Eye & ENT Emergencies

R.Nandinii17th November 2015

Eye Emergencies

Trauma• Lid laceration• Ocular trauma

(blunt/penetrating)• Blow out fracture

Non trauma• Corneal foreign body• Chemical burns• Acute red eye• Acute visual disturbances

ENT Emergencies

Trauma• Fracture of Nasal bone• Traumatic perforation of

tympanic membrane

Non-trauma• Epistaxis• Foreign body in ear/nose/throat• Otitis media• Peritonsillar abscess• Epiglotitis• Angioedema

1.Lid laceration Any laceration other than superficial skin that involves the lid

margin will need ophthalmological referral. An eyelid laceration is a potential penetrating eye injury

until proven otherwise.History Four basic questions are:-which eye is injured?-how did it happen?-when did it happen?-what are the symptoms? Nature of injury – was there any possibility of penetration into the

lid/orbit?

Examination-Wound examination – size and depth. All wounds should be explored fully for extent of damage.-Visual acuity.-Superficial ocular examination with magnification to assess for any corneal/ conjunctival laceration or penetration.-Further ocular examination including dilated fundus examination as determined by history and examination findings. Treatment/InvestigationOrbital X-Ray or CT if indicated for foreign bodies or orbital fracture. If superficial laceration:• Clean the area and surrounding skin with antiseptic such as Betadine. Subcutaneous anaesthetic with

vasoconstrictor (2% Lignocaine with Adrenaline). Irrigate and debride the wound thoroughly with saline. Identify foreign bodies if applicable. Suture with a 6/0 non-absorbable suture.

When to refer?• If the eyelid laceration is associated with ocular trauma requiring surgery such as ruptured globe or

intraorbital foreign body.• If the laceration position is nasal to either the upper or the lower eyelid punctum, for the possibility of

damage to the nasolacrimal drainage system.• If there is extensive tissue loss or distortion of the anatomy.• If there is full thickness laceration or the laceration involves the lid margin.

2. Ocular trauma History Mechanism of trauma – any history suggestive of a penetrating trauma. The type of projectile and the likely velocity (e.g. low or high) should be documented. Small projectiles at high velocities increase the likelihood of penetrating

trauma. Symptoms include loss of vision, pain on movement and diplopia. Was the patient wearing eye protection? Any previous history of ocular trauma or previous surgery is to be documented and

may suggest reduced integrity of the wall of the globe.

Blunt Closed globe injuryBlunt trauma to the eye may result in considerable damage to the intraocular contents. Fracture of the orbital wall may occur due to the transfer of mechanical energy to relatively thin orbital bone. Ruptured globe Trauma of sufficient force may result in globe rupture and typically occurs in the areas where the scleral wall is thinnest: at the limbus (which would be visible via the slit lamp) or behind the insertion of the rectus muscle (which would result in reduced ocular motility, loss of red reflex and vitreous bleeding).

Examination Visual acuity. Ocular movements – if there is considerable eyelid oedema, carefully lift up the lid while viewing the eye to

ensure there is no obvious rupture. Reduced movement may suggest ruptured globe or orbital wall fracture. Slit lamp – looking for evidence of rupture (often at the limbus). Examine for blood in the anterior chamber Examine the eyelid for lacerations Ophthalmoscopy – Red reflex (missing in intraocular haemorrhage or retinal detachment). Look for any retinal

pathology (after dilating the pupil). Investigations CT scan (axial and coronal) for orbital wall fracture if indicated (see.p40). Follow up - When to refer? Non-urgent referral within 3 days if the above findings are negative. Urgent referral to ophthalmologist- immediate consult by phone if findings are suggestive of intraocular haemorrhage, ruptured globe or orbital wall fracture Treatment Topical antibiotic drops for superficial trauma. Suture any eyelid lacerations as indicated in eyelid trauma section

Sharp (penetrating)All penetrating trauma require urgent referral to ophthalmologist – immediate consult by phone following appropriate pre-op workup. ExaminationExamination may only need to be cursory if the trauma is obvious otherwise: –-Visual acuity.-Direct ophthalmoscopy – loss of red reflex may suggest retinal trauma or detachment.-Slit lamp – looking for distorted anterior chamber structures or corneal/scleral breaks. Treatment-Ensure nil by mouth status. Strict bed rest. Injectable analgesia/antiemetic if required.-CT scan of the orbit to exclude retained ocular/orbital foreign body after discussion with ophthalmologist.-Shield (not pad) the eye making sure not to increase the intraocular pressure with further loss of ocular contents.-No ointment for penetrating eye injury.-Check for tetanus immunisation status as per current protocol.-Commence broad spectrum IV antibiotics.

