* sinusitis * bell’s palsy * trigeminal neuralgia * facial lacerations * soft tissue injuries *...
TRANSCRIPT
*Sinusitis
*Bell’s Palsy
*Trigeminal Neuralgia
*Facial Lacerations
*Soft Tissue Injuries
*Mandibular Fractures
*Maxillary Fractures
*Zygomatic Fractures
*Dental*Odontalgia*Tooth Eruption*Pericoronitis*Fractures Tooth*Subluxed/Avulsed Tooth*Dental Abscess*Ludwig’s Angina*Trench Mouth
*Ear*Acute OE
*Acute OM
*Ruptured Tympanic Membrane
*FB
*Meniere’s Disease
*Labyrinthitis
*Nose*Rhinitis
*Epistaxis
*Nasal Fracture
*FB
*Throat*Pharyngitis
*Tonsillitis
*Laryngitis
*Fractured Larynx
*Peritonsilar Abscess
*FB
*Nature of Injury/History
*Bleeding
*Airway Obstruction
*Loss of Consciousness
*Sensory Deficits/
Changes
*Medical /Surgical History
*Physical Assessment
*Psychosocial Responses
*Stress Factors
*Behavioral responses
*Diagnostic Procedures
*Radiological
*Facial Bones
*Water’s View
*Skull series
*C-spine
*CXR
*CT
*Diagnostic Procedures*Laboratory*Cultures
*Coags
*ABGs
*T&C
*ABC
*Control Bleeding
*Fluid and Electrolyte Balance
*Prevent Further CNS complications
*Control Pain
*Relieve Anxiety
*Education
Pediatric
*6-7 year: primary eruption of teeth
*Head is larger proportionally than adult’s
*Neck muscles are relatively weaker for large head mass
*Always explain and be honest
*Limitations in verbal expression
*Facial bones are more pliable and softer
Geriatric*Age-related changes*Decreased vital capacity
*Diminished ability to cough
*Visual acuity changes
*Diminished hearing
*Loss of short-term memory
*Muscle atrophy
*Chronic Disease
*Delayed responses
*Medications
*Inflammation of mucous membranes*Maxillary sinus most common*Frequently follows URI*Other causes: *allergies* dental *infections *trauma*polyps
Symptoms*Pain/Pressure
*Fever or not
*HA
*Decreased appetite
*Nasal congestion
*Nasal voice
*Red, swollen mucosa
*Purulent nasal drainage
*Conjunctivitis
*Tenderness to palpation
*Puffy eyes
*Bad breath (esp. children)
Treatment*Decongestants
*Antibiotics
*HOB elevated
*Apply heat
*Room vaporizer
*Severe: hospitalization
IV antibiotics Surgery
Education*Should improve 3-4 days
*Vaporizer, steam bath
*Increase fluids
*Avoid smoking
*“Rebound congestion”
*Paralysis of all facial muscles on one side of face
*Usually unilateral
*Swelling of facial nerve as a result of virus or immunodeficiency disease
*> 40 yrs
*Usually self-limiting
*Complete resolution in 80-90% of cases
Symptoms
*Rapid, acute onset
*Hx of Virus?
