Hematology and Oncology ITE Review Bleeding disorders o Hemostasis is a balance between excessive bleeding and thrombosis o Four components of hemostasis Vascular integrity Platelet function Coagulation factors Fibrinolysis Coagulation studies o Prothrombin time Affected by extrinsic (and common) pathways PT >2 seconds more than control is abnormal Increased PT: Vitamin K deficiency, warfarin use, liver disease o International normalized ratio (INR) PT ratio that would be obtained if WHO’s thromboplastin has been used INR of 1 is normal; 2-3 therapeutic; 2.5-3.5 for valves o Partial thromboplastin time (PTT) Affected by intrinsic (and common) pathways PTT >8-10 seconds above normal is significant Increased PTT: Factor VIII, IX, XI, XII deficiency, heparin therapy o Increased PT and PTT Heparin overdose, warfarin overdose, Vitamin K deficiency and severe liver disease, DIC, massive transfusion, thrombolytic therapy o Vitamin K dependent factors II, VII, IX, I Platelet vs coagulation disorders o Platelet disorders Petechiae, purpura (don’t blanch), epistaxis, gum/mucosal bleeding, GIB, menorrhagia Women; often acquired
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Hematology and Oncology
ITE Review
Bleeding disorderso Hemostasis is a balance between excessive bleeding and thrombosiso Four components of hemostasis
Vascular integrity Platelet function Coagulation factors Fibrinolysis
Coagulation studieso Prothrombin time
Affected by extrinsic (and common) pathways PT >2 seconds more than control is abnormal Increased PT: Vitamin K deficiency, warfarin use, liver disease
o International normalized ratio (INR) PT ratio that would be obtained if WHO’s thromboplastin has been used INR of 1 is normal; 2-3 therapeutic; 2.5-3.5 for valves
o Partial thromboplastin time (PTT) Affected by intrinsic (and common) pathways PTT >8-10 seconds above normal is significant Increased PTT: Factor VIII, IX, XI, XII deficiency, heparin therapy
o Increased PT and PTT Heparin overdose, warfarin overdose, Vitamin K deficiency and severe liver
disease, DIC, massive transfusion, thrombolytic therapyo Vitamin K dependent factors
o Platelet transfusion Six pack increases platelet count approx. 50K Indications- platelet count <10-20K, life threatening bleeding
o Idiopathic thrombocytopenic purpura (ITP) Acute ITP
Antiplatelet antibody IgG (both acute and chronic) Kids 2-6 yrs Follows viral infection Self limited; resolves spontaneously Tx supportive unless severe bleeding (plt <50K) or plt <20K Prednisone 1 mg/kg IVIG Platelet transfusion only for life-threatening hemorrhage
Chronic ITP Women 20-50 yrs Remission rare Underlying autoimmune, collagen vascular, or malignant disease Steroids IVIG, immunosuppressives, splenectomy Platelet transfusion only for life-threatening hemorrhage
o Thrombotic thrombocytopenic purpura (TTP) Subset of thrombotic microangiopathies Subendothelial and intraluminal deposits of fibrin and platelet aggregation Females; 80% mortality if untreated Infection, autoimmune disease, immunosuppressives, chemo Treatment- steroids, plasmapheresis, dialysis, FFP Avoid platelet transfusions FAT RN
Fever Anemia- MAHA; schistocytes on peripheral smear Thrombocytopenia Renal Neurologic
o Hemolytic uremic syndrome (HUS) Thrombotic microangiopathy Thrombocytopenia, hemolytic anemia, fever, neurologic, renal Less mental status change and more renal dysfunction than TTP Often kids Bacterial gastroenteritis (E coli O157:H7, Shigella)
o ASA/NSAIDs block cyclooxygenase, which decreases thromboxane formation decreased platelet aggregation
ASA effect irreversible NSAID effect reversible
o Disseminated intravascular coagulation (DIC) Platelet, coagulation, fibrinolytic disorder Diffuse bleeding from multiple sites Acrocyanosis, thrombosis, pregangrenous changes of fingers, toes, genitalia,
o Heparin induced thrombocytopenia (HIT) Antibodies to heparin/platelet factor 4 complex platelet activation and clot
formation Occurs 5-10 days after exposure Heparin > LMWH Thrombocytopenia <150K or drop of 50% from baseline Arterial or venous thrombosis Stop the heparin! Avoid platelet transfusions, lower limb dopplers (high incidence of DVT), test for
HIT antibodieso Von Willebrand’s disease
Most common genetic bleeding disorder Von Willebrand factor functions
Facilitates platelet adhesion Links platelet to endothelium Plasma carrier for factor VIII
Autosomal dominant Deficiency or dysfunction of vWF and mild factor VIII defect
Type I- decreased vWF (most common) Type II- abnormal or dysfunctional vWF
