ED/Surgery Clinical Medicine

ABCDE

Airway, breathing, circulation, deficit, exposure

S/S of respiratory distress

• S/S: SOB, trouble speaking, tachypnea, tachycardia, accessory muscle use, stridor

• Dx: assess ABC (DE)s and vitals (pulse ox, ABGs, CXR, EKG, CBC, lytes)

• Tx: tx hypoxia, supplement O2, IV, cardiopulmonary monitoring, infection, hospitalization until patient is stable

S/S respiratory failure

• S/S: cyanosis, AMS, quiet chest, agonal respirations

• Tx: aggressive ABC management, underlying conditions

O2 options

(least invasive) Nasal cannula, high flow nasal cannula, O2 facemark, non-rebreather face mask, non-invasive CPAP/BiPAP, mechanical ventilation, ECMO (most invasive)

Acute respiratory distress syndrome (ARDs)

Diffuse inflammatory lung injury→ increased alveolar capillary permeability→ noncardiogenic pulmonary edema→ severe hypoxemia

• Risks: trauma, sepsis, severe pneumonia, influenza, aspiration

• S/S: acute severe dyspnea, tachypnea, hypoxemia- often refractory to O2, diffuse crackles

Management of ARDs

• Dx:

1. B/L infiltrates on CXR

2. PaO2:FiO2 <200

3. Pulmonary wedge pressure <18 mmHg

• Tx: underlying, fluids, high dose steroids

Acute asthma exacerbation

• Risks: Respiratory infection, environment exposure, new meds, exercise, emotional stress

• S/S: Dyspnea/SOB, cough, wheeze, chest tightness, prolonged expiration

  • Mild/Mod: phrases and sentences, HR <120, dyspnea limiting activity

  • Severe: words, HR >120, accessory muscle use, dyspnea at rest

  • Life-Threatening: cannot speak, bradycardic, inability to maintain respirations, cyanosis, AMS

Management of acute asthma exacerbation

• Dx: vitals, O2 sat (pulse ox or ABGs)- goal >94%, EKG/CBC/BMP, CXR → continuous monitoring required

• Tx: supplemental O2, albuterol ipatropium bromide nebulizer (DuoNeb), steroids PO/IM/IV ASAP

Status Asthmaticus

Life-threatening and severe asthma that is does not get better with standard rescue treatment

• Tx: high dose inhaled bronchodilators, continuous nebulizer, IV corticosteroids, supplemental O2→ ventilation if needed, IV mag sulfate

COPD

• Risks: severe respiratory infection, pulmonary HTN, cor pulmonate

• S/S: increased dyspnea, change in the color and quantity of sputum, wheezing, prolonged expiration

  • Severe: acute or worsening hypoxemia, hypercapnia (confusion, tremor, plethora, stupor)

• Dx: ABG, CBC, BMP, CXR, EKG, consider viral testing

• Tx: supplemental O2 (to baseline), DuoNeb, corticosteroids, broad spectrum antibiotics pending workup (Azithromycin, Doxycycline), admit to the hospital until stable

Risk factor of aspiration pneumonia

Lethargy, AMS, poor cough reflex, SUD (intoxication), ventilation, poor dentition

Pneumonia usually presents as

CAP→ unless from a nursing home or a LTC facility

• do NOT miss aspiration pneumonia (develop quickly and can lead to ARDs or lung abscess)

Pneumonia

• S/S: fever, cough, tachypnea, tachycardia, rales/crackles, dyspnea, chest pain, hemoptysis or colored sputum “rusty”

• Dx: Clinical + CXR showing infiltrate, high WBC count on CBC, urine antigen test for Strep or Legionella (if serious presentation do a culture)

• Tx: Empiric Abx (amoxicillin or doxycycline)→ if admitted do a respiratory fluoroquinolone Moxi/Levofloxacin

  • Admit baed on PSI or CURB-65 score (confusion, uremia, respiratory rate, BP) or 65+

Different presentations of pneumonia

• Strep pneumonia: lobar; dense consolidation of an entire lobe

• Mycoplasma: atypical “walking”; diffuse b/l interstitial infiltrates, looks worse than it is

