of untreated septal hematoma?
Necrosis (disrupted blood supply leading to septal perf)
Dental fracture class Ellis I?
Through enamel only
*non tender, no color change
*non emergent follow up
Dental fracture Ellis II?
Enamel and dentin
*tender, yellow layer
Tx for Ellis II dental fx?
Ca+ hydroxide paste, dental referral, may need possible root canal
+/- Abx
Dental fracture Ellis III?
Enamel, dentin, and pulp
*tender, small dot of red visible
Tx for Ellis III dental fx?
Ca+ paste, follow up w/in 24hr
+/- Abx
What is subluxation?
Mobile angulation of tooth
What us luxation?
Displaced angulation of tooth
Tx for subluxation/luxation?
If loose or unstable –> Coe-Pak compound to splint, follow up w/ dentist
What is intrusion?
Tooth that is pushed up into gum (suspect when abnormal spacing, alignment, or blood at gum)
*most stable
What is avulsion?
Missing tooth (where is it??)
What can occur as a result of intrusion?
Neurovascular compromise
How to manage avulsion?
Milk or tooth saver X up to 12hrs and re-implant ASAP
*emergent oral surgery follow up
What to use to splint traumatized teeth?
N-butyl-2-cyanocrylate tissue adhesive and skin closure strips
Where is a lower dental block inserted?
Coronoid notch (alveolar nerves)
*angle near first and second premolar on opposite side
Imaging for mandible fx?
Xray, panorex, or CT
When is a mandible fx considered open?
If intraoral lac present
What should you be concerned about w/ mandible fx?
Inferior alveolar nerve, parotid duct, or dental involvement
Management of mandible fx?
Oral surgery follow up and Abx if open fx
Classification for maxilla fx?
Le Fort Classification, at level of: teeth (I) , nasal bones (II), orbits (III)
Is unstable maxilla fx, check for what?
CSF rhinorrhea or ocular involvement
Common ingested foreign bodies in children? adults?
Children: coins
Adults: food impaction (meat)
What may be useful in determining location if metal foreign body ingested?
X-ray
Where are esophageal coins usually found? What about tracheal coins? (FB ingestion)
-Esophageal: coronal plane (round on PA)
-Tracheal: Sagittal plane (flat on PA)
If vomiting shortly after drinking post-FB ingestion, what does this indicate?
Blockage
*requires endoscopy
What may work for FB ingestion by decreasing LES pressure?
Glucagon
What is important to know with ingested substance emergencies?
Intentional/accident (child protective or psych may be needed)? What type and amount?
What to do (if indicated) for ingested substance emergency?
Endoscopy and laryngoscopy
Severity of sx with ingested substance emergency usually correlates with ____________
degree of damage
Rx for ingested substance emergency?
NPO, IV fluids, PPI, analgesics
**AVOID LAVAGE
Complications of ingested substance emergency?
Perf with mediastinitis, pneumonitis, bleeding, esophageal-tracheal fistula, strictures, inc. risk of squamous carcinoma