Type III- no vWF Mucocutaneous bleeding (epistaxis, menorrhagia, GIB) Abnormal platelet function studies, increased bleeding time, normal platelet
count, normal PT/PTT Treatment- DDAVP (desmopressin), factor VIII concentrates, cryoprecipitate
Coagulation disorderso Hemophilias
Delayed/protracted bleeding after mild trauma or dental extraction Spontaneous hematuria Hemarthrosis and muscle hematomas
Most common in ankle in kids; knee in adults Intracranial hemorrhage Proloned PTT; normal PT and platelets Hemophilia A
X-linked recessive deficiency of Factor VIII Mild (hematuria, deep lac)- 20 U/kg Moderate (oral lac, dental, minor surgery, late hemarthrosis)- 25 U/kg Severe (CNS/GI/abd, major trauma)- 50 U/kg 1 U/kg increases activity level by 2% Cryoprecipitate, DDAVP, FFP
Hemophilia B Aka Christmas Disease X-linked recessive deficiency of Factor IX Factor IX concentrate Prothrombin Complex Concentrates (PCC), FFP, NOT Cryo
o Hypercoagulability Factor V Leiden (most common inherited hyercoagulability disorder) Prothrombin mutation Hyperhomocysteinemia Protein C deficiency Protein S deficiency
Red blood cell disorderso RBC incides
Mean corpuscular hemoglobin (MCH)- measure of hemoglobin content within RBC
Mean corpuscular hemoglobin concentration (MCHC)- measure of concentration of hemoglobin within RBC
Mean corpuscular volume (MCV)- measure of RBC size RBC distribution width- measure of deviation in volume of RBCs
Leg ulcers Retinal infarction/detachment Avascular necrosis (digits in children, femoral head in young adults) Pigmented gallstones
Proliferative disorderso Polycythemia vera
Markedly increased hemoglobin Abnormal proliferation of all 3 cell lines JAK2 mutation Hypertension, plethora, headache, hepatosplenomegaly, epistaxis, engorged
retinal veins, erythromelalgia Sludging, thrombosis, infarction in peripheral circulation Itching after hot showers- histamine release from increased basophil and mast
Waldenstrom macroglobulinemia (IgM)- most common Multiple myeloma (IgG or IgA) Leukemia with blast formation Polycythemia vera
Management Phlebotomy for polycythemia Plasmapheresis for dysproteinemias Leukapheresis for blast transformations
Multiple myeloma Proliferation of plasma cells causing a monoclonal immunoglobulin Extensive skeletal destruction and osteolytic lesions on imaging “punched out” Bone pain, anemia, hypercalcemia, renal insufficiency, hyperviscosity Rouleaux on peripheral smear Bence Jones protein on urine protein electrophoresis M spike on serum protein electrophoresis
Transfusion reactions
o TRALI (transfusion related acute lung injury) Presents acutely within 4-6 hours Noncardiogenic pulmonary edema Hypotension Looks like ARDS Stop transfusion immediately
o TACO (transfusion associated circulatory overload) Presents within several hours of transfusion Cardiogenic pulmonary edema Hypertension
o Massive transfusion Transfusion of volume of blood equivalent to patient’s entire blood volume
within 24 hour period OR Transfusion of the equivalent of one-half of patient’s blood volume at one time Coagulopathy- dilution of clotting factors, platelet destruction, DIC Hypothermia Microembolization- degeneration products of platelets, leukocytes,
Methemoglobinemia Cyanosis when concentration >15% Pulse ox 85% regardless of O2 sat Blood is dark brown-purple Precipitated by meds- nipride, nitroglycerin, local anesthetics (lidocaine,
benzocaine), quinolones Treatment is methylene blue
Oncologic emergencieso Cardiac tamponade
Carcinoma of lung and breast, lymphoma (Hodgkin’s and NHL), leukemia, malignant melanoma
o SVC syndrome Carcinoma of lung, lymphoma Slow, progressive tumor development Symptoms occur in early morning Edema/venous distention of face and upper extremities, SOB, headache, feeling
of fullness in head, facial plethora, telangiestasia, papilledema Treatment- radiation, chemo, elevate HOB; steroids or diuresis if laryngeal or
cerebral edemao Infections
Neutropenia- absolute neutrophil count (ANC) <500 Nadir occurs 5-10 days after chemo Bacterial, viral, or fungal
Most common Gram negative in neutropenic fever- Pseudomonas Isolate, broad spectrum antibiotics
o Spinal cord compression Lung (most common), breast, prostate, multiple myeloma, lymphoma Back pain, motor loss, paresthesias, incontinence Treatment- steroids, radiation, surgery
viral neuritis (cochlear branch of CN VIII) Acoustic neuroma Meniere’s disease Temporal bone fracture
Hearing loss testso Rinne test (rinne rings right next to the ear)