• Aspiration: oral anaerobes; dependent lobe infiltrates

• PCP: diffuse b/l ground glass opacities

Risks of poor outcomes of pneumonia

RR >30, HR >140, BP <90 systolic, Temp >101, AMS

Aspiration pneumonia

Pathogens enter the lung through inhalation of aerosols, hematogenous spread, or aspiration of oropharyngeal contents into lungs

• Risks: swallowing disorder, intoxication, AMS

• S/S: fever, cough, dyspnea, hx suggesting risk, dysphagia, intoxication, stroke/AMS

• Dx: clinical and CXR (dependent lobe infiltrates)

• Tx: Ampicillin-Sulbactam IV or Augmentin PO + Clindamycin or Metronidazole

Pneumothorax

Air enters the pleural space and the lung collapses

• S/S: sudden pleuritic chest pain, dyspnea, decreased breath sounds in the area of PTX, hyperresonance, decreased tactile fremitus

• Dx: CXR ± bedside US or CT

Treatment of a tension pneumothorax

Immediate needle decompression with a chest tube

Types of pneumothorax

• Primary spontaneous: occurs in absence of underlying lung dz

• Secondary spontaneous: complication of pre-existing lung disease

• Traumatic: penetrating or blunt trauma

• Iatrogenic: following procedures such as thoracentesis, bx, etc.

• Tension: pressure of air in pleural space exceeds ambient pressure in the respiratory cycle

  • trachea deviates and there is a mediastinal shift

Primary spontaneous pneumothorax

Rupture of sub pleural apical bleb in response to increased negative intrapleural pressure

• Risks: tall thin boys 10-30 yo, family hx, smoking

• S/S: chest pain, dyspnea, begin during rest and resolves within 24 hours

  • <15%: tachycardia

  • >15%: diminished breath sounds, decreased tactile fremitus, hyper resonance, unilateral lag

• Dx: CXR (look for the visceral pleural line)

• Tx: <15% and stable- observation and supplemental O2 if needed, larger- aspiration

PA view of FB

I= coin in the Trachea

O= coin in the esophagus

Acute respiratory failure

Overarching condition that states the respiratory system has failed at gas exchange

• Hypoxemic: low O2 and normal/low CO2

• Hypercapnic: CO2 dangerously high

Foreign body aspiration (FBA)

• Risks: latex balloons, food, toys (may be more than one object)

• S/S: choking, wheezing and/or coughing especially after eating or playing, stridor (if in upper airway), prolonged coughing

• Dx: CXR (normal does not exclude)→ can see segmental atelectasis, pneumonia, hyperinflation, pneumothorax

  • +expiratory view w/ aspirated FB, bronchoscopy- dx and tx

• Tx: O2, calm pt, immediate airway management if unstable

Heimlich maneuver

Perform only if pt cannot talk (no blind finger sweeps)

• Age <1: cycles of 5 back blows and 5 chest thrusts

• Age >1: abdominal thrusts, fists with thumb against the abdomen and place midline over the naval

Hemoptysis

• Risks: bronchitis, PNA, TB, CA, PE, FB, trauma, bronchiectasis, lung abscess

• S/S: cough, SOB, pleuritic chest pain, presentation depends on the cause

• Dx: CXR→ CT, CBC/PT/INR/PTT, type and cross match, sputum and gram stain, ABG, renal function

• Tx

  • Small volume: O2, underlying

  • Large volume: ABCs, high flow O2, intubation, CT consult, may need transfusion

Death in hemoptysis is commonly due to

Asphyxiation: protest the airway and control proper oxygenation

Chest wall trauma

Usually due to blunt/penetrating trauma to the thoracic region

• S/S: obvious trauma→ contusion, hematoma, laceration, crepitus, rib fracture

• Dx: CXR or CT and clinical detail

• Tx: ABCs, C-collar, intubation if needed

Rib Fracture

D/t blunt and penetrating trauma→ fracture and pain→ hypoventilation

• S/S: CP localized to fracture site, pain worse with inspiration, SOB, DOE, respiratory distress, crepitus

  • If multiple evaluate for- parenchymal damage, pneumothorax, flail chest

• Dx: CXR, CT (more sensitive)

• Tx: supportive, pain control, incentive spirometry to prevent hypoventilation

Flail chest

Segmental fracture of 3+ adjacent ribs in 2+ areas→ free floating chest wall segment→ paradoxical inward movement of the chest wall with inspiration and outward with expiration

