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ENT Emergencies

ENT Emergencies. C. Rebus R3-EM DrRebus.com. http://www.boxingscene.com/forums/showthread.php?t=329320. Conflicts. None Errors - Mine. Thanks to: Dr. Marc Francis Dr. Colleen Carey. Goals. Common and Nightmare ENT presentations, management and follow up.

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ENT Emergencies

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  1. ENT Emergencies C. Rebus R3-EM DrRebus.com http://www.boxingscene.com/forums/showthread.php?t=329320

  2. Conflicts • None • Errors - Mine. • Thanks to: • Dr. Marc Francis • Dr. Colleen Carey

  3. Goals • Common and Nightmare ENT presentations, management and follow up.

  4. http://meded.ucsd.edu/clinicalimg/head_pharyngitis.htm

  5. DDx? http://meded.ucsd.edu/clinicalimg/head_pharyngitis.htm

  6. Acute Pharyngitis (cont) • Life-threatening • Epiglottitis, diphtheria, Ludwig’s angina, peritonsillar abscess, retropharyngeal abscess, gonococcal pharyngitis, infectious mononucleosis (occlusion), and GABHS (...ARF). • Garden Variety Infectious • viral pharyngitis, non-GABHS bacterial pharyngitis, and candidiasis. • Non-infectious • Laryngeal/pharyngeal trauma, GERD, persistent cough or post-nasal drainage, thyroiditis, and malignancies.

  7. Acute Pharyngitis • What!? I'm an EMERG DOC! • In the top 10 presentations • Females: #5 • Males: #10 • National Health Statistics Reports, Number 7, August 6, 2008 (US data). http://4.bp.blogspot.com/_uekyjQXowno/SwreRGgnJ6I/AAAAAAAADwU/8VqTb-gSWl4/s1600/dung-beetle1.jpg

  8. Acute Pharyngitis (cont)

  9. Acute Pharyngitis (cont) • Who is worse then MD at DDx Bact vs Viral? • No one. • Epid • Group A Streptococcal pharyngitis is disease of youth. • 50% of pts 5 – 15 yo. • Peak incidence first few years of school. • GAS uncommon <3 yo

  10. Acute Pharyngitis (cont) • Dx? Classic Symptoms of GABHS • Pharyngeal or tonsillar exudate • Swollen anterior cervical LN • Hx fever >38*C • Absence of cough • If all 4 symptoms: 44% chance they will NOT have GABHS. • Coin 50%. http://www.afreeman.org/wp-content/uploads/2009/02/nickel.jpg

  11. Acute Pharyngitis (cont) • Rapid Strep test? • Not recommended in AB • Lacks sensitivity and evidence of improved clinical outcome. • ASOT? Lets use some science please... • Not in Dx or mgmt of acute pharyngitis. • Post treatment swab? • Not routinely.

  12. Acute Pharyngitis (cont) • How to diagnose this simple beast? • Throat Swab. • In pts with >2 classic symptoms. • Sensitivity 90 - 95%.

  13. Acute Pharyngitis (cont) • MCC? Viral ~90% • Bacterial: MCC: GABHS • GCBHS, GGBHS, N. Gonorrhoeae, arcanobacterium haemolyticum http://textbookofbacteriology.net/themicrobialworld/pathogenesis.html

  14. Acute Pharyngitis (cont) • Infectious? • 2-5 d prior to symptoms • During acute illness • ~7 d after if untreated • Back to School? • 24 hrs after start ABx • Unless symptoms don't improve -?Tx failure.

  15. Acute Pharyngitis (cont) • Mgmt • Swab and wait. • Rheumatic fever? • “I got the stuff they want” • Penicillin (no documented resistance). • Allergy? Clindamycin or Erythromycin. • Not getting better 48 – 72 hrs? FUGP.

  16. http://www.naze.net/2005/images/2005%200122%20jack%20blood%20in%20sink.jpghttp://www.naze.net/2005/images/2005%200122%20jack%20blood%20in%20sink.jpg

  17. Post-Tonsillectomy • Time Honoured Tradition of Hemostasis • Tonsils are supplied by 5 arteries in an area unable to collapse on itself.

  18. Post-Tonsillectomy (Cont) Janfaza et al. 2001. Surgical anatomy of the head and neck

  19. http://www.instantanatomy.net/headneck/areas/phoropharynx.htmlhttp://www.instantanatomy.net/headneck/areas/phoropharynx.html

  20. Post-Tonsillectomy (Cont) • This is bad. • Move them somewhere besides PLC eyeroom. • Trauma bay or get an airway cart. IV x2, CBC, INR/aPTT, crossmatch. • Ask for tonselectomy bleed pack. • Let ENT know early.

