Download - SCHHS Emergency Department

2005.1
Question 2
A 12 year old boy presents with a 2 day history of sore throat and fever
a) What is the most likely diagnosis and your DDx
b) List the key steps in your management
c) What is the most likely diagnosis and your DDx
- Extensive unilateral peritonsilar abscess – Quinsy
- Infectious mononucleosis
d)
-
List the key steps in your management
Assess airway
Analgesia
ENT – drainage
Dexamethasone 0.15mg/Kg
Access
NBM
IV antibiotics
Discuss treatment with parents
Admission to SSU
VAQ 2
A 47 year old man is brought to the emergency department with fever, throat
pain and difficulty swallowing.
A lateral neck XR is taken.
a) Describe 2 significant features of this Xray (2 marks)
Prevertebral soft tissue swelling, narrowing of airway
b) State your stepwise approach in the management of this man’s airway in the
Emergency Department (4 marks)
(Or other)
A 28 YO male presents to your rural ED (4 hours away from the closest ENT
service after being punched in the face.
His HR =80,
GCS15
BP =120/60
1: List 3 important features of this image.
2: List 2 further important findings you would look for on examination of this
man’s nose
Soon after this photo was taken he begins to bleed briskly from the L nostril.
3: Outline your approach to managing his epistaxis.
4: List your criteria urgent transfer to an ENT service.
1: -Nasal fracture with L lateral deviation of nasal bones
-Small volume bleeding predominantly from L nare.
-No displacement of medial canthus (naso-ethmoidal complex fracture less
likely)
2:
- Septal Haematoma
- Attempt to identify a bleeding point. (anterior vs posterior)
3:
-Sit up in position of comfort, ensure no airway compromise
-Apply direct pressure to anterior nose (below nasal bones)
-Apply ice to nose / oropharyngeal mucosa
If persistant – Obtain IV access/ Gp + hold blood
-Apply topical anaesthetic / vasoconstrictor (cophenylcaine)
- Suction clot from nares, if bleeding point identified can attempt cautery with
silver nitrate (not bilaterally to septum)
-Persistent epistaxis  Nasal packing
Initially on side of bleeding, if persistent both nares
(Epistats temporary awaiting transfer, Nasal tampons vs Rapid rhino vs guaze
pack +/- foley catheter.)
4:
emergant
-Persistant bleeding despite above
-Large volume bleed with HD instability or Airway / breathing compromise.
Urgent
-Requirement for posterior packing
-Septal Haematoma
6) A 27 year old previously well woman is brought to the Emergency
Department by ambulance at 2am with a one hour history of massive oral
bleeding. She had been discharged from the same hospital six days prior after a
tonsillectomy.

Vital signs are:
P 150 beats/min (regular)
BP 80/30 mmHg
RR 25 /min
SaO2 95% RA
Temp 36.8 C
a) What options are there to control the bleeding? (4 marks)
If not intubated, requires suction and positioning, consider nebulised adrenaline.
If airway secured, consider local pressure, adrenaline soaked gauze, and oral packs.
Definitive management with return to OT with ENT
b) What other management options are available to you whilst awaiting
definitive care? (2 marks)
Massive transfusion protocol
Analgesia
?TXA
SAQ 2
A 75-year-old man who is on warfarin for AF presents with a large and ongoing
epistaxis. He is currently haemodynamically stable. An INR performed yesterday,
as part of his routine monitoring was 8
Fill in the following table
Specific Treatment
-
Supportive Care
-
Warfarin Reversal
Disposition
-
Flex neck with pressure applied to the
anterior nares
Rapid rhino or similar device
Ribbon gauze soaked in adrenaline or
cophenylcaine
Prepare and monitor for potential airway
compromise
Prepare and monitor for haemodynamic
compromise
FBC and G&H
Vitamin K 10mg IV
Prothrombin X 50IU/Kg
FFP if no prothrombin X 15mL/Kg
Not for discharge home
Admit ENT or SSU with review
a) List 3 possible causes of his raised INR
-
Inadequate INR monitoring
Intentional suicidal ingestion
Recently commenced new medications
Lifestyle changes – diet, alcohol
Intercurrent illness
a. List 5 features of this photograph / presentation
b. Outline 4 concerns regarding this lady
c. You notice that she is starting to deteriorate. Outline your plan below:
1. a.
b.
c.
swollen red tongue consistent with haematoma
potential airway hazard
sitting up not on O2 currently
difficulty reversing dabigatran ? need for haematology / dialysis
(though this may well be inappropriate)
potential for airway to deteriorate with ongoing bleeding – difficult
airway
difficulty reversing dabigatran
potential complications of attempting reversal – further bleeding
with invasive line
appropriateness of aggressive airway control / reversal in an
elderly lady from an aged care facility ? level of functioning /
substitute decision makers / advanced directive
Phone call requesting the immediate presence of ENT /
anaesthetics
difficult airway equipment on hand
**draw / outline your failed airway algorithm of choice**
Question 5
21 year old man was brought in by ambulance after being struck in the anterior
midline of the neck with a hockey stick. Initial evaluation reveals he has a hoarse
voice, large haematoma and tenderness of the anterior neck. He is alert and has
no other injuries.
His vital signs are
GCS
HR
15
105
/min
BP
RR
O2 Saturation
Temperature
150/90
22
98
37.2
mmHg
/min
% on 6L O2/min
Degrees celcius
a) What potential anatomical structures may be injured in this patient? (5
marks)
b) Please list 2 methods of securing this patient’s airway and for each please
list 2 pros and 2 cons. (10 marks)
Method
Pros
Cons
c) Describe how you would perform a surgical airway (5 marks)
Question 5 Answers
a) What potential anatomical structures may be injured in this patient? (5
marks)





Airway: larygnotracheal injury
Vascular: Internal jugular vein, External jugular vein, Carotid
artery (expanding haematoma)
Soft tissues: Localised soft tissue swelling with haematoma.
C-Spine: Fracture or ligamatenous injuries
Nerves: Common laryngeal nerve
b) Please list 2 methods of securing this patient’s airway and for each please
list 2 pros and 2 cons. (10 marks)
Method
RSI
Pros
Rapid securement of
airway
Able to perform in ED
Operating Theatre
Controlled environment
Personnel: Anaesthetics
/ENT
Equipment: Fiberoptic
Cons
Uncontrolled
environment
Lack of expertise /
equipment
Time consumption
Lack of exposure to ED
staff
c) Please describe how you would perform a surgical airway (5 marks)
Cricothyroidotomy
 Preparation: PPE and antiseptic
 Anatomical Landmark: Cricothyroid membrane
 Horizontal or vertical excision into cricothyroid membrane.
 Use artery forceps to keep airway open and feed bougie before
railroading ETT (size 6.0) or the appropriate tracheostomy airway.
 Once ETT insitu, check position with ETCO2 + Fogging of tube +
Chest rise + CXR
 Inflate cuff and secure with tie.
Other specialized kits can be mentioned also: Quick Trach Kit,
Cook Kit, Needle cricothyroidotomy