Consult guidelines

Airway

• • All airway consult must be requested by the MD managing the patient, not the RN, RT, or other caregiver

    • Ask the managing MD to provide the following information:

      • Exact consult request

      • Level of urgency

      • Current vitals 

      • New noisy breathing, specifically, stridor 

      • New respiratory posturing 

  • All airway consults should be discussed with the senior resident (3rd year and up) and / or attending, as soon as possible

  • Emergent airway consults should be immediately discussed with an attending. If there's an question regarding the acuity of the consult, talk with an attending

    • Daytime: P-consult MD, On-call MD

    • Nighttime: On-call MD

    • Pediatric daytime:  P-consult MD, On-call MD; if needed, Schloegel (whoever is in clinic or available)

    • Pediatric nighttime: On-call MD

  • Junior residents (interns, especially) should only intervene on an airway consult with a senior resident (3rd year and up), unless in the case is emergent

  • Trach changes qualify as airway consults

    • Interns, trach changes should be done with a more senior resident (2nd year and up)

      • IF the airway is challenging, recruit a senior resident or attending

    • Supplies to have during a trach change:

      • The correct replacement tube - confirm this is the correct tube with the managing MD, patient, RT (if applicable)

      • Keep in mind, in most cases, you have more familiarity with what trach tube is best for a patient; Only place a trach tube if you believe it is the best tube for the patient 

      • At least one "back up" airway which may be

        • One size smaller trach tube

        • ETT

        • Exchange catheter 

        • Nasal speculum

        • Suction

        • Optional but recommended: Flexible laryngoscope

    • Trach changes should not be performed after hours, unless emergent or urgent 

    • Trach changes should be done only after the following:

      • Consenting the patient verbally, or the patient's caregiver 

      • Notifying the primary MD

      • Having the RN and RT, if applicable, at bedside 

        • RT is a must if the patient is on a vent or may require ventilator assistance 

      • Setting up and testing all of your equipment

Tracheostomy

• • Background

    • Common inpatient consult request 

  • Management

    • When consulted, clarify with the requesting MD before seeing the patient 

      • The indication for tracheostomy

      • Any potential contraindications or special challenges 

      • Urgency

      • Logistical timing 

      • Who will consent the patient 

      • Overall prognosis and goals of care 

    • See the patient and complete your note as soon as possible

      • If non-urgent, postpone until done with your urgent patient care duties

• Staffing

  • Please discuss all trach requests as soon as reasonably possible with the on call attending

  • When staffing, please ask the attending what OR times work for them

  • If they are not available, find another attending who is available ASAP and ask them what times work

  • Then take those times to the OR schedulers and see if it is possible to book the case right away into block time

  • If there is no block time available, confirm with the attending that you will be requesting an add on

  • Submit the case request immediately 

  • Contact the OR and Anesthesia to confirm the timing and staffing 

  • Special circumstances: 

    • trachs and G tubes - usually surgery or pedi surgery will be doing the G tube in the OR during the same case so you must discuss with them and clarify 

      • which service is submitting the case request

      • who is adding the second panel to the case request 

      • what procedure is going first - trach or G tube

  • Communicate this plan with

    • patient and / or family - print and sign consent at this time, if possible

    • primary team, if applicable - clarify who will order NPO and IVF

  • Lastly, communicate all of this with our entire team same day

    • put the patient on the list

    • text the team the plan

    • find out which resident will cover the case 

      • remind the team of any cases that will carry over into the next week 

"Fish-bone in throat"

• • Background

    • A very common call, especially from urgent care clinic

    • Typical complaint is patient had some fish and noticed pain with unrelenting discomfort afterwards

    • Majority of these are usually negative findings as it is very common to have globus/discomfort from passing irritation

    • Not an emergency, can be seen as an outpatient if all else stable

  • Equipment

    • Flexible laryngoscope

      • Consider bringing tower with monitor

      • May need a second person to hold the scope while you hold the tongue and forceps

    • tongue depressor 

      • Other options: 

