OFFICE PROCEDURES Flashcards
Presentation of foreign body in nose
- Witness on first day
- Delayed: unilateral purulent nasal discharge!
Techniques for removal of foreign body in nose
- Suction: aspirate w/catheter
- Blow it out: positive pressure
- Pluck it out: ENT tools or use skin adhesive
- Rinse it out: nasal irrigation
- Pull it out: catheter method
Preparing patient for removal of foreign body in nose: suction method
- Tools & support straff ready
- Pretreat w/vasoconstrictor (shrink swelling)
- Position in sniffing position! (won’t go to airway)
Positive pressure methods for removal of foreign body in nose
Parent’s kiss (plug other side of nose, blow into mouth)
- Bag valve mask over mouth
- Beamsley Blaster: tool to use highflow O2 to push out
Pulling: method for removal of foreign body in nose
- Secure child’s head
- Place balloon catheter in affected nare
- Insert past the FB and inflate balloon
- Withdraw balloon slowly, pulling FB out of dilated nare
- *good if space to get by!
Nasal wash method for removal of foreign body in nose
- Fill blue bulb syringe w/saline
- Tilt patient’s head forward over basin and make a good seal
- Instill saline into opposite nare
- Flush out FB from affected nare alone w/saline
- *esp good if organic matter – multiple pieces!
What to do after removal of foreign body in nose
Take a 2nd look! – second foreign body, trauma or underlying infection
When to refer to ENT for foreign body in nose
- Multiple failed attempts
- Pts who require sedation
- Trauma to nose
Risks to foreign body in ear
- Trauma to ear canal or rupture of TM
- Infection
- Insects!
When to refer for foreign body in ear
- Object too close to TM
- Sedation required
How to remove insect from ear
- Anesthetize ear!
- Instill lidocaine –> drowns insect –> remove
- Scoop out w/forces, curette, or swab
- Flush out w/saline (similar to cerumen)
- Pluck out (skin adhesive)
What to do after removal of foreign body from ear
- Second look! FB, trauma, infection
- Consider otic antibiotics: Cipro or ofloxacin drops 5-7days
Alarm signs for nail injury
Fracture and laceration at fingertip (osteomyelitis)
Presentation of subungual hematoma
- After crushing injury
- Bluish discoloration beneath nail
Mgmt of subungual hematoma
- Trephination: Drain hematoma if >25% of nail bed (pressure) and 1st 24h of injury.
- Do not drain if old organized clot
How to drain subungual hematoma
- Cautery or 18 gauge needle
- Prep w/betadine. Dry completely, hand on hard surface. Apply cautery or needle directly to nail. Stop once through nail. Evacuate by soaking or gentle pressure.
- No need to anesthetize w/cautery
Presentation and cause of paronychia
- Superficial infection around nail
- Painful swollen epinychial fold
- Caused by staph or strep (anaerobes in thumb suckers)
- (may be caused by ingrown nail)
Tx for paronychia
- Mild: warm soaks
- Moderate: I&D
- Severe: I&D, oral antibiotics
How to drain paronychia
- Anesthetize w/digital block
- Elevate nail fold w/scalpel
- Release pus
- Do not directly incise skin!! Needs to come through skin, not ideal
Mgmt of ingrown nail
- Need to tx or infection will occur
- Can ask pt to elevate nail ledge (cotton)
- Or can resect nail wedge
How to assess for eye injury
- Examine external eye, lids, sclera, conjunctiva, pupil, palpate bony landmarks
- Flip lid to examine for FB
- Check red reflex, pupillary responses
- EOMs and acuity
- Check for corneal abrasion
When to refer for eye injury
- Bony fracture palpated, pain on eye mvmt, suspect puncture
- (always check acuity when sending to optho!)