Tuning fork on mastoid, then next to ear Normal: air conduction better than bone (still hear vibrations next to ear) Conductive loss: bone > air conduction (vibration not heard next to ear) Sensorineural loss: test is normal
o Weber (Weber wrinkles forehead) Tuning fork on forehead (normally sounds equally loud in both ears) Conductive loss: heard better in affected ear Sensorineural loss: heard better in unaffected ear
o With bilateral sensorineural hearing loss, both tests are normal but there is decrease in hearing acuity
Vertigo
A sensation of movement of oneself (subjective vertigo) or the environment (objective vertigo) Peripheral (85-90%) vs central (10-15%) vertigo
PERIPHERAL CENTRAL
Onset Sudden SlowSeverity Intense spinning Less intense, ill-definedPattern Intermittent ConstantWorse on movement Yes NoNausea/sweating Frequent InfrequentNystagmus Horizontal, rotatory (NEVER
verticalMulti-directional, horizontal, rotatory, or vertical
Fatigues Yes NoHearing loss/tinnitus May occur NoAbnormal TM May occur NoCNS symptoms Absent Usually present (headache,
Peripheral vertigo causeso Benign paroxysmal positional vertigo (BPPV): most common cause
Caused by canalolithiasis; delayed unilateral activation of posterior semicircular canal because of impaired endolymph flow caused by clumped otoliths
Dix-Hallpike to help dx No hearing problems or tinnitus Tx: particle repositioning, sedative, antihistamines
o Vestibular neuronitis Acute onset, viral etiology??; lasts days to weeks Symptoms limited to vestibular system (balance)
o Laybrinthitis Infection of labyrinth (concurrent/recent URI) or result of ototoxic drugs Usually viral, rarely bacterial; look for OM/mastoiditis as cause Vestibular and hearing symptoms
o Meniere’s disease Unilateral or bilateral excess production of endolymph Triad: tinnitus, vertigo, sensorineural hearing loss; also N/V Ages 40-60; spells last hours but can have long symptom free intervals b/t
Vertigo is uncommon with these because the damage they cause is bilateral and vertigo requires an imbalance of sensory input between the vestibular mechanisms
o VIII nerve lesions Involving VIII directly: meningioma, acoustic schwannoma; gradual onset of
mild vertigo and unsteadiness Tumors of cerebellopontine angle: neuromas, meningiomas, dermoids;
Herpes zoster oticus (Ramsay Hunt syndrome): deafness, vertigo, facial palsy; grouped vesicles on erythematous base inside the ear canal
Central vertigo causeso Cerebellar or brainstem hemorrhage, infarction or tumoro Vertebrobasilar insufficiencyo Multiple sclerosis: due to demyelination; look for other signs of MSo Migraine related dizziness and vertigo: basilar migraine aura—vertigo, decreased
hearing, visual disturbances, dysarthria, diplopia, decreased LOC
Otitis externa
Pruritis, pain, tenderness of external canal, sense of ear fullness, white/cheesy/green discharge, pulling on ear or pressing tragus causes pain, erythema/edema of external canal
Precipitated by excessive moisture (swimmer’s ear) or trauma Causes: Pseudomonas aeruginosa, Staph aureus (also Proteus, Enterobacteriaceae, strep) Treatment
o Mild, nonpurulent: 2% acetic acid solution with hydrocortisone 1%o Edema and discharge: polymyxin B, neomycin, hydrocortisone (Cortisporin) suspension
or solution; use suspension if TM perforation present b/c less toxic to middle earo Avoid water for 2-3 weeks
Malignant otitis externao Extension of otitis externa into the mastoid or temporal boneo Seen in adult diabetics and debilitated and immunocompromisedo Caused by Pseudomonas aeruginosao Mortality up to 50%o Fever, excruciating pain, friable granulation tissue in external canal, edema/erythema of
pinna and periauricular tissue; +/- CN palsies and trismuso Admit, IV abx, ENT consult
Acute otitis media (AOM)
Epidemiology: kids 6-36 months; winter and spring; often with viral URI; viral > bacterial Eustachian tube dysfunctionretention of secretionscolonization Pathogens: S. pneumo (most common), H. flu, M. catarrhalis, S. pyogenes; S. aureus, group B
strep and gram-negative enterics may be seen in neonatal period Hx: irritability, poor feeding ear-pulling, otalgia hearing loss, URI sx Exam: TM red/opaque and may be bulging, otorrhea, loss of light reflex, decreased mobility of
TM on pneumatic otoscopy (most reliable) Tx: WASP (Wait and see prescription): ask parents not to fill rx for 48 hours and only if kid is
worse or no bettero Amoxicillin (high dose): 80-90 mg/kg/dayo Others: augmentin, clindamycin, cefuroxime, macrolides, erythromycin
