EENT Emergencies

tx blepharitis

Topical Antibiotics (Monotherapy)

• Polysporin, Erythromycin, or bacitracin

tx hordeolum

• warm compress

• abx monotherapy if resistant to conservative management

1. cephlexin or Amoxiccillin

2. clindamycin if penicillin allergy

pseudodentrites on fluroescein

HZV ophthalmicus

dendritic ulcers on fluorescein

HSV keratitis

tx allergic conjunctivitis

Naphazoline/pheniramine 0.025%/0.3% QID

tx viral conjunctivitis

• Artificial tears x 1 week

• Cold compress

tx HSV/HZV conjunctivitis

acyclovir (preferred for immunocompromised), ganciclovir, or valacyclovir

tx bacterial conjunctivitis

staph/strep: erythromycin

pseudomonas: levofloxacin

GC/chlamydia: ceftriaxone + doxy + erythromycin

tx corneal ulcer

moxi or cipro

tx for periorbital cellulitis outpatient

amox-clavulanate (augmentin) + clindamycin/bactrim

cefpodoxime if penicillin allergy

tx for periorbital cellulitis inpatient

pick 1

• ampicillin-sulbactam (unasyn)

• pipercillin-tazobactam (zosyn)

• ceftriazone if allergy

pick 1

• vancomycin

tx for orbital cellulitis

same as periorbital

pick 1

• ampicillin-sulbactam (unasyn)

• pipercillin-tazobactam (zosyn)

• ceftriaxone if allergy

pick 1

• vancomycin

use amphotericin if DM or immunocompromised

what imaging is done for suspected intraocular FB retention

ocular US or CT orbit

tx corneal laceration

• no contacts: erythromycin ointment

• contacts: levofloxacin solution

what IOP indicates acute angle glaucoma?

>20

tx acute angle glaucoma

Decrease production of aqueous humor

• β-blocker Timolol ophthalmic 0.5%

• Carbonic anhydrase inhibitors (Pick 1): Dorzolamide (Trusopt) 2% or Acetazolamide

Facilitate outflow of aqueous humor

• Topical α-adrenergic agonist (Pick 1): Brimonidine (alphagan) 0.2% or Apraclonidine 1%

• Muscarinic cholinergic agonist (Pick 1): Pilocarpine 1%–2% q15min, the q4h

Reduce Inflammation (Pick 1)

• Steroids ophthalmic: Prednisolone acetate 1% q15min x4, then q1h

Reduce volume of aqueous humor (Controversial)

• Mannitol 1-2 g/kg IV given over 45 minutes

u/l eye pain, blurred halo vision, N/V, abrupt onset, hazy cornea

acute angle glaucoma

associated w/ MS, monocular vision loss, painful eye movements

optic neuritis

which condition causes pulfrich effect and red desaturation test

optic neuritis

what is the imaging of choice for optic neuritis

MRI/MRA of brain and orbits

what finding on US indicates optic neuritis

papilledema > 5mm diameter

tx for optic neuritis

IV Methylprednisolone

sudden painless monocular vision loss w/ cherry red spot

central retinal artery occlusion

sudden painless monocular vision loss w/ blood and thunder fundus

central retinal vein occlusion

imaging for CRAO/CRVO? which is gold standard?

CT angiogram head and orbit (gold)

carotid US

pale retina?

CRAO

CRAO tx if temporal arteritis etiology (elevated ESR/CRP)

Methylprednisone

general tx for CRAO

Alteplase (TPA)

tx for CRVO

Bevacizumab Intravitreal (anti-VEGF)

painless abrupt vision loss w/ floaters, flashes of light, curtain, hazy retina

retinal detachment

what diagnostic is needed for retinal detachement

ocular US: to determine maculo on vs macula off

how do you position retinal detachment pts?

superior visual field defect/detachment: lay supine

inferior visual field defect/detachment: elevate head

general management otitis externa

analgesics

1:1 dilution NS to 3% hydrogen peroxide

otitis externa abx therapy

No Concomitate TM perforation

• Ciprofloxacin-hydrocortisone

• Ciprofloxacin-dexamethasone

• Neomycin/polymixin B/hydrocortisone

Concomitant TM perforation

• Ofloxacin (Floxin) 5gtt BID

Immunocompromised

• Systemic Antibiotics: Ofloxacin or Ciprofloxacin PO

tx malignant otitis externa

adult monotherapy

• cefepime IV

• Piperacillin-Tazobactam (Zosyn) IV

• Imipenem IV

• levofloxacin or ciprofloxacin if beta-lactam allergy

peds dual therapy

• 1 from above (beta-lactam w/ antipseudomonal)

