Maxillo-Facial And Ocular Emergencies Flashcards
Causes of Facial Trauma:
- MVC
- Assaults/ Personal Altercations
- Domestic Violence
- Handguns
- Falls
General Information for Maxillo-Facial and Ocular emergencies:
- Always care for life threatening emergencies first.
- C-spine and head injuries must be ruled out with significant facial trauma.
- Injury to vision considered after life/limb threatening injuries.
- Fractures of the facial plane may injure growth centers with can result in growth problems and functional derangement.
- Consider facial nerves involved. (“3,4,6 make my eyes do tricks”)
Facial Nerve (VII) controls these:
- Facial expression
- Taste
- Branches
- Zygomatic (close eyes)
- Temporal (wrinkle forehead)
- Buccal (elevate upper lip)
- Cervical
- Mandibular (purse lips)
Oculomotor Nerve (III) controls this:
- Pupil Response
- Ocular Movement
Trochlear Nerve (IV) controls this:
- Ocular Movement
Abducens Nerve (VI) controls this:
- Ocular Movement
Trigeminal Nerve (V) controls this:
- Facial sensation
- Jaw movement
- Bite
- Opening against resistance.
What are some Assessment tips with regard to Maxillo-facial and Ocular Emergencies?
- Raccoon Eyes
- Nasal/ear drainage may be CSF
- Deep lacerations of cheek (check for underlying damaged structures.
- Tear-drop shaped pupil
- Numbness of upper lip
- Numbness of lower lip
What can raccoon eyes signify?
- Basilar Skull fracture
- LeFort Fracture
- Naso-Ethmoid injury
General Treatment Considerations for Maxillo-facial and Ocular Emergencies:
- Elevate head of bed but clear C-spine first)
- suction
- no intranasal tubes
- Cold packs
- Antibiotics
- Tetanus Prophylaxis
Laceration considerations with regard to Maxillo-facial and ocular emergencies:
- repair within 24 hours
- Human and animal bites can be very dirty and may or may not be sutured (use mnemonic RATS = Rabies, Antibiotics, Tetanus, Soap)
- Permanent tattooing can occur from road rash and gunpowder.
- Must be careful with Vermilon border.
- No epinephrine on ears, nose, fingers, or toes.
Important things too note with nasal fractures:
- Septal hematoma must be noted early for drainage, to prevent airway obstruction.
- Involvement of nasal mucosa and lacrimal system can result in subcutaneous emphysema.
- Always check for CSF rhinorrhea.
What are some general manifestations of Maxillary fractures?
- Severe facial pain.
- visual disturbances
- swelling/ecchymosis
- Peri-orbital/orbital swelling
- subconjunctival hemorrhage
- facial asymmetry
- elongation of face
- Epistaxis
- Malocclusion
- Anesthesia/ Paresthesia of upper lip
- CSF leakage
- Airway obstruction
What are the 3 categories of Maxillary fractures?
- LeFort I
- LeFort II
- LeFort III
What is a LeFort I fracture?
Where the body of the maxilla is separated from the base of the skull.
What is a LeFort II fracture?
Fracture involves the central maxilla, nasal area, and the ethmoid bones.
What is a LeFort III fracture?
- Complete craniotomy-facial separation.
- Involves Maxilla, zygoma, Mandible, nasal bones, ethmoids, vomer, orbits, all lesser bones of cranium.
What is the treatment for Maxillary fractures?
- aggressive airway management
- suctioning to prevent aspiration.
- Fowler’s position
- Antibiotics
- Tetanus
- Surgery for internal fixation.
What are the types of Zygomatic fractures?
- Zygomatic arch
- Tripod
- Zygomatic arch
- Posterior 1/2 of infra-orbital rim
- Frontozygomatic suture
What are some manifestations of a zygomatic fracture?
- Flattened cheek.
