Common Otolaryngology Emergency Room Consults Practical Guidelines

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Common Otolaryngology Emergency Room
ConsultsPractical Guidelines

• Michael Chao, MD
• Department of OtolaryngologyHead and Neck
  Surgery
• University of California, Irvine
• July 8, 2004

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Epistaxis

• What do you ask on the phone?

• When did it start?
• How did it start? Trauma
• Prior episodes-how long does it last
• Other medical problems
• Medications-anticoagulation, antihypertensives
• Vitals
• Laboratory values

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Epistaxis

• What to ask for
• Afrin
• Head light
• Nasal packing tray
• Flexible Scope
• Silver Nitrate
• Merocel packs
• Surgicel
• Gelfoam
• Lidocaine w/ epi
• Bacitracin
• Vaseline strip gauze

• Where to get it
• Pharmacy (sometimes ER)
• Operating Room
• Operating Room (Rm5)
• Operating Room
• Usually on scope cart
• Operating Room
• Operating Room
• Operating Room
• ER Pyxis
• ER
• Operating Room

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Epistaxis

• Anatomy
• Vasculature
• ECA
• ICA
• Littles area
• Woodruffs area

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Trauma

• Blunt facial trauma
• Nasal fracture
• Temporal bone fracture
• Lacerations

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Facial Trauma Assessment

• Mechanism of injury
• Other injuries
• Eyes
• Chemosis
• Tarsal plate
• Ears
• Lacerations
• Hemotympanum
• Nose
• Fractures
• Septal hematoma

• Oral cavity
• Lacerations
• Damage to duct
• Neck
• Crepitus
• Tracheal deviation
• Cranial Nerve exam
• Evaluation of fractures
• Orbital rims
• Midface stability
• Mandibular step off

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Nasal Fractureclosed reduction

• Assess deformity
• Assess stability
• Timing

• How do I do it?
• Instruments
• Injections
• Reduction
• Stabilize

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Closed reduction nasal fracture

• Anatomy injections

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Temporal bone fracture

• Longitudinal
• Along axis of petrous pyramid
• Through middle ear
• May disrupt ossicular chain
• Transverse
• Perpendicular to long axis of petrous pyramid
• Disrupts cochlea and vestibule
• SNHL and vertigo common

• Physical Exam
• Lacerations
• Hemotympanum
• CSF otorrhea
• FN exam
• Nystagmus
• Tuning forks

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Facial Nerve Exam

• House-Brackmann
• Grade I Normal
• Grade II Good eye closure, minimal asymmetry
• Grade III noticeable synkinesis, eye closure w/
  effort, weak forehead
• Grade IV normal tone at rest, no forehead
  motion, incomplete eye closure
• Grade V minimal movement of mouth
• Grade VIComplete paralysis

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Peritonsillar Abscess

• History
• Sore throat for days
• Odynophagia
• Dysphagia
• Otalgia
• Examination
• Trismus
• hot potato voice
• Drooling
• Effaced antrerior pillar
• Bulging of tonisl to midline
• Contralateral deviation of uvula

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Peritonsillar Abscess

• Management options
• Needle aspiration
• Incision and Drainage
• Quinsy tonsillectomy
• Antibiotics
• Clindamycin
• Unasyn/Augmentin

• Equipment needed
• Hurricaine spray
• Lidocaine w/ epi
• Headlight
• Scalpel
• Suction setup
• Long tonsil clamp
• Culturette

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Inhalation injury

• Common Scenarios
• COPD, on home O2, smoking in bed
• House fire
• 4th of July firecrackers
• What you want to know
• Work of breathing
• Change in voice
• Circumstances surrounding burn

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Inhalation injury

• What you need to do
• Flexible fiberoptic exam at time of arrival
• Repeat exam 6 hours after injury
• How to expedite your work-up
• Have intern order Afrin
• Have intern bring ENT scope cart

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Inhalation injury

• What youre looking for
• Edema/erythema of supraglottis/glottis
• Soot in larynx
• Recommendations
• Cool mist O2 via face tent
• Racemic epi PRN stridor, sob
• IV steroids
• When in doubt, bump it up!