Transcript Diagnostic Workup of Ocular Emergencies

Ocular emergencies

Central Retinal Artery occlusion
◦ Sudden painless visual loss.

Retinal Detachment
◦ Painless
◦ Flashing lights ,spider webs or coal dust across visual field.
◦ Sensation of curtain lowering or raising in front of the affected eye.
Temporal Arteritis
 Acute Angle Closure Glaucoma

◦ Redness, severe eye pian, halos around lights, N/V, headaches.
Ruptured Globe
 Hypema
 Corneal Laceration
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The Eye
Diagnostic Workup of Ocular Emergencies:
Physical Exam
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Visual acuity:
◦ Check with and without glasses, using Snellen chart or other means
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Lids/adnexa:
◦ Evaluate position of the lid, contour, color
◦ Evaluate the periocular areas; check for evidence of lesions, edema
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Pupils:
◦ Evaluate size, shape, ability to respond to direct and consensual light
• Orbit:
Inspects orbits for symmetry and proptosis;
Palpates the orbital rim for “step-offs,”and mobility.
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Motility:
◦ Check for ROM with cranial nerves III, IV, VI
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(restriction or paresis of these muscles may cause diplopia)
Diagnostic Workup of Ocular Emergencies:
Other Tests
• Slit lamp:
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Best for evaluating anterior structures (e.g., cornea, conjunctiva, anterior chamber, iris, lens)
• Goldmann applanation:
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Measures intraocular pressure (also Schiotz tonometry, Tono-pen)
• Funduscopic exam:
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 Best for evaluating optic nerve, retinal vessels, retina
Pupils may be dilated or undilated
Contraindicated in patients who have an iris supported intraocular lens or untreated narrow angle
glaucoma
• Fluorescein staining:
• Increased dye uptake is indicative of damage to the corneal epithelial cells
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Flourescein Staining
Topical anesthetic
e.g Proparacaine 0.5%
•rapid onset
•Lasts about 20 minutes
Fluorescein strip
Corneal Abrasion
Corneal abrasion
Causes: trauma, contact lens
wearers.
 Clinical features: tearing,
photophobia, blepharospasm,
and severe pain.
 ED care: visual acuity, Tetanus
status updated administration
of cycloplegic(contraindicated
in narrow anterior chamber
angle pts)
Topical tobramycin,
erythromycin, or
bacitracin/polymyxin.
Contact lens abrasion tx’d
w/ciprofloxacin, ofloxacin, or
tobramycin drops.
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Patching contraindicated in
dirty abrasion and contact
lens abrasions
Oral analgesics, topical
cycloplegics are appropriate,
however, topical anesthetics
are strictlycontraindicated.
Ophthalmology follow-up is
advised within 24 hours.
Ptyregium
Ophthalmological Abnormalities
conjunctivitis
scleritis
Associated with autoimmune diseases
Ocular Emergencies?
Ocular Emergencies
Hyphema
Traumatic hyphema
Hyphema
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Blood in anterior chamber which is usually asyptomatic
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Causes
◦ Spontaneous
◦ Traumatic
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Treatment
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Upright position (bed rest)
Topical atropine 1%
Topical prednisolone acetate 1%
Immediate ophtho consult
Complications
◦ Rebleeding (Usually 3-5dys after initial event)
◦ Blood staining of corneal epithelium
◦ Secondary glaucoma
Opthalmological Abnormalities
conjunctivitis
Suconjuctival Hemorrhage
Ocular Emergencies?
Spontaneous Hyphema
Hyphema
Subconjunctival hemorrhage
Corneal Foreign Body
Corneal Laceration
Ocular emergencies

Central Retinal Artery occlusion
◦ Sudden painless visual loss.
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Retinal Detachment
◦ Painless
◦ Flashing lights ,spider webs or coal dust across visual field.
◦ Sensation of curtain lowering or raising in front of the affected eye.
Temporal Arteritis
 Acute Angle Closure Glaucoma

◦ Redness, severe eye pian, halos around lights, N/V, headaches.
Ruptured Globe
 Hypema
 Corneal Laceration
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Central retinal artery occlusion
Painless sudden loss of vision secondary to a
thrombotic plaque, embolus or vasospasm of the retinal
artery.
 Initial physical exam normal
 Dilated pupil (Marcus-Gunn pupil)
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◦ unreactive to direct light in 1-2hrs.
◦ Reactive to consensual light
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Funduscopic exam
◦ Pale disc with a cherry-red spot in macular area (fovea)
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Treatment
◦ Digital massage of globe.
