WikEM - User contributions [en]

Post-tonsillectomy hemorrhage

2014-05-28T17:33:31Z

Sharon.cu.md:

==Presentation==
*Occurs in 1-6% of tonsillectomies
*Most common on POD 5-7
*Highest incidence in 21-30 year olds
*Lowest in <6 year olds

==Work Up==
*Physical exam (do NOT remove any clots)
*CBC, T+S or T+C, coags

==Management==
*ENT consult: Always, rebleeding is common and half of presentations require surgical management
*Airway management (anticipate difficulty and have surgical back up)
*IV, O2, Monitor, NPO, upright position
*Can try direct pressure with tonsillar pack or gauze infused with lido with epi

==See Also==
[[Pharyngitis]]

==Sources==
Tintinalli, Roberts & Hedges

Post-tonsillectomy hemorrhage

2014-05-28T17:33:12Z

Sharon.cu.md:

Post-tonsillectomy hemorrhage

2014-05-28T17:24:38Z

Sharon.cu.md:

==Presentation==
*Occurs in 1-6% of tonsillectomies
*Most common on POD 5-7
*Highest incidence in 21-30 year olds
*Lowest in <6 year olds

==Work Up==
*Physical exam (do NOT remove any clots)
*CBC, T+S or T+C, coags

==Management==
*ENT consult: Always, rebleeding is common and half of presentations require surgical management
*Airway management (anticipate difficulty and have surgical back up)
*IV, O2, Monitor, NPO
*Can try direct pressure with tonsillar pack or gauze infused with lido with epi

==See Also==
[[Pharyngitis]]

==Sources==
Tintinalli

Post-tonsillectomy hemorrhage

2014-05-27T03:53:02Z

Sharon.cu.md:

==Presentation==
*Occurs in 1-6% of tonsillectomies
*Highest incidence in 21-30 year olds
*Lowest in <6 year olds

==Work Up==
*Physical exam (do NOT remove any clots)
*CBC, T+S or T+C, coags

==Management==
*ENT consult: Always, rebleeding is common and half of presentations require surgical management
*Airway management (anticipate difficulty and have surgical back up)
*IV, O2, Monitor, NPO
*Can try direct pressure with tonsillar pack or gauze infused with lido with epi

==Category==
[[ENT]] [[Pharyngitis]]

==Sources==
Tintinalli

Post-tonsillectomy hemorrhage

2014-05-27T03:51:40Z

Sharon.cu.md:

==Presentation==
*Occurs in 1-6% of tonsillectomies
*Highest incidence in 21-30 year olds
*Lowest in <6

==Work Up==
*Physical exam (do NOT remove any clots)
*CBC, T+S or T+C, coags

==Management==
*ENT consult: Always, rebleeding is common and half of presentations require surgical management
*Airway management (anticipate difficulty and have surgical back up)
*IV, O2, Monitor, NPO
*Can try direct pressure with tonsillar pack or gauze infused with lido with epi

==Category==
[[ENT]] [[Pharyngitis]]

==Sources==
Tintinalli

Post-tonsillectomy hemorrhage

2014-05-27T03:49:57Z

Sharon.cu.md: New page

==Presentation==
*Occurs in 1-6% of tonsillectomies
**Highest incidence in 21-30 year olds
***Lowest in <6

===Work Up===
*Physical exam (do NOT remove any clots)
*CBC, T+S or T+C, coags

====Management====
*ENT consult: Always, rebleeding is common and half of presentations require surgical management
**Airway management (anticipate difficulty and have surgical back up)
***IV, O2, Monitor, NPO
****Can try direct pressure with tonsillar pack or gauze infused with lido with epi

=====Category=====
[[ENT]] [[Pharyngitis]]

======Sources======
Tintinalli

Retropharyngeal abscess

2014-05-24T01:24:55Z

Sharon.cu.md:

==Background==
*Polymicrobial abscess in space between posterior pharyngeal wall and prevertebral fascia
*Adults: Due to direct extension of purulent debris from adjacent site (e.g. Ludwig angina)
**More likely to extend into the mediastinum
*Children: Due to suppurative changes within a lymph node (primary infection elsewhere in head or neck)
*Trauma: Direct inoculation (e.g. child falling with stick in mouth)

==Clinical Features==
*Sore throat (76%)
*Fever (65%)
*Torticollis (37%)
*Dysphagia (35%)
*Late symptoms:
**Stridor, respiratory distres, chest pain (mediastinitis)

