So we're gonna talk a little bit about emergencies that we see as otolaryngologist. And and with the first part really being what some things that you see in your offices and that you can be apt to take care of. Um acutely eh pistachio sis perry tonsil abscess is cute, sensory neural hairlines. I'm only going to make one quick comment about that because Dr Volker is going to talk about that. But sinusitis emergencies, facial fractures and of course pending airway emergencies. So epic stacks his nose please. Uh it's of course now it used to be most common in winter months. It's now 12 months a year with all of the anticoagulants that patients are on when Coumadin was the only one we'd only see a spattering of patients on Cuban in. But with now all the new As the relatives products is all of those different anticoagulants. We're seeing those bleeds now 12 months a year. Um Of course with hypertension control the blood pressure in your offices in Children cut their fingernails. Kids pick their noses when they're asleep. And if you ask the the history when are they nose bleeding most commonly? As early in the morning. Um When you have a strategy to take care of something, you really have to have the tools and the preparation beforehand. So a light source is very important. Headlight uh for anything that you do, lighting is uh seeing is believing and having good lighting is important and using local anesthesia with epinephrine. Um I was trained to do many surgeries especially in the V. A. With just under local anesthesia. and it was invaluable now in my practice. So this is kessel box plexus. This is a this is actually a patient that came in with six years of recurring nosebleeds. She had seen other doctors. But this is what I found in her aunt Karen areas, the most dramatic Castle Box plexus I had ever seen. Uh And she actually used, I used electric artery to cauterize those large vessels. But she came in and she said well I get nose please, how bad are they? Well it squirts across the room. I said it's a pretty bad news. Um But initially when you have patients with recurring nose please make sure they have cotton balls in Afrin. And you know the old saying just hold your nose close is great. But if you place a cotton ball with some Afrin it and then apply pressure uh it will stop in most of the times. So there's three areas. Major areas where nosebleeds occur. Of course 80% of them in an area one. And there's some important an atomic uh pearls to know about that to control them. Uh The second area is the anterior and posterior boys. In the third area is the spino palatine post here nasal artery, we're only going to address them the ones own because two and three are really major bleeds and especially the post your nose bleeds when the flow of blood is going pasta really. It's not. And uh those patients are usually showing up in the emergency room and not to come and products etcetera. Um Although almost all patients with nosebleeds will develop blood on the contra lateral side and clots. And we're gonna talk a little bit about that And what to do. Training and preparation A nosebleed is a horror show. I can tell you that every single patient thinks that they've bled out there, they're going to pass out in their bathrooms. It looks like Freddy Krueger was there. They bring pictures of the blood all over the place and I always tell them you have more than enough blood, don't worry. But they are very anxious and very scared and because of that anxiety and fear their blood pressure is up. So one of the things if you don't have sedation in your office, make sure you have some Valium, even if they're going to the emergency room, give them something to calm them down. Having the equipment and strategy control the the nosebleed is key. So this is our basic nosebleed kit, the sinus rinse bottle or a bulb syringe. Afrin topical uh Ponta cane or even topical lidocaine works on the mucus lining tissue. Um uh silver nitrate uh and um the 30 gauge and long 27 gauge needles. These are examples of some Tampa balloons and tampons uh you in your office is you should have at least one of the manufacturers components of this and I know that a lot of people don't like putting them in because they are painful, but I'm going to show you how to do it without much pain. Um the balloons need to come out within 24 hours because they really create a lot of pressure and they can cause necrosis oops. Um So if you see the bleeding area, which it's not hard to see in the anterior nares, put a little topical anesthesia on it, even 2% lidocaine and then cart arise it with the septic pencil of silver nitrate. If you can't find it, you can send it over to us in a fiber optic endoscopy will be performed in the emergency room, nasal packing is usually placed blindly by the emergency room. Either balloon packs for marisol and usually the non balloon ones are left in for three days. But the the the balloon ones should be out in 24 hours. Here's the takeaway and this is a documented study Nasal lavage. So they had 65 patients that had post here and nosebleed. It was controlled with simple nasal lavage, 65% of the time with 50 CCs of warmed five ml lavage and you can do it with a bulb or the rents. Why this works is because of two things as soon as the cloud occurs the clock. Coagulant factors are excreted. So that creates an anticoagulants or environment. And also the clot can be holding the artery open in the mouth And just getting that clot out of the mouth is or out of the nose is helpful. Emergency room nurses hate us or hate me when I tell them wash out the nose because it's not a beautiful thing, but it it stops in many, many cases. And the other key is doing a simple injection at the anterior base of the nostril because the main greater palatine artery, incisor canal artery that feeds the bottom of kessel box plexus can be controlled by the epi but also you get a nice and aesthetic so anything you do in the nose, if you put packing is not as painful. Um And of course the bleeding improves and that's about about a centimeter back from this area. And this is an example of a patient that I was bleeding and unfortunate. Let's go back well for the second, I can show this, but it's basically you take a three CC syringe and right at the base of the nostril here, You inject about two CCS and it will track back along the bone and you'll get a nice an aesthetic and if it's just kessel box plexus many times it will stop perry counselor abscesses a lot