Ear Nose and Throat Amy Godiksen BSN RN

Ear, Nose and Throat Amy Godiksen, BSN, RN, CPN CCMC Otolaryngology

Emergency Bag • • • Portable suction with suction catheters Same size tracheostomy tube with ties in place ½ size smaller trach tube Resuscitation bag Normal saline Water soluble lubricant Scissors Extra trach ties Syringe if child has cuffed tube Tap water to flush suction catheter Hand sanitizer Emergency phone list 282 Washington Street, Hartford, CT 06106. © 2016 Connecticut Children’s Medical Center. All rights reserved.

Accidental Decannulation • Stay calm, act quickly • Priority- keep the airway open • Reinsert tube immediately. Use spare trach when able, if not able- replace with tube that came out and replace with clean tube later • If unable to reinsert same size, try ½ size smaller • If unable to reinsert, call 911, start CPR as needed 282 Washington Street, Hartford, CT 06106. © 2016 Connecticut Children’s Medical Center. All rights reserved.

Preventing Accidental Decannulation • Make sure trach ties are secure, dry, and intact • Replace ties that show signs of wear (tears or thinning) • Discourage child from touching or pulling on the trach http: //www. dalemed. com/product/tracheostomy-tube-holders/ https: //www. pinterest. com/pin/211598882466075198/ 282 Washington Street, Hartford, CT 06106. © 2016 Connecticut Children’s Medical Center. All rights reserved.

Mucus plugging Video: Children’s Hospital Colorado • • • Prevention Humidification/HME Ensure adequate hydration Encourage child to cough out secretions Suction Perform routine trach changes https: //www. smiths-medical. com/products/respiratory/humidification-systems/passive-humidification-systems/thermovent-heatand-moisture-exchanger-filters 282 Washington Street, Hartford, CT 06106. © 2016 Connecticut Children’s Medical Center. All rights reserved. Treatment • Try suctioning • Place 1 -2 saline drops into trach tube to loosen secretions, then suction again • For signs of respiratory distress- change the trach tube

Respiratory distress • Early signs: Tachypnea, tachycardia, pallor, restlessness/anxiety/agitation, noisy breathing • Late signs: Retractions, nasal flaring, bradypnea, apnea, bradycardia, cyanosis, poor cap refill, low O 2 sat 282 Washington Street, Hartford, CT 06106. © 2016 Connecticut Children’s Medical Center. All rights reserved.

Bleeding: Causes and Prevention • Dryness • Frequent, deep suctioning • Infection • Irritation/granuloma • Excessive coughing • Trauma • Foreign object 282 Washington Street, Hartford, CT 06106. © 2016 Connecticut Children’s Medical Center. All rights reserved. • Use humidification • Use appropriate suctioning technique • Use water base lubricant when changing trach to prevent trauma

Bleeding: How To Treat • Gently suction to appropriate depth • Increase use of humidity/use HME • Provide saline as directed by MD http: //www. nrsg 101. com/suctioning. html 282 Washington Street, Hartford, CT 06106. © 2016 Connecticut Children’s Medical Center. All rights reserved. http: //www. halyardhealth. in/products/respiratory-health/closed-suction-systems/paediatric-closed-suction-system. aspx

Bleeding • Call the doctor if: Persistent blood-tinged or pink colored secretions or concern for illness • When to seek emergency care: Copious amounts of bright red blood 282 Washington Street, Hartford, CT 06106. © 2016 Connecticut Children’s Medical Center. All rights reserved.

Skin Care http: //healthcaresupplypros. com/img/zoom/allevyn-tracheostomy-hydrocellular-dressing. jpg • Dressings – Exudry – Split gauze – Mepilex • Daily and PRN trach care • Antifungal powder • Barrier http: //aneskey. com/paediatric-tracheostomy-care-with-great-ormond-street-hospital-london/ http: //www. tracheostomy. com/care/complications/ 282 Washington Street, Hartford, CT 06106. © 2016 Connecticut Children’s Medical Center. All rights reserved.

School Tracheostomy Orders 282 Washington Street, Hartford, CT 06106. © 2016 Connecticut Children’s Medical Center. All rights reserved.

