Facial Emergencies
General Strategy
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1. Primary/ Secondary Assessment
2. Focused Assessment
A. Subjective- HPI (pain, resp distress/ sensory changes)
auditory- ear pain, hearing loss, ringing in ears
visual- decreased tearing, blindness, visual field deficits
tactile- dec sensation, facial pain
gustatory- impairment of taste, loss of taste
olfactory- loss of smell
* facial asymmetry, rash, fever/chills, n/v, speech prob
B. PMH
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B. Objective datageneral- LOC< VS, odors, hygiene, LOD
inspection- drooling, symmetry, pupil reaction, vesicles
palpation- sensory deficits, area of tenderness
percussion- soft tissue over sinuses.
3. DiagnosticA. labs- cultures, CBC< coag profile, ABG
B. Imaging- Facial bones, water’s view, Panorex, CXR, CT
head
4. Planning/Intervention- priorities of care
5. Evaluation
Pediatric considerations
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PEDIATRIC- 85% of foreign body aspirations occur in children
<3.
- Boys 2x > girls to aspirate. Peak incidence
between 1-2 y/o. Foreign body ingestions = in boys
& girls.
- 20-38% children w/ esophageal FB ingestions
have no symptoms.
- irritability and lack of feeding ** potential sign of
dental/ENT emergencies
Pediatric “Pearls”
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Persistent
cough/wheezing may
indicate FB aspiration
Difficulty feeding may
indicate significant
ENT emergency
Abrupt onset upper
respiratory and
pulmonary symptoms
suggest FB ingestion
Geriatric considerations
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Aging related
* Visual loss, hearing loss, decreased taste and
sensitivity to touch.
* Loss of STM, slower thought processing, incr pain
threshold
* muscle atrophy, decreased flexibility
Elderly pt have chronic diseases that provide more
limitations
Geriatric “pearls”
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Malignant external otitis media and
cholesteatoma is consideration for elderly
patients c/o earache or recurrent ear
infections. (especially those w/ DM)
Falls, visual changes, MVC’s and assaults
are the primary causes of dental/ENT
trauma in the elderly
Poor eyesight contributes to FB in the
pharynx.
Bell’s Palsy
Bell’s Palsy
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One of the most common presentations of facial nerve
paralysis syndrome
Paralysis of all the facial muscles on one side of face,
including forehead
Usually preceded by URI (60%) or other viral illness
Bell’s palsy is diagnosis of exclusion
Symptoms thought to be caused by swelling of facial
nerve, in narrow course through temporal bone, nerve
becomes compressed and ischemic.
Usually unilateral
Usually in people >40 years old, and is self-limiting
Herpes Zoster Oticis
(Ramsay Hunt Syndrome)
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Viral infection involving external, middle, and inner
ear and associated with unilateral facial paralysis.
Herpetiform vesicular eruptions occur due to being
a reactivation of varicella-zoster virus on the
dermatome
The eruptions are on the external ear, TM, soft
palate, oral cavity, face, neck, and/or shoulder
More painful than Bell’s palsy.
Less incidence of full facial recovery & possibility of
permanent hearing loss
Assessment
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SubjectiveHPI- viral illness, paralysis, pain, drooling, loss of
taste, n/v, sensitivity to noise
PMH- DM, sarcoidosis, Lyme disease, VZV infection
Objectivegeneral- LOC, drooling, LOD
inspection- upward mvmt of eye on affected side
when trying to close eye, facial paralysis, lid lag,
dec lacrimation, drooping of mouth, no blink on
affected side, vesicular lesions
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Diagnostic- lyme titer, mastoid xray, CT scan,
Nursing DiagnosesPlanning/Intervention
Meds- analgesics, steroids, antivirals,
Educate- moist heat/facial massage, corneal
protection, sunglasses, reassurance
Evaluation-
Sinusitis
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Inflammatory condition of mucus membranes lining
the paranasal sinuses.
Symptoms mild-severe, progresses over 7-10 days
Bacterial disease suggested if worsening after 5
days, persistent symptoms after 10 days.
Symptoms- nasal congestion, mucopurulent
drainage, pressure over sinuses, malaise,, fever,
facial swelling
Complications- chronic sinusitis meningitis, orbital
cellulitis, epidural abscess, orbtal abscess.
Trigeminal Neuralgia
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Disorder of 5th cranial nerve
Chief complaint- excruciatingly painful
paroxysms.