• Risks: gross trauma with respiratory distress

• S/S: severe pain, respiratory distress, paradoxical chest movement

• Dx: Clinical + CXR and/or CT

• Tx: DO NOT STABILIZE THE RIBS, CPAP/BiPAP, O2 with aggressive pain control, intubation if needed

Diaphragmatic injury

Trauma tears the diaphragm→ abdominal organs herniate into the thorax

• Risks: blunt trauma, MVA, fall from height, penetrating injury

• S/S: CP, abdominal pain, can present as shoulder pain, decreased breath sounds

• Dx: CXR, CT preferred

• Tx: Sx repair

Frostbite and hypothermia (cold injuries)

• Risks: extremes of age, ETOH/drugs, psych patients, cold environment, decreased metabolic rate, CNS depressants, sepsis, dermal disease, substance abuse

• Patho: local cold injury and frostbite occur when freezing temps are reached

  • Hypothermia: increased blood viscosity, extracellular ice crystal formation and intracellular dehydration, lysis

  • Frostbite: 1. irritate the skin, 2. blisters, 3. all layers of the skin and tissue dies

Signs and symptoms of cold injuries

Initially= peripheral vasoconstriction

• Mild hypothermia (32-35 C OR 89.6-95 F): shivering, tachycardia, increased BP

• Severe hypothermia (less than 32 C or 89.6 F): AMS, loss of cough and gag reflex

• Features: cold diuresis (decrease of ADH), lethargy/comatose, prolonged immobility- rhabdo and acute renal failure, intravascular thrombosis, DIC, hyperglycemia→ hypoglycemia, ECG= Osborn J Waves, dysrhythmia A-fib→ V-fib→ asystole

Frostbite degrees

• 1st degree: “Frostnip”- edema, burning, erythema

• 2nd degree: 1st degree FB + blistering

• 3rd degree: necrosis, blue-gray discoloration of extremity, hemorrhagic blisters

• 4th degree: skin necrosis that is mummified- cyanotic insinuate (fully dead)

Chilblains (Pernio)

Painful and inflamed skin lesions d/t chronic intermittent exposure to damp non-freezing ambient temperature

• once affected patient is more susceptible to future injury

• Tx: elevate, warm, nifedipine, topical steroids, prednisone

Trenchfoot

Cooling of tissue in wet environment at above-freezing temperature from hours→days

• Tx: elevate, warm, nifedipine, topical steroids, prednisone

Management of cold injury

• Dx: core body temperature <95F

• Tx: ABCs and initial resuscitation (initiate ACLS)

  • Rewarming: passive (mild), active external (severe with no cardiac instability), active internal (severe with cardiac instability)

  • + Narcotics, Ibuprofen, Aloe Vera, penicillin G (prevent gangrene)

  • Manage blisters (clear= debride or aspirate, hemorrhagic= leave intact)

  • Thiamine depletion/alcoholism: Thiamine IV/IM, 50% glucose IV

  • Hypothyroidism/Adrenal Insufficiency: IV thyroxine and hydrocortisone

Passive rewarming

Removal from a cold environment and insulation

• Tx mild hypothermia

Active external warming

Warm water immersion, heating blankets, radiant heat, forced air

• Tx severe hypothermia without cardiac instability

Active internal warming

Inhalation of warm air, heated IV fluids, GI/bladder/peritoneal/pleural lavage, ECMO, mediastinal lavage

• Tx severe hypothermia WITH cardiac instability

All patients with more than isolated superficial frostbite or mild hypothermia

needs admission to the hospital

• Do not discharge unless there is a warm environment

Heat stroke

Thermoregulation response failure and exaggerated acute response and altered shock protein response (life threatening injury)

• Risks: heat exposure, extremes of age, HF, substance abuse, dehydration, poverty, meds (anticholinergics, BB, CCB)

• S/S: AMS (ataxia, confusion), increased body temperature (104-116F OR 40-47C), tachycardia, hyperventilation (respiratory alkalosis), end result→ endothelial damage, microcirculatory failure, multi-organ failure

Treatment of a heat stroke

ABCs, cardiac monitoring, IV line (vol depletion, watch for hyperkalemia)

