1
Q
the pigmented part of the retina located in the very center
A
macula
2
Q
perhaps the most important part of the eye.
the area of best visual acuity. It contains a large amount of cones—nerve cells that are photoreceptors with high acuity.
A
Fovea
3
Q
Eye complaints should be categorized into one of the 4 categories
A
- Vision changes/loss
- painful or painless
- complete, partial, intermittent, persistent, floaters, flashing-lights, “curtain/vail” - Change in appearance of the eye
- Eye pain/discomfort
- aching, burning, throbbing, itching, FB sensation - Trauma - mechanism of injury
4
Q
chronic use of Ophthalmic drops can cause ___ and ____
A
chemical conjunctivitis
inflammatory changes to the cornea
5
Q
These oral med can increase risk for glaucoma
A
dilating eye drops, TCA’s, MAOIs, antihistamines, antiparkinsonian drugs, antipsychotics, antispasmolytic agents
6
Q
what surgicial hx component is important to consider
A
surgical hx focused on the eye
7
Q
why is it important to ask about use of contacts or glasses?
A
contacts increase risk for bacterial corneal ulcers
lack of corrective lenses during exam will affect VA
8
Q
usually the PE usually precedes treatment except for what type of injury?
A
chemical injuries require intervention prior to PE
9
Q
what eye exam is performed first during the PE
A
Visual acuity and visual field by confrontation
- Use topical ophthalmic anesthetics if photophobia, pain or tearing interferes with exam
- VA should be assessed w/ corrective lens if available
- History of nystagmus?
10
Q
If corrective lenses are unavailable VA should be assessed via ?
A
pinhole testing
11
Q
If VA is worse than 20/200, what method do you use?
A
finger counting at 3 ft or hand motion perception at 1-2 ft
12
Q
If pt is unable to detect hand motion when assessing VA, what is the last method you can use?
A
determine if light perception is present
13
Q
If pinhole occluder is unavailable, what other method do you use?
A
use an 18 gauge needle to perforate a hole in an index card
14
Q
Other eye exams to do during the PE
A
- EOM
- impairment d/t muscle restriction, interrupted or decreased innervation, or trauma - Pupils
- size, shape, reactivity
- assess for afferent pupillary defect - Ocular adnexa: Eyebrows, eyelids, and lacrimal glands/ducts
- assess for trauma, infection, dysfunction, deformity, crepitus, proptosis, eyelid FBs - Conjunctiva, sclera, cornea, anterior chamber, iris, lens
- inspect using a slit lamp (if available) provides a 3D view of the ocular structures
- Fluorescein exam with Wood’s lamp - Intraocular pressure
- last d/t discomfort of exam
- use anesthetic - Fundoscopic exam
- may require dilation - if so, perform last
15
Q
normal ICP?
A
10-20 mmHg
16
Q
What makes orbital cellulitis different from preseptal cellulitis?
A
Orbital
- fever, pain, eyelid swelling and erythema, decrease vision/diplopia, proptosis, ptosis, chemosis, pain with and limitation off EOM
- infection extending behind the orbital septum
- Life and vision threatening, inpatient IV therapy
- Often occurs as a complication of ethmoid or maxillary sinusitis
17
Q
testing ICP is CI in what eye emergency?
A
globe rupture from blunt or penetrating trauma is suspected
18
Q
where is the infection in periorbital cellulitis?
A
infection anterior to the orbital septum
generally benign, outpatient therapy
arises from sinusitis or contiguous infection due to local skin trauma, insect bite, or hordeolum.
19
Q
REd flags for orbital involvement
A
chemosis, proptosis, increased IOP, decreased VA & pupillary response, pain with EOM
20
Q
dx for orbital cellulitis
A
Orbital CT with contrast if concern for orbital involvement or in young children who are not able to cooperate fully with exam
21
Q
complications of orbital cellulitis
A
- orbital abscess
- subperiosteal abscess
- cavernous sinus thrombosis
- frontal bone osteomyelitis
- meningitis
- subdural empyema
- epidural abscess
- brain abscess
22
Q
management for periorbital cellulitis in non-toxic pts, adults and older children with mild symptoms
A
- outpatient with oral Augmentin or Keflex
- PCN allergy: clinda
- hot compresses
- f/u in 24-48 hrs with ophthalmology
23
Q
management for periorbital cellulitis in young children and those with more severe presentation
A
- ADMIT, IV Rocephin / Unasyn + vanc
- PCN allergy: FQ + metronidazole / clinda
- ophthalmology consult
24
Q
management for orbital cellulitis
A
- immediate ophthalmology consult
- admit for IV abx - IV ceftriaxone (Rocephin) OR ampicillin-sulbactam (Unasyn) PLUS vancomycin
- topical nasal decongestant
- lateral canthotomy - if increased IOP or optic neuropathy is present
25
what is a Hordeolum or Stye
acute infection of the eyelash follicle (external) or acute infection of the meibomian gland (internal)
26
acute, subacute, or chronic swelling caused by the obstruction of the meibomian gland