    • Headlight

    • Topical anesthetic for nose and airway 

    • if fish-bone is visible - usually present in vallecula or pyriform recess

      • tonsil clamp

      • Frontal sinus forceps (front to back and side to side) 

  • Management

    • These patients warrant a thorough OC/OP exam and a flexible laryngscopic exam. If they were seen in the ED, they may also have plain films. If a fish bone is visualized, then obviously you will have to try removing it under visualization. Some can be a little tricky to remove depending on location and gag reflex and you may need to go to the OR. The majority of these patients will have negative exam, and you will have to spend time reassuring them. Generally, negative patients will improve over a course of days to weeks while a positive patient will continue to have proling symptoms or get worse

  • Reason for admission

    • If the bone cannot be obtained at bedside and OR esophagoscopy is required 

    • NPO

    • IVF

    • Case request and orders 

    • Consent 

    • Contact Anesthesia and OR 

Esophageal foreign body

• • Background

    • Most calls are from ED. They will likely have some plain films. Likely young child or old demented patient. Common objects include coins, plastic toys

  • Management

    • Generally a good idea to get both lateral and PA films as disk batteries can masquerade as a coin. Occasionally, we have been called for a FB on plain film which happened to be hyoid/cricoid/thyroid cartilages. If surgical indication, generally can be done as outpatient or next morning, although many of these patients will have dehydration, poor PO intake etc. If need admit, try to get HBS/Peds to admit. If not, can admit as 23 hour obs, do rigid esophagoscopy in AM and then discharge

  • Reason for admission

    • only for poor PO intake/dehydration/young age - have HBS (805-0988) or peds admit if possible

Airway foreign body

• • Background

    • Common call for pediatric patients

    • Usually will come with plain films

    • Many will require emergent DL/broch

    • Some will be soft calls - "no witnessed event, but some stridor, increased WOB, ambiguous CXR findings, possible pneumonia vs FB aspiration"

  • Management

    • Key is to first assess urgency i.e. physical status, O2 sats, stridor, age of child

    • Also get good history - whether FB ingestion/inhalation was observed or not, location of FB

    • Stabilize patient, alert OR and attending, coordinate with anesthesia, equipment setup in OR, consent and H&P

  • Reason for admission

    • Usually will have to admit

Peritonsillar abscess (PTA)

Background: 

You'll get calls from both ED and Medicine docs for this.  Per established interdepartment protocol, ED docs are supposed to attempt a needle drainage before calling you, but many will give you the excuse "I don't feel comfortable" or "since you are here...."  Generally, these patients will have throat pain for at least 3 days, obvious swelling of tonsillar fossa, trismus, poor PO intake, and fever.

Equipment: 

Hurricane spray (optional), Lido with epi, 18 gauge needle on syringe (if aspirating), 11 blade and tonsil clamp (if I&D), Yankaur suction, tongue depressor (can use Yankaur suction as tongue depressor), Headlight, flex scope, irrigation (saline flushes and angiocath work well)

Management: 

Airway, airway, airway

Consider starting with flexible laryngscopy to rule our supraglottitis, which requires close inpatient observation and IV antibiotics until improved

Split the difference between the fossa and uvula (Hilsinger splits the anterior pillar and the mandibular ramus instead), spray hurricane, inject local, if needle aspiration may need several passes, incise, open with clamp and suction.  Generally will get 2-10 cc of pus.  If there is pus, patients will start feeling better right away.  Most will ooze for a short period but stop spontaneously.  Yankauer suction can serve as a tongue blade and work double as suction. Can also try using a bite block (outside the Maxillo-facial or) for patients who are clamped down. Consider giving a bolus of IV fluid and 4mg dexamethasone (or other IV steroid) before they leave the ED (or even before you come in to relax the jaw).  Send out with pain meds of choice and consider PCN/clinda/augmentin, especially if no pus.  Very short burst of prednisone can also help with pain/swelling.  Call or see the next day -- should feel markedly better in 24 hours.