3. Blow out fracture HistoryMechanism of injury - for example squash ball, punch with a fist. Symptoms-Pain (especially on vertical movement), local tenderness, diplopia, eyelid swelling and crepitus after nose blowing.-A “white” blow-out fracture occurs with orbital injury with the findings of minimal periorbital haemorrhage, sunken (enophthalmic) globe, restricted eye movement in an unwell child.-Exclude head injury and refer urgently. SignsNose bleed, ptosis and localised tenderness. Examination-Complete ophthalmological examination.-Sensation of affected cheek compared with that of the contralateral side.-Infraorbital nerve involvement is demonstrated by anaesthetised upper teeth and gums on the affected side. Inferior rectus entrapment (diplopia on upward gaze)Palpate eyelid for crepitus.

InvestigationComputed tomography (CT) scan of the orbits and brain (axial and coronal views). Treatment-Nasal decongestants for 7-10 days.-Broad spectrum oral antibiotics.-Instruct patient not to blow his or her nose. (Avoid Valsalva manoeuvre).-Ice pack to the orbit for 24-48 hours. Follow up - When to refer?-Non-urgent referral – contact ophthalmogist for time frame for all cases with:-Suspected or documented orbital floor fractures.-Patients should be seen within 1-2 weeks post trauma and evaluated for persistent diplopia or enophthalmos.-Surgical repair if necessary is usually performed 7 to 14 days after trauma.

4. Corneal foreign bodiesAny foreign body penetration of the cornea or retained foreign body will require urgent referral toophthalmologist - immediate consult by phone. History-What is the likely foreign body?-Examples include dirt, glass, metal and inorganic material. -Retained organic material may lead to infection; retained metallic foreign bodies may lead to the formation of rust rings that produce persistent inflammation and corneal epithelial defect.-Velocity of impact? High speed motor drilling without eye protection may lead to a penetrating corneal/scleral injury. Examination-Visual acuity-Slit lamp - assess for the size, site/s and nature of foreign body and the depth of penetration.-Examine the cornea, anterior chamber, iris, pupil and lens for any distortion that may indicate ocular penetration and require urgent referral to an ophthalmologist.-Evert the eyelids to exclude retained foreign bodies – remove if appropriate.

5. Chemical burns History-When did it occur?-What is the chemical? (e.g. acid/alkali; alkalis are more harmful to the eye). Examples of acids include: toilet cleaner, car battery fluid, pool cleaner. Examples of alkalis include: lime, mortar & plaster, drain cleaner, oven cleaner, ammonia.-Any first aid administered and how soon after the incident? Examination-Use topical anaesthesia.-The degree of vascular blanching, particularly at the limbus, is proportional to severity of chemical burn Immediate treatment as indicated **

Chemical Burns -Measure pH using universal indicator paper to sample the forniceal space-Test and record visual acuity.-Contact poisons information or the chemical manufacturer for further information if required.

1.Instil local anaesthetic drops to affected eye/eyes.2. Commence irrigation with 1 litre of a neutral solution, eg N/Saline (0.9%), Hartmann’s.3. Evert the eyelid and clear the eye of any debris / foreign body that may be present bysweeping the conjunctival fornices with a moistened cotton bud.4. a. Continue to irrigate, aiming for a continuous irrigation with giving set regulator fully open.b. If using a Morgan Lens, carefully insert the device now.5. Review the patient’s pain level every 10 minutes and instil another drop of localanaesthetic as required.6. a. After one litre of irrigation, review.b. If using a Morgan Lens, remove the device prior to review.7. Wait 5 minutes after ceasing the irrigation luid then check pH. Acceptable pH range 6.5-8.5.8. Consult with the senior medical oficer and recommence irrigation if necessary.9. Severe burns will usually require continuous irrigation for at least 30 minutes.

6.Acute red eye

Acute Angle Closure Glaucoma Eye pain, headache, cloudy vision, colored

halos around lights, conjunctival injection Fixed, mid-dilated pupil Increased IOP (40-70 mm Hg)

Normal range is 10 – 20 mm Hg Nausea, vomiting

Scleritis-Vision may be impaired. Sclera is thickened and discoloured. The globe is tender to palpation.-Associated history of life-threatening vascular or connective tissue disease– may require appropriate physician consult (NB look for medications involving systemic steroids, NSAIDs, antimetabolites).Urgent referral – see ophthalmologist within 24 hours. Anterior chamber involvement Acute Anterior Uveitis (Iritis)-Pain, photophobia, and red eye.-Anterior chamber appears cloudy from cells and flare.Urgent referral – see ophthalmologist within 24 hours. Hypopyon-Visible accumulation of white cells inferiorly seen in severe uveitis.Urgent referral – immediate consult by phone - for investigation of infection, inflammation or ocular malignancy. Hyphaema-Usually trauma related but consider non-accidental injury in children and blood dyscrasias. Bed rest.Urgent referral – see ophthalmologist within 24 hours.

