The Washington Manual Internship Survival Guide (29 page)

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  Pertinent physical exam: Ensure stable vitals. Systemic hypertension may initiate or perpetuate bleeding. Determine the source of bleeding (anterior vs. posterior and right vs. left naris). Identify any anatomic abnormalities such as septal deviation or septal perforation that may cause turbulent airflow and resultant epistaxis. Identification of most anterior sites can be aided by nasal speculum and light source (headlight or mirror).

•
  Workup: Check coagulation values including PT/PTT, bleeding time or PFA-100, and hematocrit.

•
  Treatment:

•  Patient should be seated completely upright to decrease risk of aspiration. For the same reason, head should be tilted slightly forward, not back.

•  
Simple nasal compression for 15 minutes
will stop most nosebleeds. To be effective, this must be maintained by the patient or staff without releasing pressure for the entire
15-minute period. Do not pack the nose with tissue or gauze. These will traumatize the nasal mucosa and result in further injury. If the initial round of compression is not successful, always try a second round of nasal compression.

•  Control severe hypertension; however, most epistaxis is not directly caused by this.

•  Application of
topical vasoconstrictors
(oxymetazoline hydrochloride 0.05% or phenylephrine hydrochloride 0.25%) may help to slow down bleeding. Follow this with nasal compression as described above.

•  If a small anterior bleeder can be visualized, it can be cauterized with judicious use of a
silver nitrate
stick. Never cauterize both sides of the nasal septum, as this can lead to septal perforation.

•  Remove nasal cannula O
₂
, which dries and irritates the nasal mucosa. Replace with humidified oxygen by face mask or tent and frequent use of nasal saline spray.

•  
Nasal packing
: If the above measures fail to control bleeding, nasal packing will be required. Nasal packs are typically placed by the ENT service. This may be performed with Vaseline strip gauze or with commercially available nasal packs. When calling a consult, ensure that the patient has been positioned as above and anterior nasal compression is being maintained. Set up suction at the bedside. Anterior packs are usually well tolerated and require
prophylactic anti-staphylococcal antibiotics
to prevent toxic shock syndrome. If a standard nasal pack is unsuccessful, the patient may require placement of an Epistat balloon. This pack rests in the nasopharynx and, if placed, requires cardiac monitoring due to the possibility of vagally mediated bradyarrhythmias. All packs remain in place for 3 to 7 days and are removed by the ENT service. Stable, reliable patients can be discharged with a pack in place (except for those with Epistats) and return for removal as an outpatient. If packing fails, the patient will require embolization by interventional radiology or surgical ligation of bleeding vessels.

Complicated Acute Sinusitis

•
  
This is an emergency when the infection has extended past the sinuses to involve intraorbital or intracranial structures
. If this is suspected or confirmed, call a consultant immediately!

•
  Pertinent history: Duration of sinusitis symptoms, vision changes, mental status changes, duration/route of antibiotic therapy, previous sinus surgery. Predisposing factors include malnutrition, diabetes, chemotherapy, long-term corticosteroids, allergic rhinitis, immunodeficiency states, environmental exposures, and presence of nasogastric tube.

•
  Pertinent physical exam: Meningeal signs and orbital signs (proptosis, chemosis, ophthalmoplegia, vision loss). These suggest extension of the infection beyond the sinus and necessitate immediate attention by an ENT consultant.

•
  Workup: High-resolution maxillofacial CT (with coronal cuts) with contrast to rule out subperiosteal/orbital abscess. Head CT with contrast may be indicated to look for intracranial involvement.

•
  Treatment:

•  An ophthalmology consult is required if there is suspected orbital involvement. They will be able to document pressures and visual acuity changes that determine the need for intervention.

•  
IV antibiotics
(including anaerobic coverage).

•  Copious use of saline (Ocean) nasal spray and 3 days of oxymetazoline to aid in nasal drainage.

•  
IV steroids
(dexamethasone 10 mg or methylprednisolone 125 mg) to help diminish edema around orbits and reduce optic nerve damage.

•  
Surgery
(functional endoscopic sinus surgery or external surgical drainage) is definitive therapy to drain abscess and sinuses.

•  If optic nerve damage is imminent due to intraorbital abscess, then immediate lateral canthotomy with tendon cantholysis should be done to decrease intraocular pressure.

Vertigo

•
  Vertigo emergency:

•  Important vertigo emergencies are rare and include the following:

▪  Wallenberg (lateral medullary) syndrome

▪  Lateral pontomedullary syndrome

▪  Cerebellar hemorrhage

▪  Cerebellar infarction

▪  Vertebrobasilar insufficiency

•  History: Sensation and duration of dizziness, associated neurologic symptoms (headache, visual changes, unilateral weakness, dysarthria, or paresthesias), nausea, or vomiting.

•  Physical exam: Associated neurologic findings (diplopia, dysarthria, drop attacks, vision loss, dysphagia, loss of pain/temperature sensation, loss of motor control), Horner’s syndrome, nuchal rigidity, papilledema, nystagmus of central origin (characterized by lack of fixation suppression, spontaneously upbeating or downbeating, or that which changes direction with changing gaze direction).

•  Workup: Neurology consultation; CT/MRI or cerebral angiogram depending on suspected etiology.

•  Treatment: Dependent on etiology, may include surgical decompression, anticoagulation, and/or supportive care.