Reason for admission: 

rarely ever

Facial fracture

• • Background

    • Facial fractures, especially mandible fractures are a common "dump" from other Kaiser facilities, especially on evenings and weekends

    • Per established protocol, only subcondylar mandible fractures are to be transferred to K-Oakland

    • Whenever you get a call for a transfer of a facial fracture, have them talk with the appropriate HNS or MFS directly instead of having you be stuck as the middleman

    • Generally, these facial fractures will be scheduled for OR repair 3-10 days out, as an add-on case in the afternoon or on weekends

  • Management

    • Ask if patient has airway compromise

    • Be sure the scan is a facial bone CT

    • Ask for visual changes - if so, ask ED to get ophthalmology consult

      • For any periocular fractures that require surgery (i.e. orbital blowout) - always have pre-op ophthalmologic visual exam for documentation

    • Document function of nerves in vicinity of fracture (for example: inferior alvolar/mental for mandible, infraorbital for orbital floor or ZMC)

    • If NOE fracture document if medial canthus is secure (snap test)

    • Mandible fractures are generally open fractures, make sure they are on antibiotics, soft diet, and pain meds

    • For flopping mandible fractures, placing bridal wires in ED can help

• Staffing

  • • Please staff all traumas as soon as reasonably possible with the on call HNS attending or the MFS staff who is most available (Fallah, Shook, Williams - but no O'Ryan) 

    • When staffing, please ask the attending what OR times work for them

      • For traumas, ask if 3D recon is needed - as a rule, always request 3D recon of the facial bone CT right away by calling the radiology tech where the scan was completed; At OAK, if you wait for than 3 days, they trash the scan's raw files so you are no longer able to obtain a 3D recon 

    • If they are not available, find another attending who is available ASAP and ask them what times work

    • Then take those times to the OR schedulers (Ranisha, Soleded, or the other lady who is newer) and see if it is possible to book the case right away into block time

    • If there is no block time available, confirm with the attending that you will be requesting an add on

    • Submit the case request immediately 

      • For traumas, see if the rep is needed and what trays 

    • Communicate this plan with

      • patient and / or family - print and sign consent at this time, if possible

      • primary team, if applicable - clarify who will order NPO and IVF

    • Lastly, communicate all of this with our entire team same day

      • put the patient on the list

      • text the team the plan

      • find out which resident will cover the case 

      • remind the team of any cases that will carry over into the next week 

• • Reason for admission

    • Airway compromise (bilateral mandibluar body, LeFort, etc)

    • If need to admit for dehydration/poor PO intake/pain - ask HBS to admit

Nasal fracture

Ask ED to make sure no septal hematoma -- needs draining. Otherwise have ED place E-consult for patient to be seen in HNS clinic.

Reason for admission: 

never

Abscess

Background: 

Common cause for call.  Generally, consulting physician will expect you to drain as they are "uncomfortable" with the head and neck area.  Also will often have ED physicians calling any intraoral infection as "Ludwig's" although this entity very rare. 

Equipment: 

Lidocaine with epi, syringes, needles (18 guage, 27 guage), 11 blade, iodoform packing strips, culture swabs 

Management: 

Physical exam important to distinguish between cellulitis vs abscess, CT scan can help although notorious for inaccuracy between abscess and phlegmon (rim enhancing areas are not always abscesses).  However, general principle is to needle the area if any doubt for abscess, then open if needed.  If patient is sick, should consider admitting for IV abx.  Always culture abscess.  Pack with packing strips if external abscess.  Abx management for skin source - consider keflex, clindamycin, septra - note while septra will often cover MRSA, will often not cover MSSA.  Also very important - frequent warm compresses and raise head of bed.

Reason for admission: 

clinically sick, considerably elevated WBC, worsening despite PO abx, high fevers

Epistaxis

Background: 

Very common call especially during winter months.  Can be a PITA as often refractory to management.  Levels of care per ED physician can greatly vary.  ED tends to like "rapidrhino" packs, although some do not seem to work quite as well as merocel packs.  Many ED physicians will call a nosebleed a "posterior bleed" if whatever they have tried fails - although posterior bleed in reality not as common.  Try to get them to go down the protocol and place packs. 

