Maxillofacial and Ocular Emergencies Flashcards
1. Explain concepts related to the assessment of emergency department patients experiencing maxillofacial and ocular emergencies. 2. Describe various patient presentations related to maxillofacial and ocular emergencies. 3. List interventions necessary for patients presenting with maxillofacial and ocular emergencies.
ophthalmic branch VI
sensation to:
scalp, forehead
upper eyelid
conjunctive, cornea
nose
maxillary branch V2
infraorbital nerve (maxillary fracture)
sensation to upper lip, lower eyelid, cheek
mandibular branch V3
inferior alveolar nerve (mandibular fracture)
sensation to lower lip, chin, jaw
define Bell’s Palsy
unilateral facial paralysis due to CN VII damage
often d/t herpes simplex
sx Bell’s Palsy
facial droop can't blink/close affected eye postauricular pain change to tear production ipsilateral loss of taste HA hyperacusis: increased sensitivity to sound frequencies and volume ranges
assessing Bell’s Palsy
diagnosis of exclusion
r/o stroke, meningitis, facial nerve tumor
intervene for Bell’s Palsy
antivirals, steroids analgesics sunglasses artificial tears lubricants at night moist heat facial massage to prevent contractures/paralysis
define trigeminal neuralgia
sudden onset unilateral severe, brief, stabbing, recurrent pain along one or more branches of CN V
branches of CN V
ophthalmic (V1)
maxillary (V2)
mandibular (V3)
overview of trigeminal neuralgia
aka tic doloureux
usually w/ facial tic
worse w/ brushing teeth, chewing
fall/spring exacerbations
causes of trigeminal neuralgia
compression of CN V d/t: MS tumor trauma AV malformation
sx trigeminal neuralgia
shock-like stabbing pain for seconds or minutes
unilateral
affects: lips, cheeks, jaw, eyes, forehead, scalp, nose
intervene for trigeminal neuralgia
carbamazepine to diagnose or be therapeutic
educate about triggers
pharm management of trigeminal neuralgia
carbamazepine/baclofen phenytoin clonazepam lamotrigine valproic acid gabapentin
define temporal arteritis
inflammation of temporal artery
aka giant cell arteritis or cranial arteritis
cause of temporal arteritis
immune system issues
linked to severe infections and high dose abx
sx temporal arteritis
severe stabbing pain in temporal area
redness, swelling to temple w/ tenderness
signs of systemic infection
reduction in vision
intervene for temporal arteritis
steroids x 2 years
analgesics
biopsy
complications of temporal arteritis
if untreated:
blindness or death d/t MI or aortic dissections
define temperomandibular joint (TMJ) dislocation
anterior/superior displacement of jaw
unilateral or bilateral
causes of TMJ dislocation
trauma
yawning
grinding teeth
sx TMJ dislocation
malocclusion head/ear/neck ache pain with jaw movement pop, click, snap sensation limited ROM pain on TMJ palpation palpable depression
assessing TMJ dislocation
open/closed mouth xray
post-reduction view
MRI is image of choice
intervene for TMJ dislocation
IV for sedation
suction
manual reduction
analgesia
dc education for TMJ dislocation
soft diet for 3-4 days
awareness of habits
education on triggers
define zygomatic fractures
loss of malar eminence
2nd most common facial fracture
associated with orbital wall fractures and ocular trauma
sx zygomatic fractures
TIDES: trismus infraorbital hypesthesia diplopia epistaxis symmetrical abnormality (assymmetry)
trismus
reduced ability to open jaw r/t muscle spasm
infraorbital hypesthesia
abnormal loss of sensation to pain, heat, cold, touch
intervene for zygomatic fractures
cold pack elevate HOB ophtho consult avoid: -valsalva maneuver -sleep on affected side -straining/blowing nose
function or orbit
holds eye in correct position
two types of orbital wall fractures
blow in
blow out
blow in orbital fracture
bone fracture into orbit towards eye
eye bugling (exophthalmos) d/t baseball hitting side of face
blow out orbital fracture
bone fracture outward from eye
eye suck into socket (enophthalmos)
direct force to eye socket
sx orbital fractures
ocular entrapment diplopia edema ecchymosis subconjunctival hemorrhage infraorbital hypesthesia
intervene for orbital fractures
cold pack
ophthalmology consult
dc teaching for orbital fractures
avoid:
valsalva maneuvers
straining
blowing nose
ocular entrapement
eye unable to rotate within orbit
overview of maxillary fractures
requires tremendous force
intracranial/spinal trauma
do not always follow Le Fort classifications
complications of maxillary fractures