•
  Vertigo (general):

•  Common etiologies:

▪  Benign paroxysmal positional vertigo (BPPV)

▪  Ménière’s disease

▪  Vestibular neuronitis

▪  Migraine-associated vertigo

•  History: It is important to rule out central from peripheral causes of vertigo (see above section) as well as differentiating true vertigo (abnormal perception of motion) from light-headedness or feeling “off-balance.” Note exacerbating factors (position changes, sudden head movement, noise, sound), other otologic symptoms (hearing loss, otalgia, otorrhea, tinnitus), general medical history, medications. Duration and frequency of episodes are crucial to making the correct diagnosis.

•  Physical exam: Nausea and vomiting (these tend to point to a peripheral cause), horizontal nystagmus, fixation suppression of nystagmus, Dix-Hallpike maneuver (BPPV).

•  Workup: Rule out medical causes including hypotension or hypertension, cardiac arrhythmias, endocrine abnormalities.

•  Treatment: Dependent on the exact etiology (e.g., BPPV treatment requires Epley maneuver for otolith repositioning). Short-term symptomatic treatment may include the following:

▪  Prochlorperazine suppositories, 25 mg q6h prn.

▪  Hydroxyzine, 12.5 to 25 mg PO q8h prn.

▪  
Diazepam, 2 to 10 mg PO q6h prn.

▪  For severe cases, diazepam 5 to 10 mg IM or droperidol 2.5 mg IM.

PSYCHIATRY

Before You Call a Consult

•
  Respect patient autonomy and the right to refuse a consultation/treatment.

•
  Psychiatric consultation in and of itself may be stigmatizing.

•
  
Patients have the right to refuse consultation, unless
:

•  There is concern about the patient being a danger to himself/herself or to others.

•  There is concern about the patient’s decision-making capacity.

•
  Clinical pearl: The patient should always be told that a psychiatric consultant is coming to see him or her.

Suicidality

•
  When to suspect ideation: when the patient appears sad, depressed, or anxious; when there is a significant drug or alcohol history; when there is a history of domestic abuse; when psychosis is present.

•
  Before calling the consult, obtain the following information:

•  Key history: Age, gender, previous psychiatric treatment, presence of current suicidal ideation and suicide plan, presence of psychosis and command hallucinations, presence of anxiety, current meds, brief general medical history, and hospital course.

•  Key physical findings: Presence or absence of agitation, anxiety, overt psychosis.

•
  Treatment:

•  Keep patient safe; get a sitter until directed otherwise by psychiatry.

•  Do not let a suicidal patient leave without clearance from psychiatry; once medical issues are resolved, the patient may require transfer to psychiatry, possibly against the patient’s wishes.

•
  Clinical pearls:

•  Suicidal ideation is a symptom, not a diagnosis; a full psychiatric interview is necessary to determine the cause and direct treatment.

•  Never be afraid to ask about the presence of suicidality; you will not give the patients ideas they didn’t already have.

Violent Patients

•
  Critical diagnostic question:
Is delirium present
(i.e., does the patient have a fluctuating level of consciousness with altered mental status)?

•
  Before calling the consult, obtain the following information:

•  Key history: Age, gender, onset of symptoms, level of orientation, presence of psychosis, prior psychiatric treatment, current meds, brief medical history, and hospital course.

•  Key physical findings: Vital signs, overt psychosis, localized findings on neurologic exam.

•
  Workup: Directed at identifying the cause of the delirium; may include electrolytes, CBC, UA, UDS, LFTs, CSF studies.

•
  Treatment:

•  Protect the patient and staff;
if necessary sedate the patient with antipsychotics
(e.g., haloperidol IM in doses ranging from 0.5 mg in the frail and elderly to 5 mg in the younger and larger; better to use IM than IV due to higher risk of QT prolongation with IV administration); use restraints if necessary.

•  Identify and
treat the cause of the delirium.

•  Family members can help reorient delirious patients and lessen their violence. Dimly lit, quiet rooms help, as do glasses and hearing aids for those who need them.

•
  Clinical pearls:

•  Common, less obvious causes of delirium are anticholinergic medications, benzodiazepines, undertreated pain, opiates, and steroids. Offending medicines should be tapered or discontinued as much as possible.

•  
Avoid using benzodiazepines for sedation in delirious patients unless the delirium is from alcohol or sedative withdrawal or phencyclidine intoxication
.

•  Do not put yourself in danger. Remove all possible items in the vicinity that could be used against you (e.g., stethoscope).

•  Have security with you.

•  Stand between the patient and an open door.

•  Using antipsychotics at high doses too frequently can sometimes lead to akathisia (an internal sensation of restlessness), which can increase agitation.

Competency/Decision-Making Capacity

•
  Definitions:

•  
Competence
is technically a legal term. Only a judge can declare someone incompetent (and appoint a guardian, for example).

•  
Decision-making capacity
refers to the ability of patients to give informed consent to medical care; psychiatrists can often assist in the assessment of capacity.

•
  Evaluation of decision-making capacity is usually an emergency or urgency as the patient typically requires emergent or urgent medical care for which the patient is unable or unwilling to give consent.

•
  Before calling the consult, obtain the following information:

•  Key historical information: Age, gender, proposed medical care and risks, benefits, and alternatives particular to the patient, medical history, current meds, presence of psychosis or depression, psychiatric history.

•  Key physical findings: Presence or absence of agitation, anxiety, overt psychosis.

•
  Demonstration of decision-making capacity requires all four of the following:

1.
  The ability to communicate a choice.

2.
  Understanding of the medical situation and likely outcome of no treatment.