7.Acute visual loss

Amaurosis Fugax Symptoms-Monocular visual loss that usually lasts seconds to minutes, but may last 1-2 hours. Vision returns to normal. Signs-Essentially normal fundus exam (an embolus within a retinal arteriole is only occasionally seen Other neurological signs associated with ischemia of cerebral hemispheres. Investigation-As per protocol but usually includes assessment of cardiovascular risk factors:-Blood count/electrolytes/lipids/fasting blood sugar.-Thrombophilia screen.-Echocardiogram.-Carotid doppler studies. Management-Commence aspirin.Referral to neurology/cardiology or vascular surgery as appropriate.Patients with recurrent episodes of amaurosis fugax require immediate diagnostic and therapeutic intervention.

TAKE HOME NOTE : WHEN TO REFER IMMEDIATELY?? Decreased visual acuity Deep, rather than superficial,pain Pain unrelieved by topical anaesthetics Corneal edema Flare or cells in the anterior chamber Ciliary flush Pain in the contralateral eye on direct exposure of the unaffected eye Corneal or conjunctival foreign body which cannot be removed after one attempt in

the office In the case of corrosive burn, implement saline irrigation immediately prior to the

patient being transported to hospital. Irrigate until the effluent is pH neutral or mildly acidic as shown by the use of blue and pink litmus paper

8.Fracture of nasal bone Caused by direct trauma to the nose Features: -distorted nose shape, soft tissue swelling, tenderness over

the nasal bone area Important to exclude:-injuries to the other parts of the facial skeleton-septal hematoma (bluish swelling on both sides of the nasal septum visible from the front of the nose). If present urgent ENT referral is required for hematoma aspiration/incision and drainage, in order to prevent development of septal ischaemia or abscess, which may lead to necrosis, collapse and deformity of the cartilaginous structure of the nose. Nasal xray is done for medicolegal reasons. It does not affect mx. The need for manipulation and reduction (M&R) should be assessed 5

to 7 days post injury when the soft tissue swelling has subsided. M&R is usually done within 7 to 10 days of injury before the nasal bone become firmly set.

9. Traumatic perforation of tympanic membrane Usually caused by a slap or punch to the side of the head. Other causes: foreign body insertion, forceful ear irrigation, barotrauma, and

sudden negative pressure Features: - unilateral otalgia, hearing loss, tinnitus, vertigo & bleeding from the affected ear- Perforation of tympanic membrane seen on otoscopy (often blood stained)- Variable degree of conductive hearing loss depending on the size of the

perforation (the Weber test lateralizes to the side of the TM perforation, negative rinne test

Management:-give analgesics. DO NOT prescribe ear drops-give prophylactic broad spectrum oral antibiotics eg: amoxicillin-important to instruct patient to keep affected ear dry

10. Epistaxis Well supplied vasculature underlying mucosa Dryness: nose is humidifying organ Anterior vs posterior-Most anterior bleeding is from the septum, in younger age groups. Self limited and respond to pressure -Most posterior nosebleeds are in older population, and are more serious Diagnosis-Laterality: unilateral can be either anterior or posterior, bilateral usually means posterior -Response to compression: Anterior bleeding responds to septal compression -Severity?

Causes

Management Priorities: assess & stabilize hemodynamic status, identify the site & cause of

bleeding and stop the bleeding Institute stabilization: pinch the nostril btwn a finger and thumb for at least

10 min, apply ice packs on the bridge of the nose. Have the pt sit up and hold a bowl. (swallowing which may displace the accumulating clot, must be discouraged)

If pt unstable hemodynamically: transfer to critical care unit. Establish IV lines and administer crystalloids.

Identify the source of bleeding. Remove clotted blood with Tilley’s forcep or sucker. As each part of nasal septum comes in view, it may be sprayed with cophenylcaine

Upon cessation of hemorrheage: bleeding points can be cauterized with beads of silver nitrate on a stick or packed with gauze soaked in adrenaline 1:10000 for 15-30min. If no further bleed discharge with bed rest and outpatient ENT referral.

If bleeding persist, anterior nasal packing is required-Options: Merocel (8 or 10cm pack for adults) lubricated with tetracycline ointment or BIPP (bismuth subnitrate and iodoform paste) using a Tilleys nasal dressing forceps-Admit pt for observation and start oral antibiotics. If bleeding persist despite effective anterior nasal pack, posterior

nasal packing is required-reassess hemodynamic status-Foley catheter size 12 inserted through nostrils until tip is seen in the oral pharynx Always refer ENT for urgent referral:-if epistaxis is prolonged-in the event of repeat visits-if recurrent epistaxis presents-if the patient is elderly

11. Foreign bodies (ears) Foreign bodies can be removed using microforceps / a blunt hook

(under otoscopy or syringing) If uncooperative child, removal under general anaesthesia is advised-if foreign body is an insect: kill it with a few drops of 1% lignocaine or olive oil before removing with microforceps.-organic freign bodies (eg: pea, tissue, paper & sponge). Do not use syringing technique as they may swell up, rendering removal difficult. If removal is difficult under otoscopy, refer to ent clinic where a

microscope is available. One attempt by an emergency dept staff is recommended, falling

which the patient should be referred to the ent clinic.

