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EN2.10 | ENT Emergency Simulation Workflow — SDL Guide (Part 3)
Self-Assessment: ENT Emergency Competency Check
Test your emergency protocol knowledge with these direct questions.
Q1: In which emergency is cricothyroidotomy indicated rather than tracheostomy, and why?
Answer: Cricothyroidotomy (through the cricothyroid membrane) is indicated in a 'cannot intubate, cannot oxygenate' (CICO) emergency where the upper airway is completely obstructed and conventional intubation has failed. It is chosen over tracheostomy because it is faster, requires less dissection, and uses a more accessible midline landmark. It is a TEMPORARY measure — converted to formal tracheostomy (between 2nd and 3rd tracheal rings) within 24–48 hours.
Q2: What is the direction of packing in anterior nasal epistaxis management, and why?
Answer: The Merocel or ribbon gauze is packed along the NASAL FLOOR — horizontally, posteriorly. The nasal floor is level with the hard palate and runs straight back to the posterior choana. Packing upward into the nasal roof compresses nothing useful and fails to tamponade the bleeding vessels at Little's area. The direction 'floor of the nose, pointing straight back' is the key technique point.
Q3: Name the three sites in the oesophagus where coins and foreign bodies most commonly impact.
Answer: (1) The cricopharyngeus (Killian's dehiscence) at the level of C6 — the narrowest point of the oesophagus and the first anatomical narrowing; (2) the aortic arch and left main bronchus (approximately T4 level); (3) the lower oesophageal sphincter (gastro-oesophageal junction). Most coins stop at the first narrowing (cricopharyngeus). A coin in the oesophagus lies in the coronal plane on AP X-ray (looks round/oval); a coin in the trachea lies in the sagittal plane (looks flat/linear on AP view).
| Emergency | First action | Key mistake to avoid |
|---|---|---|
| Laryngeal FB (conscious) | Heimlich/back blows + chest thrusts | Blind finger sweep (worsens impaction) |
| Nasal FB | Positive pressure or anterior hook extraction | Pushing posteriorly (aspiration risk) |
| Anterior epistaxis | Lean forward + pinch soft nose 15 min | Leaning back (blood swallowed/aspirated) |
| Posterior epistaxis | Foley catheter balloon | Anterior packing alone is insufficient |
| Button battery | Immediate removal | Delay — necrosis within 1-2 hours |
| Cannot intubate | Cricothyroidotomy | Formal tracheostomy (too slow) |
SELF-CHECK
A patient with anterior nasal packing in situ for epistaxis is found to still have blood trickling down the posterior pharyngeal wall. The most likely reason and next management step is:
A. The packing was inserted too far anteriorly; remove and re-insert more anteriorly
B. This is a posterior epistaxis; the anterior packing cannot tamponade a posterior bleed; posterior packing (Foley balloon or posterior nasal pack) is required
C. The packing has become saturated; replace with new anterior packing
D. Administer IV tranexamic acid and observe for 30 minutes
Reveal Answer
Answer: B. This is a posterior epistaxis; the anterior packing cannot tamponade a posterior bleed; posterior packing (Foley balloon or posterior nasal pack) is required
Blood trickling down the posterior pharyngeal wall despite correctly placed anterior packing is diagnostic of a posterior epistaxis — the bleeding source is in the posterior nasal cavity (sphenopalatine/Woodruff's plexus area), and anterior packing cannot reach or compress it. The next step is posterior packing: a Foley catheter passed to the nasopharynx, balloon inflated with 10–15 mL saline, and pulled anteriorly to compress the posterior choana, supplemented by anterior packing over the Foley. Posterior bleeds also require hospital admission, blood pressure control, and ENT review.