==Diagnosis==
*CT neck w/ IV contrast
**Gold standard

*XR Soft tissue
** The prevertebral space should be less than 7mm at C2, 14mm at C6 in children regardless of the age
** The prevertebral space should be less than 22mm at C6 in adults
** If the prevertebral space should be less than one-half the width of the corresponding vertebral body
** If equivocal XR, order CT

==Treatment==
*Emergent ENT consult
**Most patients require I&D
*Secure airway
*Abx
**[[Clindamycin]] 600-900mg IV OR [[cefoxitin]] 2gm IV
** Ampicillin/sulbactam 3g IV

==Disposition==
*Admit

==See Also==
#[[PTA]]
#[[Ludwig's Angina]]
#[[Pharyngitis]]

==Source==
*Tintinalli
*emedicine.com
*Emergency Medicine Oral Board Review Illustrated, Okuda

[[Category:Peds]]
[[Category:ID]]

Retropharyngeal abscess

2014-05-24T01:24:03Z

Sharon.cu.md:

==Background==
*Polymicrobial abscess in space between posterior pharyngeal wall and prevertebral fascia
*Adults: Due to direct extension of purulent debris from adjacent site (e.g. Ludwig angina)
**More likely to extend into the mediastinum
*Children: Due to suppurative changes within a lymph node (primary infection elsewhere in head or neck)
*Trauma: Direct inoculation (e.g. child falling with stick in mouth)

==Clinical Features==
*Sore throat (76%)
*Fever (65%)
*Torticollis (37%)
*Dysphagia (35%)
*Late symptoms:
**Stridor, respiratory distres, chest pain (mediastinitis)

==Diagnosis==
*CT neck w/ IV contrast
**Gold standard

*XR Soft tissue
** The prevertebral space should be less than 7mm at C2, 14mm at C6 in children regardless of the age
** The prevertebral space should be less than 22mm at C6 in adults
** If the prevertebral space should be less than one-half the width of the corresponding vertebral body
** If equivocal XR, order CT

==Treatment==
*Emergent ENT consult
**Most patients require I&D
*Secure airway
*Abx
**[[Clindamycin]] 600-900mg IV OR [[cefoxitin]] 2gm IV

==Disposition==
*Admit

==See Also==
#[[PTA]]
#[[Ludwig's Angina]]
#[[Pharyngitis]]

==Source==
*Tintinalli
*emedicine.com
*Emergency Medicine Oral Board Review Illustrated, Okuda

[[Category:Peds]]
[[Category:ID]]

Epiglottitis

2014-05-23T21:05:46Z

Sharon.cu.md:

==Background==
*Otolaryngologic emergency
**Can lead to rapid onset of life-threatening airway obstruction
*Most cases are seen in adults (since advent of H. flu vaccine)
*Etiology
**Strep, staph, H. flu (unvaccinated)
**Caustic burns

==Clinical Features==
*Three D's:
**Drooling
**Dysphagia
**Distress
*Pain with gentle palpation of larynx and upper trachea
*Stridor
*Respiratory distress

==Diagnosis==
*Imaging only required if diagnosis uncertain
*Lateral neck x-ray
**Obliteration of vallecula
**Edema of prevertebral and retropharyngeal soft tissues
**"Thumb sign" (enlarged epiglottis)

==Treatment==
*Emergent ENT consult
*O2 (humidified)
*IVF (hydration minimizes crusting in the airway)
*[[Ceftriaxone]] 2gm IV
**Consider Vancomycin
*Nebulized epinephrine
*Steroids
**Methylprednisolone 125mg IV
*[[Intubation]] or [[cricothyrotomy]]

==Disposition==
*Admit

==Source==
Tintinalli

[[Category:Peds]]
[[Category:ID]]

Epiglottitis

2014-05-23T21:05:13Z

Sharon.cu.md:

==Background==
*Otolaryngologic emergency
**Can lead to rapid onset of life-threatening airway obstruction
*Most cases are seen in adults (since advent of H. flu vaccine)
*Etiology
**Strep, staph, H. flu (unvaccinated)
**Caustic burns

==Clinical Features==
*Three D's:
**Drooling
**Dysphagia
**Distress
*Pain with gentle palpation of larynx and upper trachea
*Stridor
*Respiratory distress