11. Foreign bodies (nose) Occurs in children, presenting with unilateral, foul smelling nasal

discharge There is the danger of inhalation and obstruction of the respiratory

tract during removal, esp if the patient is supine during the removal attempts.

If the foreign body is of an irregular shape, use small alligator forceps for removal.

If it is round or smooth foreign body, use a blunt hook to engage the posterior end of the foreign body before removing it

A cophenylcaine nasal spray may be used to aid in the removal of the foreign body by causing mucosal shrinkage.

One attempt at ED, falling which requires referral to ENT officer.

11. Foreign bodies (throat) Ask about the nature of the foreign body: fish bone, chicken

bone Ask the pt to identify the exact site of pain. Pain over the

lower part of the neck or chest may suggest an oesophageal foreign body which is not easily visualized clinically/radiologically (lat xray)

Enquire about the presence of haemoptysis or hematemesis & migratory pain, eg: from the throat to the neck, or neck to chest

Inspect the tonsillar region. Options include:-indirect laryngoscopy-fiberoptic nasopharnyngoscopy-direct laryngoscopy Inspect closely for foreign bodies at the tonsillar poles, base

of the tongue, vallecular region and pyriform fossae If no foreign body can be seen, proceed with lateral xray of

neck If xray shows presence of foreign body, inform the ENT

officer.

If xray and IDL are negative for foreign bodies and the patient is comfortable, reassure and treat symptomatically: lozenges ang gargle.

-oral antobiotics if theres ulcer or abrasion. Refer to ent as outpatient.-tca stat if dypnoea, chest pain, fever or hematemesis. If xray and IDL are negative for forein bodies but patient is still

symptomatic inform ENT officer to review and keep in view the barium swallow test (especially for lower neck pain and chest pain or rigid oesophagoscopy under GA.

12. Otitis media Common childhood illness Caused by: Strep pneumoniae, Haemophilus influenza & Moraxella

catarrhalis Features: Fever, earache, ear discharge if TM is perforated Examination: TM appears red and bulging or perforated with

mucopurulent discharge on otoscopy Treatment: -Oral antibiotic: amoxicillin-Topical nasal decongestants-Oral antihistamine-Analgesia-Antibiotic ear drops are indicated ONLY if the TM is ruptured (this differentiates from treatment of traumatic rupture of tympanic membrane)

13. Peritonsillar abscess

History –Sore throat, worse despite antiboitics –Difficulty eating, drinking (swallowing) and pain to swallow –Difficulty opening mouth (trismus)

Physical findings: –Soft palate swelling –“Hot potato voice” –Asymmetrical tonsil size –Trismus –Neck swelling Incision and drainage under local anaesthesia, refer ENT

14. Epiglottitis Acute inflammation causing swelling of the

Supraglottic structures of the larynx Older children & adults decrease incidence in children secondary to HIB vaccine Onset rapid, patients look toxic prefer to sit, muffled voice, dysphagia, drooling,

restlessness Management:-Avoid agitation-Direct visualization if patient allows soft tissue of neck-Prepare for emergent airway, best achieved in a controlled setting-Unasyn, +/- steroids

Soft tissue X-ray of neck

Anterior-posterior view is normal

Lateral view: ***THUMB PRINT*** swelling epiglottis/ary epiglottic folds fullness of the valleculae ballooned hypopharyx assess the retropharyngeal space

Epiglottitis

Acute epiglottitis: swan neck

Management In Children:

Brought in the operating room Be ready to Intubate Have a rigid Bronchoscope ready Have the Tracheostomy tray opened

***All need to be intubated to secure the airway due to the smaller airway in the child.***

Management

In Adult: All need to be admitted ICU or Step-down Unit Intubation only if compromise airway Continuous O2 sat monitoring Daily examination of their larynx

15. Angioedema Rapid swelling of the dermis, subcutaneous tissue, mucosa and submucosal

tissue Ocassionally life threatening Acquired

-IgE mediated: vasodilation and increased vascular permeability (ie. insect bites, food, etc)

-not IgE mediated (ie. ace inhibitors) Hereditary: autosomal dominant Symptoms:-Swelling + urticarial symptoms-Aphonia - complete upper airway--Stridor - incomplete upper airway-Wheezing - incomplete lower airway-Loss of breath sounds- complete lower airway

Tx: O2, anti-histamine, steroids, epinephrine Consider intubation/trach

THANK YOU.