FRCEM FINAL SBA eBook 1(Preview)

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40 <strong>FRCEM</strong> Final 3. RETROBULBAR HEMATOMA/ ORBITAL COMPARTMENT SYNDROME DEFINITION Blood found behind the globe but within the orbit, mostly occurring secondary to trauma, which can lead to optic nerve and retinal ischemia and ultimately, vision loss. DIAGNOSIS • Physical findings: o Proptosis o Decreased visual acuity o Afferent pupillary defect o Decreased extraocular movements • Increased intraocular pressure (> 40 mmHg) • CT scan (do not delay management for CT scan if orbital compartment syndrome highly suspected) MANAGEMENT • Consider lateral canthotomy if any of the following o Decreased visual acuity o Restricted extraocular movement o Afferent pupillary defect o Proptosis o Intraocular pressure > 40 mmHg • Expeditious performance of a lateral canthotomy is vision saving. Do not delay. • Consult ophthalmology emergently 4. RETINAL DETACHMENT • Retina separates from the underlying retinal pigment epithelium and choroid, either from accumulation of fluid between the two layers or vitreous traction on the retina. DIAGNOSIS • History (trauma followed by flashing lights/floaters/dark veil/curtains, or history of diabetes/sickle disease with the same complaints) • Decreased peripheral or central visual acuity • Direct fundoscopic exam à pale billowing parachute with a large retinal detachment • Dilated indirect ophthalmoscopic evaluation by ophthalmologist • Ocular ultrasound of retinal detachment seen as hyperechoic membrane is posterior part of eye, sensitivity ranges from 97%-100%, specificity 83%-100%. MANAGEMENT • Consult ophthalmology for surgical repair 5. CORNEAL FOREIGN BODY (INCLUDING RUST RING) • Small metallic foreign bodies can come into contact with the eyes, most commonly when someone is drilling or grinding a metal surface. Special attention should be paid to the identification of a corneal rust ring. Iron in its neutral form is relatively insoluble in the corneal layers. • However, over time a metallic foreign body’s surface oxidises and diffuses into the stroma. A rust ring is then formed by the combination of oxidised iron and cellular infiltrate at the level of the superficial stroma. • A rust ring can lead to: o Permanent corneal staining, o Chronic inflammation, o Corneal vascularisation, o Necrosis Therefore, should be removed within a few days of it being identified. Acute & Major Presentations Moussa Issa Bookstore
Section I: Major and Acute Presentations 41 o Rust rings can be removed either by a needle or by ophthalmic burr. It may be easier to remove rust rings 2 -3 days after presentation as local necrosis will separate the rust ring from the corneal epithelium. o If there is any doubt, these patients should be referred to an ophthalmologist 6. CHEMICAL EYE INJURIES ANGLE GRINDING o Patients will not always recall a foreign body having entered the eye so it is important to have a high index of suspicion and examine for a conjunctival or corneal foreign body if a patient presents with an uncomfortable red eye. o Local anaesthetic may be needed both to examine the eye and to remove any foreign body – Proxymetacaine has been shown to be the optimal agent. o If there is a history of a possible foreign body entering the eye and it cannot be seen then the eyelid must be everted to exclude a subtarsal foreign body, provided a penetrating injury is not suspected. If a subtarsal foreign body is present, it is easily removed using a cotton bud. o Also, where the history is of a high velocity foreign body (e.g. metallic fragment from angle grinding or hammering a metal chisel) the possibility of a penetrating injury with intraocular foreign body must be considered. ED MANAGEMENT o Instillation of local anaesthetic o Small loose conjunctival foreign bodies can be washed out with water or removed with a cotton bud. o If the foreign body is adherent or embedded in the cornea, a needle may be used to lift it out of the cornea. This must be done either using a slit lamp or loupes to ensure accuracy and minimal damage to the cornea. o Once the foreign body has been removed any remaining epithelial defect can be treated as an abrasion. Acute & Major Presentations • Definition: chemical burn of the eye with acidic or alkaline compounds • Clinical features o Intense pain o Visual impairment o Blepharospasm: involuntary eyelid closure o Erythematous conjunctiva or whitening of the conjunctiva o Photophobia • Treatment o Immediate and thorough irrigation with copious sterile saline (preferred if available) or cold tap water o Continued irrigation in the emergency department (ED) with a plastic scleral lens (Morgan® lens) until the pH normalizes for acidic agents or for 2–3 hours for alkaline agents o Mechanical removal of solid particles that become acidic or alkaline when combined with water, e.g., dry lime o Antibiotic eye drops (e.g., tetracycline) o Ophthalmologic consultation o Topical glucocorticoids (prednisolone acetate 1%) • Complications o Scarring, clouding, and/or ulceration of the cornea o Neovascularization of the cornea o Adhesion of the eyelid (palpebral conjunctiva) to the globe (bulbar conjunctiva) o Blindness Patients should be advised to irrigate with a copious volume of water or saline for at least 15 minutes before arrival to the ED because immediate irrigation is the most important factor in preventing morbidity! Moussa Issa Bookstore
Page 1 and 2: Disclaimer i
Page 3 and 4: Disclaimer iii Disclaimer Copyright
Page 5 and 6: Acknowledgments v Acknowledgments T
Page 7 and 8: Table of Contents vii 11. Dental Em
Page 9 and 10: Table of Contents ix 34. Psychiatri
Page 11 and 12: Section I: Major and Acute Presenta
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Page 69: Section I: Major and Acute Presenta

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