• Hi flow O2, IV normal saline, benzos (shivering or seizures)

• Evaporative cooling- fans on a disrobed patient and spraying tepid water→ can also do lavage or bypass

• Rhabdomyolysis- IV hydration, diuretics (furosemide), sodium bicarb

Heat exhaustion

Clinical syndrome that results from heat exposure

• S/S: malaise, fatigue, weak, dizzy, syncope, HA, N/V, myalgia, diaphoresis, tachycardia, tachypnea, HoTN

• Dx: core temperature normal or slightly increased, neuro exam is normal (NO AMS), hemoconcentration, check creatinine kinase (rhabdomyolysis)

• Tx: rest, evaporative cooling, IV normal saline or oral electrolytes

  • Tx aggressive to prevent a stroke

Heat syncope

Type of heat exhaustion- volume depletion, peripheral vasodilation, decreased vasomotor tone

• Risks: elderly, poorly acclimatized individuals

• Dx: R/o serious underlying conditions, evaluate if the patient hit their head

• Tx: rest, PO/IV hydration

Heat cramps

• Risks: athletic events

• S/S: painful muscle spasms (calves, thighs, shoulders)

• Tx: oral electrolyte or IV NS (discuss future electrolyte use)

Heat tetany

Occurs d/t respiratory alkalosis (hyperventilation)

• S/S: parasthesia of the upper extremity, circumoral parasthesia, carpopedal spasm

• Tx: remove heat stress, self-rebreathing through a paper bag

Heat Edema/Heat Rash

• Edema: self-limited mild swelling of hands and feet

  • Tx: elevated extremity, compression stockings (NO DIURETICS)

• Rash: maculopapular eruption: pruritic rash→ non pruritic rash

  • Tx: Anti-staph abx & 1% salicylic acid

Thermal burns

Direct tissue coagulation and microvascular reactions, increased capillary permeability, fluid shift intravascular→ interstitial areas, larger burns→ can cause hypovolemic shocks

• Risks: 18-35 (working age), >65

  • Risk of death: increased age, increased burn size, inhalation injuries, females

• >20% BSA: systemic response, interstitial edema (organs and soft tissue)

  • after successful fluid resuscitation: hypermetabolic state, x2 CO, x2 BMR

Thermal burns are categorized by

Size, depth, burn size (% of BSA involved)

Rule of 9‘s (thermal burns)

• Anterior trunk: 18% (chest 9%, abdomen 9%)

• Posterior trunk: 18% (upper back 9%, lower back/buttock 9%)

• Entire arm: 9% (front 4.5%, back 4.5%)

• Entire leg: 18% (front 9%, back 9%)

• Genitalia: 1%

*Lund and Browder- peds rule for burns

Depth of thermal burns

• Superficial: red, dry, painful with NO blisters

• Superficial partial thickness: red, moist, blanches, blisters, intact capillary refills, 14-21 days for healing

• Deep partial thickness: pale/white/yellow, capillary refill and pain absent, absent/sluggish blanching, healing 3 wks-3 mo

• Full thickness: white/brown/charred, pale/leathery painless, do NOT heal spontaneously→ need sx and/or grafting

Smoke inhalation injury

upper and lower airways d/t heat, particulate matter, toxic gases

• Risks: closed space fires, intoxication, head injury, dementia

• S/S: upper airway edema (acute airway compromise), cough, wheeze, respiratory distress

  • PE: facial burns, singed nose hairs, soot in the nose/mouth, hoarseness, carbonaceous sputum

• Dx: CXR, fiberoptic bronchoscopy, carboxyhemoglobin levels

• Tx: humidified O2, ET tube/mechanical vent, bronchodilators, pulmonary toilet

Carbon monoxide poisoning injury

• S/S: HA, vomit, confusion, lethargy coma

  • PE: facial burns, singed nose hairs, soot in the nose/mouth, hoarseness, carbonaceous sputum

• Dx: CXR, fiberoptic bronchoscopy, carboxyhemoglobin levels

• Tx: hyperbaric O2 therapy

Treatment of thermal burns

ABCs, Hi flo O2 to anyone with smoke inhalation

• Airway- may need to intubate

• Fluids- 2 large bore IVs, Parkland Formula (LR formula)