- Step off deformity
- Asymmetry
- Peri-orbital swelling
- Ecchymosis
- Subconjunctival hemorrhage
- Pain with movement of jaw.
- TIDES ( Trismus, Infraorbital anesthesia, Diplopia, Epistaxis, Symmetry absence.)
What is Trismus?
Tonic contraction of muscles of mastication.
What is an Orbital Blow-Out fracture?
Fracture of orbital floor from blunt trauma.
What can become entrapped in an orbital blow-out fracture?
- Inferior rectus muscle
- Inferior oblique muscle
- Infraorbital nerve
- Orbital fat
- Connective tissue
- globe
What are some manifestations of an Orbital blow-out fracture?
- Inability to gaze upward.
- Diplopia
- Bulging eye (may also see exopthalamus).
- Epistaxis
- Infraorbital paresthesia
- Periorbital edema/ecchymosis
- Subconjunctival hemorrhage.
- Subcutaneous Emphysema when blowing nose.
What should you advise the patient to be care with when they have an orbital blow-out fracture?
- Nose blowing
- coughing
- sneezing
- vomiting
- straining
What are some manifestations of Mandibular fracture?
- point tenderness
- crepitus
- step off deformity
- malocclusion
- decreased range of motion
- asymmetry
- Paresthsia of lower lip/chin
- Trismus
What is the treatment for a Mandibular fracture?
- Airway management
- Cold packs
- Surgery for intermaxillary fixation/wiring.
- antibiotics
- Dental growth can complicate fracture.
What are the classifications of Mandibular fractures (by location)?
- Condyle (growth center which occurs downward and forward.
- Angle
- Body
- Dentoalveolar
- Symphysis (less common)
What is a Hyphema?
Bleeding into anterior chamber from blood vessels in the iris.
What comorbities increase the rate of complications associated with a Hyphema?
- Bleeding disorders
- Anticoagulant therapy
- Kidney disease
- Liver disease
- Sickle cell disease
What are some complications that can occur due to a Hyphema?
- Secondary glaucoma
- Corneal blood staining
- Loss of vision
- Loss of eye
(If there is any rebleeding within 2-5 days they need to come back)
What is the treatment for a Hyphema?
- strict bed rest vs. mild activity.
- elevate head of bed 30 degrees.
- Beta blockers
- Mydriatics for comfort (to dilate pupil)
- Steroids
- Antifibrinolytics
- Analgesics
- Anti-emetics
- Patch both eyes
- Diuretics
What causes a globe rupture of the eye?
- Blunt or penetrating trauma.
- Most common area of rupture is under recuts muscles because it is very thin.
What are manifestions of Globe rupture?
- Decreased IOP <10.
- Decreased vision
- Assymetry
- Globe protrusion
- Irregular Pupil boarders
- Altered Light Perception
- Pupil Herniation
- Nausea
- Tear-drop shaped pupil (tip of the drop is point of perforation).
- Extrusion of aqueous/vitreous humor.
What are the Interventions for a Globe Rupture?
- No manipulation
- Leave impaled object in place.
- Patch both eyes
- Semi-fowler’s
- No eye drops
- Pain management
- Tetanus
- Anti-emetics
- Surgery
- Antibiotics
- Rigid eye shield
- Send to ophthalmology.
What are the types of Ocular Burns?
- Chemical
- Thermal
- Radiation
What is important to know about Chemical Ocular Burns?
- These are the most urgent.
- Acids cause damage immediately by immediate desaturation of tissue proteins, then act as a barrier against further damage.
- Alkalis are the worst because they continue to damage by combining with cellular lipids producing coagulation necrosis.
- Top priority is irrigation until pH neutral (7-8). This may take 30 minutes of irrigation with 2L of NS/LR.
What is important to know about Thermal Ocular burns?
- Rarely involves globe.
- May cause lid contracture.
What is important to know about Radiation Ocular burns?
Ultraviolet
- These burns are very painful and can cause keratitis (corneal inflammation) and conjunctivitis.
