13.3 Epistaxis, Red Eye Emergencies, Peripheral Vascular Disease & Aortic Aneurysms

ENT: Epistaxis

Epistaxis, or nosebleed, is a common emergency department presentation. It is categorized into anterior and posterior bleeds based on the anatomical origin.

Anterior Epistaxis: This accounts for the vast majority (over 90%) of nosebleeds. The bleeding source is typically Kiesselbach's plexus (Little's area), a vascular anastomosis on the anterior nasal septum. Causes include digital trauma (nose-picking), dry air, allergic rhinitis, and minor facial trauma. Management begins with basic first aid: having the patient sit upright, lean slightly forward (to prevent blood from draining into the pharynx), and apply firm, continuous direct pressure to the cartilaginous lower part of the nose for at least 10 to 15 minutes. If bleeding persists, visualization with a nasal speculum is necessary. Topical vasoconstrictors (e.g., oxymetazoline) can be applied. If a specific bleeding point is identified, chemical cautery with silver nitrate is highly effective. Refractory cases may require anterior nasal packing.

Posterior Epistaxis: These are less common but potentially more severe and harder to control. They often originate from the sphenopalatine artery branches in the posterior nasal cavity. Patients are typically older and may have underlying hypertension or coagulopathy. Bleeding is often brisk and may primarily drain down the posterior pharynx rather than from the nares. If anterior packing fails to control significant bleeding, a posterior bleed must be suspected. Management requires posterior nasal packing (e.g., using a Foley catheter or specialized balloon devices), which carries risks of hypoxia and reflex bradycardia. Therefore, patients with posterior packing require hospital admission for observation and airway monitoring. ENT consultation is mandated for refractory cases, which may ultimately necessitate arterial embolization or surgical ligation.

Ophthalmology: Red Eye Emergencies

While many causes of a 'red eye' are benign (e.g., viral conjunctivitis, subconjunctival hemorrhage), certain conditions are vision-threatening and require prompt recognition and referral.

Acute Angle-Closure Glaucoma: This occurs when the trabecular meshwork is blocked by the peripheral iris, causing a sudden and severe rise in intraocular pressure (IOP). Patients present with abrupt onset of intense eye pain, headache, blurred vision, and seeing 'halos' around lights, often accompanied by severe nausea and vomiting. Examination reveals a significantly injected (red) eye, a cloudy or 'steamy' cornea, and a pupil that is non-reactive and mid-dilated. The globe feels rock-hard to palpation. This is a true ophthalmologic emergency. Initial medical management aims to lower IOP rapidly using topical beta-blockers, alpha-agonists, and carbonic anhydrase inhibitors, along with systemic agents like acetazolamide or mannitol. Definitive treatment requires laser peripheral iridotomy.

Corneal Ulcer (Keratitis): An infection of the cornea, often bacterial, but can be viral, fungal, or amoebic. Contact lens wearers, especially those who sleep in their lenses, are at high risk, particularly for Pseudomonas aeruginosa infection. Patients present with red eye, severe pain, photophobia, tearing, and a feeling of a foreign body. Fluorescein staining reveals a corneal epithelial defect with underlying stromal infiltrate. Prompt diagnosis and treatment with intensive topical fortified antibiotics are crucial to prevent corneal scarring or perforation.

Vascular Surgery: Peripheral Arterial Disease (PAD)

PAD is a manifestation of systemic atherosclerosis causing stenosis or occlusion of the arteries supplying the lower extremities. The classic symptom is intermittent claudication—reproducible cramping muscle pain (usually in the calf) that is induced by exercise and relieved by a short period of rest. As the disease progresses, patients may develop rest pain (typically in the toes or foot, worsening at night and relieved by hanging the foot over the side of the bed) or tissue loss (ischemic ulcers or gangrene), signaling critical limb ischemia (CLI).

Physical examination may reveal diminished or absent peripheral pulses, hair loss on the legs, shiny and thin skin, and dependent rubor. The initial diagnostic test of choice is the Ankle-Brachial Index (ABI), calculated by dividing the highest ankle systolic pressure by the highest brachial systolic pressure. An ABI of < 0.9 is diagnostic for PAD; an ABI < 0.4 indicates severe PAD. Management includes aggressive risk factor modification (smoking cessation is paramount, statin therapy, blood pressure control, diabetes optimization), structured exercise programs, and antiplatelet therapy (e.g., aspirin or clopidogrel). Medications like cilostazol can improve walking distance. Patients with CLI or lifestyle-limiting claudication refractory to medical therapy require evaluation for revascularization (endovascular angioplasty/stenting or surgical bypass).

Vascular Surgery: Abdominal Aortic Aneurysm (AAA)

An AAA is defined as a focal dilation of the abdominal aorta greater than 3.0 cm in diameter, most commonly occurring infrarenally. The primary risk factors are advancing age, male sex, smoking history, and a family history of AAA. Most AAAs are asymptomatic and discovered incidentally on imaging. However, a symptomatic AAA (presenting with abdominal, back, or flank pain) or a ruptured AAA (presenting with the classic triad of severe pain, pulsatile abdominal mass, and hypotension) are life-threatening surgical emergencies.

Screening: The U.S. Preventive Services Task Force (USPSTF) recommends a one-time screening for AAA using abdominal ultrasound in men aged 65 to 75 years who have ever smoked (defined as 100 or more cigarettes in their lifetime).

Management: Management depends primarily on the aneurysm's diameter. Small AAAs are monitored with serial imaging. Elective surgical repair (either open repair or endovascular aneurysm repair - EVAR) is indicated when the risk of rupture outweighs the surgical risk. The general indications for elective repair are an aneurysm diameter ≥ 5.5 cm in men (often ≥ 5.0 cm in women, due to their smaller baseline aortic diameter) or rapid expansion (defined as growth > 0.5 cm in 6 months or > 1 cm in a year). Any symptomatic AAA, regardless of size, necessitates urgent evaluation for repair.

Key Comparison: High-Yield ENT, Ophthalmology & Vascular Emergencies

Leukoria

Leukoria — a white pupillary reflex — is an ocular emergency in infants and children and warrants urgent referral.

• Retinoblastoma is the critical diagnosis: a child (typically <2 years) with leukoria or strabismus detected on the red-reflex exam. It is the most common primary intraocular malignancy of childhood; bilateral disease suggests a germline RB1 mutation. Urgent ophthalmology referral plus imaging is mandatory.
• Other causes of leukoria include congenital cataract, Coat disease, and retinopathy of prematurity; all require urgent ophthalmology referral. Any asymmetry or absence of the red reflex at the newborn or well-child exam mandates the same urgent referral.