Lightning Lectures with Drs. Huttner and Loche

Foreign body aspiration
-	Presentation
o	Usually sudden onset coughing and choking
o	Can develop stridor, cyanosis, respiratory arrest
-	Diagnosis
o	CXR negative in > 50% of tracheal foreign bodies, 25% of bronchial foreign bodies
o	Bronchoscopy = gold standard
-	Treatment
o	If conscious, back blows, abdominal thrusts, chest thrusts
o	Laryngoscopy to remove with Magill forceps
o	Intubation can be used to push object into R mainstem bronchus and allow aeration of one lung

Mastoiditis
-	Usually results from untreated otitis media – mastoid air cells are continuous with middle ear
-	Most common cause is strep pneumoniae or strep pyogenes
-	Diagnosis
o	Clinical in most cases
o	Consider CT in toxic appearing children or if extracranial complications
-	Treatment
o	If not recurrent and no abx in 6 months > Unasyn q6h at 50 mg/kg
o	If recurrent or recent abx > Zosyn q6h 75 mg/kg
o	Add Vanc if septic
o	Treat 7-10 days IV, follow by 4 weeks of po antibiotics
o	Consult ENT
-	Complications – meningitis, CNS abscess, venous sinus thrombosis

Malignant Otitis Externa
-	Usually adults with diabetes
-	Caused by Pseudomonas in 95% of cases
-	Presentation – often have granulation tissue in the inferior EAC and purulent drainage
-	Initial treatment is with ciprofloxacin IV 400 mg q8h
-	Consider Zosyn for severe infection or immunocompromise 
-	Can lead to osteomyelitis of the skull base or TMJ

ENT Lecture with Dr. Vinh

Airway complications: Tracheostomy vs Laryngectomy
-	Tracheostomy: ask three questions
o	Why does patient have tracheostomy?
	Most common is failure to wean from vent > still able to intubate from above
	Anatomic obstruction from tumor, etc. > typically will be difficult to intubate from above
o	How long has trach been present?
	Takes at least 1 week for tract to mature
o	What type of trach is it? Cuffed or uncuffed?

-	Laryngectomy
o	Trachea is directly connected to skin
o	There is no airway from the nose and mouth
  cannot bag over mouth or intubate from above
o	Can use pediatric size BVM over stoma to bag

Complicated airways
-	Ludwig’s Angina – submandibular space infection which causes upper airway obstruction
o	Odontogenic infections account for ~70% of cases
o	Treatment with Unsyn and Vanc + surgical drainage and/or tooth extractions
-	Angioedema
o	Treatment
	Corticosteroids, antihistamines, epinephrine, stop ACE-Is
o	Always perform flexible laryngoscopy – laryngeal edema may be much worse than visible oropharyngeal edema
-	Peritonsillar abscess
o	Management – antibiotics (unasyn or augmentin), +/- steroids, +/- I&D or needle aspiration
o	Can have trismus (usually due to pain)
-	Epiglottitis 
o	Majority of cases caused by staph and strep – empiric antibiotics with Vanc and Unasyn
o	Swelling of the larynx causes disproportionate narrowing of the airway compared to other anatomic sites
-	Head and neck cancer

Securing the airway
-	Supportive measures
o	Treat underlying cause
o	Supplemental O2
o	Racemic epi – useful for laryngeal edema
o	Heliox 
-	Sedation/anesthesia?
o	Anesthesia causes airway obstruction due to loss of muscle tone, suppression of protective arousal responses and decrease in respiratory reserve
-	Make plan for intubation
o	Fiberoptics for oropharyngeal obstruction
o	Cricothyroidotomy for laryngeal obstruction
-	Fiberoptic intubation
o	Transoral vs transnasal
o	Local anesthesia is key if unable to sedate  atomizers and 4% lidocaine
o	Afrin and serial dilation with nasal trumpets

Transfer Center Lecture with Dr. Mallory

-	Similar to air traffic control – connects to physicians working clinically and directs patients to appropriate facilities
-	RNs and medical directors working in the transfer center have knowledge of which services are offered at which hospitals and are able to direct calls accordingly
-	Also have up to date information about specific bed availability at different facilities

Ophthalmology for the ED with Dr. Rashidi

-	Pupillary exam
o	Afferent pupillary defect – tested with swinging flashlight test
o	Test direct response and consensual response
o	Shape of pupil is important to check
-	Visual acuity
o	If unable to read letters/numbers, at least relay if patient can count fingers, detect light, etc.
-	Intraocular pressure
o	Up to 21 mmHg is normal

-	Corneal abrasions treatment
o	Smaller abrasions – erythromycin ointment 3-4x/day x4-5 days
o	Wood, ticks, fingernail – moxifloxacin drops 4x/day x4-5 days
o	Large, central, or concerning features – consult ophtho

-	Chemical burns
o	Use Morgan lens
o	Check pH before using any drops – normal 6.5 – 7.5 

-	Traumatic iritis/mydriasis
o	Treat with dilating drops (atropine or cyclopentolate 0.5 or 1%)

-	Hyphema 
o	Needs ophtho consult to check for posterior trauma

-	Retrobulbar hemorrhage
o	Causes orbital compartment syndrome – can result in irreversible vision loss
o	Needs lateral canthotomy and cantholysis

