Consult guidelines

Airway

Tracheostomy

"Fish-bone in throat"

Esophageal foreign body

Airway foreign body

Peritonsillar abscess (PTA)

Background: 

You'll get calls from both ED and Medicine docs for this.  Per established interdepartment protocol, ED docs are supposed to attempt a needle drainage before calling you, but many will give you the excuse "I don't feel comfortable" or "since you are here...."  Generally, these patients will have throat pain for at least 3 days, obvious swelling of tonsillar fossa, trismus, poor PO intake, and fever.

 

Equipment: 

Hurricane spray (optional), Lido with epi, 18 gauge needle on syringe (if aspirating), 11 blade and tonsil clamp (if I&D), Yankaur suction, tongue depressor (can use Yankaur suction as tongue depressor), Headlight, flex scope, irrigation (saline flushes and angiocath work well)

 

Management: 

Airway, airway, airway

Consider starting with flexible laryngscopy to rule our supraglottitis, which requires close inpatient observation and IV antibiotics until improved

Split the difference between the fossa and uvula (Hilsinger splits the anterior pillar and the mandibular ramus instead), spray hurricane, inject local, if needle aspiration may need several passes, incise, open with clamp and suction.  Generally will get 2-10 cc of pus.  If there is pus, patients will start feeling better right away.  Most will ooze for a short period but stop spontaneously.  Yankauer suction can serve as a tongue blade and work double as suction. Can also try using a bite block (outside the Maxillo-facial or) for patients who are clamped down. Consider giving a bolus of IV fluid and 4mg dexamethasone (or other IV steroid) before they leave the ED (or even before you come in to relax the jaw).  Send out with pain meds of choice and consider PCN/clinda/augmentin, especially if no pus.  Very short burst of prednisone can also help with pain/swelling.  Call or see the next day -- should feel markedly better in 24 hours.

 

Reason for admission: 

rarely ever

Facial fracture

Nasal fracture

Ask ED to make sure no septal hematoma -- needs draining. Otherwise have ED place E-consult for patient to be seen in HNS clinic.

 

Reason for admission: 

never

Abscess

Background: 

Common cause for call.  Generally, consulting physician will expect you to drain as they are "uncomfortable" with the head and neck area.  Also will often have ED physicians calling any intraoral infection as "Ludwig's" although this entity very rare. 

 

Equipment: 

Lidocaine with epi, syringes, needles (18 guage, 27 guage), 11 blade, iodoform packing strips, culture swabs 

 

Management: 

Physical exam important to distinguish between cellulitis vs abscess, CT scan can help although notorious for inaccuracy between abscess and phlegmon (rim enhancing areas are not always abscesses).  However, general principle is to needle the area if any doubt for abscess, then open if needed.  If patient is sick, should consider admitting for IV abx.  Always culture abscess.  Pack with packing strips if external abscess.  Abx management for skin source - consider keflex, clindamycin, septra - note while septra will often cover MRSA, will often not cover MSSA.  Also very important - frequent warm compresses and raise head of bed.

 

Reason for admission: 

clinically sick, considerably elevated WBC, worsening despite PO abx, high fevers

Epistaxis

Background: 

Very common call especially during winter months.  Can be a PITA as often refractory to management.  Levels of care per ED physician can greatly vary.  ED tends to like "rapidrhino" packs, although some do not seem to work quite as well as merocel packs.  Many ED physicians will call a nosebleed a "posterior bleed" if whatever they have tried fails - although posterior bleed in reality not as common.  Try to get them to go down the protocol and place packs. 

 

Equipment: 

Merocel packs, bacitracin ointment or some other lube, epistat balloons (if needed), headlight, nasal speculum, lidocaine with epi (if needed). Can investigate nose with 0-degree scope to identify and address site of bleeding if amenable.

 

Management:  

Several things to check on history/exam - prior hx (HHT), side of bleed, approximate amount of blood lost, use of anticoagulants, reason for poor hemostatis - chemo, renal failure, hepatic failure, uncontrolled hypertension, lab values H/H.  If bleeding not too brisk, suction and check to see if you can isolate site of bleed (not always possible).  If able to isolate (i.e. anterior septum), consider local management with silver nitrate cautery.  Injecting some lido with epi at the focal site of bleed can help with hemostasis as well.  Also locating a focal source can possibly improve with comfort as you may be able to substitute a long merocel back with a short anterior pack.  If rapidrhino not working, consider merocel pack or epistat.  If one pack does not work, consider bilateral pack (pressure from opposite side can help) or two packs in one side (although uncomfortable).  If patient continues to bleed despite all possible measures, will have to admit for possible OR control vs IR embolization.

 

Reason for admission: 

for OR vs IR control of persistent bleed, posterior packs; if bleeding has stopped but patient needs admission for transfusion/observation, have HBS admit   

Ear foreign body

Background: 

Generally not an emergency.  Can see as outpatient.

Angioedema

Background: 

Usually consulted for concern of airway compromise. ED should have given epi, benadryl, H2 blocker.

 

Management: 

If process reversed, is safe to observe in ED for 2 hours then D/C with atarax elixir for future episodes. Consider "angioedema labs": CBC diff, creatinine, ALT, TSH, C2, C4, C1 esterase inhibitor level and function, CH 50, SPEP, U/A. F/u in allergy department.

Post-tonsillectomy bleed

Background: 

Usually POD #0 or 5-10 (scab falling off).  Whether still actively bleeding or not, should go in and see patient - departmental responsibility.

 

Equipment: 

Headlight, tongue blade, Yankauer suction, lido with epi (if needed), bovie cautery (if needed), Floseal (if needed)

 

Management:  

If blood clot in fossa, remove to visualize area.  May be able to stop bleed in ED, but active bleed will often need to go to OR.  Important to coordinate with anesthesia as these patients can be airway risk.  If it is a child or someone that may not tolerate cauterization in ED, think twice about removing the clot in the ED. You may not be able to address it then and there if it starts bleeding.

 

Reason for admission: 

Anemia, observation, if going to OR

Facial laceration

Background: 

Wide range of ED physician's comfort levels. Simple lacs should be closed by ED physicians.  Many will say "because it's in a cosmetically sensitive area..."  You should get ED to get all the instruments set up for you, but you will often need to bring your own from clinic (i.e. fast absorbing plain gut sutures, good needle drivers and pickups).  In general, good idea to get pre-closure photo documentation.  Occasionally, there will be an issue whether plastic surgery or HNS should close.  Plastics does not have residents, so generally we end up closing the lacs.  However, if patient demands plastics come in (it happens), discuss this with plastics.  Remember, the plastics attending should not get you to do the "dirty" work (i.e. come assess the patient before they come in). Remember to code these cases as our program was sited as lacking in facial lac repairs in past years. 

 

Equipment:

Lidocaine with epi, syringe, needles, good needle driver, pickups, sutures, gloves, 15 blade, scissors

 

Management:

Get ED to clean the wound out before you arrive and arrange the equipment.  If mid face laceration is lateral to lateral canthus and pt has VII paralysis, or disruption of Stenson's duct, need to explore and repair. Check for facial factures.  Can close all lacs except human bites if well irrigated (consider adding betadine to irrigant.)  Pediatric patients may need repair under conscious sedation (ketamine) - call ahead to get that set up by ED before you arrive.