• Foley catheter: maintain output 0.5-1 mL/kg/hr

• Cooling of burns: cool immediately, immerse in cool water and use cold compress

• Pain: narcotic analgesia and can add anxiolytic agents

• Large blisters >2cm or large joints= drain and debride→ Small= leave intact

• Abx: topical silver sulfadiazine (alt is bacitracin or triple abx) and synthetic occlusion dressing

• TETANUS PROPHYLAXIS

Avoid putting abx on thermal burns

until they are evaluated by an expert (do not cover, need to see full extent of injury)

Circumferential burns

• Limbs: compromise of distal circulation (compartment syndrome)

• Chest/Neck: may require mechanical ventilation support

Tx: escharotomy may be needed

Chemical burns

Commonly face, eyes, extremities (usually a lower mortality rate than a thermal burn)

• Alkalis (liquefaction necrosis) are MUCH WORSE than acids (coagulation necrosis, leathery eschar)

  • Acid: dark brown or skin discoloration

• Tx: removal of garments, copious irrigation→ IV fluids, analgesia, tetanus immunoprophylaxis

  • Ocular: irrigation with 1-2 L NS for 1-2 hours and return eye back to 7.2-7.4

    • EMERGENT OPTHO CONSULT

Human Bites

Crushing or tearing of tissue with potential injury to underlying structures of inoculation of tissues

• Usually on hands and upper extremities→ infection major serious sequela

• Clenched fist injury

• Tx: Copious irrigation of wound with normal saline and debridement

  • typically leave hand open and other places can do 1 closure

  • prophylactic Augmentin and tetanus prophylaxis

  • If present with mod/severe infection: admit and start IV abx- Cefoxitin or amp-sulbactam

Clenched Fist Injury (CFI)

Occurs in metacarpophalangeal (MCP) region as a fist strikes the mouth/teeth

• Dx: visualize direct injury and all underlying structures (CXR), ROM

• Tx: VIA human bite

  • Anything beyond a minor injury in the hand consult a hand surgeon

Dog bites

P. Multocida (cat bites), anaerobes, aerobes

• Dx: X-ray (infection, FB, bony involvement), culture infected wounds

• Tx: copious irrigation and debridement

  • Primary closure for facial/scalp wounds and gaping wounds

  • leave open hands, feet, puncture wounds, delayed presentation

  • Explore large/extensive bites in the OR

  • Give abx (puncture wounds on hands, face, high risk): Augmentin (Allergy= clinda + bactrim or clinda+ cipro)

  • Significant infection= admit and give IV amp-sulbactam and tetanus prophylaxis

Cat bites

80% will get infected, MCC by P. Multocida

• S/S: rapid inflammatory response with pain and swelling, bone/join infection, bacteremia

• Dx: X-ray (FB, bone)

• Tx: wound care with irrigation and debridement, consider a 1 vs 2 closure, tetanus prophylaxis

  • Prophylactic abx (if on hand, immunocompromised, arthritis, compromised joints)- Augmentin, cefuroxime, doxycycline

Brown recluse (arachnid bite)

• S/S: mildly erythematous firm and heal over several days→ necrotic and form eschar

  • Loxoscelism: systemic reaction 1-2 days after→ fever, chills, vomiting, arthralgia myalgia, petechiae, hemolysis→ can lead to severe DIC

• Dx: clinical, bite usually unwitnessed

• Tx: supportive (no antivenin), tetanus, analgesics, abx, Dapsone o hyperbaric O2

Black Widow (arachnid bites)

Immediate pin prick sensation that allows patient to identify the attacking agent

• S/S: erythematous skin lesions (target), muscle cramps, abdominal wall cramps

• Tx: wound treatment, analgesics/benzos for pain and cramping, Antivenin

Snake bites

• S/S: fang marks with local pain and welling

  • minimal: local swelling, no sysgmic s/s

  • mod: swelling that spreads, systemic

  • severe: extensive swelling with potential life threatening systemic signs and abnormal coagulation

• Tx: minimize activity, immobilize bite below the heart, wound care, tetanus prophylaxis

  • If swelling and progressing→ give Antivenin

  • Watch for compartment syndrome at least 8 hours observation

Coral snakes

“Red on yellow kill a fellow, red on black venom lack”