==Diagnosis==
*Imaging only required if diagnosis uncertain
*Lateral neck x-ray
**Obliteration of vallecula
**Edema of prevertebral and retropharyngeal soft tissues
**"Thumb sign" (enlarged epiglottis)

==Treatment==
*Emergent ENT consult
*O2 (humidified)
*IVF (hydration minimizes crusting in the airway)
*[[Ceftriaxone]] 2gm IV
*Nebulized epinephrine
*Steroids
**Methylprednisolone 125mg IV
*[[Intubation]] or [[cricothyrotomy]]

==Disposition==
*Admit

==Source==
Tintinalli

[[Category:Peds]]
[[Category:ID]]

Croup

2014-05-23T20:46:46Z

Sharon.cu.md:

==Background==
*Croup = laryngotracheobronchitis
*Affects 6 mo-3 yr (peak in 2nd year)
*Fall & winter
*Etiology
**Parainfluenza (50%), [[Bronchiolitis (RSV)|RSV]], rhinovirus
***Consider diphtheria if not immunized
*Spasmodic croup
**Sudden onset of barking cough/stridor
**No viral prodrome, unlike standard croup
**Difficult to differentiate from croup
*Must rule-out foreign body

==Diagnosis==
#1-2 day of URI followed by barking cough, stridor
#Low-grade fever
#NO drooling or dysphagia
#Duration = 3-7d, most severe on days 3-4

===Croup Score===
*Inspiratory stridor
**None (0 points)
**When agitated (1 points)
**On/off at rest (2 points)
**Continuous at rest (3 points)
*Retractions
**None (0 points)
**Mild (1 points)
**Moderate (2 points)
**Severe (3 points)
*Air entry
**Normal (0 points)
**Decreased (1 points)
**Moderately decreased (2 points)
**Severely decreased (3 points)
*Cyanosis
**None (0 points)
**When crying (2 points)
**At rest (3 points)
*Alertness
**Alert (0 points)
**Restless, anxious (2 points)
**Depressed (3 points)

'''Assessment'''
*<2 Very mild
*2-9 Mild to moderately severe
*>9 Severe croup

==Work-Up==
#Consider CXR if concerned about alternative dx
##Steeple sign on AP (not Sp, not Sn)
#Consider nasal washings for RSV, parainfluenza, influenza.

==Treatment==
#Cool mist
#Steroids
##Give to all pts with croup
###Dexamethasone 0.15-0.6mg/kg PO/IM (max 10mg)
#Epinephrine (nebulized)
##Give for moderate-severe cases
#Do NOT give albuterol (may worsen edema (vasodilation))
#Intubation rarely needed
##Use one half size smaller tube if intubating

==Disposition==
#Consider discharge if:
##3hr since last epinephrine
##Able to tolerate PO
##Nontoxic appearance
#Admit:
##Persistent respiratory sx/signs
##≥2 tx with epinephrine

==External Links==
*[http://www.mdcalc.com/westley-croup-score/ MDCalc - Westley Croup Score]

==See Also==
[[Bronchiolitis (RSV)]]

==Source==
*Tintinalli
*Rosen
[[Category:Peds]]
[[Category:ID]]

Croup

2014-05-23T20:46:17Z

Sharon.cu.md:

==Background==
*Croup = laryngotracheobronchitis
*Affects 6 mo-3 yr (peak in 2nd year)
*Fall & winter
*Etiology
**Parainfluenza (50%), [[Bronchiolitis (RSV)|RSV]], rhinovirus
***Consider diphtheria if not immunized
*Spasmodic croup
**Sudden onset of barking cough/stridor
**No viral prodrome, unlike standard croup
**Difficult to differentiate from croup
*Must rule-out foreign body

==Diagnosis==
#1-2 day of URI followed by barking cough, stridor
#Low-grade fever
#NO drooling or dysphagia
#Duration = 3-7d, most severe on days 3-4

===Croup Score===
*Inspiratory stridor
**None (0 points)
**When agitated (1 points)
**On/off at rest (2 points)
**Continuous at rest (3 points)
*Retractions
**None (0 points)
**Mild (1 points)
**Moderate (2 points)
**Severe (3 points)
*Air entry
**Normal (0 points)
**Decreased (1 points)
**Moderately decreased (2 points)
**Severely decreased (3 points)
*Cyanosis
**None (0 points)
**When crying (2 points)
**At rest (3 points)
*Alertness
**Alert (0 points)
**Restless, anxious (2 points)
**Depressed (3 points)

'''Assessment'''
*<2 Very mild
*2-9 Mild to moderately severe
*>9 Severe croup

==Work-Up==
#Consider CXR if concerned about alternative dx
##Steeple sign on AP (not Sp, not Sn)
#Consider nasal washings for RSV, parainfluenza, influenza.

