Board / Inservice Review Part 2

1. Department of Emergency Medicine University of Pennsylvania Health System Board / Inservice Review Part 2 • Angela M. Mills, MD

2. HEENT • 5%

3. Orbital Trauma • Orbital floor weakest point • medial wall 2nd weakest • best xray  Water’s view • teardrop sign on xray • Retrobulbar hemorrhage • acute decreased visual acuity, proptosis, dilated non-reactive pupil • consider lateral canthotomy

4. Orbital Floor Fracture

5. Tear Drop Sign

6. Orbital Trauma • Hyphema • usually bleeding from ciliary body vessels after blunt trauma • most common / serious complication rebleeding in 3-5 days • Retinal detachment • flashing lights or floaters may herald detachment before loss of vision

7. Retinal Detachment

8. Orbital Trauma • Alkali burns • liquefaction necrosis • worse than acid burns • irrigate copiously • Acid burns • coagulation necrosis • less destructive

9. Cornea • Abrasion  no eye patch • do not prescribe topical anesthetic drops • Ulcer in contact lens wearer  Pseudomonas • Perforation  teardrop–shaped pupil • positive Seidel test • fluorescein washed away by leaking aqueous humor

10. Corneal Laceration

11. Conjunctivitis vs Iritis • Conjunctivitis  palpebral erythema • itch better with topical anesthetic • hyperpurulent think GC • Iritis  central erythema • ciliary flush • debris in anterior chamber (cell & flare) • no relief from topical anesthetic

12. Ciliary Flush

13. Infection • Preseptal Periorbital • eye not involved • full EOM • normal acuity • Staphylococcus most common • Septal  Orbital(true emergency) • pain with EOM, proptosis, decreased vision • may be dental / sinus origin • Staphylococcus most common • Mucormycosis: DM, immunocompromised

14. Preseptal Cellulitis

15. Septal Cellulitis

16. Herpes • Herpes Keratitis • Dendritic / branching pattern • Avoid steroids • Hutchinson’s sign • Zoster of nose tip

17. Herpes

18. Sudden Vision Loss • Glaucoma haloes • Retinal detachment  curtain • Amaurosis fugax  transient • CRAO  sudden, painless • Vitreous hemorrhage  floaters • Temporal arteritis  tender scalp

19. Glaucoma • Optic neuropathy 2/2 increased IOP • Acute angle closure  mimic acute abd • Begins abruptly, dark room • Red painful eye, HA, n/v • Steamy cornea, midposition fixed pupil • Haloes around lights • Elevated IOP (40 – 70 mm Hg)

20. Glaucoma Treatment • Timolol  decrease IOP • Pilocarpine  open angle • Acetazolamide  decrease aqueous humor production • Apraclonidine (alpha-adrenergic) • Mannitol  osmotically drains eye

21. Acute Angle Glaucoma

22. Central Retinal Artery Occlusion • Sudden, painless loss of vision • Monocular blindness • Pale retina, fixed dilated pupil • Cherry-red spot in macula • True ocular emergency • Treat digital massage of globe • Ophtho consult

23. CRAO

24. Nose • Most common facial fracture • Persistent bleeding with FX  CSF rhinorrhea • Septal hematomadrain • Epistaxis • Anterior  Kiesselbach’s • should stop spontaneously • Posterior  palatine / sphenopalatine • Packing  admission

25. Septal Hematoma

26. Otitis • Otitis Externa  swimmer’s ear • Staph  acetic acid / abx • malignant otitis externa  skull base osteomyelitis • Pseudomonas  admission, ABX • Otitis Media  S. pneumoniae, H. flu • Otalgia + fever  amoxicillin • Bullous myringitis  Mycoplasma • erythromycin

27. Dental • Most common nontraumatic dental emergency pain from caries / abscesses • Most important concern  airway • Implant avulsed teeth ASAP • Or preserve in Hank’s sol’n, milk, saliva • Dental fractures  Ellis class I, II, III • enamel, dentin, pulp

28. ANUG • Acute Necrotizing Ulcerative Gingivostomatitis • Trench-mouth, Vincent’s infection • Fiery, red, swollen, painful gums • Fusobacteria and spirochetes • Local compresses and systemic ABX

29. Ludwig’s Angina • Sublingual / submandibular cellulitis • connective tissue, fascia, muscle • Dysphonia, trismus, tongue elevation, airway compromise • Odontogenic infection (molars) • Mixed aerobic / anaerobic

30. Ludwig’s Angina

31. Peritonsillar Abscess • Complication of beta-strep tonsillitis • Adolescents, young adults • Hot potato voice, drool • Displacement of tonsil and uvula • Needle aspiration, abx