• S/S: tremor, salivation, respiratory paralysis, seizures, bulbar palsies

• Tx: hospitalize for 24-48 hours, Antivenin

Beta blockers increase

risk for severe prolonged anaphylaxis

Anaphylaxis

Type I hypersensitivity reaction

• Risks: PCN, NSAIDs, ACE-I, radiocontrast, peanuts, shellfish, milk, eggs, dues, idiopathic

  • Can occur in second or delayed 1+ hours; some can be biphasic with further release 4-8 hrs later

  • S/S: pruritus and urticaria- red wheals, angioedema, face/neck, resp- stridor, dyspnea, wheeze, GI- N/V, cramps, diarrhea

  • Dx: Hx of exposure with above symptoms

  • Tx: A-Fs- Airway (anticipate intubation), Breathing (high flo O2 PRN, nebulized albuterol), Circulation (1-2 L NS, epi if HoTN remains), Epi, Further (antihistamines, steroids, glucagon for pts on B-Blockers)

Observation recommendations for anaphylaxis

• Mild: observe 1 hours

• If epi given: observe 6 hours after dose

• Severe: ICU admission

Drowning

Submersion in liquid medium resulting in respiratory distress

• Risks: <15 yo, substance abuse, injuries, DV, child abuse

• S/S: awake and stable= good prognosis

  • Poor outcomes: unstable CV function, coma, low GCS, need for CPR, intubation, pressors

• Dx: Hx, O2 PRN, CXR, CBC/lytes, ABGs, Clear C-spine

• Tx

  • Asymptomatic: monitor 4-6 hours, pulmonary and O2 stay normal patient can go home

  • Rest of patients: Admission and recover within 48 hours typically

Head trauma

Basilar, orbit, maxillary, mandible, nasal fracture

• Risk: assault, MCV, fall

• Dx: Head CT without contrast, can do maxiofacial CT (bony tenderness, penetrating trauma, Canadian head CT rule)

Canadian Head CT rule

Do CT if 1+ of these are present

• GCS <15, signs of a basilar skull fracture, 2+ vomiting episodes, 65+ yo, amnesia for >30 minutes, dangerous mechanics of injury

Basilar skull fracture

• S/S: battle sign, raccoon eyes, CSF leak (halo sign), hemotympanum

Nasal bone fracture

Common; tender bruising over nose

• Dx: X-ray (displaced vs. non displaced)

• Tx: Elevate head, ice, ENT referral

  • If displaced and <6 hrs from injury: reduce back into place

Caution of a septal hematoma

Refer these to surgery

Mandible, maxilla, Le Fort (midface) fractures

Septal hematoma

Blood collection in the nasal septum

• Risks: nasal bone fracture (complication of fracture), surgery, anticoagulant use, intranasal drug use

• S/S: nasal shape deformity, pain and swelling

• Tx: urgent drainage of the hematoma

Orbital blowout fracture

Inferior wall or orbital floor fracture→ ocular emergency

• S/S: diplopia/opthalmoplegia, proptosis, infraorbital nerve entrapment

• Tx: opt consultation and abx prophylaxis= Augmentin

Tooth trauma

• Primary tooth: no treatment required

• Secondary tooth: sublaxation (mobile), luxation (partial avulsed), avulsion (tooth out of socket)

  • Tx: brace with zinc oxide, dental referral

Cheek lacerations

Check the involvement of salivary glands or injury of facial nerve

• Tx: Consult plastics if need closure help, consult ENT if there was a duct injury

Lip lacerations

do a nerve block for closure

• Vermillion borders: possible bad outcomes cosmetically→ consult plastics

• Through and through: deep and external closure

• Mucosal injury: no repair

Ear lacerations

do a ring block, never suture cartilage→ consult ENT

Eyelid lacerations

Reder optho→ torn lid margins, lacrimal duct damage, FB/penetrating

Nasal FB

Unilateral malodorous discharge

• Tx: + pressure or instrument

Ear canal FB

• Cerumen (MC): peroxide soal and irrigation

• Insect: kill with lidocaine and irrigate

• Button battery: stat ENT consult

• Human hair: associated with hiccups (rare)

Malignant otitis externa

MCC pseudomonas (immunocompromised patients)

• S/S: ottorrhea with pain out of proportion to the exam, febrile and systemic illness