Infrared
- Permanent loss of vision from absorption of rays via the iris and an increased temperature in the lens.
- Complications include cataracts, focal retinitis, and x-ray burns.
What are some types of Lid infections?
- Hordeleum
- Chalazion
- Blepharitis
What is a Hordeleum?
- stye
- Infection of eyelash oil gland.
- Use a warm compress
- May need I&D.
What is a Chalazion?
- Internal Hordeoleum.
- Inflammation of meibomian gland (sebaceous gland).
- causes dryness, burning, and irritation.
What is Blepharitis?
- inflammation of the eyelid.
- Causes ulceration.
- Usually caused by Staph Aureus.
- Red scales on lashes.
What is Keratitits?
Inflammation of the cornea.
What can cause Keratitis?
- Ulcer
- Bacteria
- Fungus
What are the manifestations of Keratitis?
- Light sensitivity
- Redness
- Painful
- Profuse tearing
- Hypopyon (condition involving inflammatory cells in the anterior chamber of the eye)
What is the treatment for Keratitis?
- Cultures
- Antibiotics
- Fungal drops
- Cyclopegics drugs (used to dilate the pupil)
- No Patching
What is Uveitis/ Iritis?
Inflammation of the uveal tract.
What are some manifestations of Uveitis/ Iritis?
- Unilateral
- Blurred vision
- Photophobia
- Constricted pupil
- Tearing
- Headache
- Pain
- Pain in affected eye when light is shone in opposite eye.
What is the treatment for Uveitis/ Iritis?
- Analgesia
- Antibiotic Opthalamic
- Topical Steroids
- Mydriatic Drugs
What is Orbital Cellulitis?
- Can be life threatening.
- Associated with infected sinus/throat
- Also known as Cavernous Sinus Thrombosis.
What are the usual etiologies of Orbital Cellulitis?
- Pneumococcal
- Staphylococcal
- Streptococcal
What are the manifestations of Orbital Cellulitis?
- Chills
- Headache
- Fever
- Lethargy
- Nausea/ Vomiting
- Decreased Vision
- Facial/Globe Edema
- Vascular congestion of eyelids
- Exopthalamus
- Decreased pupil reflexes
- Papilledema
- Paralysis of extra-ocular muscles
What is the treatment for orbital cellulitis?
- Antibiotic (Opthalamic)
- Parenteral Antibiotics
- Bed rest
- Hospitalization
- Warm compresses
What is Central Retinal Artery Occlusion?
- A true ocular emergency (only have 60-90 minutes to get to surgery).
- Painless loss of vision.
What are the etiologies of Central Retinal Artery Occlusion?
- Embolus
- Thrombus
- Giant Cell Arteritis
- Angiospasms
What is the treatment for Central Retinal Artery Occlusion?
- Must re-establish circulation.
- Ocular Massage
- IOP lowering drugs
- Vasodilation techniques
What is Retinal Detachment?
A retinal tear with seepage of vitreous humor between retina and choroid which causes loss of blood supply.
What are the manifestations of Retinal Detachment?
- see flashing lights.
- see floaters
- “veil” over eyes
What is the treatment for Retinal Detachment?
- Bedrest
- bilateral eye patches
- laser repair
What is Glaucoma?
- Two types : Open Angle and Closed Angle.
- Aqueous Humor which is produced by the ciliary body is blocked and cannot exit through the Schlemm’s canal.
What are the manifestations of Glaucoma?
- Severe eye pain
- Hard globe
- severe headache
- decreased peripheral vision
- fixed, dilated pupil
- foggy cornea
- halos around lights
- nausea/vomiting
What is the treatment for Glaucoma?
- Decrease IOP
- Pilocarpine 2% q 15 minutes until constriction- causes pupillary constriction (miotic).
- Timolol 0.5% to decrease IOP.