Beware of infants less than 2 months, especially if fever or toxic; need septic workup and broad spectrum coverage b/c more likely to be infected by coliforms, GBS, S. aureus
AOM with clear or hemorrhagic blisters within the layers of TM; ear pain and mild hearing loss Etiology: viral or bacterial (same organisms as AOM); not really Mycoplasma pneumonia as
previously thought
Mastoiditis
Complication of untreated or inadequately treated AOM; also complication of leukemia, mono, sarcoma of temporal bone, Kawasaki disease
S. pneumo (most frequent), H. flu, S. pyogenes, S. aureus Otalgia, otorrhea, fever, headache, hearing loss, outward and downward displacement of pinna,
posterior auricular (mastoid) tenderness, abnormal TM Complications: osteitis, labyrinthitis, meningitis, encephalitis, brain abscess, damage to CN VII Dx with CT temporal bone Admit, IV abx (ceftriaxone, unasyn), ENT consult, +/- myringotomy with tubes or mastoidectomy
Sudden hearing loss, severe otalgia, vertigo If acute, see irregular borders with blood on edges or in canal; if chronic, smooth margins and
no blood Most common area to perforate is pars tensa because most anterior and thinnest If complete hearing loss, nausea, vomiting, vertigo, facial palsyimmediate ENT because might
have concurrent injury to ossicles, labyrinth or temporal bone Tx: no water in ear, reassurance, analgesia, ENT referral; consider abx if due to infection or
forceful water entry (water skiing) or polluted water; if coexisting otitis externa, topical antibiotic suspension (not solution) should be used
Ear FB: if live bug in ear, instill lidocaine to kill it prior to removal
Auricular hematoma
Must I&D and place protective pressure dressing to prevent formation of “cauliflower ear” Reassess in 24 hours for blood reaccumulation; may require repeat drainage
NOSEEpistaxis
Anterior (Kiesselbach’s plexus on anteroinferior nasal septum)-90%; posterior (sphenopalatine artery)-10%
Posterior bleeds usually in elderly, hypertensive pts with atherosclerosis Causes
o Trauma (look for septal hematoma)o Foreign bodyo Nose picking (most common)o Dry nasal mucosa (winter)o Allergies
o Nasal irritants (cocaine, nasal sprays)o Anticoagulantso Pregnancyo Change in atmospheric pressureo Infection (rhinitis, sinusitis)o Osler-Weber-Rendu (telangiectasias, visceral lesions, family hx)
Jury is out on whether hypertension causes nosebleeds Treatment
o Direct pressure for 10 minuteso Blow nose to clear clotso Couple squirts of neosynephrineo Control focal anterior epistaxis with silver nitrate (only helpful when bleeding minimal;
hold for 5-10 sec and on one side of septum-cauterizing both sides of septum can perforate)
o Hemostatic materials-Surgicel, Gelfoamo Anterior nasal packing
Leave in place 1-3 days Discharge on antistaph abx (Keflex) to prevent sinusitis, toxic shock syndrome
o If posterior bleed, needs posterior packing, admission, ENT consult, supplemental O2 Complications
o Rebleeding/severe bleeding (may require transfusion)o Sinusitis, otitis media-due to obstruction of sinus ostia and Eustachian tubes by packingo Toxic shock syndromeo Pressure necrosis of septumo Nasopulmonary reflex-with posterior packs; promotes bronchoconstriction and
increases vascular resistancehypoxia, hypercarbiao Fatal airway obstruction with dislodgement of posterior packingo Bradycardia, dysrhythmias, coronary ischemia with posterior packing
Nasal fractures
Most commonly fractured facial bone Diagnose on exam; imaging not required unless other facial fractures suspected If no deformity, need only analgesia and nasal decongestant Refer to ENT in 2-7 days (when swelling has subsided) for reduction Gross angulation can be reduced in ED If fracture associated with laceration of nasal mucosa or skin, anti-staph abx needed
Nasal septal hematoma
Bluish-purple, grapelike swelling of nasal septum Need to vertically incise and drain, pack nasal cavity, anti-staph abx, ENT in 24-48 hrs Failure to drainavascular necrosis of nasal septum-“saddle nose” deformity
CSF rhinorrhea
Fracture of cribriform plate of ethmoid bone May not develop for days to weeks Clear nasal discharge following trauma; may have hyposmia/anosmia and headache
Usually unilateral and increased by leaning forward or compression of jugular vein Dx: CT (most reliable); ring sign (filter paper on bed sheet—2 rings=CSF); dipstick CSF glucose
>30 mg/dl Tx: place patient in upright position, neurosurgery consult, avoid