Chalazion
27
s/s of Hordeolum/Chalazion
pain, erythema, swelling
28
management for Hordeolum/Chalazion
1. **Warm, moist compresses** for 10-15 minutes QID
1. Erythromycin 0.5% ophthalmic oint BID for 7-10 days
1. Do not manipulate the lesion
1. Complication
- cellulitis - use systemic antibiotics
abscess - refer to ophthalmology for I&D
29
1. Painless **mucopurulent discharge** with matting of the eyelids after sleep
1. Conjunctiva is **injected**, occasional **chemosis**
1. Cornea is clear without fluorescein uptake
1. Rapid onset with severe purulent discharge - concern for GC/TC
Bacterial Conjunctivitis
30
how to dx Bacterial Conjunctivitis
1. **Fluorescein exam** to rule out herpetic dendrite, ulcer, abrasion
1. **C&S** if purulence is severe
31
management for bacterial conjunctivitis
1. Topical ophthalmic abx x 5-7 days
- Trimethoprim–polymyxin B
- Fluoroquinolone or tobramycin for _contact wearers_ (Pseudomonas)
2. Admit infants <30 d old and those with severe hyperacute onset
- consult ophthalmology and start empiric IV abx to cover GC/TC
32
1. mild-moderate **watery discharge**
1. conjunctival **injection**, occasional **chemosis**, small **subconjunctival hemorrhages** and preauricular **_LAD_**
Viral Conjunctivitis
33
dx for Viral Conjunctivitis
1. **Fluorescein exam** to r/o herpetic lesion
- punctate fluorescein stain if complicated by keratoconjunctivitis
1. Slit lamp - follicles (small, regular, translucent bumps) on the inferior palpebral conjunctiva
34
management for viral conjunctivitis
1. Cool compresses
1. Naphcon-A - topical antihistamine/decongestant
1. Artificial tears 5-6 x/d
1. Educated on contagiousness and self resolution after 1-3 wks
35
1. **watery** discharge, redness, and **intense itching**
1. erythematous swollen eyelids
1. injected and edematous conjunctiva
- **papillae** (irregular mounds of tissue with a central vascular tuft) on the inferior conjunctival fornix
Allergic Conjunctivitis
36
dx for Allergic Conjunctivitis
Fluorescein exam to r/o herpetic lesion
37
management for Allergic Conjunctivitis
1. **Cool compresses** QID
1. **Naphcon-A** - topical antihistamine/decongestant
1. **Artificial tears** 5-6 x/d
1. Refer to ophthalmology if severe or resistance to therapy
38
Inflammation of the anterior uveal tract (iris and ciliary body)
Iritis (Anterior Uveitis)
39
causes for Iritis (Anterior Uveitis)
usually result from corneal insult or conjunctivitis. May be idiopathic (50%) , or related to trauma, auto-immune, infections.
40
s/s of iritis
1. unilateral or bilateral pain
1. **photophobia with consensual photophobia** (hallmark)
1. conjunctival injection/perilimbal flush
1. miosis with poor reactivity
1. diminished VA - due to clouding of aqueous humor
41
dx for iritis
1. Slit-lamp
- **keratic precipitates** (deposits of inflammatory cells on the corneal endothelium)
- **aqueous flare** and **cells** in anterior chamber (from **protein deposits**)
1. **Hypopyon** if severe presentation
1. Fluorescein staining to rule out associated ulcer, abrasion, dendritic lesion
1. Measure IOP (normal in most cases)
42
management for iritis
1. **cycloplegia** (duration 2 to 4 days) for pain
- Cyclogyl / cyclopentolate 1%
- _LA Homatropine 5%_ - agent of choice
1. **Topical steroids** to suppress inflammation 1% prednisolone drops 1 drop QID
- Often not part of treatment from the ED.
1. **refer to ophthalmology** with in 24-48 hours
43
Avoid this steroids for iritis if there there these additional conditions:
1. corneal abrasion
1. infectious
1. if IOP is elevated
44
An infection of the corneal stroma
Corneal Ulcer
45
Corneal Ulcer can be caused by what?
1. bacterial, viral, fungal
1. associated with trauma - contact lens wearers
46
s/s of corneal ulcer
pain, redness, tearing, photophobia, blurry vision
47
dx of corneal ulcer
* **Fluorescein** - staining **corneal defect** with surrounding white hazy infiltrate, iritis and/or hypopyon
* ulcer cx (performed by ophthalmologist in ED) by scraping lesion with sterile scalpel/needle
48
management for corneal ulcer
1. Ophthalmic (topical) **fluoroquinolone** (ofloxacin/cipro)
- tobramycin (cheaper alt)
1. Topical **cycloplegic** for pain
1. **_AVOID eye patching_**
1. Consult ophthalmology if immunocomp
- topical antifungal/antiviral in addition
- NO topical steroids unless advised by ophthalmology
1. If unable to see ophthalmology in ED - f/u in 12-24 hrs
49
An infection of the cornea and conjunctiva by HSV
Herpes Simplex Keratoconjunctivitis
50
s/s Herpes Simplex Keratoconjunctivitis
1. Unilateral photophobia, pain, eye redness, diminished VA
1. Preauricular LAD
1. +/- vesicular eruption of eyelid, conjunctival injection, corneal hypoesthesia
- Assess for corneal sensation prior to installation of anesthetics
51
Fluorescein staining shows uptake in classic pattern of dendritic lesion or geographic ulcer is diagnostic for what dx?