• gentamycin IV

tx for otitis media

WASP b/c most viral

monotherapy abx if sx worse for 48-72 hrs

1st line: amoxicilin, azithromycin, clindamycin (if PCN allergy)

2nd line if recent abx use:

• Amoxicillin-clavulanate (Augmentin)

• Cefuroxime

• Cefpodoxime

• Ceftriaxone

imaging needed to dx mastoiditis

CT Mastoid w/ IV contrast

tx mastoiditis

1. Broad-spectrum gram (+) coverage (Pick 1)

• Ampicillin-Sulbactam (Unasyn) IV

• Ceftriaxone (Rocephin) IV

Risk of pseudomonas

• Piperacillin-Tazobactam IV

• Cefepime 2g IV

Severe PCN allergy = Aztreonam IV

2. MRSA Coverage (Pick 1)

• Clindamycin IV

• Vancomycin

tx dental caries

• chlorhexedine rinse

• amoxicillin or clindamycin (if PCN allergy)

what imaging is needed for gingival or periodontal abscess

soft tissue CT with IV contrast

tx for gingival and periodontal abscess

1. I & D followed by chlorhexidine

tx for gingival & periodontal abscess

Outpatient: uncomplicated (monotherapy)

• Amoxicillin-Clavulanate (Augmentin)

• PCN Allergy

  • Doxycycline

  • Clindamycin

Inpatient: complicated (monotherapy)

• Ampicillin-sulbactam IV

• Concern for pseudomonas: Piperacillin-tazobactam IV

• PCN Allergy

  • Ceftriaxone or Cefepime IV (Pseudo)

  • Clindamycin IV

raised tongue, woody-brawny floor swelling, tongue protrusion, dysphonia

ludwig’s angina

imaging needed for ludwig’s angina

CT w/ contrast

tx ludwig’s angina

triple therapy

1. Piperacillin-Tazobactam (Zosyn) or Cefepime or Meropenem

2. clindamycin

3. vancomycin

tx sinusitis general

• hypertonic saline

• Vasoconstrictors: Phenylephrine or Oxymetazoline (Afrin)

• antihistamines

  • 1st Generation “drowsy” Diphenhydramine (Benadryl)

  • 2nd Generation “nondrowsy”: Loratadine (Claritin), cetirizine (Zyrtec)

• steroids: Fluticasone propionate (Flonase)

tx sinusitis abx

monotherapy

• Amoxicillin-Clavulanate (Augmentin)

• Clindamycin (PCN allergy)

• doxy (PCN allergy)

gold standard: Mucormycosis

Histopathology: but do not wait for confirmation to treat

tx Mucormycosis

• surgical debridement

• Hyperbaric Oxygen Therapy

• Fe Chelation: Deferasirox

• antifungal: Amphotericin B

tx pharyngitis outpatient

No antibiotic use in last 3 months: Monotherapy

• Bicillin IM x 1 (Better for noncompliant patients)

• Amoxicillin x 10 days

• Penicillin Allergy

  • Clindamycin 300mg QID

  • Azithromycin (Z-Pack)

Antibiotic use in last 3 months

• Amoxicillin-clavulanate (Augmentin)

tx pharyngitis inpatient

Monotherapy

• Ampicillin-sulbactam IV

• Piperacillin-Tazobactam IV (Pseudomonas)

• Ceftriaxone or Cefepime IV (Pseudomonas + allergy)

• Clindamycin IV (PCN allergy)

tx peritonsillar abscess general

needle aspiration

I&D

steroids

• Methylprednisolone

• Dexamethasone

tx peritonsillar abscess

outpatient monotherapy

• Amoxicillin-clavulanate

• Clindamycin (allergy)

inpatient monotherapy

• Ampicillin-Sulbactam (Unasyn) IV

• Piperacillin-Tazobactam IV

• clindamycin (allergy)

tx Retropharyngeal Abscess

Dual Therapy

1, Gram (+/-) Broad spectrum (Pick 1)

• Ampicillin-Sulbactam (Unasyn) IV

• Pipercillin-Tazobactam (Ps)

• Ceftriaxone or Cefepime (Ps + allergy)

2. MRSA Coverage (Pick 1)

• Vancomycin IV

• Clindamycin IV