coughing/sneezing/blowing/nasal packing
Nasal FB
Most common in kids 2-3 years May present only with unilateral foul smelling nasal discharge, persistent unilateral epistaxis,
foul body odor Removal: topical vasoconstrictor and anesthetic facilitates exam and therapy; positive pressure
techniques (have parent blow puff of air into child’s mouth while occluding uninvolved nostril), suction catheter, forceps, etc
FACESinusitis
Infection of paranasal sinuses (ethmoid, maxillary, frontal, sphenoid); maxillary most common Results from occlusion of sinus ostia, most commonly caused by local mucosal swelling
secondary to viral URI (also allergic rhinitis, trauma, mechanical obstruction from tumors/FB/abnormal anatomy)
Less than 3 weeks-acute; greater than 3 months-chronic Purulent nasal discharge, upper tooth/facial pain, maxillary sinus tenderness, headache,
percussion tenderness, swollen nasal mucosa, opacification on transillumination, nasal congestion
Acute: same bugs as AOM (S. pneumo, H. flu, S. pyogenes, M. catarrhalis, S. aureus) Chronic: anaerobes Usually doesn’t require imaging for initial dx
thickening, sinus wall displacemento CT not specific—40% asx and 87% pts with recent URI have abnormal findings
Tx: most resolve spontaneouslyo Decongestants –topical and oralo Consider abx if sx >7 days—amoxicillin, Bactrim, augmentin, doxy, azithromycin for 10-
14 days Complications
o Orbital cellulitis (ethmoid)o Skull osteomyelitis-Pott’s puffy tumor (frontal)—doughy-feeling tender mass o Meningitis, epidural abscess, subdural empyema, brain abscess (frontal)o Cavernous sinus thrombosis (sphenoid or ethmoid)
Also caused by central face infection Veins of face, oral cavity, middle ear, mastoid drain to cavernous sinus
High fever, toxic, eyelid edema, proptosis, chemosis, facial edema, altered mental status, headache, cranial nerve palsies (III, IV, V1, V2, VI); VI most commonly affected-lateral gaze palsy
Sialolithiasiso Usually submandibularo Dry mouth, pain, worse at meal timeso 90% seen on xrayso Can get secondary staph infectionso Tx-massage, analgesics, sialogogues, warm compresses, milking, sometimes surgery
Parotid duct/facial nerve proximityo A vertically oriented laceration posterior to the corner of the eye and bisecting a line
drawn from the tragus of the ear to the center of the upper lip and involve both the facial nerve and the parotid ductENT should repair these
Facial fractures
Le Fort fractureso Rarely occur in pure form; usually in combinationo Beware of airway and concurrent C-spine injury!!!o Avoid NG tube to avoid intracranial passageo Check for CSF rhinorrheao Le Fort I: horizontal fracture of maxilla at level of nasal floor
Upper dental arch mobileo Le Fort II: fractures through maxilla, nasal bones, and infraorbital rim
Upper dental arch and nose mobile Look for injury to infraorbital nerve
o Le Fort III: fractures through zygomaticofrontal suture or zygoma and frontal bone above nose
Entire face is mobile; “dish pan” face Basilar skull fracture
o Skull base involves floor or anterior/middle/posterior cranial fossao Battle’s sign, raccoon eyes, hemotympanum, CSF rhinorrheao May take hours to develop signs
Mandible fractureo Second most commonly fractured facial boneo Ring structure—look for second fracture (>50%)o Jaw deviates TO the side of fracture, difficulty with mouth opening, decreased ROM,
malocclusion (most sensitive)—tongue blade testo Badly fx mandible can result in airway compromise (tongue support is compromised)o Dx with panorex, CTo Any fracture in tooth-bearing region considered open because periodontal ligament
communicates with oral cavity—antibioticso Teeth that are angulated and sometimes avulsed—alveolar fractureso Lateral crossbite—unilateral condylar fractureso Displacement of lower incisors, interruption of arch continuity—symphysis fractureso Ecchymosis or hematoma of floor of mouth—suspicious for mandibular fxo Anesthesia of lower lip—injury of inferior alveolar or mental nerve secondary to fxo Admit for airway compromise, excessive bleeding, severely displaced, grossly infected,
comorbid disease Mandible dislocation
o Can result from trauma, yawning, laughingo Jaw locked open (condyle locked anterior to articular eminence), difficulty
talking/swallowingo Bilateral—anterior open biteo Unilateral—jaw displaced AWAY from dislocationo Manual reduction with downward pressure applied to posterior teeth to dislodge
condyle; chin then pressed posteriorly so condyle returns to fossa. Protect your thumbs!!