- Antiemetics
- Narcotics
- Ophthalmology consult
- diuretics
What are the etiologies of a Ruptured Tympanic Membrane?
- slap over the ears
- driving injury
- aircraft/ altitude injury
- blast injury
- self-instrumentation
What are the manifestations of a Ruptured Tympanic Membrane?
- Pain
- Bleeding
- Hearing impairment
What is the treatment for Ruptured Tympanic Membrane?
- May heal spontaneously
- Antibiotics
- May need surgical repair
What is Otitis Media?
Middle ear infection
What are the manifestations of Otitis Media?
- Pain
- fullness in ear
- decreased hearing
- N/V
- Fever
- Pulling at ear
What is the treatment for Otitis Media?
- Decongestants
- Antibiotics
- Analgesics
- Myringotomy
What is Otitis Externa?
An inflammatory reaction that causes swelling and maceration in the external ear canal. Can get cellulitis from this.
What are the etiologies of Otitis Externa?
- Swimmer’s ear
- Cleaning canal with object
- Chemical irritant
- Earphones/ earmuffs/ earplugs
- Perforated Tympanic Membrane
What is Labyrinthitis?
Inner ear infection that can mimic cardio-vascular concerns.
What are the manifestations of Labyrinthitis?
- severe dizziness
- nystagmus
- N/V
- Hearing loss
- Difficulty standing/ walking
What is the treatment for Labyrinthitis?
- bed rest
- IV hydration
- antiemetics
- Diazepam (IV)
- Meclizine
What is Meniere’s Disease?
A disorder of vestibular system of the inner ear that usually affects individuals aged 40’2 to 60’s.
What are the symptoms of Meniere’s Disease?
- Rotational Vertigo
- Diaphoresis
- Sensitivity to sound
- Ataxia
- Tinnitus
- Headache
- Feeling of spinning
- Hearing loss
- Blurred vision
- N/V
- Pressure in ear
- Nystagmus
- Can have vagal symptoms (abdominal pain, diaphoresis, Bradycardia, pallor)
What is the treatment for Meniere’s Disease?
- Vasodilating agents
- Meclizine
- Diuretics
- Steroids
- Anticholinergics
- Benzodiazepines
- Bed rest
- Position changes slowly
- Avoid alcohol/ caffeine
- ENT referral
What is Ludwig’s Angina?
- board-like swelling (submandibular, sublingual, submental).
- can be caused by the spread of existing untreated dental infection or cellulitis.
- Need to be concerned with airway compromise.
What is the treatment for Ludwig’s Angina?
- ABC’s
- Pain relief
- Antibiotics
- Elevate head of bed
- Oxygen
- Continuous Pulse-Oximetry
- Monitor vital signs and mental status
- IV fluids
What is a Peri-Tonsillar Abscess?
Collection of pus that penetrates the tonsillar capsule and may invade the muscle in surrounding tissue.
What are the manifestations of a Peri-Tonsillar Abscess?
- Difficulty speaking
- Trismus
- Dysphagia
- Drooling
- Deviation of uvula
What is the treatment for Peri-Tonsillar Abscess?
- Airway management
- Antibiotics
- Possible I&D
What are the 2 types of Epistaxis?
Anterior and Posterior
What are the etiologies of epistaxis?
- Infection
- Trauma
- Foreign bodies
- Anticoagulant therapy
- Hypertension
- Coagulation disorders
- Tumor
What labs need to be performed on an Epistaxis patient?
- CBC
- Protime (if patient is on Coumadin)
What is the treatment for Epistaxis?
- Cocaine
- Balloon/foley (for posterior bleeds)
- Packing
- Silver Nitrate (for anterior bleeds)
- Nasal tampon
What are some complications to be concerned with regarding Epistaxis?
- Syncope
- Hypoxia
- Dislodged nasal packing
- hypovolemia
- Sinusitis
- Toxic Shock
- Cardiac Dysrhythmias
- Respiratory/ Cardiac Arrest