*Unilateral facial weakness/paralysis
*Retro auricular and/or facial discomfort
*Drooling
*Dysphagia
*Inability to close eye on affected side
*Decreased lacrimation
*Drooping of mouth
*Speech difficulty
*Positive corneal sensation /negative blink
*Inability to wrinkle forehead
*Diagnostics*Exclude other diseases
*Treatment/Education*Explain this disease
*Not a stroke
*Recovery within 3 weeks
*Artificial tears
*Eye patch
*Gentle manual closure of eye
*Not contagious
*Keep face warm, avoid drafts
*Possible analgesics and steroids
*Moist heat
*Facial muscle exercises
*Fifth cranial nerve
*Usually second and third division – maxillary and mandibular areas
*Brief, recurrent paroxysms of excruciating facial pain
*> 40 yrs and female
*Right side affected more often than left
Symptoms*Electrical shock type pain
*Unilateral
*Minimal to no sensory loss
*Painful paroxysms precipitated by touching of trigger zone
Diagnosis*History and physical exam
*Exclude other diseases
Treatment*Tegretol, Dilantin, analgesics
*Surgical interventions
Education
*Majority of patients respond to medical therapy within 48 hrs
*25-50% eventually will require surgical intervention
*Avoid cold exposure (iced drinks, winds, swimming)
*Side effects of medications
*Lacerations
*Abrasions
*Puncture wounds
*Contusions
*Avulsions
*Range from simple isolated injury to those accompanied by airway obstruction, edema, hemorrhage, facial trauma, and multisystem injuries
Symptoms/Assessment*MOI
*Facial asymmetry/swelling
*Pain/tenderness
*Foreign bodies
*Motor and sensory deficits
Diagnosis*Rule other S/S of more extensive facial injures, CNS injury, and multisystem injury
*Radiographs
*CT
*Cultures
*Treatment*Control bleeding*Irrigate wounds copiously*Clean intact skin and wound edges*Replace tissue flaps*Td*Analgesics*Ice to area of trauma, not to avulsed part
*Suture
*Anesthetic*Lido with epi unless contrindicated
*Restraint
*Lighting
*Scissors to cut hair / never shave or cut eyebrows
Education
* Wound care
*One of the most frequently fractured facial bone
*TMJ dislocation may accompany
*Fight and crashes most common causes
Symptoms/Assessment
*MOI
*Pain/point tenderness
*Malocclusion
*Facial asymmetry
*Bleeding around mouth
*Numbness of lower lip
*Trismus
*Edema/hematoma
*Ruptured tympanic membrane
*Mobility of fracture fragments
*Ecchymosis in floor of mouth
*Sunlingual edema
Diagnostics*PA, lateral, oblique skull films
*Waters’
*CT
Treatment*Ensure patent airway
*Prevent aspiration of blood, teeth, bone fragments, etc
*Control bleeding
*Have emergency airway equipment readily available
Ice
*Analgesics
*Surgical reduction/wiring
*Antibiotics
*½ and ½ peroxide and water
*Td
Education
*S/S infection
*Mechanical soft diet
*Use a straw
*Drink plenty of liquids
*Less common than mandibular
*Usually associated with other multisystem injuries
*LeFort I, II, III
*Common causes: fight and crashes
Symptoms/Assessment
*MOI
*Pain/tenderness
*Swelling
*Asymmetry/distortion
*Infraorbital mobility/paresthesia
*Ecchymosis
*Epistaxis
*Malocclusion
*Visual disturbances
*CSF rhinorrhea
*Subconjuctival hemorrhage
*Midface maxillary mobility
*S/S of intracranial, spinal, or multisystem injuries
Diagnostics
*Waters’ view
*Individual facial films
*CT scan
Treatment/Education*Ensure airway patency
*Prevent aspiration
*Positioning – Fowler’s/Semi-Fowlers
*Emergency intubation available
*Control bleeding
*Cold packs to face
*Definitive treatment*Open reduction
*Internal wiring
*Antibiotic prophylaxis
*Hospital admission
*Td
*Support and reassurance
*Causes: Fight, Crash, and Falls
*Tripod fractures
*Frequently associated with orbital floor fractures – blow-out fractures
Symptoms/Assessment*MOI
*Pain/point tenderness
*Bleeding
*Edema
*Pain with jaw movement
*Visual disturbances/diplopia
*Facial asymmetry
*Epistaxis
*Subjunctival hemorrhage
*Paresthesia of cheek, nose, upper lip of affected side
*SQ emphysema
Diagnosis*Waters’ view
*Submentovertical view
Treatment/Education*Analgesia
*Position and elevate head
*Ice
*Definitive treatment*Open reduction
*Internal wire fixation
*Hospital admission
*Explanations and reassurance
History
*Bleeding
*Obstructed Airway
*Swelling/Edema
*Asymmetry/
Dislocation
*Fever/Chills
*Nausea/Vomiting
*Drooling
*Facial numbness
*Dysphasia/Dysphagia
*Foul odor and taste in mouth
*Loss of hearing
*Tinnitis or vertigo
*Trismus
*Discharge/Drainage
*Itching
*Neck pain
*HA
*Medical History*HTN
*CAD
*Atherosclerosis
*Neuro diseases
*Dental/ENT surgery and/or infections
*CA
*Smoking
*Diabetes
*Radiology*Chest
*Waters’
*CT scan
*Laboratory*Cultures
*CBC
*Sed rate
*Coags
*ABGs
*ABCs
*Control Bleeding
*Fluid Volume
*Pain control
*Anxiety
*Definitive Treatment
*Prevent Complications
*Education
*Pediatric
*85% of FB aspirations < 3 y/o*Boys twice as likely than girls
*Persistent cough or chronic wheezing may be indicative of aspirated FB
*In 20-38% of esophageal ingestions there are no symptoms
*Abrupt onset of respiratory and pulmonary symptoms suggest FB ingestion.