Tripod fractures (zygomatic-maxillary complex)o Blow to cheek results in fx of zygomatic arch, zygomaticofrontal suture, infraorbital
foramen. Also, fx of lateral wall of maxillary sinus and orbital flooro Flattening of cheek, periorbital swelling/ecchymosis, diplopia, step-off deformity of
inferior orbital rim, anesthesia of cheek/upper teeth/lip/gum Orbital floor fractures (“blowout” fx)
o Orbital fat, bone, extraocular muscles may protrude into maxillary sinus and become entrapped
o Diplopia, enophthalmos, upward gaze palsy, hypesthesia of infraorbital nerveo CT, abx if sinus involvement, surgery if persistent enophthalmos, visual changes, muscle
entrapment
MOUTH Numbering the teeth
o Adults: start from upper right third molar (#1) and around to upper left third molar (#16). Then down to lower left third molar (#17) and around to lower right third molar (#32)
o Kids: lettered starting on upper right second molar (A) and around to upper left second molar (J). Then down to lower left second molar (K) and around to lower right second molar (T)
Nerve blockso Supraorbital nerve block: forehead/scalpo Posterior superior alveolar nerve block: maxillary molars (except portion of first molar)o Infraorbital nerve block: midface, maxillary incisors, premolars, lower eyelid, upper lip, side
of nose, portion of first molaro Inferior alveolar nerve block: mandibular teeth, lower lip, chin
Tooth emergencieso Tooth fractures
Ellis I: fracture of enamel only; no hot/cold sensitivity; tx elective Ellis II: fracture of enamel and dentin; hot/cold sensitivity; see yellow dentin on
exam; tx with calcium hydroxide paste and see a dentist w/in 24 hrs Ellis III: fracture of enamel, dentin, pulp; severe pain; see pink dot on exam; moist
cotton or calcium hydroxide paste and see dentist ASAPo Alveolar osteitis “dry socket”
Loss of clot with localized osteomyelitis 2-5 days postextraction (most often 3rd molar) Tx: pain meds not that great, nerve block, irrigate socket, pack with iodoform gauze
dampened with eugenol, antibiotics, dentist ASAPo Dental pain
Reversible pulpitis with caries: sharp intermittent tooth pain subsides quickly, worse with cold temps; tx with filling
Irreversible pulpitis with caries: dull, continuous pain persists minutes to hours, worse with hot temps; tx with PCN, pain meds, root canal
Pericoronitis: gum inflammation due to food impaction around crowded, malerupted or impacted third molars; tx with irrigation and abx if surrounding cellulitis
Periapical abscess: most common cause of severe tooth pain. Inflammation, infection, necrosis of apical portion of tooth; can erode into abscess through cortical bone. Suspect if tooth severely painful on percussion. Parulis: abscess draining externally on gums. Tx=abx, extraction
Periodontal abscess: gum disease is MCC of tooth loss; gum inflammation, calculus, infection, abscess; tx with I&D, clinda, flagyl
o Avulsed teeth Do not reimplant primary teeth—risk of alveolar ankylosis Reimplant quickly--1% loss of survival per minute Rinse gently with saline; do not brush or will remove periodontal ligament Transport medium: saliva, milk, Hank’s solution (best) Prophylactic PCN, soft diet, Td
Electrical burns to lipo Worry about delayed hemorrhage from labial artery 3-14 days later
Acute necrotizing ulcerative gingivostomatitis (“trench mouth”)o Infection of gingiva precipitated by psychological stress, smoking, poor oral hygieneo Only periodontal lesion in which bacterial actually invade nonnecrotic tissueo Fusobacterium, spirocheteso Pt c/o pain, metallic taste, foul breath, fever, malaise, lymphadenopathyo Gingivae swollen, fiery red; interdental papillae swollen, ulcerated, “punched out” and
covered with grayish pseudomembrane
o Warm saline irrigation, hexadine rinse, abx (PCN, clinda, flagyl)o Other conditions with gingival hyperplasia: phenytoin, diabetes, nifedipine, acute leukemia
Aphthous ulcer vs herpetic lesionso Aphthous ulcers: single circular ulcer <1cm with central yellow area surrounded by
prominent band of erythema. Can occur anywhere in oral cavity EXCEPT lips, hard palate, attached gingiva. Tx with abx, topical steroids, anesthetic rinses
o Herpetic lesions: clusters of small vesicles that coalesce. Occurs exclusively on the lips, hard palate, attached gingiva. Tx with topical acyclovir
Candidiasis vs hairy leukoplakiao Candidiasis: painless, white, curd-like plaques on erythematous base that SCRAPE off with