◦ 95:5 mixture of O2 and CO2
◦ Optho consultation for anterior chamber paracentesis.
Cellulitis
Pre-septal
Post-septal or orbital
A 25 y/o female presenting with c/o swelling of face.
Perform an interview.
Perform an exam and record your findings.
Write down your treatment plan for this patient.
Periorbital Cellulitis
Preseptal cellulitis
Presentation:
warm, indurated,
erythematous eyelids.
Without restriction of
ocular motility
Proptosis, painful eye
movemment
Impaired puillary function
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Tx:
 Pts >5yrs augmentin PO.
 Pts <5yrs a septic workup
 Toxic-appearing pts, pts
with comorbidities,
<5yrs old. Hospital
admission parenteral
ceftriaxone and
vancomycin may be
required.
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Postseptal cellulitis
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Should be susupected
whenever
signs/symptoms of
periorbital cellulitis
presents with fever,
toxicity, proptosis,
painful ocular
motility, or limitied
ocular excursion.
Emergent dx w/
orbital & sinus CT
scan non-contrast.
 Ophthalmologic
consultation
 Hospital admission
 IV cefuroxime are
required.
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Oromaxillofacial Emergencies
Toothache/periodontal abscess and dz
 Dental trauma
 Fractured mandible
 LeForte fractures
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Dental trauma
Dental fracture are classified by the Ellis system
Ellis 1fractures involve only the enamel of the
tooth. These injuries may be smoothed with an
emery board or referred to a dentist for
cosmetic repair.
 Ellis 2 fractures (70% of tooth fractures) involve
the creamy yellow dentin underneath the white
enamel. The patient complains of air and
temperature sensitivity. Exposed dentin must
be thoroughly dried and promptly covered with
a temporary dental dressing such as zinc
oxide/eugenol paste.
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Dental trauma
Ellis class 3 fractures are tooththreatening fractures that involve the pulp
and can be identified by a red blush of the
dentin or a visible drop of blood after
wiping the tooth.
 A dentist should evaluate the patient with
Ellis 3 fracture immediately.
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Dental trauma
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Dental avulsion happens when a tooth has been
completely removed from the socket.
Dental avulsion is a dental emergency!
Primary teeth in children should not be
replaced because of risk to permanent teeth.
Permanent teeth that have been avulsed for
<3hours must be immediately reimplanted.
If a patient arrives with an empty socket and the
tooth cannot be located, adjacent tissues should
be searched. X-ray may be necessary to exclude
displaced or aspirated teeth.
Fractured mandible
Patients with open fractures require
admission and IV antibiotics. PCN,
clindamycin, or a first generation
cephalosporin is recommended.
 Many patients with closed fracture may be
managed on an outpatient basis.
 Temporomandibular reduction is
performed by ER physician a barton
bandage is applied and the patient is d/c’d
on a liquid diet with close follow-up
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Maxillofacial Trauma
In patients that have sustained
maxillofacial trauma, important points that
should be obtained in the history include:
Mechanism of injury
Loss of consciousness
Facial paresthesias
Malocclusion
Visual changes such as diplopia
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Examination
Physical exam should begin with:
Inspection of the face- evaluating for
elongation or asymmetry.
Muscles of facial expression should be
assessed
Ecchymoses around the eyes (raccoon’s
eyes) or over the mastoids (battle’s sign)
suggest basilar skull fracture.
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LeForte Fracture classification
LeForte I, a transverse fracture separates the
body of the maxilla from the lower portion of
the pterygoid plate and nasal septum. With
stress on the maxilla, only the hard palate and
upper teeth move.
 LeForte II, a pyramidal fracture of the central
maxilla and the palate.
 LeForte III, or cranial –facial disjunction, occurs
when the facial skeleton separates from the
skull. The entire face shifts with tugging.
 LeForte IV, fracture includes the frontal bone as
well as the midface.
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LeForte Fracture
Exam should include:
Visual acuity
Pupils examined for reactivity
Swinging light test to check for
Marcus Gunn pupil, which
initially dilates rather than
constricts when first
illuminated.
Eyes checked for hyphema
Extraocular movements
Distance between medial canthi
should be checked (normally
30-40mm)
Nose examined for deformity,
CSF rhinorrhea
Ears examined for trauma
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Mouth examined for
lacerations, tooth trauma,
malocclusion
Plain films are excellent
screening studies.
CT imaging is required to
make definitive dx.
ED care and disposition
Airway control
 Hemorrhage control with direct pressure
 In LeFort fractures, bleeding may be
controlled manually realigning the
fragments.
 Severe epistaxis requires direct pressure
or nasal packing. In massive
nasopharyngeal bleeding, passing a foley
catheter w/balloon inflation may be lifesaving.