==Treatment==
#Cool mist
#Steroids
##Give to all pts with croup
###Dexamethasone 0.15-0.6mg/kg PO/IM (max 10mg)
#Epinephrine (nebulized)
##Give for moderate-severe cases
#Do NOT give albuterol (may worsen edema (vasodilation))
#Intubation rarely needed
##Use one half size smaller tube if intubating

==Disposition==
#Consider discharge if:
##3hr since last epinephrine
##Able to tolerate PO
##Nontoxic apperance

#Admit:
##Persistent respiratory sx/signs
##≥2 tx with epinephrine

==External Links==
*[http://www.mdcalc.com/westley-croup-score/ MDCalc - Westley Croup Score]

==See Also==
[[Bronchiolitis (RSV)]]

==Source==
*Tintinalli
*Rosen
[[Category:Peds]]
[[Category:ID]]

Sore throat

2014-05-23T20:27:04Z

Sharon.cu.md:

==Differential Diagnosis==
===Acute===
====Bacterial Infections====
#[[Streptococcal Pharyngitis]] (Strep Throat)
#[[N. gonorrhea]]
#C. diptheriae

====Viral Infections====
#Rhinovirus
#Coronavirus
#Adenovirus
#[[Herpesvirus]]
#Influenza virus
#Coxsackievirus
#[[EBV]]
#HIV (Acute Retroviral Syndrome)

====Noninfectious====
#[[Stevens-Johnson Syndrome]]
#Pemphigus
#[[Angioedema]]

====Other====
*[[Retropharyngeal Abscess]]
*[[Peritonsillar Abscess]]
*[[Epiglottitis]]
*[[Kawasaki Disease]]
*[[Neck Trauma|Penetrating injury]]
*Caustic exposure
*[[Lemierre's Syndrome]]

===Chronic===
*[[GERD]]
*obstructive sleep apnea
*fungal infections (ex. candida)
*chronic [[sinusitis]] with post nasal drip
*inhalation of irritants (smoke, chlorine gas)
*breathing dry air
*glossopharyngeal neuralgia
*Tumor:
**Tongue
**Larynx
**Thyroid
*monomyelocytic leukemia
*[[Thyroiditis]]
*[[Esophageal Foreign Body|Retained Foreign Body]]

==See Also==
[[Strep Pharyngitis]]

==Source==
Harwood-Nuss, Rosens, Tintinalli

[[Category:ENT]]

Sore throat

2014-05-23T20:26:22Z

Sharon.cu.md:

Stridor (peds)

2014-05-23T20:23:21Z

Sharon.cu.md:

==Diagnosis==

==DDX==
#<6mo
##Laryngotracheomalacia
##Vocal cord paralysis (weak cry)
##Subglottic stenosis (previous intubation)
##Airway hemangioma (usually regresses by age 5)
##Vascular ring/sling
#>6mo
##Croup
##Epiglottitis
##Bacterial tracheitis
##Foreign body (sudden onset, asymmetric)
##Retropharyngeal abscess (muffled voice, fever)

==See also==
[[Stridor]]

==Source==
Tintinalli

[[Category:Peds]]
[[Category:ENT]]

Stridor (peds)

2014-05-23T20:21:03Z

Sharon.cu.md:

==Diagnosis==

==DDX==
#<6mo
##Laryngotracheomalacia
##Vocal cord paralysis (weak cry)
##Subglottic stenosis (previous intubation)
##Airway hemangioma (usually regresses by age 5)
##Vascular ring/sling
#>6mo
##Croup
##Epiglottitis
##Bacterial tracheitis
##Foreign body (sudden onset, asymmetric)
##Retropharyngeal abscess (muffled voice, fever)

==Source==
Tintinalli

[[Category:Peds]]
[[Category:ENT]]

Ludwig's angina

2014-05-21T17:29:35Z

Sharon.cu.md:

== Background ==
*Bilateral infection of submental, submandibular, and sublingual spaces
*Cellulitis without clear fluctuance/abscess
*85% of cases arise from an odontogenic source, usually mandibular molars
**Strep, staphylococcus, bacteroides
*Patients usually 20-60yr; male predominance
*Intubation may be very difficult
**Consider awake endoscopic NP or OP intubation
**Anesthesia or ENT back-up if possible