Herpes Simplex Keratoconjunctivitis
52
management for Herpes Simplex Keratoconjunctivitis
1. _Infants < 30 d old_ - **admit** w/ urgent consult
1. _Eyelid_ - **PO antiviral**
1. _Conj_ - **topical trifluridine w/ erythromycin ophthalmic**
1. _Corneal_ - **urgent consult**
- topical / oral antiviral per ophthalmology recommendation
- ophthalmology f/u in 24-48 hours
2. **_AVOID topical steroids_**
53
complications of herpes simplex keratoconjunctivitis
corneal scarring if not treated promptly
54
HZV involving the V1 division of the trigeminal nerve
Herpes Zoster Ophthalmicus
55
1. Painful vesicular rash on erythematous base involving the upper eyelid and tip of the nose - **Hutchinson sign**
1. Fever, malaise, HA
1. Ocular involvement
- Red eye, blurred vision, eye pain/photophobia
- keratitis, anterior/posterior uveitis
1. +/- Optic neuritis (unilateral pain or vision loss), elevated **IOP**
Herpes Zoster Ophthalmicus
56
dx for Herpes Zoster Ophthalmicus
Fluorescein stain - **pseudodendrite** (no epithelial erosion)
- smaller in size, elevated w/o central ulceration, do not have terminal bulbs, and have relative lack of central staining (in comparison to true HSV dendrite)
57
management for Herpes Zoster Ophthalmicus
1. Ophthalmology consult
1. Severe - admit for IV acyclovir
1. _Skin_
- **cool compresses**
- **PO antivirals** x 7-10 d (if rash present < 7 d)
- **topical bacitracin/erythromycin**
2. _Ocular_
- **erythromycin ophthalmic ointment**
- _pain_: **cycloplegic, oral opiate, cool compresses**
- _anterior uveitis (iritis)_ - topical steroids (only under direction of ophthalmology)
--- **prednisolone acetate** - _absolute certainty of **NO** corneal lesions on slit-lamp prior to administration_
3. _All < 40 y/o_ - work up for immunocomp state
58
Bleeding under the conjunctiva
Subconjunctival Hemorrhage
59
s/s of Subconjunctival Hemorrhage
bright red blood under the bulbar conjunctiva
hx of trauma; sneezing, coughing, vomiting, straining (Valsalva), hypertension, or can occur spontaneously
dx: clinical
60
management for subconjunctivial hemorrhage
Reassurance
educate that complete resolution may take 2-3 wks
61
Death of the corneal epithelial cells due to exposure to UV light
Ultraviolet Keratitis
Occurs when failure to use eye protection leads to exposure to arc welding, tanning bed lights or prolonged sun exposure
62
s/s of UV keratitis
1. slow onset of FB sensation and mild photophobia, 6-12 hours after exposure, progressing to severe pain/photophobia
1. blepharospasm, tearing, conjunctival infection
- topical anesthetics (tetracaine) needed
63
dx for UV keratitis
**_Slit-lamp_** - diffuse punctate **corneal edema,** uptake of fluorescein - **punctate corneal abrasions**
64
management for UV keratitis
1. +/-Eye patching
1. cycloplegic, oral analgesics, topical abx
1. Improvement after 24-36 hours of treatment
65
an insult/trauma to the cornea leading to a superficial or deep epithelial defect
Corneal Abrasion
66
s/s of Corneal Abrasion
tearing, photophobia, pain, blepharospasm
- topical anesthetic (proparacaine) is often needed to complete exam
67
dx for corneal abrasion
search for ocular FB
**fluorescein stain with slit lamp**
68
management for corneal abrasion
1. ketorolac ophthalmic solution
- oral opiate or cycloplegic if large abrasion or severe pain
2. topical abx
- erythromycin ointment or FQ/tobramycin if contact wearer
3. f/u within 24-48 hrs with ophthalmology
69
Usually small piece of metal, wood, or plastic that becomes embedded superficially in the cornea
**corneal FB**
Need to determine cause of FB and the chance of a high-velocity globe penetration
Activities such as grinding, hammering metal on metal, operation of high speed machinery
70
s/s and dx for corneal FB
1. Edema of the lids, conjunctiva, and cornea
1. FB sensation, tearing, blurred vision, photophobia
1. **Evert lid** to look for additional FBs
1. Use **slit lamp** to look for less obvious corneal FB’s
1. Hyphema/microhyphema suggest globe perforation
71
If FB is present in cornea for >24 hrs, what may be observed?
**WBCs may migrate** into cornea anterior chamber cause causing a **white ring** around the FB or a flare/cellular deposit respectively
72
For a corneal FB, Hyphema/microhyphema suggest globe perforation, how can you further assess?
Seidel test
73
what diagnostic do you order if suspected intraocular FB or globe rupture when dealing with a corneal FB
CT orbit
74
management for corneal FB
1. Consult ophthalmology if **hyphema** noted
2. Removal of FB
- instill topical anesthetic to BL eyes
- use 18-25-gauge needle, under slit lamp or other microscopic view to remove FB
--- remove rust ring if present unless pt can be seen by ophthalmology within 24 hrs
- CI in uncooperative or intoxicated patients
3. Resultant corneal abrasion - tx appropriately
4. F/u with ophthalmology
5. Update Td if appropriate
75
when managing a corneal FB when would you want a 24 hr f/u with ophthalmology?
1. rust ring present
1. FB is in central line of vision
1. deep in corneal stroma
76
when managing a corneal FB when would you want a 48 hr f/u with ophthalmology?
if symptoms persist
77
how would you evaluate extent of injury with lid lacteration?
1. lid margin
1. full thickness
1. underside of lid
1. cornea/globe involvement
1. nasolacrimal duct system
1. loss of full lid movement (ptosis)
Td immunization status
78
when to consult oculoplastic surgeon for lid lacerations
1. involving **lid margin** (>1mm)
1. within **6-8 mm of medial canthus**
1. involving the **lacrimal duct or sac**
- apply fluorescein into eye - if appearance into wound suspect canalicular involvement
1. involving the **inner surface of the lid**
1. associated with **ptosis**
1. involving the **tarsal plate**
1. involving the **levator palpebrae muscle**
79
a lid laceration is observed to have
- a horizontal laceration with ptosis
- orbital fat is seen protruding through the laceration
what muscle is observed?
levator palpebrae muscle
Consult oculoplastic surgeon
80
management for lid lacteration
1. If lid edge margin < 1mm - do not suture - heals spontaneously
1. Repair superficial lacerations not meeting criteria for oculoplastics
- repair using soft, absorbable or nonabsorbable 6-0 or 7-0 suture (small suture material)
1. Oral cephalexin (Keflex) and erythromycin ophth ointment
1. Cold compresses
1. DC pending f/u with ophthalmology in 24 hours
81
presentation of Globe Rupture
1. Hx of high speed FBy or penetrating injury - hammering or grinding without eye protection
1. PE
- severe subconjunctival hemorrhage
- shallow or deep anterior chamber (when compared to unaffected eye)
- hyphema
- teardrop-shaped pupil
- limited EOM
- extrusion of globe contents
- reduction in VA
- (+) Seidel test - may be negative if penetrating wound has sealed
Once dx is suspected remainder of exam is suspended
82
diagnotics for globe rupture
CT scan of orbit
confirms dx and presence of FB
83
management for globe rupture
1. Apply eye shield, keep upright and NPO
1. IV broad spectrum antibiotics with antiemetic
- IV **vanc + ceftazidime**
--- _FQ_ if PCN/ceph allergy
- IV **ondansetron** (Zofran)
- avoid increase in IOP
1. Update Td (if indicated)
1. Emergent ophthalmology consult
84
how to inspect/assess a blunt eye trauma, and why?
