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Toronto Notes 2019 Otolaryngological Presentations and Emergencies
Investigations
• CBC,electrolytes,bloodglucose,coagulationstudies±cardiacbiomarkers±toxicologyscreen • non-contrastCThead:lookforhemorrhage,ischemia
• ECG±echocardiogram:ruleoutAFib,acuteMIassourceofemboli
• otherimaging:carotidDoppler,CTA,MRAasappropriate
Management
• ABCs;intubationwithRSIifGCS≤8,rapidlydecreasingGCS,orinadequateairwayprotectionreflexes
• thrombolysis:immediateassessmentforeligibility;needacuteonset,<4.5hfromdrugadministration
time AND compatible physical findings AND normal CT with no bleed
• elevating head of bed if risk of elevated ICP, aspiration, or worsening cardiopulmonary status
• NPO,IV±cardiacmonitoring
■ judge fluid rate carefully to avoid overhydration (cerebral edema) as well as underhydration (underperfusion of the ischemic penumbra)
• BP control: only treat severe HTN (sBP >200 mmHg, dBP >120 mmHg, mean arterial BP >140 mmHg) or HTN associated with hemorrhagic stroke transformation, cardiac ischemia, aortic dissection, or renal damage; use IV nitroprusside or labetalol
• glycemiccontrol:keepfastingglucose<6.5%inacutephase(5d)
• cerebraledemacontrol:hyperventilation,mannitoltodecreaseICPifnecessary
• consult neurosurgery, neurology, medicine as indicated
Medications
• acuteischemicstroke:thrombolytics(rt-PA,e.g.alteplase)ifwithin4.5hofsymptomonsetwithno evidence of hemorrhage on CT scan
• antiplateletagents:preventrecurrentstrokeorstrokeafterTIAs,e.g.Aspirin®(1stline);clopidogrel, Aggrenox® (2nd line)
• anticoagulation:DVTprophylaxisifimmobile;treatAFibifpresent
• follow-upforconsiderationofcarotidendarterectomy,cardiovascularriskoptimization
Otolaryngological Presentations and Emergencies
• seeOtolaryngology,OT6
• earsymptoms:otalgia,auralfullness,otorrhea,hearingloss,tinnitus,vertigo,pruritis,fever
• riskfactorsforhearingloss:Q-tipuse,hearingaids,headphones,occupationalnoiseexposure
Dizziness and Vertigo
• distinguishfourtypesofdizziness:vertigo(“roomspinning”),lightheadedness(“disconnectedfrom environment”), presyncope (“almost blacking out”), dysequilibrium (“unstable, off-balance”)
• broaddifferentialanddiversemanagement(seeFamilyMedicine,FM25andOtolaryngology,OT12)
• consideradversedrugevents
Otalgia (see Otolaryngology, OT6) • differentialdiagnosis
■ infections: acute otitis externa, acute otitis media, otitis media with effusion, mastoiditis, myringitis, malignant otitis externa in diabetics, herpes simplex/zoster, auricular cellulitis, external canal abscess, dental disease
■ others: trauma, temporomandibular joint dysfunction, neoplasm, foreign body, cerumen impactions, trigeminal neuralgia, granulomatosis with polyangiitis
• inspectforotorrhea,palpateouterear/mastoid,otoscopicexaminationtolookforbulgingerythematous tympanic membrane, perforation, membrane retraction, infiltration, vesicles, ulcers, masses, lesions
• C&Sofearcanaldischarge,ifpresent
• CTheadifsuspicionofmastoiditis,malignantotitisexterna
• antibiotics/antifungals/antiviralsforrespectiveinfections
Hearing Loss (see Otolaryngology, OT7)
• differentiateconductivevs.sensorineuralhearingloss
• ruleoutsuddensensorineuralhearingloss(SSNHL),amedicalemergencyrequiringhighdosesteroids
and urgent referral
• anelderlypatientpresentingwithunilateraltinnitusorSNHLmustbepresumedtohaveanacoustic
neuroma (vestibular schwannoma) until proven otherwise
• consideraudiogramandreferraltoorfollow-upwithfamilyphysician
Emergency Medicine ER39
If patient presents within 4.5 h of onset of disabling neurological deficits greater than 60 min with no signs of resolution, they may be a candidate for thrombolysis. Do brief assessment and order stat CT head
Absolute Exclusion Criteria for tPA
• Suspectedsubarachnoidhemorrhage
• Previousintracranialhemorrhage
• Cerebral infarct or severe HI within the past
3mo
• BP>185mmHgsystolic,or>110mmHg
diastolic
• Bleedingdiathesis
• ProlongedPT>15sorINR>1.7
• Platelet count <100,000
• Heparin received within last 48 h
• Currentuseofthrombininhibitorsordirectfactor
Xa inhibitors
• Bloodglucose<2.8mmol/L(<50mg/dL)
• IntracranialhemorrhageonCTorlargevolume
infarct
Relative Exclusion Criteria for tPA
• Onlyminororrapidlyimprovingsymptoms
• Pregnancy
• GIorurinaryhemorrhagewithinthepast21d • Seizureatonsetcausingpostictalimpairments