*Irritability and lack of feeding in infants may be potential S/S of ENT/Dental emergencies
*Geriatric
*Difficulty in mastication
*Loss of sensation
*Progressive hearing loss
*Most dental and ENT emergencies in the elderly is related to falls, visual changes, MVCs, and assaults
*Toothache / Dental caries
*Sharp to throbbing
*If left untreated, will eventually lead to necrosis
*Prevention is best treatment
Symptoms*Pain in diseased tooth
*May be referred to gum line, jaw, temple, ear, neck
*More intense nocturnal pain
*Heat or cold stimulus
*Tooth discoloration
*Foul breath
Diagnostics*Rule out abscess
Treatment*Topical anesthetic
*Antibiotics
*Analgesic
Education*Preventative hygiene
*Follow-up with dentist
*Primary teeth in infants and children
*Wisdom teeth
Symptoms*Pressure/Tenderness
*Irritability/Agitation
*Low-grade temp
*Diarrhea
*Refusal to eat or drink
*Nasal discharge
*Crying
*Drooling
*Reddened, edematous tissue over erupting tooth
*Rash around mouth
Treatment*Gentle massage
*Teething ring
*Orajel
*Tylenol/Ibuprofen
*Warm saline mouth rinses
*Soft solid diet
*Erupting or impacted molars
*Acute inflammation surrounds the gingival tissue or crown of erupting tooth
*Commonly seen in the 30 y/o adult
*Complications: cellulitis, Ludwig’s angina, and peritonsillar abscess
Symptoms*Nonspecific diffuse extraoral pain or pain upon opening mouth
*Earache on affected side
*Sore throat, jaw pain
*Unerupted third molar
*Red, inflamed soft tissues around crown
*Lymphadenopathy, trismus and fever if has progressed to systemic
Treatment/Education*Irrigate pericoronal flap with warm NS to remove debris
*Refer to dentist for debridement or tooth extraction
*If infection:*Antipyretics
*Antibiotic
*Assist with drainage of abscess
*Common causes: Falls, MVCs, Physical abuse, Sport-related injuries, Seizures
*Ellis Class I –
*involve only the enamel, minor, rough appearance
*Ellis Class II
*Enamel portion and the dentin
*Pain sensitivities
*Should be seen by dentist in 24hr
*Ellis Class III –
*Enamel portion, dentin, and pulp
*Dental Emergency
Symptoms/Assessment*MOI
*Disfigurement of tooth/change in color
*Pain/tenderness*Spontaneous
*Hot or cold
*Inspiration
*HA
*N/V Involvement of enamel, dentin, pulp
*Malocclusion
*Bleeding
*Intraoral or extraoral wounds
Treatment*Suspect and rule out other injuries*Fracture involving enamel and dentin*Apply Calcium Hydroxide to protect*Mild oral analgesic*Dental referral within 24 hrs*Antibiotics
*Fracture involving pulp
*High risk of infection
*Apply Calcium Hydroxide to exposed crown surface
*Oral analgesic
*Dental referral for pulpectomy
Symptoms/Assessment
*Pain at site
*Bleeding
*Neck pain
*Respiratory status
*Other wounds
*Other injuries
*Prevalent in ages 7-10
Treatment
*Local anesthetic
*Subluxed or partially avulsed should be repositioned for stability
*Avulsed must be replanted with 30 minutes (no longer than 6 hrs)
*Clean mouth and socket with NS or cold water
*Tooth should be transported in moist saline gauze or milk
Education*Minimal mobility will
usually heal within 2 weeks
*Soft diet
*Avoid biting into anything with affected tooth
*Avoid hot and cold substances
*Refer to dentist or oral surgeon
*Localized accumulation of pus in a cavity of a tooth
*Gingival swelling results from plaque and debris collecting between tooth and gingiva
*Peridontal disease results when infections spreads into surrounding tissues and bone
*Periapical abscess results when infections has spread beyond the bone and the virus, bacteria has colonized
Symptoms*Pain