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Otolaryngology Emergencies
Otalgia/Tympanic Membrane Perforation
 Sinusitis
 Epistaxis
 Peritonsillar Abscess/Retropharyngeal
abcess
 Epiglottis
 Angioedema
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Otalgia
Ear pain may be primary or referred pain.
 Primary causes include: trauma, infection,
foreign body, cerumen impaction,
choleastoma, and neoplasm.
 Referred pain may occur with dental
disease, oropharyngeal and
retropharyngeal processes, nasal cavity
pathology, and disorders of the throat and
neck.
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Tympanic Membrane Rupture
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90% heal without intervention.
Antibiotics are not indicated unless a
coexistent infection is present.
Mastoiditis
Occurs as infection spreads from the
middle ear to the mastoid air cells.
 Pts present with otalgia, fever,
postauricular erythema, swelling and
tenderness.
 Protrusion of the auricle with obliteration
of the postauricular crease may be
present
 CT scan will delineate the extent of bony
involvement.
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Sinusitis
Viral URI and allergic rhinitis most
common precipitating factors.
 Most common pathogens associated with
acute bacterial sinusits are:
 S. pneumoniae
 H. influenzae
 M. catarrhalis
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Sinusitis
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Maxillary sinusits presents with pain in the infraorbital
area.
Frontal sinusitis causes pain in the supraorbital and
lower forehead region
Ethmoidal sinusitis is serious in children because of its
tendency to spread to the CNS, often produces a dull,
aching sensation in the retro-orbital area.
Sphenoidal sinusistis is uncommon and has vague signs
and symptoms
The diagnosis is often clinical
X-ray of the sinuses are generally not required in the
ED.
Sinusitis
Tx includes nasal decongestant sprays,
oxymetazoline or phenlyephrine, for no
longer than 3 days.
 Antibiotic choices for 14-21 days
regimens incluldes: ampicilllin, bactrim,
biaxin, second-generation cephalosporins,
and augmentin.
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Epistaxis
Anterior epistaxis accounts for 90% of all
nosebleeds, with majority originating from
Kiesselbach’s plexus
 Posterior epistaxis origninates from
branches of the sphenopalatine artery and
is more common in the elderly.
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Epistaxis
Posterior epistaxis is suspected when:
Anterior source is not identified
Bleeding occurs from both nostrils
When blood is seen draining into the
posterior pharynx after anterior sources
have been controlled.
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Diagnostic studies
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CBC
Coagulation studies (PT, PTT, platelet function
tests)
BUN, serum creatinine
LFTs
CT scan of the paranasal sinuses
MRI of the head
Internal and external carotid angiography
Nasal endoscopy and nasopharyngoscopy
Plain nasal or sinus X-ray.
Treatment options
Anterior epstaxis
 Direct pressure
 Vasoconstrictrive
agents(neo-synephrine,
cocaine)
 Silver nitrate cautery
 Anterior nasal packing
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Posterior epistaxis
 Dehydrated sponge
packing
 Balloon tamponade
devices
 Arterial ligation
 Embolization
 All patients with
nasal packing require
antibiotic prophylaxis
with antistaphyloccal
agents to prevent
sinusitis and toxic
shock syndrome.
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Peritonsillar abscess
Is the most frequent deep space infection
of the head and neck.
 Group A beta-hemolytic Strep is the most
common cause.
 Mixed aerobic/anaerobic bacteria are
often present
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Clinical features
Symptoms include:
Fever
Malaise
Sore throat
Odynophagia
Dysphagia
“hot potato voice”
Otalgia
Varying degrees of trismus
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Signs include:
Unilateral tonsillar
enlargement with
infereomedial
displacement
Palatal & uvula edema
Contralateral deflection of
the uvula
Tender ispsilateral anterior
lymphadenopathy
Drooling
dehydration
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DDX
Tonsillitis
 Peritonsillar cellulitis
 Infectious
mononucleosis
 Retropharyngeal
abscess
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Tumor
 Internal carotid
artery aneurysm
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ED care and disposition
Aspiration of purulent material with an
18- or 20- gauge needle is both diagnostic
and therapeutic
 Intraoral bedside U/S can in detection and
guidance of needle aspiration.
 Antibx therapy: PCN is the tx of choice
Alternative antibx clindamycin in PCNallergic patients.
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Complications
Airway obstruction
 Aspiration of ruptured abscess contents
 Septicemia
 Retropharyngeal abscess
 mediastinitis
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Retropharyngeal abscess
Is most common in children less than 5
years old, but it can also occur in adults.