Use eyelid speculum/retractor or bent paperclip - using fingers will increase IOP further worsening a globe injury
85
PE components for blunt eye trauma
1. Assess **VA, pupil, anterior chamber, globe**
1. If globe appears intact perform complete eye exam:
- **inspect for proptosis**
- assess **EOM**
- **palpate orbital rim**
- assess **sensation of inferior orbital nerve**
--- below the eye and ipsilateral side of nose
- **slit-lamp with fluorescein**
--- assess for abrasions, lacerations, FB, hyphema, iritis, and lens dislocation
- If globe still appears intact **assess IOP**
86
complications of blunt eye trauma
1. Ruptured globe
1. Postseptal hemorrhage
1. Hyphema
1. Orbital blowout fracture
87
postseptal hemorrhage complication ater a blunt eye trauma occurs most frequently in patients on ?
anticoagulants
88
after a blunt eye trauma, the pt is now experiencing restriction of upward or lateral gaze, paresthesia along the infraorbital nerve route, subcutaneous emphysema
what is this compliation?
Orbital blowout fracture
results in entrapment of the **inferior rectus muscle**
89
indications for CT facial bones w/o contrast for blunt eye trauma
1. suspected postseptal hemorrhage
1. hyphema
1. orbital blow out fracture
1. step off of orbital rim
1. concern for globe rupture not fully evident on PE
1. intraocular FB
90
management and disposition for blunt eye trauma
1. **DC home** with f/u to ophthalmology w/n 48 hrs **if normal VA** (compared to baseline) and **nml ocular anatomy with full function**
1. _Tx traumatic iritis_ (no corneal injury) - **prednisolone acetate + cycloplegic** (after consultation with ophthalmology)
1. Emergent consult ophthalmology
- indications: globe rupture, postseptal hemorrhage, hyphema, orbital blow-out fracture, intraocular FB
91
First thing of action for chemical oxular injury?
Intervention prior to history/PE - **Eye irrigation immediately** (at the scene of the incident if possible)
92
irrigation procedure for chemical ocular injury
1. Apply topical anesthetic
1. Attach NS or LR to a Morgans lens
1. Check pH after 2 L of irrigation have occured
- Wait 5-10 minutes before checking pH
- Use pH paper in lower cul-de-sac
- Irrigation continues until the pH returns to 7.4 for 30 minutes
1. Once pH returns to normal inspect fornices and everted eyes
- sweep with moistened cotton-tipped applicator to ensure there are no residual particles
93
when do you do a PE for chemical ocular injury? what do you do for w/u?
After successful irrigation
* Slit lamp - assess for necrosis, corneal defects, assess everted lids
* IOP
94
management and disposition for chemical ocular injury
1. Cycloplegic, opioid pain meds
1. Erythromycin ophthalmic ointment
1. Update Td
Disposition: If discharged - f/u with ophthalmology within 24 hours is needed
95
6 indications for emergent opthalmology consult for chemical ocular injury?
1. increased IOP
2. pronounced chemosis
3. conjunctival blanching
4. epithelial defect
5. corneal edema
6. opacification exposure to hydrofluoric acid, lye or concrete
96
____ angle, also called closed angle or Acute angle closure glaucoma
narrow angle
Open Angle = Chronic glaucoma
97
an area of tissue in the eye located around the base of the cornea, near the ciliary body, and is responsible for draining the aqueous humor from the eye via the anterior chamber (the chamber on the front of the eye covered by the cornea).
trabecular meshwork
98
A group of eye diseases characterized by **neuropathy to the optic nerve, with or without elevation in intraocular pressure**
Glaucoma
99
Second leading cause of blindness ww next to cataracts
glaucoma
100
what happens to the optic disk on ophthalmologic examination is seen with glaucoma?
Cupping
101
An obstruction of aqueous humor outflow - results from the lens or the peripheral iris blocking the trabecular meshwork
Acute Angle Closure Glaucoma
102
Acute Angle Closure Glaucoma
Usually follows a history of an event that lead to pupillary dilation:
| (4)
1. exposure to dark room (movie theater)
1. reading
1. use of dilating agents, inhaled anticholinergics
1. use of cocaine
103
Hx:
* sudden onset
* **eye pain** or frontal/supraorbital **HA**
* rarely painless monocular vision loss
* blurred vision **colored halos around lights**, N/V
Acute Angle Closure Glaucoma
104
PE:
1. **fixed midposition pupil**
1. **hazy cornea**
1. conjunctival injection
1. **Increased IOP** - may exceed 60-80 mmHg (normal 10-20 mmHg)
- affected eye is very firm to palpation
- use tonometry to confirm
Acute Angle Closure Glaucoma
105
DDX for Angle closure Glaucoma
1. Iritis
1. Trauma
1. Hyphema
1. Subconjunctival hemorrhage
1. Corneal abrasion
1. Infectious keratitis
1.