*May radiate to ear, jaw, and neck
*Not relieved by analgesics
*Swelling of face, neck, pharynx
*Fever
*Bad breath
*Malaise
*Chills
*Sore gums
Treatment*Systemic analgesic
*Antipyretic
*Assist with I&D (may leave drain in place)
*Educate warm NS rinses every 1-2 hrs
*Refer to dentist
Diagnosis*Soft tissue X-ray
*WBC
*Culture
*Results from a secondary dental infection involving the lower second and third molars
*Bilateral diffuse swelling and extending cellulitis involving the submandibular, submental, and sublingual areas occurs
*Difficulty talking and swallowing and breathing ensues as the neck and face become swollen and causes elevation of the tongue
*Dyspnea
*Pallor or cyanosis
*Tachycardia
*Agitation
Symptoms*Pain and swelling of jaw and neck
*Fever/Chills
*Malaise
*Dysphagia
*Dysphasia
*Elevation of tongue and floor of mouth toward palate
Diagnosis*CBC
*Sed rate
*Soft tissue films
*Cultures of exudate
Treatment*Maintain airway
(emergency cric)
*Fowler’s position
*Oxygen
*I&D (with culture)
*Antibiotic
Education*Rinse mouth with warm NS 2-3 times every hour
*Hot, moist compress to jaw and neck every hour
*a.k.a Dry Socket
*Pain post extraction more than 2-3 days
*Best treated with irrigation of the clot and topical oral analgesia/anesthetic
*Monitor for development of osteomyelitis
*Small vessels that continue to bleed
*Have patient bite on gauze over extraction site for 30 minutes
*May be anesthetized with lido with epi and sutured
*Avoid hard or hot foods
*Trench Mouth
*Non-contagious
*May follow a URI
*Also associated with debilitating illnesses, emotional stressors, nutritional deficiencies, and
smoking
Symptoms/Assessment*Pain
*Fever/Chills/Malaise
*Bleeding gums
*Poor oral hygiene
*Fetid breath
*Lymphadenopathy
*Gray ulcers on pharyngeal structures
Treatment*Topical or local anesthetic
*Antibiotics
*Antipyretic
*Refer to dentist
*Teach proper oral hygiene
*Swimmer’s Ear
*Inflammation of external auditory canal and auricle of the ear
Symptoms*Pain/Tenderness
*Diminished hearing
*Swelling/Redness/ Discharge
*Pruritis
*Low-grade fever
*Fullness in ear
*Cellulitis
Treatment*Topical antibiotic for one week
*Cleaning debris out of ear with cotton tip applicator, suction
*Ear wick saturated with antibiotic and/or steroids when ear canal is acutely swollen
*Hot, moist compress
*Keep ear canal dry
*Bacterial infection of middle ear
*Causes: barotrauma, Eustachian tube dysfunction, and URI
*Swelling prevents effective drainage and allows bacteria to proliferate
*Commonly seen in infants and children
Symptoms/Assessment*Earache that increases with prone position
*Pulling at the ear
*Sensation of fullness in ear
*Decreased hearing
*URI
*Fever/Chills
*Anorexia
*Vertigo/dizziness
*Purulent nasal drainage
*Erythema of pharynx
*Erythema of TM
*Retracted or bulging TM
Treatment/Education*Antibiotic
*Antipyretic
*Analgesic
*Follow-up within 2 weeks
*Primarily caused by infection
*May be caused from impact injury and explosive acoustic trauma
*Healing is usually spontaneous
Symptoms/Assessment*Pain
*Bloody or purulent discharge
*Vertigo
*Tinnitus
*Fever/Chills
*Barotrauma
*Previous infection/illness
*Slit-shaped or irregular TM
*Decreased hearing in ear
*Disequilibrium
Treatment/Education*Antibiotic
*Analgesic
*Antipyretic
*May need to assist in removing blood and debris from ear canal
*Avoid getting ear wet
*Hydration
*Follow-up
*Commonly seen in adults
*Avoid irrigating vegetable FBs
*Mineral oil or 2% Lidocaine for insects
Symptoms/Assessment*Discomfort or pain
*Decreased hearing
