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Facial Emergencies
General Strategy
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
B. Objective data- general- LOC< VS, odors, hygiene, LOD inspection- drooling, symmetry, pupil reaction,
vesicles palpation- sensory deficits, area of tenderness percussion- soft tissue over sinuses. 3. Diagnostic- A. 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 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”
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 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”
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 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) 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
Subjective- HPI- viral illness, paralysis, pain, drooling, loss
of taste, n/v, sensitivity to noise PMH- DM, sarcoidosis, Lyme disease, VZV
infection Objective- general- 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
Diagnostic- lyme titer, mastoid xray, CT scan, Nursing Diagnoses- Planning/Intervention Meds- analgesics, steroids, antivirals, Educate- moist heat/facial massage, corneal
protection, sunglasses, reassurance Evaluation-
Sinusitis-
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
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
Inflammation of parotid gland
Usually caused by bacteria or virus, but can be caused by HIV,TB, and calculi formation
Fractured tooth
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 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-
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 re-implantation & healing.
Tooth should be transported In milk, saline, or under pts tongue in cooperative pt.
Ludwig’s angina-
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
Foreign Object in the ear
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
Acute Otitis Media
* bacterial or viral infection of middle ear
*commonly preceded by URI.
* more common in children due to narrower, shorter eustachian tubes.
Acute Otitis Externa-
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
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-
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
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.
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)
Evaluation- airway, pain relief
Epiglottitis
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.
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