32. Tonsillitis

33. Peritonsillar Abscess

34. ENT • Ramsay-Hunt Syndrome • Herpes zoster involving TM and external ear canal, pharynx, facial nerve paralysis, cornea • Ear trauma  drain subperichondral hematoma • Angioedema of tongue ACE inhibitors

35. Angioedema

36. Hematology • 2%

37. Blood Products • 1 U PRBC ↑ Hgb ~ 1 gm% • Hematocrit ~ 3x Hgb • 1 U platelets ↑ count 5,000 – 10,000 • Autotransfusion: no functional plt, fibrinogen • Universal donor  O-negative • Treat symptoms, not numbers

38. Blood Products • Most common reaction  febrile • Most serious reaction  hemolytic • Disease transmission virtually zero • Most common disease transmission  Hepatitis C • Massive transfusion risks  • hypothermia, thrombocytopenia, hypocalcemia, coagulation defects

39. Coagulopathy • Warfarin  inhibits vitamin K factors • II, VII, IX, X • FFP  immediate reversal, short-lived • Vitamin K  reverses over 4-24 hrs • Heparin  binds antithrombin III • discontinuing usually enough • short half-life • protamine 1 mg / heparin 100 U

40. Hemophilia • Classic Type A  X-linked • Normal amount Factor VIII, abnormal function • Normal PT, prolonged PTT • Morbidity  joint bleeds • Mortality  head bleeds, AIDS • Treatment • DDAVP, recombinant Factor VIII • Cryoprecipitate  • moderate bleed (GI) 25-50 U/kg • major bleed (CNS) 50 U/kg

41. DIC • Simultaneous deregulation of coagulation and fibrinolytic pathways • consumptive coagulopathy • ↑ PT, ↑ PTT, ↓ Plt, ↓ fibrinogen, ↑ FSP, ↑ D-dimer • Treat primary condition • FFP, plt’s, heparin

42. Thrombocytopenia • ITP • increased plt clearance by reticuloendothelial system • adults  steroids • kids  IV immunoglobulin • TTP • Classic pentad in 40% • Thrombocytopenia, hemolytic anemia, fluctuating neurologic exam, renal disease (mild), fever • Rx  plasma exchange, plasmapheresis

43. Von Willebrand’s Disease • Most common genetic bleeding d/o • Autosomal dominant • Prolonged bleeding time • Normal PT, prolonged PTT ~ 25% • Platelet count normal, ↓ function • Rx  DDAVP, FFP, cryoprecipitate

44. Anemia • Most common human enzyme defect  G6PD deficiency • hemolysis with oxidants • Hemolytic-uremia syndrome • renal failure, hemolysis, fever, low platelets • diarrhea precursor  E.coli 0157:H7 most common

45. Sickle Cell Disease • Vaso-occlusive  painful • evaluate for precipitating causes • infection, dehydration, trauma, cold exposure • labs not useful in Dx, r/o complications • Aplastic BM failure, ↓Hct, ↓RC • Hemolytic ↓Hct, ↑ RC • Sequestration large spleen in kids • RX  IVF, analgesia, O2, transfuse prn

46. Sickle Cell Disease • Acute chest syndrome • secondarily infected pulmonary infarction • high mortality, severe ↓ in pulm fxn • Infectious crises • especially children < 5 • functional asplenia • encapsulated organisms (pneumococcus) & Salmonella, S. aureus (osteo)

47. Oncology • Leukemia blast crisis  flu-like sx’s with ↑ immature cells • Leukemoid reaction  ↑ WBC due to infection, resembles leukemia • Neutropenia (<1000 /ml)  death • Multiple myeloma • plasma cell malignancy • pain in back, ribs • Hypercalcemia ~ 30%, hyperviscosity

48. Tumor Compressions • Spinal cord  steroids, radiation • Upper airway  establish definitive airway • Pericardial tamponade  echocardiogram  pericardiocentesis if unstable • Superior vena cava syndrome • head/neck/upper chest congestion, facial plethora, ICP increase, papilledema • RX  diuretics, steroids, radiation

49. SVC Syndrome

50. Oncology • Hypercalcemia  ↓ QT  NSS, furosemide • SIADH  ↓Na, normovolemia, ↑ UNa • RX  NSS, diuretics • Hyperviscosity syndrome fatigue, HA, CVA, blindness, seizures • RX  NSS, phlebotomy • Adrenal insufficiency  hydrocortisone • consider in all cancer pts w/ fever, dehydration, hypotension, shock