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ENT

EMERGENCY
ENT EMERGENCY
Epistaxis

Foreign body in aerodigestive tract

Epistaxis
Epidemiology
Child and adult :
anterior epistaxis
Elderly : posterior
epistaxis
90% of epistaxis
occure at anterior site
More commom in
winter

Epistaxis
anterior epistaxis

posterior epistaxis

Blood supply of nose
External carotid
artery

Internal carotid
artery
Kiesselbachs plexus
(Littles area)
Most common site of
anterior epistaxis
Blood supply
1. Anterior Ethmoidal a.
2. Superior Labial a.
3. Greater palatine a.
4. Sphenopalatine a.

Littles
area
Etiology
Local causes

Systemic causes
Local causes
Trauma (most common from nose
rubbing)
Infectious/Inflammatory (URI , AR,
sinusitis)
Septum deviation
Neoplasm
Vascular (anurysm)
Dessication (cold, dry air)
Foreign Bodies/other


Etiology
Systemic causes
-Atherosclerotic vascular
disease ( HT, old age)
-Coagulation deficits
-Hereditary hemorrhagic
telangiectasia (Osler-weber-
Rendu)
-Idiopathic cause (10%)


Etiology
Hereditary hemorrhagic telangiectasia
Management
History
Severity, location, duration, frequency
History of allergy, sinusitis, nose rubbing, trauma
Underlying disease
Medication
Physical exam
Complete ENT exam
Identifed site of bleeding
Management
Investigation
CBC
Coagulogram
Film sinus
CT
Treatment
Pressure
Cauterization
- Chemical
- Electrocautary
- Laser
Packing
Ligation
Embolization


Treatment
Pressure (first aids)
Compression with or without
vasoconstriction agent
Neck flexion and mouth open
Cold pack
Treatment
Cauterizaton
Chemical
- silver nitrate
- Trichloroacetic acid
Electrocautery
Laser
Working from peripheral to central
Avoid cautery on opposite surface
of septum
Treatment
Packing
Anterior packing
- Vaselin gauze
- Absorbable material
(in coagulopathy)


Anterior packing

Anterior packing
bayonet forcepts
good light
T.C.A.
suction bovie/bipolar
silver nitrate
epistat
merocel

surgicel
speculum
Treatment
Packing
Porterior packing
- Roll gauze (traditional)
- Inflatable baloon
- Foley catheter
(12-14 Fr.,inflated with
8-15 ml. of water)
- Epistaxis catheter

Traditional posterior packing
1
2
3
4
Traditional posterior packing
5
6
Foley catheter
Epistaxis catheter
Treatment
Artery ligation

External carotid artery ligation
- Easy but high failure rate(45%)

Internal maxillary ligation
Failure rate 0-25%

Ethmoid artery ligation
Treatment
Embolization
Indication

1. Fail from other treatment
2. Contraindication to surgery
conclusion
Anterior epistaxis

pressure cautery ant.packing

fail

Posterior epistaxis

Post.packing ligation embolization

Foreign body
In aerodigestive tract
Foreign body
in aerodigestive tract
FB in airway passage

FB in food passage

FB in airway passage
Nose

Larynx and trachea

Bronchus
FB in airway passage
Nose
- Most common in children 1-6 years - old
- Mx : restrain the child tightly
: appropriate light
: appropriate equipments
hook
alligator
FB in airway passage
Larynx trachea and bronchus
Initial evaluation : assess urgency
Respiratory distress
- dyspnea, restless, RR>25/min
- retraction & stridor
**Immdiate action plan for safe airway**



Evaluation of airway problem
Hx : choking, coughing, cyanosis
(immediately while eating food, playing toy)
X-ray
: neck (AP, lateral), chest, abdomen
: decubitus film in both direction
- dependent lung : less aeration
- if these pattern reversed : FB can be
suspected

FB in airway passage
Position of flat object
in going down the air and food passage
Children younger than 1 year
Five Back blows and Five chest thrusts
American Heart Association and American Academy of Pediatrics
Children older than 1 year
Five Abdominal thrusts
: supine position in
unconcious children
Five Abdominal thrusts :
upright position in
concious children
American Heart Association and American Acadamy of Pediatrics
Repeated Five Heimlich maneuver
Older children and adults
American Heart Association and American Academy of Pediatrics
Cricothyrotomy
Open airway via cricothyroid mm.
Risk to damage subglottis ,
converted to tracheotomy in 3-5
days
Palpate cricothyroid space with index finger
Transverse incision directly over the cricothyroid m.
Handle of the knife is inserted into the wound twisted
vertically to open the wound
Endotracheal tube is inserted and secured


Emergency Tracheotomy

Better to perform elective tracheotomy
under LA. than emergency tracheotomy
Needed good team work & co-operation

Emergency Tracheotomy
Vertical incision : cricoid cartilage &
extends inferiorly 1 1.5 inches
Left hand to stabilize Larynx
Make incision through skin,
platysma, strap muscle, thyroid
isthmus
Stay in the midline
Use left hand as a dissector & palpate
trachea
Vertical tracheal incision at 2
nd
and
3
rd
ring
Tracheal Dilator help to insertion
ET-tube
FB in food passage
Oral cavity & oropharyx
- Tonsil : most common site
- Have point of tenderness
FB in food passage
Esophagus
- FB those lodged in esophagus should
be removed endoscopically
- large, sharp FB are removed surgically
- FB > 2.5 cm in diameter and 5 cm. in
length probably not pass through the GI
tract. So, endoscope or surgical removal
should be done.

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