airway compromise loss of bony stability difficulty swallowing edema blood traumatic debris
assessing maxillary fractures
facial, head CT
facial XR
chest XR if missing teeth
intervene maxillary fractures
airway suctioning elevate HOB ice ophthalmology, neuro, ESS consults for Le Fort II, III fractures
Le Fort I
transverse detachment of entire maxilla above teeth at level of nasal floor
malocclusion, lip lac, fractured teeth, maxillary swelling
aka free-floating maxilla
Le Fort II
pyramidal-shaped fracture with:
transverse detachment of maxilla at base
fracture of bridge of nose at top
fractures through lacrimal and ethmoid bones into median portion of both orbits
massive edema, nasal bone fracture, epistaxis, face lengthening, paresthesia to cheeks, malocclusion
Le Fort III
craniofacial disjunction that creates a free-floating segment of mid-face (complete separation of cranial attachments from facial bones)
involves maxilla, zygona, orbits, bones of cranial base
massive swelling, severe intrafacial hemorrhage, diplopia, malocclusion
tip to remember Le Fort fractures
A man with a Mustache goes to the Pyramids and takes of his Mask
mandibular fractures
blunt trauma
concern when malocclusion: most common fracture sites at canine or third molar sites, angel of mandible and condyles
sx mandibular fractures
malocclusion trismus edema ecchymosis signs of trauma point tenderness numbness to lower lip
dc teaching for mandibular fractures
jaw rest
soft diet
avoid talking/using jaw
avoid strenuous exertion
define peritonsillar abscess
collection of purulent material around tonsils that may lead to deep tissue infection
often follows pharyngitis, tonsillitis
sx peritonsillar abscess
uvula deviation drooling/difficulty swallowing fever halitosis muffled voice pain in throat that radiates to ear swollen soft palate cervical lymphadenitis erythematic tonsils with exudate trismus
intervene peritonsillar abscess
airway throat cultures fluids, abx, steroids, pain needle aspiration, I&D ENT
Ludwig’s angina
bacterial cellulitis of floor of mouth
fast moving - lethal
causes of Ludwig’s angina
untreated dental abscess
abx resistant abscess
sx Ludwig’s angina
resp distress submandibular, sublingual swelling pain, tenderness dysphagia, drooling muffled voice, trismus fever
intervene Ludwig’s angina
airway labs, blood cultures fluids, abx, pain xray, CT if stable admission, surgery
dental subluxation
loose toolth
intervene for dental subluxation
mild: soft diet
moderate: dental consult
avulsed tooth
tooth out of socket
intervene avulsed tooth
preserve tooth:
replace in socket
put in cheek/gum, under tongue
put in glass of milk
put in Hank’s balanced electrolyte solution
replace max 6 hours, ideally 30 min
anterior epistaxis
more common that posterior
front of nasal cavity
hemorrhage bright red
drips from nostrils
causes of anterior epistaxis
nose picking
dry mucosa
intranasal meds or inhalant use
posterior epistaxis
more profuse
hemorrhage dark red
drips down throat
causes of posterior epistaxis
elevate HOB, suction fluids pinch nostrils 10 min cauterization nasal packing
types of cauterization for posterior epistaxis
silver nitrate sticks
diathermy
electrocautery
nasal packing for posterior epistaxis
nasal sponge
epistaxis balloon
pledget soaked with 4% cocaine, phenylephrine, lidocaine with epi
nasal foreign body
most common in peds
monitor for potential aspiration
sx nasal foreign body
nasal, sinus pain
purulent nasal drainage
recurrent epistaxis
fever
intervene nasal foreign body
blow nose balloon catheter post obstruction decongestants alligator forceps educate on dangers of small objects
define sinusitis
bacterial infection of mucosal lining of paranasal sinuses
sx sinusitis
pain depends on sinus cavity nasal congestion mucopurulent discharge malaise, fever facial swelling
intervene sinusitis
Water’s view XR for frontal view
oral abx
analgesia, antipyretics
dc teaching sinusitis
hob elevated to relieve pressure
otitis externa overview
infection of external auditory canal
aka swimmer’s ear
causes of otitis externa
usually bacterial
excessive moisture
trauma
sx otitis externa
pain with movement of tragus, auricle swelling, erythema of ear canal discharge eharing loss periauricular cellulitis
intervene otitis externa
analgesics, abx warm otic drops heat, keep ear dry no objects into canal earplugs
otitis externa overview
infection of external auditory canal
aka swimmer’s ear
causes of otitis externa
usually bacterial
excessive moisture
trauma
sx otitis externa