of times. Primary care will see these and really get nervous and it's really this is low lying fruit because that absence is right in the view and putting a needle into it. You can really advocate for the patient's pain presents with unilateral swelling, deviation of the uvula swelling in the angle of the jaw. Hot potato voice. Um It's not that difficult to um diagnose. So this is what you have a simple 10 cc syringe, a spinal needle or 20 to 18 gauge 1% Zilla Kane. Um And after decades in unison or clear son. And this is these are examples of perry towns for absences. Um christmas is almost pathan A Monica, patients are having a hard time opening their jaw because the irritation of the terra grade muscles, it's most probably a perry translator abscess. And as you see there the abscesses right in view where to put the needle safely. So you draw a horizontal line from the moller, straight, actually a vertical line from the Mueller. Straight up horizontal line from the superior pillar of the contra lateral tonsils. And as you see right there is a spot where you can safely put the needle and this is an example of draining a perry counselor abscess very simply lovely. And the patients immediately get great relief. This is put in there so you can see the the things that everybody is afraid of is the carotid artery and that inject and putting the needle into the, created the abscess almost protects you from that. And as you see here in this cat scan um If you stay medial to the molar and um just superior to the contra lateral super pole. You're going to hit straight dead center in that abscess and train it. Um The the carotid arteries are lateral. They are protected by the territory of muscles. Unless you go at a trajectory laterally with your needle, you won't, you rarely hit it. I've not heard of anyone hitting a vascular structure by doing a needle drainage of repairing counselor abscess. So that's don't worry about that. Quickly led wigs and in china. What's this? It's usually related to dental Origin but it's a sub mental um cellulitis. It is a real emergency because these patients at least 70-75% of the cases need airway control either via tracheostomy or via emergency intubation. It's not an abscess. It's a cellulitis tender firm. Usually dental issue. Hot potato voiced company had just made all related to the um ah Infectious systemic process. As you see, abscesses in the upper airway 5% required trick or airway and Ludwig's Angina 75 and 200 people quickly dr Volker is going to talk about this. This is how what what I would recommend. It's something that we found it is it is practical easy, simple and you can get a really valuable hearing test and your M. A. Can administer it. They don't have to do anything that's done on an ipad with high definition um headphones and the ipad is um sold by the company with uh changes in the software to be able to get 250 hertz up to 4000 hertz. A normal ipad does not have that ability. So you really can't get a valuable hearing test. And this takes about five minutes. And for screening audio grams for every primary care, you should be doing them as part of your wellness exams on every patient. Now that you have a simple option to do it and it's reimbursable Uh screening Oughta Graham pays 80 bucks by Medicare and its valuable your when patients come in and say how's your hearing? Oh my hearing is fine. Well, hearing loss is a silent disease. You should ask their spouse or their bedfellow if they're hearing well. And they'll tell you the truth because if you haven't heard it, you don't even know it existed. So the subjective aspect of hearing loss is a big issue. So this is a really great uh easy aspect for primary care. Quickly orbital cellulitis. This patient, as you see, has a Thelma pleasure, he can't move his eye and he's got an orbital abscess that was drained. Train easily of course, immediate surgery. Uh And I. V. Antibiotics. Quickly facial fractures, Facial fractures have dramatically decreased because of seatbelts. No one. But then on top of that airbags. And as you see here uh the statistics have have have really changed since the advent of that. Most of the facial fractures that we've seen were usually related to car accidents. And of course this is orbital zygomatic. So the most common secondary to note nasal fractures when you do have a nasal fracture or a uh zygomatic orbital fracture. You have to tell the patients not to blow their nose. Um because I've seen it probably 20 times where patients would sneeze or blow their nose after a fracture and then they developed a new mo orbit. Um and this is an example of a patient with that. There was an orbital blowout fracture as you see on the on the right side. And the key with surgery versus no surgery is entrapment or an al thalamus or no entrapment orale thalamus. And here's just examples of the IMF erectus being entrapped in the fracture line and then just fat hernia waiting down, which is a non surgical case. Um Here is uh example of one of our kings players this year who developed a fracture from a slap shot and he uh had a pretty dramatic orbital nasal fracture. As you'll see in a second, penetrating injuries are not common, but in ice hockey, they do happen. Um So that there it is right there. And here is the fracture. Um His his entire mid face was depressed about a centimeter and a half. And this is the reconstruction when he woke up in the recovery room, he said, can I get on the ice tomorrow? I said, no, let's give it a couple of days. So here he is. Uh three weeks after surgery, he scored in his winning goal in his first day back and here he is there pending airway obstruction. There was another hockey player that got a puck in the in the in the job which caused a very rare sliding door fracture with with fracture fragments in the in the tongue. There management algorithm is obviously oxygen oxygen, oxygen. Getting it some way into the obstructed airway. Either by an Ambu bag, Lauren go mask airway or even just trans tracheal oxygenation. And this is a very simple way of trans tracheal oxygenating someone with an Ambu bag or just putting a needle in just to deliver oxygen. And this gentleman, as I was saying, I had an emergency airway so severe that his tongue was prolapse ng out of his mouth and I couldn't that obviated any I. M. F. But he did just fine. So having said that, thank you for listening and there's a couple of emergencies that you did
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