== Clinical Features ==
*Dysphagia
*Odynophagia
*Trismus
*Edema of upper midline neck and floor of mouth
*Late signs
**Stridor, drooling, cyanosis

== Diagnosis ==
*CT face with contrast
**Only obtain if diagnosis is question
**Pt may lose airway in scanner if lies flat

==Treatment==
*Airway management
*Emergent ENT consult for I&D
*Abx
**Must cover typical oral flora
**Usually 3rd generation cehpalosporin + (clindamycin or metronidazole)
*Awake intubation

==Disposition==
*Admit, usually ICU for airway monitoring

==See Also==
#[[PTA]]
#[[Retropharyngeal Abscess]]
#[[Pharyngitis]]

==Source==
*Tintinalli
*ER Atlas
*Rosen's

[[Category:Peds]]
[[Category:ENT]]

Ludwig's angina

2014-05-21T17:29:10Z

Sharon.cu.md:

Ludwig's angina

2014-05-21T17:27:51Z

Sharon.cu.md: bullets

== Background ==
*Bilateral infection of submental, submandibular, and sublingual spaces
*85% of cases arise from an odontogenic source, usually mandibular molars
**Strep, staphylococcus, bacteroides
*Patients usually 20-60yr; male predominance
*Intubation may be very difficult
**Consider awake endoscopic NP or OP intubation
**Anesthesia or ENT back-up if possible

== Clinical Features ==
*Dysphagia
*Odynophagia
*Trismus
*Edema of upper midline neck and floor of mouth
*Late signs
**Stridor, drooling, cyanosis

== Diagnosis ==
*CT face with contrast
**Only obtain if diagnosis is question
**Pt may lose airway in scanner if lies flat

==Treatment==
*Airway management
*Emergent ENT consult for I&D
*Abx
**Must cover typical oral flora
**Usually 3rd generation cehpalosporin + (clindamycin or metronidazole)
*Awake intubation

==Disposition==
*Admit, usually ICU for airway monitoring

==See Also==
#[[PTA]]
#[[Retropharyngeal Abscess]]
#[[Pharyngitis]]

==Source==
*Tintinalli
*ER Atlas

[[Category:Peds]]
[[Category:ENT]]

Peritonsillar abscess

2014-05-21T17:24:54Z

Sharon.cu.md: sources

==Background==
*Abscess between tonsillar capsule and superior constrictor and palatopharyngeus muscles
*Microbiology
**Polymicrobial: strep/staph, anaerobes, eikenella, haemophilus

==Clinical Features==
*Symptoms
**Fever
**Sore throat
**Odynophagia/dysphagia
*Signs
**Trismus
**Muffled voice ("hot potato voice")
**Contralateral deflection of swollen uvula

==DDX==
*Peritonsillar cellulitis
*[[Mono]]
*Lymphoma
*Herpes simplex tonsillitis
*[[Retropharyngeal Abscess]]
*Internal carotid artery aneurysm

==Diagnosis==
*Ultrasound
**Differentiates cellulitis from abscess
**Can identify neck vasculature prior to aspiration
*CT w/ IV contrast
**Differentiates PTA from parapharyngeal or retropharyngeal space infection

==Treatment==
#No difference in outcome when comparing needle aspiration with I&D
#Needle Aspiration
##Apply anesthetic spray to overlying mucosa
##Have pt hold suction, and use as needed
##Use laryngoscope or disassembled vaginal speculum with wand as tongue depressor and light source
##Inject 1-2mL of lidocaine with epi into mucosa of anterior tonsillar pillar using 25ga needle
##Cut distal tip off of needle sheath and place over 18ga needle to expose 1 cm of needle to prevent accidentally plunging deeper than desired
##Aspirate using 18ga needle just lateral to the tonsil, no more than 1cm (internal carotid artery 2.5 cm posterolateral)
###May require multiple aspirations to find the abscess (first try superior then middle then inferior poles)
###Consider spinal needle if pt has significant trismus.
#I&D
## 11 or 15 blade scalpel
## Do not penetrate more than 1cm
## May be indicated if significant pus with needle aspiration
#Abx
##Outpatient
###[[Clindamycin]] 300mg PO Q6hrs x7-10d OR
###[[Amoxicillin/Clavulanate]] 875 mg PO BID x 7-10d OR
###[[Penicillin V]] 500mg PO + flagyl 500mg QID
##Inpatient
###[[Ampicillin/Sulbactam]] 3 gm (75mg/kg) IV QID OR
###[[Pipericillin/Tazobactam]] 4.5 gm IV TID OR
###[[Ticarcillin/Clavulanate]] 3.1 g IV QID OR
###[[Clindamycin]] 600-900mg IV TID
#Steroids
##Improves duration and severity of pain
##Methylprednisolone 125mg IV x1 OR dexamethasone 10mg PO/IM x1
#Indications for tonsillectomy:
##Airway obstruction
##Recurrent severe pharyngitis or PTA
##Failure of abscess resolution with drainage

