Emergency Medicine—Eye, Ear, Nose, and Oral
Emergency Medicine—Eye, Ear, Nose, and Oral
EYE
Examination
1) Visual acuity
2) Pupillary function
3) Extraocular motility
4) Visual fields
5) Slit lamp
6) Intraocular pressure
7) Fundoscopy
Corneal Abrasion
Corneal abrasion is a superficial disruption of the cornea resulting from trauma. The cornea is round, avascular, and clear over the anterior eye. It refracts light and protects the eye
Clinical Presentation
1) History – ocular pain, sensation of foreign body, blurred vision, photophobia
2) PE – conjunctival injection, visual acuity defects
3) Contact lens users are prone to ulceration due to Pseudomonas aeruginosa
Diagnosis
1) Visual acuity – blurred vision if near central vision
2) Upper eyelid eversion – foreign body
3) Fluorescein staining
Treatment
1) Topical anesthetics to facilitate exam – proparacaine. Always use anesthesia!
2) Cycloplegic eyedrops – dilate the pupil. Reduce ciliary body spasm, reducing pain. Use in caution in patients with narrow-angle glaucoma. Common side effect is photophobia
3) Irrigation with NS to remove foreign bodies
4) Discharge with broad spectrum antibiotics – Emycin or Polysporin
5) Aminoglycoside/fluoroquinolone for contact lens patients due to P. aeruginosa
6) Oral analgesics
7) Follow-up in 24 hours
Corneal and Conjunctival Foreign Body
Clinical Presentation
1) Pain
2) Sensation of foreign body
3) Rust ring – evidence of metal piece inside eye
Diagnosed
1) Fluorescein
2) R/O intraocular foreign bodies – use soft tissue x-ray or CT scan. Do not use MRI if suspect metal foreign body
Treatment
1) Remove object with moist cotton swabs
2) Use proparacaine
3) Antibiotic ointment
Acute Angle Closure Glaucoma
Acute Angle Closure Glaucoma is an increase in IOP. Untreated can result in blindness. Aqueous humor is a clear fluid substance that bathes the lens and cornea. It is produced by the ciliary process and drains into the episcleral veins by canal of Schlemm.
Clinical Presentation
1) History – sudden eye pain, blurred vision, headache, n/v, halos around lights
2) PE – visual acuity defects, conjunctival injection, cloudy cornea, midway positioned or dilated
3) Slow or sluggish response to light
4) Elevated IOP
Management
1) Improve aqueous humor flow – Pilocarpine 2% eyedrops, laser iridectomy
2) Inhibiting aqueous humor production – Timolol .5% eyedrops
3) Reducing aqueous or vitreous humor volume – Mannitol IV draws water into the circulation and out of the eye
Central Retinal Artery Occlusion
Central retinal artery occlusion causes retinal ischemia and painless vision loss. Eye emergency. Can lead to retinal infarction if not treated within 90 minutes. Risk factors include HTN, a-fib, collagen vascular disease, sickle cell disease, acute glaucoma, and orbital hemorrhage
Clinical Manifestations
1) History – acute, painless monocular vision loss with risk factors
2) PE –macula is cherry red due to retinal thinning, unresponsive pupils, edematous retina, and increased IOP
Management
1) Reestablish central retinal artery blood flow and retinal perfusion – Global ocular massage
2) Anterior chamber paracentesis –
3) Acetazolamide IV
Disposition
1) Hospitalization for treatment by ophthalmologist
Orbital Cellulitis
Periorbital cellulitis does not enter the orbit. Orbital cellulitis is infection posterior to the orbital septum within the orbit. It is a deeper infection and is more emergent. Both should be treated aggressively to avoid extension into meninges and brain via cavernous sinus.