 In adults, it is caused by direct extension
of purulent material from an adjacent site
or abscess formation following
retropharyngeal cellulitis.
 Other causes include: foreign body
penetration, vertebral osteomyelitis or
diskitis, and hematogenous spread from
distant sites.
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Clinical features
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Symptoms include:
Fever
Sore throat
Odynophagia
Dysphagia
Neck stiffness
Neck pain
Muffled voice
Stridor
Respiratory distress
Patients may want to lay
supine, sitting them up
may increase dyspnea
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Signs include:
Tender cervical
lymphadenophathy
Neck swelling
Torticollis
Pharyngeal erythema and
edema
DDX and diagnosis
Retropharyngeal space tumor
Foreign body
Aneurysm
Hematoma
Edema
Lymphadenopathy
The lateral soft tissue neck X-ray may
demonstrate thickening in the preverterbral
space.
 CT scan of the neck can help differentiate from
abscess and help define the extent of infection.
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ED care and disposition
Airway management
 Parenteral antibiotics
 Urgent ENT consult
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First line antibiotic tx
for adults include:
Clindamycin
PCN G +Flagyl
Ampicillin-sulbactam is
alternative tx.
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Epiglottis
Is most often seen in adults with a mean
age of 46.
 Most commonly due to H. influenze type
b infection.
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Clinical features
Symptoms
 1-2day hx of
worsening dysphagia,
odynophagia, and
dysphonia
 Clinical indicators
of imminent
airway obstruction
include dyspnea,
drooling, aphonia,
and stridor.
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Signs
Throat pain is
disproportionate to
clinical exam
Anxiety
Fever tachycardia
Cervical adenopathy
Pain with general
palpation of the
trachea or larynx.
DDX and diagnosis
DDX
 Pharyngitis
 Inf mononucleosis
 Croup
 Deep space neck abscess
 Diptheria
 Pertussis
 Laryngeal trauma
 Foreign body aspiration
 laryngospasm
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Diagnosis
 All diagnostic proc
should be deferred in the
unstable patient
 Lateral soft-tissue neck
X-ray(“thumbprint sign”)
 Direct fiberoptic
laryngoscopy classically
reveals a cherry red
epiglottis.
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ED care and disposition
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Emergent otolaryngology consultation
ED physician must be prepared to establish a
definitive airway
Initial airway mgmt consists of supplemental
humidified O2, comfortable patient positioning,
Heliox can be given as a temporizing measure.
Adults often managed without intubation
If intubation is needed awake nasotracheal
fiberoptic intubation is the preferred method.
If orotracheal intubation is unsuccessful surgical
cricothyroidotomy may be required
IV cefuroxime is the recommened 1st line tx.
Angioedema of the upper airway
Causes include:
C1-esterase inhibitor deficiency
IgE-mediated type 1 allergic rxn
ADR to ACE inhibitor therapy
Idiopathic reaction
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Clinical Features
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patients with airway involvement can
present with “throat tightness”, dyspnea,
cough, hoarseness, and stridor.
ED care and disposition
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In adults, epinephrine 1:1000 SQ. This can be
repeated q15-20mins prn.
Benadryl
Methylprednisone
Histamine antagonist
Fiberoptic nasopharyngoscopy is used to assess
possible laryngeal edema.
Patients with laryngeal edema, potential for
airway compromise, and/or worsening
symptoms despite maximal therapy require
admission!
Airway management
Indications for airway management
techniques include:
Oxygenation
Ventilation
Protection of the airway
Facilitation of therapy
Anticipation of a clinical course that
requires preventive management
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Airway management
All patients who require airway
management should be on a cardiac
monitory, receive pulse oxy with oxygen,
and have IV access.
 The method of airway mgmt is dependent
upon the patient, the indications, and the
perceived airway difficulty.
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Techniques
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Tracheal intubation Is the
most common technique
for definitive airway
management.
Nasotracheal intubation
may be indicated when
laryngoscopy is
predicted to be difficult
or neuromuscular
blockade is
contraindicated.
Bag-valve-mask
ventilation provides
ventilation and
oxygenation, but not
airway protection from
aspiration.
 Esophageal airways are
devices used primarily in
the prehospital setting
when orotracheal
intubation is not an
option. Devices are
inserted blindly in apneic
unconscious pts.
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Techniques
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Laryngeal mask
airway can be places
blindly without
manipulation of the
patient’s head, and
does not protect
against aspiration and
should be considered
temporizing device in
the emergency
setting.
Surgical airway
techniques.
 The most common
indication for a
surgical airway is
failure to intubate
and ventilate.
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