==Complications==
*Airway obstruction
*Rupture abscess with aspiration of contents
*Hemorrhage due to erosion of carotid sheath
*Retropharyngeal abscess
*Mediastinitis
*Recurrence occurs in 10-15% of patients
*[[Lemierre's Syndrome]]

==Disposition==
*F/u in 2-3 days
*Return Precautions:
**SOB
**Worsening throat or neck pain
**Enlarging mass
**Bleeding
**Neck stiffness

==See Also==
*[[Pharyngitis]]

==Source==
*Tintinalli
*UpToDate
*Roberts & Hedges
[[Category:ENT]]
[[Category:ID]]
[[Category:procedures]]

Peritonsillar abscess

2014-05-21T17:22:43Z

Sharon.cu.md: bullets

==Background==
*Abscess between tonsillar capsule and superior constrictor and palatopharyngeus muscles
*Microbiology
**Polymicrobial: strep/staph, anaerobes, eikenella, haemophilus

==Clinical Features==
*Symptoms
**Fever
**Sore throat
**Odynophagia/dysphagia
*Signs
**Trismus
**Muffled voice ("hot potato voice")
**Contralateral deflection of swollen uvula

==DDX==
*Peritonsillar cellulitis
*[[Mono]]
*Lymphoma
*Herpes simplex tonsillitis
*[[Retropharyngeal Abscess]]
*Internal carotid artery aneurysm

==Diagnosis==
*Ultrasound
**Differentiates cellulitis from abscess
**Can identify neck vasculature prior to aspiration
*CT w/ IV contrast
**Differentiates PTA from parapharyngeal or retropharyngeal space infection

==Treatment==
#No difference in outcome when comparing needle aspiration with I&D
#Needle Aspiration
##Apply anesthetic spray to overlying mucosa
##Have pt hold suction, and use as needed
##Use laryngoscope or disassembled vaginal speculum with wand as tongue depressor and light source
##Inject 1-2mL of lidocaine with epi into mucosa of anterior tonsillar pillar using 25ga needle
##Cut distal tip off of needle sheath and place over 18ga needle to expose 1 cm of needle to prevent accidentally plunging deeper than desired
##Aspirate using 18ga needle just lateral to the tonsil, no more than 1cm (internal carotid artery 2.5 cm posterolateral)
###May require multiple aspirations to find the abscess (first try superior then middle then inferior poles)
###Consider spinal needle if pt has significant trismus.
#I&D
## 11 or 15 blade scalpel
## Do not penetrate more than 1cm
## May be indicated if significant pus with needle aspiration
#Abx
##Outpatient
###[[Clindamycin]] 300mg PO Q6hrs x7-10d OR
###[[Amoxicillin/Clavulanate]] 875 mg PO BID x 7-10d OR
###[[Penicillin V]] 500mg PO + flagyl 500mg QID
##Inpatient
###[[Ampicillin/Sulbactam]] 3 gm (75mg/kg) IV QID OR
###[[Pipericillin/Tazobactam]] 4.5 gm IV TID OR
###[[Ticarcillin/Clavulanate]] 3.1 g IV QID OR
###[[Clindamycin]] 600-900mg IV TID
#Steroids
##Improves duration and severity of pain
##Methylprednisolone 125mg IV x1 OR dexamethasone 10mg PO/IM x1
#Indications for tonsillectomy:
##Airway obstruction
##Recurrent severe pharyngitis or PTA
##Failure of abscess resolution with drainage

==Complications==
*Airway obstruction
*Rupture abscess with aspiration of contents
*Hemorrhage due to erosion of carotid sheath
*Retropharyngeal abscess
*Mediastinitis
*Recurrence occurs in 10-15% of patients
*[[Lemierre's Syndrome]]

