Trauma Flashcards
What are you looking for in Trauma Eye Exam?
- cornea clear?
- Pupil round?
- Pupil black?
- blood clotted behind cornea?
- red reflex?
- eyes move symmetrically?
List the Diagnostic Evaluation tools/test
- visual acuity testing
- seidel test
- slit lamp
- ophthalmoscopic exam
- ocular ultrasound
- CT
- Xray
Corneal Abrasion
- Sx
- Dx
- Red flag
- Tx
Sx
-pain and photophobia
Dx
-fluorescein dye
Flag
-white infiltrate in the wound means current infection.
Tx
- do not patch
- contact leses- topical abx drops (cipro for pseudomonas)
- erythromycin ointment
- pain meds (oral, NOT topical)
Corneal Foreign Body
- common foreign bodies
- removal of FB
- tx
-griding, drilling, welding, hammering,
Removal:
-remove w/ needle or cotton swap
Tx:
- Abx/Analgesia prn (NOT anesthetic drops)
- prompt referral*
Corneal or Conjunctival FB tx
-especially metal
metal will form rust ring in 1 day, remove metal at slit lamp w/ 18g needle. May need dremel like tool to further remove rust ring.
Make sure no intraocular FB as well,.
Corneal Lacerations
- when is it considered a globe injury?
- tx
-if laceration is through all layers of the cornea
Tx:
- cover eye with paper cup
- no pressure on eye
- systemic analgesics and antiemetics to help lower IOP
- Tetanus shot
- AVOID topical analgesics and topical abx
**OPTHO consult is EMERGENT!
Tx is likely sutures, glue, or contact patch lens, IV abx: cephalosporin (Ancef) or Vancomycin PLUS gentamycin PLUS clindamycin if intraocular FB suspected
Complications of Corneal Laceration
- corneal or intraocular FB
- infection
- traumatic cataracts
- secondary glaucoma
- retinal detachment
Signs and Symptoms of Conjunctival Laceration
Symptoms: ocular irritation, pain, FB sensation
Signs: chemosis, subconjunctival hemorrhage, torn conjunctiva
Conjunctival Laceration Work up
- eye examination under topical or general anesthesia, includes dilated fundus exm to rule out intraocular FB
- seidel test to rule out open globe injury (put fluoroscein in eye, waiting for it to wash out, the aqueous is leaking out)
- ultrasonography
- CT to rule out intraocular FB
Conjunctival Laceration management
- observation
- prophylactic topical abx for small laceration
- surgical repair may be required for large lacerations
- follow up w/ ophtho.
Lid Lacerations
-types
- full thickness lid lacerations
- Lid lacerations/canalicular system
- presence of orbital fat in an eyelid laceration
- laceration through the eyelid margin
Lid Lacerations:
- require evaluation of what?
- tx
- eval for open globe injury or traumatic hyphema in ALL lid lacerations
Tx:
-refer!!
What is the concern with the presence of orbital fat in an eyelid laceration?
-indicates damage to the orbital septum and possibly to underlying levator muscle.
Penetrating Trauma ED Management
- Examine the other eye Visual acuity
- place eye sheild
- NPO and immediate ophtho consult
- evaluate tetanus immunization status
- IV cephalosporin(Ancef)
- DO NOT measure IOP if: ruptured/penetrated globe is suspected
- Radiographs/CT
- might not be a bad idea to patch the good eye so they dont move the bad eye and stimulate a pupillary response.
Intra-ocular FB: Four main goals of Rx
- preservation of vision
- prevention of infection
- restoration of normal eye anatomy
- prevention of long term complications.
Clinical features suggesting ruptured globe/penetration
- eyelid laceration
- shallow anterior chamber
- hyphema
- irregular pupil
- significant Visual acuity loss
- poor view of optic nerve
if patient presents with deep eye pain and hx of metal on metal hammering.. you are expecting to see a corneal FB or corneal abrasion but none is seen then need to rule out _____ with ____.
introcular FB with a CT scan. Consider US if available.
NO MRI.
Globe Rupture
- causes
- characteristics
- what is the likely result of damage to the posterior segment of the eye?
Causes:
-blunt or penetrating trauma
Characteristics
- any full thickness injury to corneal, sclera, or both
-Likely result is permanent vision loss. EMERGENCY!!!!!!
Clinical Features of Globe Rupture
- obvious corneal or scleral abrasion
- volume loss to eye
- iris or ciliary body prolapse
- iris abnormalities
- 360 bullous subconjunctival hemorrhage (posterior rupture)
- intraocular or protruding foreign body
- decerased visual acuity
- relative afferent pupillary defect
Globe Rupture Eval and Tx
- Tetanus status
- CT scan
- emergent ophtho consult
- NPO for surgery
- do not remove FB
- avoid eye manipulation that will increase IOP
- No eye drops
- bed rest with HOP 30 degrees (helps lower IOP)
- Treat n/v aggressively
- IV analgesics
- IV abx; vanco, ceftasidime, or cipro for PCN allergy
Orbital Wall fxs;
- most common site of fx
- effects of these fx
- the orbital floor and medial wall
- fx area may entrap fat of EOM
Orbital Wall Fx Evaluation:
visual acuity and color testing
EOM (may be limited d/t swelling)
Inspect for proptosis or enopthalmos
palpate for step off fx or crepitus
check facial sensation
Blowout Fx
- aka
- where is this fx?