*Swelling of external ear
*Insect buzzing in ear
*Agitation
Treatment/Education*Assist with removal*Irrigation*NS*Alcohol*Mineral oil*Lidocaine
*Suction*Use Flashlight for insect
*Disorder of the vestibular system in the inner ear
*Abnormal accumulation of fluid in the cochlea and labyrinth causing severe rotary vertigo, N/V, and tinnitus
*Commonly seen 40-60 y/o
*Causes: blow to the head, infection, allergies, or degeneration of the inner ear
*Attack may last several hours
Symptoms/Assessment*Rotational vertigo
*Falls toward affected ear
*N/V
*Diaphoresis
*Tinnitus
*Hearing loss
*Heightened sensitivity to sounds
*HA
*Blurred vision
*Moist, pale skin
*Nystagmus
*Rule out intracranial lesion
*Hx of otitis media
Education* Safety R/T
vertigo, falling, meds
* Make position changes slowly
* Follow-up
* Avoid alcohol and caffeine
* Hydration
Treatment*Medications*Diuretics*Anti-emetic*Antihistamines*Vasodilator
*Bed Rest*Quiet environment*Surgery if severe and refractory to medical tx
*Inflammatory response of the inner ear; may involve nerves connecting the inner ear to the brain
*Bacterial or Viral
*HA
*Disequilibrium
*Normal neuro exams
*Orthostasis
*Recent hx of ear infection, URI, viral illness
Symptoms/Assessment*Patient feels they are moving
*Unsteadiness
*N/V
*Hearing abnormalities
*Ear pressure
Treatment*Antihistamines
*Antiemetics
*Sedatives
*IVF
*Antibiotics
*Inflammatory condition of the nasal mucosa
*Viral or bacterial URI
*Spread by droplet contact
Symptoms/Assessment
*Sneezing
*Postnasal drip/Copious nasal discharge
*Nasal obstruction
*Muscle aches
*Malaise
*HA
*Water or itchy eyes
*Sore throat
*Mild fever/chills
*Inflammation of throat and sinuses
*Nasal mucosa erythematous, edematous, and congested
Treatment/Education
*Antipyretics
*Decongestants
*Antihistamines
*Nasal corticosteroid
*Hydration
*Teach to use nasal decongestants for only a few days
*Symptoms usual resolve in 7 days
*Usually results from the erosion of superficial blood vessels from the anterior and inferior nasal septum
*Causes: Nose-picking, FB, Nasal trauma, Rhinitis, Forceful nose blowing
*Anterior epistaxis usually treated with frim pressure (pinching)
*Posterior epistaxis requires nasal packing
Symptoms/Assessments*Bleeding
*History of epistaxis
*Recent trauma or surgery
*N/V
*Hx of aspirin and/or antiplatelets meds
*Hx of HTN/atherosclerosis
*Erythema and swelling of nasal mucosa
*Blood in auditory canal
*Anxiety
*Tachycardia
*Sense of impending doom
Treatment/Education*ABCs*Control bleeding*Direct pressure*Nasal packing*Suctioning*Cauterization*Hemostatic material
*Establish IV
*Medications*Anesthetic
*Topical vasoconstrictors
*Decongestant
*Antihypertensives
*Avoid blowing nose forcibly
*Most frequently fractured bone
Symptoms/Assessment*MOI
*Visual deformity
*Swelling
*Nasal bleeding
*Nasal obstruction
*Crepitus
*Pain/Tenderness
*Rule out septum injury
Diagnosis*Nasal/facial films
Treatment/Education
*Assess for other injuries
*Control hemorrhage*Direct pressure
*IV
*Packing
*Ice pack
*Medications*Anesthetic
*Decongestant
*Vasoconstrictor
*Analgesic
*Antibiotics
*Commonly seen in children
Symptoms/Assessment*Nose pain/swelling
*Nasal discharge
*Foul smell from nose
*Unilateral bleeding
*Agitation
Treatment/Education*Blow nose to dislodge or remove
*Topical vasoconstrictive
*Assist in removal*Suction
*Forceps
*Foley catheter
*Sore Throat
*Usually associated with viral URI
*Most cases resolve with symptom management
*Spread by droplet transmission
*Common during late fall, winter, early spring