-	Eyelid laceration
o	Medial lacerations – concern for canaliculus injury

-	Acute angle closure glaucoma
o	IOP lowering drops – timolol, apraclonidine, latanoprost, pilocarpine
o	IV Diamox 500 mg
o	IV mannitol 1-2g/kg over 45 minutes

Ejection Fraction and Cardiac Imaging with Dr. Baker

• Normal EF findings on POCUS – wall thickening and symmetric contraction during systole, anterior leaflet of mitral valve slapping interventricular septum
• Ways to calculate EF using POCUS
• EPSS = End point septal separation
  • Less than 7 mm = normal
  • Greater than 10 mm = reduced EF
• Fractional shortening – measures LV in systole and diastole
• Fractional area change – uses RV volumes in end systole and end diastole to calculate EF
• Simpson Biplane method – US will calculate change in volume of the LV between end diastole and end systole

Lightning Lectures with Drs. Gellert and Wells

• Ludwig’s Angina
  • Rapidly progressive gangrenous cellulitis of the submandibular spaces
  • Polymicrobial
  • Clinical diagnosis, imaging not required
  • Management
    • Airway – preferred awake fiberoptic intubation
    • Antibiotics – Unasyn OR Rocephin + Vanc OR Clindamycin
    • Surgical – Tooth extraction, debridement
• Retropharyngeal Abscess
  • Abscess between posterior pharyngeal wall and prevertebral fascia
  • Late findings – stridor, respiratory distress, drooling, neck stiffness
  • Complications
    • Acute Necrotizing Mediastinitis (~25% mortality)
    • Sepsis
    • Aspiration
    • Lemierre’s syndrome – septic thrombophlebitis of IJ
  • Diagnose with CT neck w/contrast
  • Management
    • ENT consultation
    • Antibiotics – Cllindamycin 600-900 mg IV or Cefoxitin 2 mg IV or Augmentin 3 g IV
• Peritonsillar Abscess
  • Abscess between tonsillar capsule, superior constrictor muscles
  • Classic “hot potato voice”, uvula deviation
  • CT can help differentiate between cellulitis, RPA
  • Management
    • I&D or Needle Aspiration
      • For I&D use scalpel to incise 1 cm deep into abscess cavity
      • Use guard on scalpel to prevent deeper incision and vascular injury
    • Medications – Decadron 10 mg IV + Rocephin 2 g IV + Clindamycin 600 mg IV
    • Need ENT/PCP f/u in 24-48 hours if not admitted

Tracheostomy Complications with Drs. Lehnig and Nelson

• Approximately 1% of tracheostomies associated with major complications
  • 50% mortality with major complications
  • Usually occur after 1 week
• Emergent complications = decannulation, obstruction, hemorrhage
  • Decannulation
    • Replace ASAP as stoma will begin to close
    • If < 7 days old, recannulate under direct visualization with fiberoptics
    • If > 7 days, use direct visualization
  • Obstruction
    • Mucous plugs, blood clots, tube displacement
    • Remove inner cannula > suction trach > deflate cuff > remove trach > bag ventilate or intubate
  • Hemorrhage
    • If > 48 hours since placement, consider TI fistula, infection, coagulopathy, aggressive suctioning
    • Should be evaluated by surgeon
• Urgent complications = TE fistula, tracheal stenosis, infection, cutaneous fistula
• Tracheo-innominate artery fistula
  • Sentinel bleed occurs in 50% of patients
  • Management
    • External compression over sternal notch
    • Internal compression with hyperinflated cuff (up to 50 cc of air)
    • Remove trach > oral or stomal intubation > hyperinflate cuff
    • ET tube beyond fistula > digital compression of artery against manubrium

PEM Lecture – HEENT Problems with Dr. Lund

• Otitis media
  • Antibiotics duration by age
    • < 2 yrs – 10 days
    • 2-5 yrs – 7 days
    • > 6 yrs – 5 days
  • Antibiotics of choice
    • Amoxicillin high dose (90 mg/kg/day)
    • Augmentin – if amox in last 30 days or concurrent conjunctivitis
    • Ceftriaxone – IV or IM x3 days 50 mg/kg
    • Allergies – non-severe = cefdinir, cefpodoxime; severe = clindamycin
• Neck Masses
  • Thyroglossal Duct Cyst
    • Most common neck mass
    • Moves with swallowing
    • Can get infected – treated with clindamycin, augmentin, Keflex
  • Brachial Cleft
    • Treat the same as thyroglossal duct cyst > refer to ENT
  • Fibromatosis Coli
    • Result of neonatal torticollis causing shortening of SCM muscle
  • Lymphadenitis
    • Could be caused by bacterial infection of 1+ node, mycobacterium, cat scratch disease
• Post operative tonsillectomy bleeding
  • Management
    • Suction, IV placement
    • Lean forward
    • Direct pressure laterally with Magills or long clamp
    • Nebulized TXA
• Epiglottitis
  • Keep calm, avoid aggressive exam maneuvers
  • Inhalational anesthesia with no paralytics
  • Needle cric as temporizing measure
  • Antibiotics – cefotaxime or ceftriaxone AND clindamycin or vancomycin