- eom sx
- tx
- inferior wall fx, entrapment of the inferior rectus muscle
- aka orbital fx
-restricted upward gaze, diplopia
- refer for surgery within 3-10days
- Abx until surgery (keflex or Augmentin)
- no nose blwing, may use afrin nasal spray
1/3 of blowout fxs have associated ocular trauma such as:
- abrasion
- traumatic iritis
- hyphema
- lens dislocation/subluxation
- retinal tear/detachment
UV Keratitis/ Photokeratitis
- cause
- presentation
causes:
- UV radation of eyes
- recreational sun exposure
- sunlamps/tanning beds
- UV lights
- damaged metal halid lamps (gyms)
- aquarium disinfection lamps
Presentation:
- photophobia
- FB sensation
- Bil. erythema face and lids
- visual acuity slightly decreased
- chemosis of bulbar conjunctivitis
- no discharge
- cornea hazy
- pupils constricted
- latent period 6-12 hrs***** after exposure (Hx is very important that onset was 6-12hrs after exposure!!!)
- very painful
UV keratitis
- exam
- tx
- superficial punctate staining of the cornea with fluroscein
tx: oral analgesics, lubricant abx ointment (erythromycin), re check in 1-2 days
Hyphema
- what is this?
- emergency?
-blood in the anterior chamber, most likely complication of blunt trauma, can result in permanant vision loss.
THIS. IS. AN. EMERGENCY!!!!!
Hyphema Classification and ED management
Classification: spontantous and traumatic (blunt trauma or penetrating trauma)
Management:
assess concomitant injury
manage IOP increases
immediate referral
Hyphema Tx
- elevate head
- dilate pupil to avoid movements of iris (which may cause additional hemorrhaging)
- control IOP (Tx >30mmhg)
- –beta blocker (Timoptic)
- –PO or IV carbonic anhydrase inhibitor (acetazolamide) *DONT USE with sickel cell trait/disease pt.
- –IV mannitol (if no response to above)
Hyphema Management & complications
- ophtho consult
- eye patch
- reverse trendelenburg
- anesthesia/ anti-emetic
- IOP control > 30mmhg
- Admission to hospital
- anti-coagulated
- -decreasing visual acuity
- -ED eval. > 1day after initial injury
Complications:
- re-bleed
- post traumatic glaucoma
Chemical Injuries
- types of chemical burns
- which burn is worse?
- is this an emergency?
alkalis (basee) and acid burns
alkkalis is worse!!! (goes deeper into the orbit)
-yes, true ocular emergency
Chemical Burn Tx
- requires immediate intervention– copious irrigation w/ Lactate Ringers or Normal Saline 1-2liters
- continue irrigation until eye pH returns to 7.5 range
-assess ocular damage and manage accordingly
Chemical Burn Tx after irrigation if….
-no corneal epithelia defects noted
-corneal clouding or epithelial defect present
no defects: erythromycin ointment qid
defects: erythromycin ointment qid and clycloplegia for pain (scopolamine or clyclopentolate)
* optional- eye patching
PROMPT ophtho consult.
Traumatic Iritis
- what is this?
- symptoms
- Tx
-inflammation of the iris
Sx:
-pain, blurred vision, HA, photopobia, lid bruising/edema, pupil sluggish
Tx:
- ophtho consult
- usually resolve in one week
- topical steroids to decrease inflamm
- cycloplegic several times/day
Retrobulbar Hemorrhage
- presentation
- cause
- tx
- disruption and hemorrhage of posterior arterial supply increasing IOP
- proptosis/ malposition of the eye
*“Time is Retina”
Cause:
- trauma
- recent eye surgery/injections
Tx:
- emergently ophtho referral for surgery
- an attmept to decerase pressures–canthotomy
Cellulitis
- what are the two types of the eye?
- what is each kind?
- cause
- what is the easiest way to differentiate between preseptal and orbital?
Preseptal and orbital cellulitis
Preseptal= infection of soft tissues anterior to the orbital septum, mild and rarely has complications
Orbital= infection of the contents of the orbit (fat and occularis muscles) may cause loss of vision or potentially be fatal
- cause:
- spread from the sinues, ehtmoid most common
- polymicrobial
- -staph aureus and streptococci
-EOMs are painful in cellulitis.
Orbital and Preseptal cellulitis tx
Preseptal:
-outpatient tx if >1yo w/ oral abx (clindamycin or bactrim PLUS augmentin)
Orbital:
-inpatient w/ IV ABX (vanco + ampicillin-sulbactam for 2-3weeks
Is there…
- eyelid swelling w/ erythema
- eye pain/tenderness
- pain w/ eye movement
- proptosis
- ophthalmoplegia +/- diplopia
- vision impairment
- chemosis
- fever
- leukocytosis
Preseptal
- yes
- maybe
- no
- no
- no
- no
- rarely
- maybe
- maybe
Orbital
- yes
- yes, deep eye pain
- yes
- usually
- yes
- maybe
- maybe
- usually
- usually