106
management for Acute Angle Closure Glaucoma
1. Immediate ophthalmologic consult
2. supine
3. Pharm
- _acetazolamide IV_ - if IOP > 50 mmHg, severe vision loss or unable to tolerate PO therapy
- _timolol/apraclonidine_ - wait 1 min between each drop
- _mannitol IV_ - if IOP >40 mmHg after 30 mins after mannitol
- _pilocaprine_ - induces mitosis but isn’t effective until IOP is < 50 mmHg
107
gold standard for Angle closure Glaucoma diagnosis?
Gonioscopy - Views the iridocorneal angle
108
definitive tx for Acute Angle Closure Glaucoma
Laser peripheral iridotomy
109
1. Inflammation along optic nerve
1. Vision loss is **often painless** (can be painful with EOM)
- Reduction in color vision MC affected
- Mild loss of VA up to complete loss of light perception
Optic Neuritis (ON)
110
PE + managment for optic neuritis
1. VA including a **Red desaturation test** - affected eye will often perceive the object as pink or a lighter red
2. **(+) afferent pupillary defect**
3. Funduscopic:
- swollen and **edematous optic disk** = **_anterior ON_**
- **nml optic disk** = **_retrobulbar ON_**
Management: Emergent consult with ophthalmology and neurology
111
Sudden painless monocular vision loss
hx of amaurosis fugax (transient vision loss)
Central Retinal Artery Occlusion
112
PE for Central Retinal Artery Occlusion
1. **(+) afferent pupillary defect**
1. Fundoscopy - compare R to L
- retina will **infarct** and become **pale, less transparent, and edematous**
- macula remains red - “**cherry red spot**”
- Segmented arterioles - “**boxcarring**”
113
management and prognosis for CRAO
* Management - Emergent ophthalmology and neurology consult
* Prognosis - Permanent vision loss will occur 4 hours after onset
114
_Sudden painless monocular vision loss_
vision loss is variable **ranging from vague blurring to rapid loss**
Central Retinal Vein Occlusion
115
PE and management for Central Retinal Vein Occlusion
1. (+) afferent pupillary defect
1. Fundoscopy - compare R to L
- **optic disc edema, diffuse retinal hemorrhages “blood-and-thunder fundus”**
Management: Ophthalmology consult with a follow-up in 12-24 hours
116
Sudden onset of painless monocular vision changes
“floaters”, “flashes of light”, dark veil/curtain
Retinal Detachment
117
PE/work-up/management for retinal detachment
PE:
- ocular exam nml other than _VA and visual fields by confrontation_
- fundoscopy nml - majority of detachments occur in peripheral retina (not visualized on fundoscopy)
Work-up: Bedside US
Management: Urgent consult (w/i 24 hours) with ophthalmology for a dilated eye exam
118
* **pruritus, otalgia**, and tenderness of the external ear - worse with mastication/movement of the auricle
* **otorrhea** and **decreased hearing** in more severe presentations
* **Erythema and edema of the external** auditory canal, spreading to the tragus and auricle
* **Clear - purulent discharge** with crusting of the external canal
* _Severe cases_ - complete occlusion of the auditory canal, periauricular edema/erythema, LAD
Otitis Externa
119
management for OE
1. Analgesics - Tylenol/Motrin
1. Cleansing of the external canal - gentle irrigation using hydrogen peroxide 1:1 with warm saline or water and gentle suction under direct visualization
1. Otic drops
- **acetic acid/hydrocortisone** (**CI in perforated TM or if unable to visual TM**)
- **ofloxacin (Floxin) or ciprofloxacin/hydrocortisone (Cipro HC)**
--- avoid _Cipro_ if suspected/confirmed TM perforation
--- _ofloxacin safe for TM perforations_
1. **Ear wick** - Indicated if swelling is severe and prevents full application of otic drop
120
* Red flags: elderly, DM immunocompromised pts
* **Persistent sx despite standard therapy (2-3 wks)**
* **Severe otalgia and edema; granulation tissue on floor of EAC** possible
* Assess CN’s - _**VII** is usually first to be affected_
Malignant Otitis Externa
121
diagnostics and management for Malignant Otitis Externa
1. Dx: CT head w/ contrast = “bone erosion”
1. Tx:
- Urgent ENT consult
- IV abx - tobramycin + piperacillin; ceftriaxone; cipro
- Pain - IV opiate is usually needed
- Admission with ENT consult
122
Infection of the inner ear
OM
123
1. Hx
- otalgia
- +/- fever, otorrhea, hearing loss
2. Physical Exam
- TM erythema, yellow/white exudate behind intact TM or in canal if TM is perforated
- Retracted or bulging with impaired mobility
dx?
OM
124
management & disposition for OM
Oral abx
1. **Amoxicillin - DOC**
- Alt - cefdinir, zithromycin limited efficacy against H. flu and S. pneumo.
- _Recent Abx use or recurrent OM_ - Augmentin or cefdinir
2. Analgesics - Tylenol/Motrin
Disposition - home to f/u with PCP in 3-5 day
125
MCC organisms of OM
1. **S. Pneumoniae**
1. **H. Influenzae**
1. **M Catarrhalis**
1. S. Pyogenes
1. S. Aureus
1. as well as respiratory viruses.
126
dx and management Acute Mastoiditis
1. Diagnosis
- **_CT head w/ contrast confirms_**
- **mastoid “clouding”** early in disease; **loss of bony septae** of the mastoid air cells, **destruction/irregularity of the mastoid cortex, periosteal thickening**
2. Management - EM ENT consult, IV **vancomycin and ceftriaxone**, Admission
127
A complication of OM in which the infection spreads to the mastoid cells
Acute Mastoiditis
128
1. History
- otalgia, fever, postauricular pain and swelling
2. Physical Exam
- PE findings same as OM
- protrusion of the auricle with loss of postauricular crease
- postauricular erythema, swelling and tenderness
what is this dx?