==Disposition==
*F/u in 2-3 days
*Return Precautions:
**SOB
**Worsening throat or neck pain
**Enlarging mass
**Bleeding
**Neck stiffness

==See Also==
*[[Pharyngitis]]

==Source==
*Tintinalli
*Uptodate
[[Category:ENT]]
[[Category:ID]]
[[Category:procedures]]

Peritonsillar abscess

2014-05-21T17:15:59Z

Sharon.cu.md: bullets

==Background==
*Abscess between tonsillar capsule and superior constrictor and palatopharyngeus muscles
*Microbiology
**Polymicrobial: strep/staph, anaerobes, eikenella, haemophilus

==Clinical Features==
*Symptoms
**Fever
**Sore throat
**Odynophagia/dysphagia
*Signs
**Trismus
**Muffled voice ("hot potato voice")
**Contralateral deflection of swollen uvula

==DDX==
*Peritonsillar cellulitis
*[[Mono]]
*Lymphoma
*Herpes simplex tonsillitis
*[[Retropharyngeal Abscess]]
*Internal carotid artery aneurysm

==Diagnosis==
*Ultrasound
**Differentiates cellulitis from abscess
**Can identify neck vasculature prior to aspiration
*CT w/ IV contrast
**Differentiates PTA from parapharyngeal or retropharyngeal space infection

==Treatment==
#No difference in outcome when comparing needle aspiration with I&D
#Needle Aspiration
##Apply anesthetic spray to overlying mucosa
##Have pt hold suction, and use as needed
##Use laryngoscope or disassembled vaginal speculum with wand as tongue depressor and light source
##Inject 1-2mL of lidocaine with epi into mucosa of anterior tonsillar pillar using 25ga needle
##Cut distal tip off of needle sheath and place over 18ga needle to expose 1 cm of needle to prevent accidentally plunging deeper than desired
##Aspirate using 18ga needle just lateral to the tonsil, no more than 1cm (internal carotid artery 2.5 cm posterolateral)
###May require multiple aspirations to find the abscess (first try superior then middle then inferior poles)
###Consider spinal needle if pt has significant trismus.
#Abx
##Outpatient
###[[Clindamycin]] 300mg PO Q6hrs x7-10d OR
###[[Amoxicillin/Clavulanate]] 875 mg PO BID x 7-10d OR
###[[Penicillin V]] 500mg PO + flagyl 500mg QID
##Inpatient
###[[Ampicillin/Sulbactam]] 3 gm (75mg/kg) IV QID OR
###[[Pipericillin/Tazobactam]] 4.5 gm IV TID OR
###[[Ticarcillin/Clavulanate]] 3.1 g IV QID OR
###[[Clindamycin]] 600-900mg IV TID
#Steroids
##Improves duration and severity of pain
##Methylprednisolone 125mg IV x1 OR dexamethasone 10mg PO/IM x1
#Indications for tonsillectomy:
##Airway obstruction
##Recurrent severe pharyngitis or PTA
##Failure of abscess resolution with drainage

==Complications==
*Airway obstruction
*Rupture abscess with aspiration of contents
*Hemorrhage due to erosion of carotid sheath
*Retropharyngeal abscess
*Mediastinitis
*Recurrence occurs in 10-15% of patients
*[[Lemierre's Syndrome]]

==Disposition==
*F/u in 2-3 days
*Return Precautions:
**SOB
**Worsening throat or neck pain
**Enlarging mass
**Bleeding
**Neck stiffness

==See Also==
*[[Pharyngitis]]

==Source==
*Tintinalli
*Uptodate
[[Category:ENT]]
[[Category:ID]]
[[Category:procedures]]

Paracentesis

2014-05-21T17:12:09Z

Sharon.cu.md: bullets

==Equipment==
*Lidocaine with epi
*chlorhexidine
*Paracentesis kit (catheter, 11 blade, syringes, bandaid)
*Ultrasound
*Vacuumed bottles

==Procedure==
# Use ultrasound to identify safe ascites pocket to drain
## if no ultrasound available, can percuss to identify pocket
## Try to pick site away from inferior epigastric artery
## LLQ preferred over RLQ
## Midline infraumbilicus is avascular (linea alba) but has lower success rate
# Prep area
# Anesthesize area with Lidocaine
# Use needle to enter peritoneum, advance catheter upon withdrawing ascitic fluid
# Attach cathether to vacuum bottles for therapeutic tap, Withdrawal with syringe for diagnostic tap