Clinical Manifestations
Periorbital Cellulitis
1) Erythema and swelling
2) No pain with EOM
3) No proptosis
4) No diplopia
Orbital Cellulitis
1) Conjunctival injection
2) Fever
3) Edematous erythematous periorbital soft tissue
4) Tenderness with EOM
5) Elevated IOP
6) Impaired visual acuity
7) Sensation can be impaired
Diagnosis
1) CT soft tissue orbital infiltration
2) Cultures
Management
1) Admit with broad spectrum antibiotics such as Clindamycin and ceftazidime
2) Orbital cellulitis – fever, toxicity, periorbital swelling should be hospitalized with IV antibiotics
EAR
Ear Pain
History Questions
1) History of trauma, surgery, recent infection
2) Specific symptoms
3) Pain quality
4) Exact location of the pain
Physical Exam
1) Palpate area surrounding ear to identify lymph nodes
2) Pain, swelling and erythema at mastoid process
3) If pain in canal look for discharge from canal
4) View canal, TM
5) If ear exam is normal, examine teeth
Acute Mastoiditis
Acute Mastoiditis can be an extension of AOM. Etiology is s. pneumoniae, s. pyogenes, and s. aureus
Clinical Manifestations
1) Fever
2) Pain
3) Swelling and erythema at mastoid
4) Canal with no erythema or discharge
5) Possibly findings of AOM
Treatment
1) ENT consult
2) Admission
3) IV antibiotics – Cefotaxime
Foreign Body
Clinical Manifestations
1) Insect noted on canal or on TM
Treatment
1) Removal by Frazier suction, alligator forceps, or curette
2) For insect, instill lidocaine in canal and flush out insect
3) If secondary canal trauma, treat for otitis externa
4) Do not flush the ear with water if the foreign body is an organic substance
Otitis Externa
Otitis externa is caused by p. aeruginosa, s. aureus, or fungal infection. Caused by excessive moisture which removes cerumen and causes the pH of the ear to elevate. Commonly seen in swimmers
Clinical Manifestations
1) Ear pain and itching
2) Otorrhea
3) Erythematous canal
4) Pain with pinna movement
5) Faulty hearing if canal is occluded
Treatment
1) Wick through obstructed canal for antibiotic administration
2) Treat with topical steroid and antibiotic preparations such as hydrocortisone-polymyxinneomycin or ciproHC
3) Analgesics
4) Consider malignant otitis in diabetics, immunocompromised, or elderly – treat with anti-pseudomonal and hospitalization
Acute Otitis Media
Acute otitis media is caused by s. pneumonia and h. influenzae.
Clinical Manifestations
1) TM erythematous
2) Dull light reflex
3) Limited motility
4) Landmarks may not be visible
5) Ear pain
6) Conductive hearing loss
7) History of URI
Treatment
1) Amoxicillin for 10 days
2) Augmentin if recent treatment failure
3) Bactrim
Perforation of TM
Etiology is blunt or penetrating trauma
Clinical Manifestations
1) Pain
2) Otorrhea
3) Tinnitus
4) Retraction of TM
Treatment
1) Most need no intervention
2) No antibiotics unless infection present
NOSE
Epistaxis
Most episodes of epistaxis are without life threatening blood loss. Typical site of bleeding is Kiesselbach’s area of anteriomedial nostril. Anterior nosebleeds are usually caused by digital trauma. Posterior nosebleeds are usually caused by HTN.
History Questions
1) Picking your nose?
2) Dry air?
3) Pregnancy?
4) History of anticoagulant therapy?
Physical Exam
1) Both nostrils should be examined for bleeding and the integrity of the septum
2) Observe posterior pharynx for blood dripping – posterior
3) Bright red blood – anterior
4) Dark red blood – posterior
Management
Anterior
1) Pinch nostrils and lean forward
2) Silver nitrate for cautery – only if the bleeding can be localized
3) Anterior packing if bleeding persists – Merocel
4) If nasal packing, give prophylactic Augmentin
Posterior
1) Arterial site – use vasoconstrictive agents
2) Foley catheter or nasal balloon devise
3) Admit for airway observation, prophylactic antibiotics and ENT consultation
Nasal Obstruction
Clinical Manifestations
1) Object might be visible
2) Purulent discharge from one nostril
Treatment
1) Puff technique – have mother blow into child’s mouth, holding unaffected nostril closed with finger. Should dislodge object
2) Remove object with forceps
3) Insert small Foley catheter past object, inflate balloon and pull out to remove object
Nasal Fracture
Diagnosis
1) Suggested by mechanism of injury, swelling, tenderness, crepitance, gross deformity, periorbital ecchymosis
2) Look for septal hematoma – applies pressure to the septum. Can lead to necrosis due to pressure
Treatment
1) Ice/analgesics
2) OTC decongestants
3) Follow up in 2-5 days for re-examination
4) Treatment of septal hematoma is incision and drainage with anterior nasal packing
ORAL AND DENTAL EMERGENCIES
Dental Fractures
Ellis Classification
1) Type I – enamel
2) Type II – dentin
3) Type III – pulp and presents as a red blush of dentin
Clinical Manifestations
1) Air and temperature sensitivities
Treatment
1) Dry dentin and cover with zinc oxide/eugenol paste
2) See dentist within 24 hours
Concussion
Concussion is no abnormal loosening.