Nosebleeds Common causes How to prevent 1. 2. 3. 4. 5. 6. 7. • Keep nails short, discourage nose-picking • Treat allergies • Use humidifier • Protective athletic equipment for sports that could cause nose injury Nose picking Injury/trauma Blowing nose too hard Dryness Cold/allergies Medications (nasal sprays) Clotting disorders (Von Willebrands disease, hemophilia) 8. Large vessels https: //stuffdutchpeoplelike. com/2012/02/20/picking-their-noses/ 282 Washington Street, Hartford, CT 06106. © 2016 Connecticut Children’s Medical Center. All rights reserved.

5 Ways to Stop a Nosebleed http: //www. hog. org/handbook/article/3/33/nosebleeds 1. 2. 3. 4. 5. Sit upright and lean forward Pinch nostrils Ice Do not use nasal packing Avoid picking or blowing nose after bleeding has stopped Call the doctor if: Suspected foreign object, do not try to remove it When to seek emergency care: If bleeding continues after 20 minutes of applying pressure If nosebleed is a result of fall or trauma to head If child is dizzy, weak or has difficulty breathing 282 Washington Street, Hartford, CT 06106. © 2016 Connecticut Children’s Medical Center. All rights reserved.

Treatment • Humidification i. e. nasal saline spray, Ayr gel • Bacitracin or Neosporin • Afrin • Nasal cautery with silver nitrate (in office) or bigger vessels with electrocautery in OR 282 Washington Street, Hartford, CT 06106. © 2016 Connecticut Children’s Medical Center. All rights reserved.

Otitis Externa vs. Acute Otitis Media • Symptoms of otitis externa: – Ear pain (can be severe and is exacerbated by touching or pulling on earlobe and tragus) – Pain with chewing/moving jaw – Swelling and redness of the outer ear and ear canal – Enlarged and tender lymph nodes around ear – Usually afebrile • Symptoms of acute otitis media: – – – – Ear pain (worse when lying down, chewing or sucking = caused by pressure changes) Fever Drainage TM erythematous Difficulty hearing Nausea/vomiting Dizziness Irritability 282 Washington Street, Hartford, CT 06106. © 2016 Connecticut Children’s Medical Center. All rights reserved.

Urgent vs. Non Urgent Ear Pain Non urgent: Refer to PCP or non-urgent visit/call to ENT • Wax accumulation or waxy drainage • Tube extrusion • Tube otorrhea • Otitis media with or without tubes • Otitis externa • Middle ear effusion causing popping or fullness 282 Washington Street, Hartford, CT 06106. © 2016 Connecticut Children’s Medical Center. All rights reserved. Urgent: refer to ENT or ED • Mastoiditis – Post auricular erythema and edema – Proptosis/lateral and forward displacement of the ear • • • Foreign object Change in mental status Facial nerve dysfunction Sudden hearing loss Severe pain or severe headache • Vertigo • Trauma

http: //www. medindia. net/patients/patientinfo/mastoiditis. htm http: //ic. steadyhealth. com/mastoiditis-symptoms-facts https: //london. cylex-uk. co. uk/company/yogesh-bajaj-ent-consultant-23696119. html 282 Washington Street, Hartford, CT 06106. © 2016 Connecticut Children’s Medical Center. All rights reserved.

Criteria for Surgery Tympanostomy tubes T&A • Acute Otitis Media (AOM) >3 infections/year for 3 consecutive years >5 infections/year for 2 consecutive years >7 infections/year for 1 year >4 infections in 6 months >6 infections in 1 year • Persistent OME with hearing loss and associated language, speech/learning issues Bilateral: >3 months Unilateral: >6 months 282 Washington Street, Hartford, CT 06106. © 2016 Connecticut Children’s Medical Center. All rights reserved.

Thank You! About Connecticut Children’s Medical Center is the only hospital in Connecticut dedicated exclusively to the care of children. Connecticut Children’s is a nationally recognized not-for-profit with a medical staff of more than 1, 000 providing comprehensive, world-class health care in more than 30 pediatric specialties and subspecialties. Connecticut Children’s Medical Center is the primary pediatric teaching hospital for the UConn School of Medicine, has a teaching partnership with the Frank H. Netter MD School of Medicine at Quinnipiac University and is a research partner of Jackson Laboratory. Connecticut Children’s Office for Community Child Health is a national leader in community-based prevention and wellness programs. 282 Washington Street, Hartford, CT 06106. © 2017 Connecticut Children’s Medical Center. All rights reserved.