Equipment: 

Merocel packs, bacitracin ointment or some other lube, epistat balloons (if needed), headlight, nasal speculum, lidocaine with epi (if needed). Can investigate nose with 0-degree scope to identify and address site of bleeding if amenable.

Management:  

Several things to check on history/exam - prior hx (HHT), side of bleed, approximate amount of blood lost, use of anticoagulants, reason for poor hemostatis - chemo, renal failure, hepatic failure, uncontrolled hypertension, lab values H/H.  If bleeding not too brisk, suction and check to see if you can isolate site of bleed (not always possible).  If able to isolate (i.e. anterior septum), consider local management with silver nitrate cautery.  Injecting some lido with epi at the focal site of bleed can help with hemostasis as well.  Also locating a focal source can possibly improve with comfort as you may be able to substitute a long merocel back with a short anterior pack.  If rapidrhino not working, consider merocel pack or epistat.  If one pack does not work, consider bilateral pack (pressure from opposite side can help) or two packs in one side (although uncomfortable).  If patient continues to bleed despite all possible measures, will have to admit for possible OR control vs IR embolization.

Reason for admission: 

for OR vs IR control of persistent bleed, posterior packs; if bleeding has stopped but patient needs admission for transfusion/observation, have HBS admit   

Ear foreign body

Background: 

Generally not an emergency.  Can see as outpatient.

Angioedema

Background: 

Usually consulted for concern of airway compromise. ED should have given epi, benadryl, H2 blocker.

Management: 

If process reversed, is safe to observe in ED for 2 hours then D/C with atarax elixir for future episodes. Consider "angioedema labs": CBC diff, creatinine, ALT, TSH, C2, C4, C1 esterase inhibitor level and function, CH 50, SPEP, U/A. F/u in allergy department.

Post-tonsillectomy bleed

Background: 

Usually POD #0 or 5-10 (scab falling off).  Whether still actively bleeding or not, should go in and see patient - departmental responsibility.

Equipment: 

Headlight, tongue blade, Yankauer suction, lido with epi (if needed), bovie cautery (if needed), Floseal (if needed)

Management:  

If blood clot in fossa, remove to visualize area.  May be able to stop bleed in ED, but active bleed will often need to go to OR.  Important to coordinate with anesthesia as these patients can be airway risk.  If it is a child or someone that may not tolerate cauterization in ED, think twice about removing the clot in the ED. You may not be able to address it then and there if it starts bleeding.

Reason for admission: 

Anemia, observation, if going to OR

Facial laceration

Background: 

Wide range of ED physician's comfort levels. Simple lacs should be closed by ED physicians.  Many will say "because it's in a cosmetically sensitive area..."  You should get ED to get all the instruments set up for you, but you will often need to bring your own from clinic (i.e. fast absorbing plain gut sutures, good needle drivers and pickups).  In general, good idea to get pre-closure photo documentation.  Occasionally, there will be an issue whether plastic surgery or HNS should close.  Plastics does not have residents, so generally we end up closing the lacs.  However, if patient demands plastics come in (it happens), discuss this with plastics.  Remember, the plastics attending should not get you to do the "dirty" work (i.e. come assess the patient before they come in). Remember to code these cases as our program was sited as lacking in facial lac repairs in past years. 

Equipment:

Lidocaine with epi, syringe, needles, good needle driver, pickups, sutures, gloves, 15 blade, scissors

Management:

Get ED to clean the wound out before you arrive and arrange the equipment.  If mid face laceration is lateral to lateral canthus and pt has VII paralysis, or disruption of Stenson's duct, need to explore and repair. Check for facial factures.  Can close all lacs except human bites if well irrigated (consider adding betadine to irrigant.)  Pediatric patients may need repair under conscious sedation (ketamine) - call ahead to get that set up by ED before you arrive.