Category: Head, Eyes, Ears, Nose, and Throat (HEENT)

Eye Complaints

Common Complaints

  • Red Eye
  • Decreased Vision
  • Trauma to the Eye

Approach to a Vision Complaint

  • Step 1: Assess visual acuity
    • Visual acuity is the “vital sign of the eye”
    • Snellen eye chart is best
    • If patient unable to see chart…
      • Count fingers?
      • Able to see light?
  • Step 2: Examine the conjunctiva/cornea with fluorescein
    • How to apply fluorescein
      • Recline patient 45 degrees
      • Pull down on lower eyelid to create pocket
      • Place anesthetic eye drops in pocket (ex. tetracaine)
      • Wet the fluorescein strip with eye drops and apply to pocket
      • Have the patient blink to distribute the dye
    • Look under woods lamp for bright “uptake” areas that don’t move with blinking
      • These represent abrasions, ulcers, etc
    • This step is also a good opportunity to evert the eyelids and examine for foreign bodies if appropriate
  • Step 3: Examine the anterior chamber with slit lamp
    • “Cell and flare” (example HERE)
    • Representative of iritis, uveitis
    • This is also a good opportunity to examine any other abnormal areas of the eye under magnification!!!
  • Step 4: Check intraocular pressure
    • Pressure >20mmHg (especially when unequal) is concerning for acute angle closure glaucoma
    • Multiple tools to measure pressure on market, ask somebody to show you how to use
  • Step 5: If appropriate, use ultrasound to evaluate posterior eye
    • Multiple things can be diagnosed with ultrasound of the eye
      • Retinal detachment
      • Optic neuritis
      • Papilledema
      • Foreign bodies

Additional Reading

Sore Throat

You must know the FOUR emergent causes of sore throat!

Step 1: Apply the Centor Criteria

  • Determines if patients is at risk for Group A strep (“strep throat”)
  • 4 Criteria
    • Fever
    • No cough
    • Tonsiller exudates
    • Lymphadenopathy
  • Interpretation
    • If patient has ALL of the criteria
      • Treat for strep throat
    • If patient has NONE of the criteria
      • Don’t even test for strep throat
    • If patient has SOME of the criteria
      • Consider testing for strep throat

Step 2: Prescribe Antibiotics

  • B-lactams work best
    • Penicillin
    • Amoxicillin
  • If patient has allergy, consider alternative agent
    • Azithromycin
    • Clindamycin

Step 3: Pain Control

  • NSAIDS
  • Steroids

Step 4: Consider EBV (Epstein-Barr Virus)

  • Consider in patients not getting better on antibiotics
  • Examine for splenomegaly
    • If present, no contact sports

Step 5: Consider the FOUR Emergent Causes of Sore Throat

  • Ludwigs angina
    • Airway emergency
    • Infection UNDER the tongue
  • Peritonsillar abscess (PTA)
    • Complication of bacterial pharyngitis
    • Causes “trismus” (difficulty opening mouth)
    • Frequently need to be drained
  • Retropharyngeal abscess
    • Airway emergency
    • Difficult to diagnose by exam alone
      • Infection is BEHIND airway
      • Seen on lateral neck xray
  • Epiglottitis
    • Airway Emergency
    • “The Triad”
      • Drooling
      • Dysphagia
      • Distress (respiratory)
    • Lateral neck xray shows “thumbprint sign”

Additional Reading

  • Peds O- Oxygen, Airway, and Respiratory Disorders (EM Clerkship)
  • Airway Infectious Disease Emergencies (UNM)

Dental Pain

Minor complaint. Huge SLOE points!

Step 1: Identify Which Tooth is Causing Pain

  • Bonus points if you number teeth correctly!
    • Number 1-32
      • Tooth #1 is top right
      • Tooth #32 is bottom right
    • Refer to dental chart for reference

Step 2: Correct Terminology When Making Diagnosis

  • Pulpitis
    • Pain in the tooth itself
    • Reversible
      • Triggered by hot/cold etc (then goes away)
    • Irreversible
      • Does not resolve
  • Gingivitis
    • Pain of the gingiva around the tooth
  • Periapical abscess
    • Pain with percussion of tooth

Step 3: Give Pain Medicine

  • NSAIDS have been shown to work best
    • Naproxen
    • Ibuprofen
  • Opiates for breakthrough pain
    • Hydrocodone-acetaminophen (Norco)
    • Oxycodone-acetaminophen (Percocet)

Step 4: Consider Antibiotics

  • Pulpitis does not require antibiotics
  • Gingivitis/Periapical abscess frequently improve on antibiotics
    • Penicillin VK

Step 5: Inferior Alveolar Nerve Block

Additional Reading

  • Inferior Alveolar Nerve Block (YouTube)
  • Common Dental Emergencies (AFP)

Epistaxis

Don’t forget to wear protective gear. Gown up!

Initial Encounter

  • History
    • Anticoagulants
    • Easy bleeding/bruising
    • Lightheadedness
  • Exam
    • Pallor
    • Tachycardia/Hypotension

Step 1: Put on Personal Protective Equipment

  • Gown
  • Gloves
  • Mask
  • Eye Protection

Step 2: Clear Nose and Visualize Bleeding

  • Have patient blow out/remove any clot and look for source of bleed
  • Kiesselbachs plexus
    • “Anterior” epistaxis
  • Sphenopalatine artery
    • “Posterior” epistaxis
      • Most severe/dangerous form

Step 3: Spray In Oxymetazoline (Afrin)

  • Hold pressure for 15 minutes after initial application

Step 4: Cauterize With Silver Nitrate

  • Avoid bilateral cauterizations
    • Can cause septal perforation
  • Anesthetize as necessary
    • 4% lidocaine on gauze and leave in nose for 10 minutes prior to cauterization

Step 5: Pack the Nose

  • Multiple commercial products available for this
  • The utility of antibiotic prophylaxis at this step is unclear
  • Patient goes home with packing in place

Additional Reading

© 2020 EM Clerkship, LLC

Theme by Anders NorenUp ↑