Ophthalmologic and ENT Emergencies William Beaumont Hospital Department of Emergency Medicine Sudden Loss of Vision Central retinal artery occlusion Central retinal vein occlusion Retrobulbar neuritis Amaurosis fugax Retinal detachment Central Retinal Artery Occlusion Sudden monocular painless, complete loss of vision Fundoscopic exam: pale retina with macular red spot Central Retinal Artery Occlusion Treatment STAT opthy consult Digital massage of the globe Increase CO2 (arteriolar dilatation) – carbonic anhydrase inhibitor (i.e. acetazolamide) Definitive treatment – paracentesis of the anterior chamber Central Retinal Vein Occlusion Sudden monocular painless, and near complete loss of vision Fundoscopic exam: chaotic, bloodstreaked retina Stat ophthalmology consult Optic Neuritis Progressive loss of central vision May be painful, scotoma, flashing lights Peripheral vision preserved Associated with multiple sclerosis in 25% of cases Amaurosis Fugax Fleeting painless loss of monocular vision Due to minute emboli of the central retinal artery Consult neurology for TIA workup Retinal Detachment Painless Prodromal floaters or flashing lights, followed by “lowering curtain” Opthy consult Red Eye Acute angle closure glaucoma Acute iritis Conjunctivitis Herpes simplex keratitis Corneal ulceration Chemical conjunctivitis Corneal abrasions Acute Angle Glaucoma Sudden severe unilateral ocular pain Decreased visual acuity Precipitous increased IOP blindness if untreated Symptoms: HA, nausea, blurred vision or rainbow halos Pupil dilatation is often precipitant event from sympathomimetics, parasympatholytics, stress, fatigue, darkness. Acute Angle Glaucoma Red eye Nonreactive middilated pupil Corneal edema Shallow anterior chamber High intraocular pressure (60-90)** Hazy cornea **Normal IOP <20 Glaucoma Treatment Stat opthy consult for definitive treatment – iridectomy Timolol – beta blocker Pilocarpine – parasympathomimetic Acetazolamide – carbonic anhydrase inhibitor Mannitol 50% glycerol – oral hyperosmotic – if patient can tolerate PO – give in place of mannitol Timolol Solution Beta blocker Decreases aqueous humor formation 0.5% solution – 1-2 drops at 10-15 min intervals x 3, then 1 drop every 12 hours Pilocarpine Parasympathomimetic Produces miosis 2% solution – 1 drop every 30 minutes until the pupil constricts, then 1 drop every 6 hours Side effects: bradycardia, hypotension, sweating, tremors Acetazolamide Carbonic anhydrase inhibitor Inhibits aqueous humor formation 500 mg IV every 12 hours or 500 mg PO every 6 hours Side effects: respiratory depression, metabolic acidosis Mannitol Increases blood osmolality, creating a gradient that draws water from the vitreous cavity 20% 1-2 grams/kg IV over 30-60 minutes Side effects: headache, confusion, CHF, dehydration Acute Iritis Blurred vision, photophobia, ocular pain Exam: – Ciliary flush – Anterior chamber cells and flare – Constricted pupil – Decreased visual acuity – Lower IOP – Consensual photophobia Acute Iritis: Treatment Cycloplegics – i.e. Homatropine – dilates the eyes Topical steroids Close opthy follow up Acute Iritis Conjunctivitis Nonpainful red eye Bacterial, viral, or allergic Herpes Simplex Keratitis Red eye with foreign body sensation Dendritic fluorescein uptake Treatment: acyclovir drops, cycloplegics Steroids contraindicated Opthy consult Corneal Ulceration Red, painful eye Slit lamp – White flocculent infiltrate of the cornea – Hypopyon Anterior chamber exudate May lead to corneal destruction and perforation ?Admit, IV antibiotics Corneal Ulceration Chemical Conjunctivitis Alkali burn – absolute ocular emergency – Liquefactive necrosis – Immediate irrigation (pH 7-7.5) – Opthy consult – Only opthy emergency in which visual acuity is not checked until after therapy has begun Alkali Burns Chemical Conjunctivitis Acid burn – Coagulative necrosis – Immediate irrigation as above – Opthy consult Corneal Abrasions Foreign body sensation and photophobia Diagnose: fluorescein uptake with slit lamp exam – rule out foreign body with lid eversion Suspect foreign body if “ice rink sign” – fine linear abrasions in upper 1/3 cornea Rule out corneal ulceration Do not use steroid drops –may be difficult to rule out early HS keratitis Treatment: antibiotic ointment/drops, analgesics Prognosis is very good Corneal Abrasion Traumatic Eye Injuries Corneal laceration Perforated globe Intraocular foreign body Hyphema Blow-out orbital fracture Traumatic iritis or retinal detachment Corneal Laceration Tear shaped pupil – prolapse of the iris Small black fragments representing iris pigment may be seen and initially mistaken for a foreign body May not see the laceration itself Treatment: metal shield, STAT opthy consult for surgical repair Corneal Laceration Perforated Globe Suspect if penetrating wound to the eyelid Decreased visual acuity, soft globe (do not palpate) Fundoscopic exam may reveal vitreous hemorrhage Treatment: Metal shield, STAT opthy consult for surgical repair Intraocular Foreign Body Patient often gives a history of striking metal on metal May be initially