pain with movement of tragus, auricle swelling, erythema of ear canal discharge eharing loss periauricular cellulitis
intervene otitis externa
analgesics, abx warm otic drops heat, keep ear dry no objects into canal earplugs
otitis media
infection of inner ear
blocked Eustachian tubes
fluid buildup behind TM
most common age group for otitis media
6 mo - 3 yo after URI
sx otitis media
sharp middle ear pain sensation of fullness hearing loss fever bulging tympanic membrane history of URI pulling at ear
intervene otitis media
systemic abx
analgesics
antipyretics prn
mastoiditis
rare complication of otitis media
infection may erode mastoid and affect surrounding structures
sx mastoiditis
recent, recurrent otitis media pain, swelling in mastoid area otalgia hearing loss fever, HA possible tympanic membrane rupture
intervene mastoiditis
ID consult
IV abx
analgesics
surgery
labyrinthitis
inflammation of inner ear or labyrinth
usually follows otitis media, URI, allergies
rare in children
sx labyrinthitis
self limiting recent infection vertigo w/ movement hearing loss, tinnitus N/V otalgia fever nystagmus
intervene labyrinthitis
r/o neuro bed rest, hydration antiemetics benzos abx corticosteroids
cause of ruptured tympanic membrane
trauma
barotrauma
infection
sx ruptured tympanic membrane
sudden, severe sharp pain at time of rupture
bloody, purulent drainage
hearing loss, tinnitus
vertigo
intervene ruptured tympanic membrane
analgesia
do not irrigate
abx
90% heal spontaneously
dc teaching rupture tympanic membrane
keep ear dry
cotton ball w/ petroleum jelly to decrease moisture
wear ear protection
complications of ear foreign body
bleeding
live insects - anxiety
tympanic membrane rupture
sx ear foreign body
ear pain purulent discharge, foul odor hearing loss dizziness N/V
intervene ear foreign body
kill insects w/ lidocaine, mineral oil suction, alligator forceps don't irrigate if organic don't push into ear canal consider sedating
how to irrigate an ear
adults: superiorly and posteriorly
pediatrics: posteriorly and interiorly
dc teaching for Meniere’s disease
limit salt, sugar avoid caffeine, alcohol, smoking limit activity bed rest slow movements, position changes
sx Meniere’s disease
tinnitus, hearing loss rotational vertigo N/V nystagmus vagal stimulation episodic -few min to several hours -can recur for weeks/months
causes of Meniere’s disease
no known cause can develop at any time more common 40-60 yo clustered or sporadic no curable resolution known
intervene Meniere’s disease
meclizine anithistamines steroids anticholinergics benzos diuretics
dc teaching for Meniere’s disease
limit salt, sugar avoid caffeine, alcohol, smoking limit activity bed rest slow movements, position changes
cycloplegics
eye drops
dilate and paralyze pupil
miosis
constricted pupil
mydriasis
dilated pupil
enophthalmos
sinking of eye inward
exophthalmost
bulging of eye outwards
ptosis
drooping eyelid
how to administer eye drops
instill into conjunctival sac
never directly to cornea
never more than 1 drop at a time
never meds while wearing contacts
define corneal abrasion
scratching of cornea by foreign body
most common eye injury seen in ED
differentiate from corneal ulcer
sx corneal abrasion
pain sensation of foreign body photophobia tearing blurred vision
assessing corneal abrasion
visual acuity
topical anesthetic before exam
fluorescein staining
slit lamp exam
intervene corneal abrasion
ophtho abx drops
topical ophtho nonsteroidal agents
systemic analgesics
no patching
define corneal ulceration
inflamed epithelium of cornea
common causes of corneal ulceration
infection (bacterial, fungal, parasitic, viral) often following eye injury, trauma, or other injury
complications of corneal ulceration
can cause blindness in 24-48 hours if left untreated
true ocular emergency
risk factors for corneal ulceration
contacts
eye trauma
immunosuppression
sx corneal ulceration
pain, photophobia sensation of foreign body tearing, blurred vision eyelid swelling purulent discharge "white spots"
intervene keratitis
abx, antivirals, antifungals
topic cycloplegics
systemic analgesics
no patch
define keratitis
corneal inflammation
can cause permanent damage and blindness
causes of keratitis
herpes simplex
bacterial, fungal, amoebic infections
contact lenses
exposure to UV light
sx keratitis
pain, photophobia mucopurulent drainage purulence in anterior chamber decreased vision reddened sclera
intervene keratitis
abx, antivirals, antifungals
topic cycloplegics
systemic analgesics
no patch