Clinical Manifestations
1) Tenderness to percussion
Management
1) NSAIDs
2) Soft diet
3) Dental referral
Subluxation
Subluxation is a loose tooth
Management
1) NSAIDs
2) Soft diet
3) Dental referral
Extrusive Luxation
Extrusive luxation is when the tooth is coming downward.
Treatment
1) Reposition tooth and splint with zinc oxide
2) Evaluate in 24 hours
Lateral Luxation
Lateral luxation is when the tooth is laterally displaced
Treatment
1) Splinting
Intrusive Luxation
Intrusive luxation is when the tooth is forced below the gingival line
Dental Avulsion
In dental avulsion, secondary teeth must be replaced within 3 hours. Handle avulsed tooth by crown only, rinse with water and have replanted immediately. Root must be moist. If not soak in citric acid, then stannous fluoride and then doxycycline
Tongue Lacerations
Tongue lacerations that actively bleed require suturing. Smaller lacerations will heal on their own. Use 4 0 absorbable sutures and approximate as closely as possible.
Lip Lacerations
Lip lacerations may possibly involve the transition between lip tissue and skin of the face. Use infraorbital nerve block for upper lip and mental nerve for lower lip. If oral laceration, prophylaxis with Penicillin or Clindamycin for 5 days
Tooth Eruption
Tooth eruption is the emergence of secondary teeth.
Treatment
1) Cold compress and acetaminophen
Wisdom Teeth in Adults
Treatment
1) Penicillin, ibuprofen, clindamycin, and warm saline mouth rinses
2) Oral surgeon if necessary
Tooth Decay
Tooth decay is the most common cause of toothache. It is periapical pathology.
Clinical Manifestations
1) Pain localized to one tooth
2) Pain can radiate to head, neck, ear
3) Decayed tooth
4) Percuss teeth with metal object will elicit pain
Treatment
1) Penicillin or Clindamycin, ibuprofen, oxycodone
2) I/D if abscess present
Pulpitis
Pulpitis is inflammation of the pulp. The pulp is exposed through the center of tooth. Presents as deep throbbing pain on exposure to hot or cold.
Periodontal Infection
Periodontal infection is acute bacterial infection of the periodontal tissues localized to gingival or mucosa adjacent to the involved tooth.
Treatment
1) Antibiotics
Periodontal Abscess
Periodontal abscess results from plaque and debris entrapped between the tooth and gingiva.
Treatment
1) Oral antibiotics – Penicillin or clindamycin
2) Analgesics
3) Chlorhexidine mouth rinses
4) Large abscess need I/D by dentist
5) Dental referral
Acute Necrotizing Ulcerative Gingivitis
Acute necrotizing ulcerative gingivitis is found mainly in patients with lowered resistance due to HIV, malnourishment, stress, and alcoholics.
Clinical Manifestations
1) Pain
2) Ulcerated Interdental papillae
3) Gingival bleeding
4) Fever
5) Malaise
6) Extremely foul breath odor
Treatment
1) Metronidazole
2) Chlorhexidine mouth rinses
Oral Candidiasis
Oral candidiasis is a.k.a. oral thrush. Risk factors include elderly, young, and immunocompromised patients. It is an opportunistic infection.
Clinical Manifestations
1) Removable white curd-like plaques on an erythematous mucosal base causes bleeding
Treatment
1) Oral antifungal agents such as clotrimazole troches, Nystatin, and fluconazole
Aphthous Stomatitis
Aphthous stomatitis is a.k.a. canker sores. It is an intraoral ulceration triggered by cell-mediated immunity (HSV type VI).
Clinical Manifestations
1) Painful small round ulcerations with yellow-gray centers surrounded by red halos
2) Found on buccal and labial mucosa
Treatment
1) Usually self-limiting – 7-10 days
2) Give topical steroid mouth rinse for pain
Herpetic Stomatitis
Herpetic stomatitis presents as burning followed by small vesicles, which form scabs. Symptoms can be severe in immunocompromised patients.
Management
1) Antiviral therapy
HSV Type I
HSV type I presents as labial vesicles that rupture and crust and intraoral vesicles that ulcerate. Found on lip and oral mucosa.
Management
1) Antivirals
2) Look for secondary infection
Coxsackievirus
Coxsackievirus is transmitted through fecal/oral or airborne route
Types
1) Type A – found on oropharynx. Associated with herpangina
2) Type B – associated with pneumonia and bronchitis
Clinical Manifestations
1) Presents as vesicles and ulcers on the tonsilar pillars, uvula, soft palate, posterior pharyngeal wall
2) Also associated fever, sore throat, headache, and dysphagia
Treatment
1) Self-limiting – lasts 5-10 days
2) Supportive
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