tongue blade. Risk: extremes of age, abx, dentures, diabetes, steroids, HIV, chemotherapyo Hairy leukoplakia: asymptomatic white patches with hair-like projections, often on lateral
tongue, that CANNOT be scraped off with tongue blade. Caused by EBV; 80% develop AIDS within 3 years
Ludwig’s anginao Progressive cellulitis of floor of mouth; submandibular, sublingual, submaxillary spaces
involved bilaterallyo Airway obstruction occurs in 33%o Precipitated by abscess to posterior mandibular molars (most commonly 2nd)o Anaerobes (Bacteroides) and aerobes (staph, strep)o Dysphagia, odynophagia, dysphonia, trismus, drooling, neck/sublingual pain, massive
brawny edema of floor of mouth/anterior neck, fever, elevated tongueo Tx—keep sitting up, airway/airway/airway, ENT, abx (PCN+flagyl, cefoxitin, clinda, unasyn),
ICUo Complications—Airway compromise is #1; extension to deeper layers of neck or
chestmediastinitis, mediastinal abscess Masticator space infection
o Bounded by muscles of mastication (masseter and internal pterygoid muscles)o From extension of anterior space infection (buccal, sublingual, submandibular space) or
infection of third molaro Strep and anaerobeso Lateral facial swelling, pain, fever, trismuso Tx—abx (PCN, clinda), ENT, admission
NECK/THROAT Croup (laryngotracheobronchitis)
o Most common cause of upper respiratory obstruction in childhoodo Usually 6 mo-3yrs, male>female; caused by virus (parainfluenza); fall and wintero Affects glottis and sublottic tissueso Preceding viral URI for 2-3 days, gradually increasing cough; insidious onset, nontoxic
retractions, stridor), nasal discharge, low-grade fevero CXR—subglottic narrowing of tracheal air column-“steeple sign”
o Tx--cool mist, O2, hydration, racemic epi if stridor at rest (observe for rebound), steroids (decadron 0.15-0.6 mg/kg IM), no antibiotics
o Admit—persistent stridor at rest, unable to tolerate po, unreliable social, incomplete response to racemic epi, multiple doses of racemic epi, severe presentation
Epiglottitiso Adults >children since Hib vaccine; peak incidence 20-40 yrs; nonseasonalo S. pneumo (also GABHS, toxic fumes, superheated steam, gasoline ingestion, angioedema)o Affects supraglottic tissues (epiglottis, aryepiglottic folds, arytenoids in kids; can extend to
prevertebral soft tissues, valleculae, base of tongue, soft palate in adults)o Usually no prodome in kids; adults have 1-2 day URI; progression is rapid (adults can be
respiratory distress (tachypnea, dyspnea, inspiratory stridor), restlessness, tachycardia out of proportion to fever; can be less impressive in adults
o Unremarkable oropharynx exam (if it is done)o Diagnosis ideally in OR—cherry red epiglottis; do not disturb a child for exam and
radiographs; notify ENT, anesthesiao If less severe, lateral xrayenlarged “thumbprint” epiglottiso Tx—ceftriaxone, ENT, ICU
Bacterial tracheitis (membranous laryngotracheobronchitis)o Bacterial infection of subglottic region with copious tracheal secretions; superimposed upon
viral URIo Has features of both croup and epiglottitiso Ages 3 mo -10 yrs (usually <3 yrs); nonseasonalo S. aureus (also H. flu, S. pyogenes, M. catarrhalis)o Prodrome of URI or croup then rapid progression, toxic appearance, barking cough,
respiratory distress (stridor and retractions), high fevero Direct visualization confirms dx; should be done by ENT in OR; see pseudomembranes and
purulent secretionso Tx—O2, ENT/anesthesia, abx (-cillin plus ceftriaxone), ICU
Parapharyngeal abscesso Space lateral to pharynx and medial to masticator space; extends from base of skull to hyoid
boneo Precipitated by dental, pharyngeal, tonsillar infectiono Anaerobes and aerobeso Neck pain, sore throat, dysphagia, odynophagia, unilateral swelling of neck/angle of
o Tx—airway, IV abx, ENT, steroids, ICUo Complications—airway obstruction, spread (CN IX-XII neuropathies, carotid artery extension,
septic thrombosis of internal jugular vein) Peritonsillar abscess
o Most common deep head/neck infectiono Between tonsillar capsule and superior constrictor muscle; complication of untreated or
partially treated suppurative tonsillitis, also mucosal trauma, odontogenic spreado Teenagers/young adults; rare in kids <12; males>femaleso Can occur after tonsillectomy
o Polymicrobial (GABHS, strep, H. flu, staph, bacteroides, fusobacterium)o Unilateral sore throat, dysphagia, odynophagia, drooling, “hot potato” voice, inferior and
medial displacement of tonsil, deviation of uvula to opposite side, ear pain, trismus, fever, tender cervical lymphadenopathy, foul breath