causes of ocular burns
chemical
thermal heat
radiation
acid chemical ocular burns
limited penetration
alkali chemical ocular burns
penetrate deeply until neutralized
lye-containing substances
sx ocular burns
severe pain decreased visual acuity excessive tearing photophobia blepharospasm foreign body sensation
types of chemical ocular burns
acid
alkali
petroleum-based products
blepharospasm
involuntarily tightly closed eyelid
intervene for ocular burns
immediate irrigation with NS or LR until 7-7.5 pH
irreversible damage at 11.5 pH
anesthetic drops
tetanus
patch
ophtho
ocular foreign body overview
generally superficial
organic can blind in 24-48 hrs
organic w/ higher infection rate
metallic leaves rust ring
sx ocular foreign body
sensation of “something in eye”
excessive pain, tearing, photophobia
intervene ocular foreign body
ophtho anesthetic agent before exam
examine for other foreign body or rust ring
treat corneal abrasion
how to remove ocular foreign body
invert upper lid
irrigate with NS
gently remove w/ cotton tip
25/27 gauge needle if adhering to cornea
acute angle closure glaucoma
aqueous humor cannot escape anterior chamber
intraocular pressure increases
compresses optic nerve CN III
complications of acute angle closure glaucoma
blindness within hours if not treated
sx acute angle closure glaucoma
acute eye pain decreased periph vision halos around lights N/V severe HA red eye fixed, slightly dilated pupil cloudy cornea globe may feel firm
intervene acute angle closure glaucoma
drain, decrease pressure miotic eye drops topic beta blockers carbonic anhydrase inhibitors antiemetics opioids
dc teaching acute angle closure glaucoma
head above waist
avoid coughing, straining
don’t lift > 5 lbs
ophtho follow-up
define acute conjunctivitis
inflammation of membrane that lines the eyelid and sclera
causes of acute conjunctivitis
infection - bacterial, viral, fungal
allergic
chemical
sx acute conjunctivitis
crusted eyelid in morning sensation of foreign body conjunctival erythema discharge pruritus - allergic
types of discharge in acute conjunctivitis
bacterial - purulent
allergic, viral - serous
sx iritis/uveitis
painful red eye, redness around outer ring of iris
blurred vision photophobia tearing decreased visual acuity irregular pupil
intervene iritis/uveitis
cycloplegics
warm compress
ophtho consult
define iritis (uveitis)
inflammation of middle portion of eye - iris, ciliary body, choroid
causes of iritis/uveitis
idiopathic trauma infection systemic conditions -rheumatic disease -syphilis -lupus
sx iritis/uveitis
painful red eye, redness around outer ring of iris
blurred vision photophobia tearing decreased visual acuity irregular pupil
intervene iritis/uveitis
cycloplegics
warm compress
ophtho consult
retinal artery occlusion
loss of perfusion to retina
circulation must be restored within 60-90 min to prevent permanent blindness
causes of retinal artery occlusion
emboli (a.fib), thrombosis
HTN
giant cell arteritis
angiospasm
sx retinal artery occlusion
sudden, painless loss of vision w/ reported “curtain came down over my eye”
elevated intraocular pressure
assessing retinal artery occlusion
intraoccular pressure reading (normal 10-21 mmHg)
EKG - a.fib
coags
intervene retinal artery occlusion
high triage supine digital massage by MD acetazolamide topical beta blocker sublingual nitro fibrinolytics anterior chamber paracentesis
retinal detachment
tear in retina allows vitreous humor to leak, diminishing blood supply to retina
causes of retinal detachment
trauma (sudden onset)
degenerative (gradual onset)
sx retinal detachment
photopsia - flash of light
sudden decrease/loss of vision
“veil” or “curtain” effect
assessing retinal detachment
visual acuity
detailed fundus, slit lamp exam
ophtho US
intervene retinal detachment
ophtho consult
surgery
absolute bedrest
bilateral patching
hyphema
blood in anterior chamber of eye
causes of hyphema
trauma
bleeding disorders
fibrinolytic agents
sx hyphema
pain
reddish hue to vision
intervene hyphema
minimize activities that increase intraocular pressure
head up position
patch affected eye
analgesia, steroids
no aspirin or NSAIDs
ruptured globe
loss of integrity of the globe usually r/t traumatic ocular injury
penetrating blunt (2/2 increase intraocular pressure)
sx ruptured globe
tear-drop shape to pupil
visual disturbances
evisceration of aqueous or vitreous humor
intervene ruptured globe
secure protruding objects bilateral patch elevate HOB never instill topical meds ophtho consult