Acute Mastoiditis
129
A complication of OM characterized by bullae formation on the TM and deep external auditory canal.
Bullous Myringitis
130
1. History
- severe otalgia, intermittent otorrhea due to ruptured bullae
- hearing loss (reversible)
2. Physical exam
- **intact bullae along the TM and EAC** - blood filled, serous, serosanguineous
- middle ear effusion
dx? tx?
Bullous Myringitis
same as OM
131
Accumulation of blood between the skin and the cartilage of the auricle due to blunt trauma
Hematoma
132
presentation and tx for hematoma?
* Swelling, pain and ecchymosis of the auricle
* **Consult ENT: Immediate I&D** with evacuation of the hematoma followed by **compressive dressing** to prevent reaccumulation
* If left untreated: scarring with deformity leading to cauliflower ear
133
H&P of FB in ear
1. History - insertion of FB in ear, visualization of FB in ear, sensation of movement in ear, ear pain or loss of hearing
2. Physical Exam
- FB is visualized on otoscopic exam
- look for signs of TM perforation and infection
134
management for FB in ear
1. immobilize live insects with lidocaine 2% solution before removal
1. FB removal
- use **forceps** or **hooked probe** under direct visualization or **suction**
- **irrigation** with warm water or saline for small objects (non-organic objects) - _organic objects may absorb liquid and swell_
1. Consult ENT if TM perforation is present or if object cannot be removed
135
* History of barotrauma, blunt/penetrating/acoustic trauma, lightning strikes (rarely)
* Sudden onset of pain and hearing loss
* +/- bloody otorrhea, vertigo, tinnitus
* rupture of TM, ensure full visualization of TM and canal
what dx
Tympanic Membrane Perforation
136
management for Tympanic Membrane Perforation
1. Most TM ruptures will heal spontaneously
1. Uncomplicated TM perforations can be discharged home
- _blunt or noise trauma_ that are isolated injuries
- ENT f/u 7-10 day f/u is acceptable
1. **Penetrating TM ruptures - f/u with ENT in 24 hrs**
1. Otic antibiotics are needed only if foreign material remains in canal or middle ear
137
2 classifications for epistaxis
anterior or posterior
1. **Anterior bleed** - visualized on external exam
2. **Posterior bleed** - unable to directly visualize bleed, blood from bilat nares or in posterior pharynx, failure to control with anterior packing
3. Use nasal speculum to attempt visualization of bleed
138
which epistaxis is happens MC at the sphenopalatine artery and Kiesselbach plexus?
* anterior - kiesselbach
* posterior - sphenopalatine
139
management for epistaxis
1. If severe bleed/hemodynamic instability - **type and crossmatch blood**
- MC in posterior bleed and pts taking anticoagulants
2. Place in **“sniffing” position** - lean forward, neck in neutral position, nose straight
3. Direct pressure application
4. Chemical cauterization - **anterior sites only**
5. **Thrombogenic Foams And Gels**
6. **nasal packing**
140
how to perform direct pressure application for epistaxis
1. evacuate all clots via nose blow
2. apply intranasal vasoconstrictor
- oxymetazoline 0.05% or phenylephrine 0.25% - 2 sprays/nostril
3. pinch nose for 10-15 minutes without disturbing pressure
- hands-free tongue depressor device
141
how to do chemical cauterization for epistaxis
**anterior sites only**
1. Utilize after 2 attempts at **direct pressure have failed AND the bleeding vessel is visualized**
1. Anesthetize the nasal mucosa with 3 cotton swabs soaked in 1:1 mixture of 0.05% oxymetazoline and 4% lidocaine
1. Silver nitrate stick directly on bleeding vessel
1. CI - active hemorrhage, bilat bleeding, recent cauterization (within last 4-6 wks)
*Electrocautery is only performed by ENT*
142
epistaxis - management utilized if chemical cautery fails
Thrombogenic Foams And Gels
1. Gelfoam and Surgicel (oxidized cellulose)
- apply directly to visualized bleeding mucosa
2. FloSeal (hemostatic gelatin matrix mixed with human thrombin)
- inject mixture directly into bleeding nare, filling the nare completely
- FloSeal will begin to break down after 3-5 days and provides complete healing in apps 8 wks
143
indications for nasal packing for epistaxis
failure of chemical cautery, gel/foam not available, posterior epistaxis suspected
144
3 types of nasal packing
epistaxis balloon, tampon/sponge, ribbon packing
145
what is the epistaxis balloon (rapid rhino)?
* easier to use and more comfortable for patient than other packing options
* fabric is coated with cellulose, promoting platelet aggregation
146
what are nasal tampons/sponges for epistaxis and their management?
1. Available sizes
- 5 cm length for anterior packing
- 10 cm length for posterior packing
1. Coat tampon with water-soluble antibiotic ointment
1. Gently insert along nasal floor
1. Irrigate tampon (while in proper place) with 5 ml of NS if it has not expanded within 30 seconds of placement
1. Tape drawstring to face to secure
1. Remove in 2-3 days
147
last packing resort, most uncomfortable for patient and most difficult to insert
| epistaxis
Ribbon gauze
148
Posterior packing alternative for epistaxis
1. 14-French foley catheter
1. Anesthetize the nares with oxymetazoline and lidocaine (as discussed previously)
1. Cut tip of catheter just beyond balloon if sensitive gag reflex
1. Lubricate distal ⅓ of foley with lidocaine gel
1. Advance foley along nasal cavity floor until the end is visualized in posterior oropharynx
1. Inflate balloon with 7 ml of air and pull back until it becomes lodged in the choanal arch
- DO NOT use saline to inflate tube as this could cause aspiration if rupture occurs
- if balloon doesn’t lodge deflate balloon and insert again adding 10 ml of air - avoid using > 10 ml air due to risk of necrosis
1. Secure catheter to face with tape
149
complications for epistaxis
vasovagal syncope, dislodgement of packing, recurrent bleeding, sinusitis, toxic shock syndrome - more likely with posterior nasal packing
150
epistaxis - Admit and consult ENT if:
Posterior packing is required or anterior epistaxis is uncontrolled
151
epistaxis - Prophylactic abx recommended if ?
what abx?