- Deep or large abrasion, abrasion in direct line of site
Presenting Sx of corneal abrasion
Tearing, painful eye, photophobia
Causes of corneal abrasion
- Debris, injury from fingernail, contact lens
- Neuropathy from Bell’s palsy (dry eyes)
Assessing for corneal abrasion
- Position supine
- Anesthetize w/proparicaine
- Fluoroscein stripor drops
- Apply to nasal aspect of eye
- Lights up green w/wood’s lamp
- Pooling is normal
- Do not use if suspect globe rupture!
Tx for corneal abrasion
- No patching (impedes healing)
- No numbing!
- Rx for antibiotic ointment
DDx for corneal abrasion
Always be alert for HSV!!
Factors to assess for in burns
- Method, severity, extent
- Assess for associated injuries
Methods of burn
- Light: intense light, UV
- Chemical: acids, bases, caustics
- Thermal: flame, steam, not liquids
- Electrical: current, lightening
- Radation: nuclear sources
Severity of burns
- 1st degree: red painful skin, like a sunburn, heals in 2-3 days w/no scar
- Superficial partial thickness: red w/wet painful blisters. Heals 2 wks w/minimal scarring
- Deep partial thickness: thrombosed vessels give speckled look, more scarring
- Full thickness: pale charred leathery skin, not as painful w/nerves damaged
When to refer to burn center
Any full thickness burn! Emergency eval for burn center admission.
How to calculate extent of burn
- Calculate BSA involved
- Adults: rule of 9s
- Children: Patient’s palms= 1% and add it up
What to do in case of burn / triage
- Stop burning – remove clothing
- Cool skin (avoid direct ice)
- Keep blisters intact
- Apply antibiotic ointment
- Refer as needed
Wound care for first degree burns
NSAIDs
Wound care for 2nd degree burns
Clean w/soap/water, debride dead tissue, apply ointment, cover w/gauze
Wound care for 3rd degree burns
Cover and transfer to hospital
Home care instructions for burns
- Change bandage every day
- Wash w/soap and water
- Check for infection
- Re-apply ointment
- Return for infection or debridement
Burns: When to admit to hospital
- 2nd and 3rd degree burns w/ >10% BSA
- Involves hands/feet, face, circumferential around joints, perineum
- Associated injuries (inhalation, chemicals)
- Concerns for abuse/neglect
When to use tissue adhesives
- Cyanoacrylate
- Great for wound closures!
- NOT for high tension areas (chin, fingers), highly contaminated wounds (bites), densely hairy areas (scalp)
How to apply tissue adhesive
- Position to avoid dripping!
- Clean wound and dry before closure
- Reduce tension on wound, pull together to approximate
- 1-2 layers
- No bandage, no ointment
- *petroleum to create barrier to eye. Petroleum can also be used to remove if drips!
Who gets nursemaid’s elbow?
Toddlers! Subluxed radial head
Assessment for nursemaid’s elbow
- Examine arm for swelling, crepitus, deformity
- If not present –> reduce arm
- Not in pain though may be apprehensive and guard arm
Methods to reduce nursemaid’s elbow
- Hyperpronation: position arm slightly extended, grasp elbow with one arm, grasp patient hand w/other, rotate to pronate hand until thumb pointing to floor
- Supination/flexion: position arm at 90 degree angle, grasp elbow w/non-dominant hand, rotate palm up and flex at elbow
Education w/nursemaid’s
- At risk for repeats!
- Don’t swing by hand!
How to use slings and splints
- Immobilize above and below injury (e.g., forearm injury – if you don’t immobilize elbow, can supinate and pronate)
- Extra padding in pre-verbal kids
- Leave fingers exposed for assessment of circulation
- Immobile position should be functional
- Close f/u!
How to make a splint functional
- Upper extremity needs to be elbow flexed, wrist extended, fingers flexed
- Lower extremity: knee extended, ankle 90 degrees
When to refer when requiring sling/splint
- Angulation or deformity
- Sensory changes or nerve injury (hours after injury)
- Pain persists after 1 week