  21. Post-Tonsillectomy (Cont) • 0.5 – 10% depending on Sx. • Bleeding • Intraoperative • Primary (<24hrs) • Secondary (1-10 days) • 5 – 7 POD most common

  22. Post-Tonsillectomy (Cont) Post-op day 5 – 7

  23. Post-Tonsillectomy (Cont) • Minor Bleeding • Seated position in surgical area • Suction • Look • Call ENT – likely reluctant

  24. Post-Tonsillectomy (Cont) • Major Bleeding • Back to basics – Pressure. • Kelly clamp + epi 2% soaked gauze. • ENT. They need OR. • Presume stomach is full of blood from ooze. • It is a bad airway.

  25. Post-Tonsillectomy (Cont) • Dispo • ENT to R/V. • (Admission)

  26. http://www.beerkada.net/images/nosebleed1.jpg

  27. Epistaxis • So? http://www.esnr.com/www/case_studies/content/nosebleeds_epistaxis_fig1.htm

  28. Epistaxis (cont) • Anterior 95%

  29. Epistaxis (cont) • Posterior 5%

  30. Epistaxis (cont) • Posterior

  31. Posterior epistaxis from the left sphenopalatine artery. http://emedicine.medscape.com/article/863220-media

  32. Epistaxis (cont) http://chestofbooks.com/health/anatomy/Human-Body-Construction/The-Mouth-And-Throat-Part-2.html

  33. Epistaxis (cont) Roberts: Clinical Procedures in Emergency Medicine, 5th ed.

  34. Epistaxis (cont) Br J Ophthalmol 2003;87:1051 doi:10.1136/bjo.87.8.1051

  35. Epistaxis (cont) http://academia.hixie.ch/bath/eye/home.html

  36. Epistaxis (cont) • Fatal Posterior Nasal Packing? • (from a fictitious CMPA call) 'You put what, where?' • Epistaxis, medical history, and the nasopulmonary reflex: what is clinically relevant? Otolaryngol Head Neck Surg. 1994 Apr;110(4):363-9 • Jacobs et al. Posterior packs and the nasopulmonary reflex. Laryngoscope. 1981 Feb;91(2):279-84.

  37. Epistaxis (cont) http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79932-80545-113132.jpg

  38. Epistaxis (cont) • Posterior Nasal Packing • *to stabilize the anterior packing = tamponade • Nasostat • Rubber Chicken • Foley Roberts: Clinical Procedures in Emergency Medicine, 5th ed.

  39. Epistaxis (cont) • Posterior Nasal Packing – 10F Foley • 10-15ml N.S. http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79932-80545-113136.jpg

  40. Epistaxis (cont) • Show of hands: Rx ABx with packing? • I'll tell you, it's Zero. Unless you have structural heart disease. • Concern • Staph toxic shock syndrome, sinusitis, and clinically-evident bacteremia • Evidence • 3 RCT, 163 pts. Lack power. • Incomplete evidence. • Polymixin B/oxytetracycline reduced flora on packing.

  41. Epistaxis (cont) • Why so much about a bloody nose? • It is distressing. • It is common. • Public (and health care) knowledge of 1st aid is poor. • The next bloody nose visit can be a public health moment (teaching=freedom).

  42. Epistaxis (cont) http://drdavidson.ucsd.edu/Portals/0/Pathway/NoseBled.htm

  43. http://www.aafp.org/afp/2007/0115/p243.html

  44. Sinusitis • The Forgotten Badboy of the URTI http://www.topalbertadoctors.org/informed_practice/cpgs/acute_sinusitis.html

  45. Sinusitis • Defn • Inflammation of one or more of the paranasal sinus cavities, the cause of which may be allergic, viral, bacterial, or rarely fungal • Exclusions • <6wks, immunocomp, severe underlying dz, complications of acute bacterial sinusitis, hospital acquired sinusitis.

  46. Sinusitis (cont) • Acute Sinusitis • <4 wks. • Recurrent • 4+ episodes/yr lasting 10+ days, symptom free b/w. • Chronic • >12 wks with/without Rx.

  47. Sinusitis (cont) • MCC? • Viral • 200x that of bacterial! • S. pneumoniae, H.influenzae

  48. Sinusitis (cont) • Persistent symptoms of URTI without improvement after 10 - 14 days or worsening after 5 days with both: • nasal congestion/purulent nasal discharge and facial pain • +/- fever, maxillary toothache, facial swelling. • Physical findings of: swelling and/or erythema, tenderness on palpation/percussion of paranasal sinuses, periorbital swelling, erythema/swelling of nasal mucosa, post nasal drip • Nasal/nasopharyngeal cultures NOT recommended • Transillumination of the sinuses is of limited value in adults TOP Guidelines, 2008 Update

  49. Sinusitis (cont) • Abx? 1st Line • Amoxicillin 500mg PO TID 10d • Allergy? • Doxycycline 200mg PO once, then 100mg PO BID 10 d • TMP/SMX 1 DS PO bid 10d TOP Guidelines, 2008 Update

  50. Sinusitis (cont) • What!? I'm an EMERG DOC! • Progress, in this case, is bad. http://www.emedmag.com/html/pre/fea/features/061505.asp

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