* packing will be present >48 hours
* augmentin
* PCN allergy: cephalosporin or Bactrim
152
follow-up and pt ed for epistaxis
* Follow up - All packing must be removed in 2-3 days by ENT or ED - 2 days is most ideal
* pt ed - Avoid NSAIDs for 3-4 days
153
* fever, odynophagia, petechial or **vesicular lesions** along soft palate and tonsils
* **cough, rhinorrhea, nasal congestion**
which type of pharyngitis
viral pharyngitis
154
* fever, headache, sore throat, odynophagia,
* tonsillar **exudates**/erythema, cervical **LAD**
which type of pharyngitis
bacterial pharyngitis
155
Centor Criteria?
- tonsillar exudates
- tender anterior cervical adenopathy
- absence of cough
- fever
156
DDx to consider for pharyngitis/tonsillitis
mononucleosis, influenza, acute URI
157
If 2 or more Centor criteria are met, perform ?
rapid strep test
- McIsaac scoring system or modified Centor Criteria, includes age.
- Younger than 15 adds a point, older than 15 but younger that 45 0 point, and
- Older than 45 is a negative risk factor -1 point
158
Ulcers for pharyngitis/tonsillitis are almost always ____!!!
VIRAL
159
Palatal Petechiae is caused by what pathogen?
GABHS
Strep pyogenes
160
tx for Pharyngitis/Tonsillitis
1. Non-bacterial: supportive - antipyretics, analgesics, IV fluids if dehydrated
1. Bacterial: **Single dose of PCN G 1.2 million U IM / amoxicillin 500 mg BID x 10d**
- PCN allergy (rash) - Cephalexin / Cefdinir / Cephalosporins
- anaphylaxis - Azithromycin / clinda
161
1. HX
- Fever, malaise, sore throat, odynophagia, dysphagia, “hot potato” voice, otalgia, +/- trismus
2. PE
- Unilateral tonsillar enlargement
- Palatal and uvula edema
- **Contralateral deflection of uvula**
- Tender ipsilateral anterior lymphadenopathy
- Drooling
- Dehydration
Peritonsillar Abscess
162
Pt ed for pharyngitis/tonsillitis
1. Tell pt change toothbrush after 24 hours
1. Not contagious any longer after 24 hours of treatment
1. Strep will “go away” on it’s own without antibiotics
- However, a patient will remain contagious for 2-3 weeks after symptoms abate
163
Peritonsillar Abscess
a collection of purulent material between the tonsillar capsule, the superior constrictor, and palatopharyngeus muscle
164
DDx peritonsillar abscess
peritonsillar cellulitis, mononucleosis, retropharyngeal abscess, HSV tonsillitis, neoplasm, internal carotid aneurysm
165
Dx peritonsillar abscess
1. Imaging is often not needed due to classic presentation of disease allowing for confident clinical diagnosis
1. **Intraoral US** - _confirms presence of abscess_ when differentiating between cellulitis and abscess
1. _CT scan w/ contrast_ of the neck (not C-spine)
166
management for peritonsillar abscess
1. **Needle aspiration or I&D** (consult ENT if necessary)
1. _Non-toxic + successful drainage + can tolerate PO_ = DC w/ PO abx
- **PCN VK + metronidazole** x 10 d
- _allergy_: clinda + metronidazole
1. _Toxic pts_ - **sepsis workup, IV pip-taz**
167
a collection of pus in the space anterior to the prevertebral fascia that extends from the base of the skull to the tracheal bifurcation
Retropharyngeal Abscess
168
1. History
- look for source: recent intraoral procedure, trauma, foreign bodies (fishbone/pencil), or extension from odontogenic infection
- sore throat, dysphagia, neck pain/torticollis
- stridor in children
2. Physical Exam
- muffled voice
- cervical adenopathy
- respiratory distress
dx?
Retropharyngeal Abscess
169
dx Retropharyngeal Abscess and its findings?
1. _lateral soft tissue neck x-ray_
- thickening and protrusion of the retropharyngeal wall
2. **_CT neck w/ IV contrast - GOLD STANDARD_**
- use if high suspicion and XR not definitive
- _early_: **nonsuppurative edema**, mild **fat stranding**, linear fluid, minimal mass effect
- _later_: **necrotic nodes** with central **low attenuation** and **ring enhancement**
170
management for retropharyngeal abscess
1. Prepare for **emergent airway placement**
1. Urgent ENT consult for surgical intervention and admission
1. **IV fluids, NPO**
1. **IV clinda / cefoxitin**
- Alt: pip-taz / Unasyn
171
An inflammatory condition of the epiglottis, most often infectious in nature
Epiglottitis
172
1. 1-2 day progressive **dysphagia, odynophagia and dyspnea**
1. +/- drooling, inspiratory stridor, fever
1. sx worse when supine, improved when upright
- **upright, leaning forward, neck extended with mouth open**
1. tachycardia
2. cervical adenopathy
3. **tenderness of anterior neck** with gentle palpation of the larynx and upper trachea
dx?
epiglottis
173
_Lateral soft tissue neck XR_ shows obliteration of the vallecula - **“thumbprint” sign**
dx?