More common in women, usually 50-69
Exacerbated by exposure to cold and facial
stimulus
Parotitis
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Inflammation of parotid
gland
Usually caused by bacteria
or virus, but can be caused
by HIV,TB, and calculi
formation
Fractured tooth
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Most frequent dental emergency in ED.
Can result from sports activity, MVC, falls, seizures,
physical assault.
Consider- 50% of physical trauma in child abuse is
in head/neck region
Assess for concurrent head injury.
Watch for aspiration of tooth
Classifications of tooth
fractures
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Class I- most common, involving only enamel.
Injured area is chalky white. Cosmetic restoration
available w/i 24-48 hrs.
Class II- pass through the enamel and expose
dentin. Fracture appears ivory/yellow. Urgent for
children b/c of lack of protective dentin and RF for
bacteria to easily get in pulp causing infection or
abscess if exposed >6hrs. Adults treated w/I 24 hrs.
Class III- dental emergency. Injury to enamel,
dentin, and pulp cause pink/bloody tinge to fracture.
Exposure of pulp, exposes nerve.
Tooth avulsion
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Dental emergency- if tooth
torn from socket, tissue
hypoxia develops, followed
by eventual necrosis of
pulp.
Re-implantation w/I 30 min
increases chance for reimplantation & healing.
Tooth should be
transported In milk, saline,
or under pts tongue in
cooperative pt.
Ludwig’s angina
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Usually results from
secondary dental infection
involving the lower second
& 3rd molars and can lead to
airway mgmt problems.
Bilateral diffuse swelling &
extending cellulitis involving
(Submandibular,
submental, & sublingual)
Neck & face swollen with
protrusion and elevation of
tongue, causes difficulty
talking & swallowing.
THE EAR
The ear consists of 3 parts
external- consists of auricle and external canal
middle- air filled cavity inside temporal bone,
contains tympanic membrane
inner- contains bony
labyrinth, holds sensory
organs for equilibrium
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Foreign Object in the ear
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The object may have entered external canal
accidentally or intentionally.
Often in children it is not discovered until purulent
drainage noted.
Small insects that enter canal produce great
discomfort due to mvmt & buzzing.
Vegetable foreign bodies absorb moisture, result in
enlargement, increased obstruction of ear canal,
and offensive odor.
Ear infections- definitions
Acute Otitis Externa
* “swimmer’s ear”
* bacterial or fungal
infection
* RF- moisture in ear
canal from retained
H2O, or trauma
resulting from Q tip or
foreign object in ear
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Acute Otitis Media
* bacterial or viral
infection of middle ear
*commonly preceded by
URI.
* more common in
children due to
narrower, shorter
eustachian tubes.
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Acute Otitis Externa
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S/S- painful outer ear and canal, itchy ear, impaired
or diminshed hearing, feeling of fullness in ear,
discharge of ear canal, fever.
HALLMARK SIGN- reproducible pain when earlobe
manipulated
interventions/ Monitoring- usually no systemic abx
unless pt DM, usually abx ear gtts. Apply hot, moist
compresses to external ear. Avoid swimming 7-10
days until cleared. Ear plugs should be
encouraged.
Epistaxis- assessment
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HPI- duration, frequency, amt of bleeding. Constant
oozing ( anterior), posterior (more profuse, possible
arterial hemorrhage), possible FB, trauma.
PMH- HTN, artherosclerosis, bleeding disorders
Physical assessment- LOC< BP, tachycardia, fear
of dying. Inspect- bleeding, erythema and swelling
or nasal mucosa, Blood in auditory canals.
Diagnostic- CBC, coags, T&C, CT is tumor
suspected
Treatments
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Anterior bleeds- sitting position, leaning forward.
Direct pressure.
Posterior bleeds- direct pressure for at least 10
minutes, high fowler’s position, IV, ENT consult,
assist with cauterization, monitor VS.
Evaluation- bleeding, VS.
Peritonsillar abscess
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s/s- severe sore throat, painful/difficult swallowing,
trismus, and uvular deviation, muffled voice and
unable to swallow own saliva
usually Streptococci bacteria invades tonsillar
capsule and areaolar tissue.
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Treatment- ABC’s, O2, IV,
HOB 60-90 degrees
provide warm saline throat irrigations
prepare for I & D
Meds (abx, topical anesthetics, analgesics,
narcotics, antipyretics)
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Evaluation- airway, pain relief
Epiglottitis
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Infection and inflammation involving epiglottitis.
Frequently caused by HIB.
Predominately child illness btwn 2-7 yrs old,
decreased dramatically since Hib vaccine initiated.
Abrupt onset fever and sore throat.