*tip: Placing Cx in BCx tube increases yield

==Workup==
#Cell count with dif
#Cx (BCx bottles)
#Grm stain

Consider:
#Albumin and SERUM albumin
#Protein
#Glucose
#LDH and SERUM LDH at same time
#Amylase

Specific circumstances:
#TB smear and Cx
#Cytology
#TG
#Billirubin

==Diagnosis==
===SBP===
Any:
#>500 WBC
#>250 PMNs
#Positive gm stain (single microbe)

^For bloody tap, subtract 1 WBC for every 250 RBC

===Consider Peritonitis (eg. perf appy, chole)===
Any:
# >10,000 WBC
# Polymicrobial gm stain
# Total protein >1g/dL
# Glu <50
# Increased LDH

==If on Peritoneal Dialysis==
SBP if:
1) >100WBC OR >50% NEUT

===If on Nightly APD===
SBP if:
# >50%NEUT
# Amyase (>100 suggestive of intra-abd process)

==See Also==
[[Spontaneous Bacterial Peritonitis (SBP)]]

==Source==
12/06 DONALDSON

[[Category:Procedures]]
[[Category:GI]]

Beta-blocker toxicity

2014-05-21T17:07:23Z

Sharon.cu.md:

==Background==
*Coingestion with [[Calcium Channel Blockers]], [[Tricyclic Antidepressants]], and [[Antipsychotics]] increases mortality
*Agents with membrane-stabilizing activity are esp lethal
**Prolongs QT > dysrhythmias
***Propranolol
***Sotalol

==Diagnosis==
*Cardiac
**Bradycardia
**Hypotension
**Ventricular dysrhythmias
*CNS
**Mental status change
***Delirium, coma
**Seizure (esp w/ propranolol)
*Other
**Hypoglycemia (uncommon in adults)
**Bronchospasm (uncommon)
**Hypothermia

==Work-Up==
#ECG
##PR prolongation
##Bradycardia
##[[QT Prolongation]]
##Any bradydysrhythmia
#Glucose
#Chemistry

==DDx==
#Calcium-channel blockers
##Unlikely to cause CNS changes
##Hyperglycemia is more common
#Digoxin
##Nausea/vomiting is more common
#Clonidine
##Miosis, somnolence
#Cholinergic agents
##SLUDGE

== Management ==

#Consider charcoal if present within 2 hr of ingestion
#Bradycardia (symptomatic)
##Atropine 0.5-1mg q3-5min up to 0.04mg/kg
#Hypotension
##IV fluids
#Hypoglycemia
##Adult - D50
##Ped - 2.5mL/kg of D10

If IV fluid and atropine are not sufficient then consider:

#Glucagon
##Half-life is 20min
##Consider concurrent administration of ondansetron (causes n/v)
##Adult: 5mg IV bolus over one minute
##Ped: 50mcg/kg
##Rebolus if no response after 10min
##If effective start infusion at:
###Adult: 2-5mg/hr
###Ped: 70mcg/kg/hr
#High dose insulin and glucose
##Augments myocardial contraction
##Regular Insulin 1 Unit/kg IV Bolus accompanied by 0.5g/kg dextrose
##Regular insulin 1Unit/kg/hr Drip
##D50W drip at 0.1-0.2gram/kg/hr 
#Vasopressors
##Consider if all of above has failed
##Epinephrine
###Adult: Start 1 mcg/min and titrate to MAP=60
###Ped: Start 0.1mcg/kg/min
#Fat Emulsion Therapy - "Intra-lipid"
##IV 20% Intralipid at 1.5 mL/kg Bolus
###Bolus could be repeated 1-2 times if persistent asystole
##if responsive to bolus initiate infusion at 0.25 mL/kg/min for 1hr then R/A
###Infusion rate could be increased if the BP declines
#Hemodialysis
##Only effective for Nadolol, sotalol, and atenolol

==Disposition==
*Admit all symptomatic patients
*Admit all sotalol ingestions (long half-life)
*Observe all others for ~ 6hr

==See Also==

==Source==
#Rosen's
#http://emedicine.medscape.com/article/813342-overview
#http://www.lipidrescue.org/
#EB Medicine May/Jun 2014 Vol 4, No 3
[[Category:Cards]]
[[Category:Tox]]

Beta-blocker toxicity

2014-05-21T17:04:53Z

Sharon.cu.md: Added bullet