What is the gold standard for confirming?
epiglottis
Transnasal fiberoptic laryngoscopy - risk of airway obstruction during exam
174
management for epiglottis
1. Emergent ENT consult and admission
1. Prepare for emergent airway placement
- Place on cardiopulmonary monitors
- Do not leave pt unattended
- Pt should **remain upright**
1. Humidified oxygen, IV fluids
1. **IV cefotaxime + vanc**
- _Severe PCN allergy_: rsp FQ
1. **IV methylprednisolone 125 mg** - reduce inflammation and edema
175
Extension of a dental abscess into a surrounding structure or deep neck space
Odontogenic Abscess
176
where can Odontogenic Abscesses occur? (3)
retropharyngeal, parapharyngeal spaces, floor of mouth
177
1. hx of dental pain/abscess
1. erythema edema of the labia or buccal gingiva, intraoral or dento-cutaneous fistula (tooth abscess)
1. trismus, fever, edema of the upper neck/floor of mouth, displacement of the tongue, airway compromise (Ludwig’s angina)
1. sore throat, dysphagia, dyspnea (retro-parapharyngeal abscess)
dx? w/u?
Odontogenic Abscess
* _superficial infection_ - bedside US to confirm
* _deep_ - CT neck with IV contrast
178
2 complications with Odontogenic Abscess
1. Ludwig’s angina
2. Necrotizing infection
179
cellulitis of the sublingual and submaxillary space
which odontogenic abscess complication? tx?
Ludwig’s angina
rapidly progressive - obtain definitive airway early in presentation
180
**toxic appearing with hemodynamic instability**, skin discoloration, crepitus of the subcutaneous tissue, fever, confusion
which odontogenic abscess complication?
tx?
Necrotizing infection
requires immediate surgical fasciotomy
181
management for odontogenic abscess
1. _Non-toxic with superficial (dental abscess)_
- **PCN VK / amoxicillin PO**
--- allergy - clinda
2. _Toxic, deep infection, complication of odontogenic infections_
- Urgent ENT consult and admission
- IV fluids, NPO
- **IV unasyn + clinda + cipro**
182
swallowed FB are a concern particularly in who?
kids, mental illness, prisoners
183
MC food that becomes lodged in esophagus
Meat
184
1. Clinical Presentation
- Children: refusal or inability to eat, vomiting, gagging and choking, stridor, neck or throat pain, and drooling
- Adults: retrosternal pain (upper ⅓ of esophagus), dysphagia, vomiting, choking, coughing, aspiration if attempting to “wash down” in esophagus
2. Physical Exam
- Assess airway, nasopharynx, oropharynx, neck and chest
which dx
swallowed FB
185
dx swallowed FB
1. “FB film” - chest and abdomen
- will only reveal radiopaque objects
2. CT chest without contrast
- will shows non-radiopaque objects
- provide information on perforation and signs of infection
186
how will swallowed coins look on XR
* circular face on AP/PA if in esophagus
* circular face on lateral view if in trachea
187
tx for swallowed FB
1. Assess for airway compromise and risk of aspiration
- complete esophageal obstruction leads to pooling of secretions and aspiration
2. Determine need for urgent endoscopy
- do not delay endoscopy for further imaging
188
7 circumstances warranting urgent endoscopy for esophageal FB
1. ingestion of sharp or elongated objects (toothpicks, aluminum soda can tabs)
2. ingestion of multiple FB
3. ingestion of button batteries
4. evidence of perforation
5. coin at the level of the cricophargyngeus muscle in kid
6. airway comp
7. presence of FB for >24 h
189
management/disposition for swallowed FB
1. Expectant therapy: if object is past pylorus and meets no “red flags” for obstruction
- serial x-rays (if radiopaque) until complete passage
2. Distal esophageal objects
- IV glucagon, 1-2 mg in adults, may relax the lower sphincter and allow passage of the object
3. Successful endoscopy without complications: discharge home
190
management for food impaction
1. complete esophageal obstruction requires emergency endoscopy
1. partial obstruction: treat expectantly with f/u in 12-24 hours to ensure passage
- if passage hasn’t occurred endoscopy is needed
191
management for coin ingestion? alt procedure?
1. coins in the esophagus should be removed
1. endoscopy is procedure of choice
- alt: foley catheter performed under fluoroscopy by experienced provider
192
management for swallowed sharp objects
1. if in esophagus, stomach or duodenum - immediate endoscopy
1. if distal to duodenum and is asx - daily xrays until passage
1. if passage doesn’t occur within 3 d - consult surgery
1. consult surgery immediately if s/s of perforation
- pain, emesis, fever, GI bleed
193
special considerations with swallowed button battery and its management
1. True emergency requiring prompt removal if found in the esophagus
- battery will lead to rapid mucosal injury and necrosis
- perforation within 6 hrs of ingestion
1. _passed esophagus_ - f/u in **24 hrs for repeat exam**
1. Repeat **XR at 48 hrs to ensure passage through pylorus**
1. Complete passage takes 48-72 hours for most patients
194
management for narcotic ingestion (body packers)
1. commonly ingested inside a condom - can hold up to 5 grams of narcotics
2. rupture of 1 pack = fetal
3. **_endoscopy CI_ d/t risk of rupture**
4. **visible with plain film**
5. admit for observation until packet reaches rectum
Emergency Medicine
flashcards
Decks in class (20)
# Cards
-
Principles of Emergency Medicine30
-
EENT194
-
The Approach to HA in the ER88
-
Fevers and Seizures111
-
Tintinalli's - HA74
-
Chest pain146
-
Syncope62
-
Environmental emergencies113
-
Dyspnea95
-
Resuscitation and Shock63
-
Trauma65
-
Abdominal pain141
-
Abdominal Pain pt 2100
-
Male Genitalia Emergencies83
-
Lower Extremity Pain the ED58
-
Pain and Wound Management134
-
The Approach to an Altered Mental Status in the ED79
-
OBGYN Emergencies63
-
Psychiatric Emergencies36
-
poisoning and ingestions100