o Abx (PCN, unasyn, clinda, cefoxitin, emycin), decadron, needle aspiration (not deeper than 1 cm and stay medial to avoid laterally located carotid artery)
Retropharyngeal abscesso Anterior to prevertebral fascia and posterior to pharynxo Kids 6 mo-3yrs (b/c large retropharyngeal nodes prone to infection; these involute w age)o S. aureus, GABHS, anaerobeso Usually follows URI, pharyngitis, OM, wound infection s/p penetrating injury to posterior
of posterior pharyngeal wall, tender cervical adenopathy, toxic, sit with neck in extensiono Soft tissue neck xray done in sniffing position—neck in extension and during inspiration
normal retropharyngeal space <1/2 width of adjacent vertebral body; RPA will be thickened
Prevertebral infectiono Space between prevertebral fascia and cervical spineo Usually from cervical osteomyelitis (staph, TB)o Bilateral bulging of pharynx, tenderness of C-spineo Xray—retropharyngeal swelling or osteo of spineo Tx—abx, neurosurgery
o Monospot helpful if positiveo If given ampicillin, 95% get EBV-induced antibodies to it and a rasho Care regarding potential splenic rupture is appropriateo Steroids if: airway obstruction, severe hemolytic anemia, thrombocytopenia, neurologic
(encephalitis, GBS) Diphtheria
o Secondary to noncompliance with DPT immunization; spread by contact with respiratory secretions; incubation one week
o Corynebacterium diphtheria=club-shaped Gram + bacilluso Infectious invasiontissue necrosis produces pseudomembrane in posterior pharynx; can
lead to airway obstructiono ToxinCV (myocarditis/AV block/endocarditis); nephritis; hepatitis; neuro (eyes-strabismus,
ptosis; palate-first muscles affected; limb paralysis; loss of DTRs)o Sore throat, fever, malaise, toxic, tachycardia, hoarse/muffled/absent voice, exudative
o Culture on Loeffler’s or tellurite mediao Tx—Abx (PCN, emycin), diphtheria antitoxino Asymptomatic, immunized contacts—Td boostero Asymptomatic, partially immunized or unimmunized—one dose IM PCN and begin
immunization series Group A beta-hemolytic strep (GABHS)
o Late winter, crowded conditions; <20 yrs; rare in <3 yrso Centor criteria: fever, tender cervical adenopathy, exudative tonsillitis, no cougho Abdominal pain, vomiting, headache common in kidso Strep screen helpful if positiveo Tx—10 days PCN or single IM benzathine PCN; cephalosporins and azithro usually reserved
Nonsuppurative Strep toxic shock syndrome Glomerulonephritis-abx do not decrease incidence Rheumatic fever-abx within 9 days prevent this
o Jones criteria for diagnosis (need 2 major or 1 major and 2 minor PLUS evidence of recent strep infection
o Major criteria J (Joints): migratory polyarthritis of large joints, usually
starting in legs and migrating up O-imagine a heart (carditis): CHF, pericarditis, new murmur
(mitral valve damage) N (nodules): subcutaneous-painless, firm collections on
back of wrist, outside elbow, front of knees E (erythema marginatum): begins on trunk or arms as
macules and spreads outward to form snakelike ring while clearing in middle. Never starts on face; worse with heat
S (Syndenham’s chorea): St. Vitus’ dance; rapid movements of face and arms
o Minor criteria Fever Arthralgias Labs-ESR, CRP, leukocytosis EKG-prolonged PR interval Previous rheumatic fever or rheumatic heart disease
o Evidence of Group A Strep infection Positive throat culture, elevated or rising ASO or DNAase
titer, recent scarlet fever Airway obstruction
o Labored respirations: tachypnea, retractions, nasal flaringo Stridor
Inspiratory: (supraglottic or glottic) indicates obstruction above or at the larynx, ex. epiglottis
Biphasic: (subglottic) indicates obstruction below the larynx, ex. croup Expiratory: indicates bronchial or lower tracheal obstruction
o Hoarseness, dysphagia, coughing, cyanosis Foreign body aspiration
o Kids 1-4 yrs; males>femaleso Peanuts most common agent; hot dogs most common cause of fatal aspirationo Narrowest part of airway is where FB get lodged
Adults—vocal cords Kids—cricoid cartilage
o Presenting signs Aphonia: complete upper airway obstruction Stridor: incomplete upper airway obstruction Wheezing: incomplete lower airway obstruction Coughing: incomplete obstruction at larynx or distal airways
o Is the coin in the esophagus or airway??? Esophageal FB: lies in frontal/coronal plane and will be round in PA view Tracheal FB: lies in sagittal plane and will be round in lateral view (on edge in PA
view)o Partially obstructing FB
Seen best on expiratory films “ball valve” effect: hyperinflation of obstructed lung due to air trapping, shift of