painless, but then patient develops monocular pain and decreased visual acuity May not see the wound Diagnosis: CT scan, ultrasound or x-ray of the globe Treatment: Opthy consult for surgical removal Orbital Foreign Body Hyphema Hemorrhage in the anterior chamber See blood/vitreous line in inferior iris Treatment – – – – – Bed rest Head of bed elevation Opthy consult Steroids Miotics Blow-out Orbital Fracture Blunt globe trauma (i.e. fist to eye) transmits forces that lead to orbital floor fracture Inferior rectus muscle may prolapse through the fracture Pain and diplopia or loss of upward gaze, enophthalmos (sunken eye), infraorbital anesthesia Treatment: OR if entrapment, opthy consult Blow-out Fracture Moving on to ENT Emergencies… Ear Disorders Auricular hematoma Otitis externa Malignant otitis externa Ramsey Hunt Foreign body Tympanic membrane rupture Otits media Auricular Hematoma Blunt trauma Untreated, can result in cartilage necrosis (“cauliflower ear”) Treatment: – Needle aspiration – Compression dressing Auricular Hematoma Otitis Externa Swelling of the external canal Pain with movement of the auricula Treatment: – Abx/steroid ear drops – Ear wick Malignant Otitis Externa Deep pain with movement of TMJ, granulation tissue on the floor of the auditory canal at bony-cartilage junction Immunocompromised patient Pseudomonas aeruginosa Facial nerve paralysis multiple CN involvement meningitis Treatment: STAT ENT consult, surgical debridement, IV abx Malignant Otitis Externa Ramsay Hunt Syndrome Herpes Zoster Vesicular rash of ext auditory canal & auricle Usually with sensorineural hearing loss and facial nerve paralysis Treatment: – Admit – IV acyclovir – Steroids Ramsay Hunt Syndrome Ear Foreign Body Tools for removal: – Irrigation (not vegetable matter) – Alligator forceps – Suction – Hook – Cerumen loop Live insects should be stupefied with lidocaine or mineral oil prior to removal Ear Disorders Tympanic membrane rupture – ENT referral Otitis media – hopefully you all know what this is Nasal Disorders Epistaxis Foreign body Acute sinusitis Cavernous sinus thrombosis Epistaxis Anterior most common – Kiesselbach’s plexus Posterior often due to uncontrolled HTN Rule out coagulopathy Silver nitrate or cautery Oral antibiotics if nasal pack Nasal Foreign Body Treatment – Suction – Ear curette – Forceps Acute Sinusitis Treatment: nasal and oral decongestant, antibiotics (augmentin, macrolide, 2nd or 3rd cephalosporin) if sxs > 1 week Complications: – Pott’s puffy tumor – osteitis of anterior frontal sinus wall frontal lobe abscess – Meningitis – Acute periorbital cellulitis – Tx: admit for IV abx – CT scan to rule out orbital cellulitis Cavernous Sinus Thrombosis High fever Toxic appearing Chemosis, CN 3 & 6 palsies, papilledema Lethargy, coma or seizures Diagnosis: CT, MRI Throat Disorders Pharyngitis Mononucleosis Ludwig’s Angina Peritonsillar abscess Epiglottis Retropharyngeal abscess Croup Pharyngitis Group A strep Treat to prevent complications, acute rheumatic fever and ARHD Glomerulonephritis not prevented by Abx Mononucleosis EBV Pharyngitis, fever, cervical lymphadenopathy Splenomegaly in 50% Dx: monospot, atypical lymphocytes Treatment: fluid, rest, steroids, avoid ampicillin (rash), contact sports/trauma (splenic rupture) Ludwig’s Angina Bilateral cellulitis of the floor of the mouth True emergency (airway obstruction) Elderly, debilitated men (alcohol abuse) Dx: CLINICAL – brawny edema of submandibular area, febrile, protruding elevated tongue, respiratory distress Tx: IV abx (clindamycin or Unasyn or PCN + MTZ) and airway protection Ludwig’s Angina Peritonsillar Abscess Fever, trismus, dysphagia Adolescents, young adults Enlarged inflamed tonsil extending medially Displaces uvula to opposite side ENT consult for I & D, IV Abx (PCN or Clindamycin or Unasyn + MTZ), IVF, IV steroids Peritonsillar Abscess Retropharyngeal Abscess Children aged 6 mos – 3 yrs Staph aureus, Group A strep, anaerobes Fever, neck pain, muffled voice, dysphagia Child prefers to lie supine (do not force to sit up) Diagnosis: prevertebral edema on lateral soft tissue neck X-ray Treatment: ICU admit, IV abx, ENT surgical drainage PCN or Clindamycin or Unasyn + MTZ Epiglottis Abrupt high fever, sore throat, stridor, dysphagia Child is drooling, stridorous, muffled voice, sitting up with chin forward and neck extended Any age – children more worrisome H. influenza, Group A strep, B. catarrhalis Epiglottis Dx: thumb print sign on lateral neck x-ray Tx: cricothyrotomy set up at bedside, intubation by ENT in OR if possible, ICU admit for IV antibiotics, humidified oxygen, IV fluids Ceftriaxone + Clindamycin or Vancomycin OR Unasyn alone Croup Inflammation of the larynx and subglottic airway Parainfluenza most common (RSV, adenovirus) 2-3 days of URI sxs, worsening to a barking cough, hoarse voice, and stridorous Rare after age 6 Diagnosis: steeple or pencil sign on AP soft tissue neck x-ray Tx: steroids (0.6 mg/kg dexamethasone), humidifed oxygen, racemic epinephrine Steeple/Pencil Sign What is it? What is it? The End Any Questions?