*Strep
Symptoms/Assessment*Sore throat*Difficulty swallowing*Pain referred to ears, neck, jaw*Fever/Chills*Harsh cough*Anorexia*Fatigue*Body aches
*Enlarged tonsils
*Cervical lymphadenopathy
*Exudate on pharynx and/or tonsils
*Foul breath
*Nasal speech
*Flushed face
Treatment/Education
*Antipyretic
*Analgesic
*Steroids
*Antibiotics
*Warm saline irrigation
*Rest
*Hydration
*Follow-up
*Tonsils act as filters for lymphatic circulation
*Similar to pharyngitis
Symptoms/Assessment
*Throat Pain
*Recent URI
*Pain/Difficulty swallowing
*Referred pain
*Fever/Chills
*Fatigue
*Fetid breath
*Tachycardia
*Red and swollen tonsils
*Purulent exudate on tonsils
*Enlarged cervical and submandibular lymph nodes
*Flushed face
*Culture (strep)
Treatment/Education
*ABC
*Warm saline irrigation
*Hydration (cool liquids)
*Rest
*Antibiotic
*Antitussive
*Steroids
*Follow-up
*For chronic tonsilitis: tonsillectomy
*Hoarseness
*Voice harsh and raspy
*Commonly a viral infection
*Constant urge to clear the throat or tickling sensation
Symptoms/Assessment
*Dry, tickling sensation in throat
*Partial to complete loss of voice
*Hoarseness
*Fever/Chills
*Sore throat
*Dyspnea
*Difficulty swallowing
*Dry cough
*Anorexia
*Reddened larynx and vocal cords
*Swelling of larynx and epiglottis
*Rhinorrhea
*Throat cultures
Treatment/Education
*Warm room that humidified
*Rest voice
*Antibiotic
*Inhaled steroid
*Antitussive
*Antipyretic
*Zinc
*Ice to anterior throat
*Humidifier
*Results from direct trauma (blunt or penetrating) to neck
*Common causes: MVC, strangulation, sports injuries
Symptoms/Assessment
*MOI
*Hoarseness
*Change in voice
*Pain on swallowing
*Cough
*Dyspnea
*Hemoptysis
*Ecchymosis
*Abrasions
*SQ emphysema
*Loss of normal prominence of thyroid cartilage
*Inspiratory stridor
*Substernal or Intercostal retractions
Diagnosis*CT scan
*Rule out other injuries
*Soft tissue films are not sensitive to laryngeal injury
Treatment*ABC / C-spine
*Cric or trach
*High humidity oxygen
*ABGs
*Treat concomitant injuries
*Surgery
*Infection penetrating the tonsillar capsule and superior constrictor muscle into the surrounding areolar tissue
*Streptococci bacteria are usually the pathogen
*Drainage of pus by an ENT
or oral surgeon provides immediate relief
Symptoms/Assessment
*Sore throat
*Pain on swallowing
*Ear fullness
*Fever/Chills
*Pus / exudate on tonsils
*Difficulty opening mouth
*Drooling
*Muffled voice
*Difficulty breathing
*Enlarged affected tonsil
*Displacement of uvula
*Edema and erythema of soft palate
*Profuse salivation
*Torticollis
*Increases respiratory rate
*Recent tonsilitis
Diagnosis*Culture and sensitivity
Treatment*ABC
*Pulse OX
*Oxygen
*HOB 60 to 90°
*IV hydration and medication
*Warm saline irrigation
*Antibiotics Topical anesthetic
*Analgesic
*Antipyretic
*Ice collar to throat
*I&D
*Common cause of accidental death in US Children < 6 y/o
*Can lead to obstruction of mainstem bronchus or distal trachea
*Airway management is priority
*Heimlich maneuver and/or abdominal thrusts
Symptoms/Assessment
*Sore throat
*Vocal changes
*Drooling
*Coughing
*Difficulty swallowing and/or breathing
*Difficulty talking
*Known ingestion
*FB visible in pharynx or larynx
*Stridor
*Tachycardia
*Excessive salivation
*Skin cool and moist
*Hemoptysis
*Hematemesis
*Agitation
Diagnosis*PA and lateral CXR
*Soft tissue of neck
Treatment/Education*ABC
*Finger sweep
*Heimlich
*Oxygen
*IV
*HOB 60 to 90°
*Prepare for potential emergency intubation
*Minimize environmental stimuli
*Removal procedures*Balloon-tipped Foley
*IVCS