Conference Notes from 5/10

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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

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