• Dx: CT- bony erosion

• Tx: IV abx (piperacillin-tazobactam, ceftazidime, cefepime) with ENT consult

Ramsay-Hunt Syndrome

Herpes Zoster Oticus

• S/S: Triad- vesicles in the auricle canal, ipsilateral facial paralysis, ear pain

• Tx: Acyclovir, HEENT referral

Auricle hematoma

Evacuate (aspiration vs I&D)→ pressure dressing 48-72 hours to prevent cauliflower ear from forming

Ludwig’s Angina

Polymicrobial cellulitis of oral floor, base of tongue

• Risks: tooth infection, trauma to oral cavity

• S/S: trismus, sublingual tenderness, can’t handle own secretions, systemic illness

• Tx: Hospital admission for abx (unasyn, clindamycin, pen G and metronidazole) and airway management

Peritonsilar abscess

• S/S: unilateral sore throat, truisms, hot potato voice, displaced uvula

• Tx: I&D, abx (clindamycin, Augmentin)

Centor criteria for strep

• F: fever

• A: adenopathy

• C: lack of cough

• T: Tonsilar exudates

Acute angle closure glaucoma

Iris completely blocks the drainage angle, forcing pressure levels to jump from a normal 10–21 mmHg up to 40–80 mmHg

• Risks: female 60-70 yo, Asians, Intuit, + family hx

• S/S: acute ocular pain, N/V, blurred vision with halos, conjunctiva injection, non-reactive pupil

• Dx: OP >21 mmHg and can be >60 mmHg

• Tx: Optho consult, acetazolamide IV, topical B-blocker, analgesics/anti-pyretics, pilocarpine, laser iridotomy

Central retinal artery occlusion

Sudden painless vision loss of one eye; medical emergency caused by a sudden blockage of the main blood vessel supplying the retina, most commonly due to a blood clot or cholesterol plaque→ amarosis fugax can precede (transient loss of vision lasting seconds→ mins)

• Dx: pale fundus with narrowed arterioles with segmented flow and a bright red macula “cherry red spot”

• Tx: optho consult, lower IOP= acetazolamide, anti-coagulate, revascularize

Central retinal vein occlusion

Blood clot blocks the main vein carrying blood away from the retina, leading to blurred vision, fluid swelling, and potential vision loss

• Risks: DM, HTN, CAD

• S/S: decreased visual acuity, afferent pupillary defect, abnormal red reflex

• Dx: retinal hemorrhages, dilated veins, cotton wool spots, optic disc edema (blood and thunder)

• Tx: Optho referral

Optic neuritis

Inflammation of the optic nerve that causes pain with eye movement, blurry or lost central vision, and dull color perception and eye scotoma

• Risks: females 18-45 years old, 1st sign of demyelinating disease (MS)

• S/S: swollen optic disc, other neuro s/s

• Dx: neuro workup

• Tx: IVIG/steroids, optho referral

Giant Cell Arteritis (GCA)

An inflammation of the lining of your arteries, most often affecting the head, temples, and neck

• Risks: PMR (50%), elderly

• S/S: profound unilateral vision loss, jaw claudication, new onset HA, scalp tenderness

• Dx: ESR >60 mm/hr, CTA (gold standard)

• Tx: optho referral, steroids

Retinal detachment

Retinal hole tear with seepage of fluid between retina and choroid

• S/S: flashing lights, floaters, vision loss, “curtain like” gray or black shadow, visual field defects

• Tx: optho

Corneal abrasion

• S/S: FB sensation, light sensation, tearing

• Dx: Fluorescein stain

• Tx: erythromycin eye drops

Corneal FB

Use a 25G needle and take a lateral approach to removal while using a slit lamp

• Do not remove rust rings

Corneal ulcer

Pain, redness, photophobia (more open and higher risk of infection that the abrasion)

• Dx: slit lamp

• Tx: fluoroquinolone abx drops, refer optho

PRICER therapy for MSK complaints in the ER

• P- protect injury

• R- Rest

• I- Ice

• C- compress

• E- elevation

• R- rehab (OT/PT)

Herpes simplex keratitis

Infection by VZV (HSV-1)

• S/S: branching/dendritic ulcer, sensitivity to light, blurred or hazy vision

• Tx: acyclovir topical or PO