Trauma Eye Exam

Trauma Eye Exam

• Ocular trauma can occur during work, hobbies, recreation, or leisure activities
• Blunt trauma, sharp objects, MVAs, BB guns, pellet guns, nails, and fireworks can cause ocular trauma
• Ocular trauma is more prevalent among males
• Wearing safety glasses can prevent eye injuries
• Eye drops should be administered with a 3-5 minute waiting period between each type

Trauma-Oriented Eye Exam

• The following conditions warrant a referral; corneal ulcer, corneal infiltrate, chemical splash
• Metallic foreign bodies with a rust ring need foreign body and rust ring removal
• Refer if unable to remove rust ring

Physical Exam (PE) Findings Requiring Immediate Referral

• Evidence of penetrating trauma
• Significant vision loss, worse than 20/40
• Absent red reflex
• Hyphema
• Corneal Infiltrate
• Corneal ulcer
• Failure to improve over 24-48 hours

Exam Procedures

• Perform an initial penlight exam to identify any foreign bodies
• In suspected penetrating trauma, assess for extruded ocular contents and dilated non-reactive or irregular pupils
• Severe pain during the eye exam may indicate a difficult exam

Contraindications to Eye Exam

• Refer trauma to the globe involving rupture, globe laceration, or intraocular foreign bodies

Eyelid Laceration

• Caustic splash requires immediate irrigation for 20-30 minutes with saline, until pH normalizes

Complications During Eye Exam

• Patient discomfort can result in pain, photophobia, nausea, or vomiting

Anesthesia

• Administer topical anesthetics like Proparacaine or Tetratcaine
• Darkening the room can help with photophobia
• Administer antiemetics

Cornea Anatomy

• The cornea is avascular
• It is composed of cellular and non-cellular components

Cellular Components of the Cornea

• Epithelial cells
• Keratocytes
• Endothelial cells

Non-Cellular Components of the Cornea

• Collagen
• Glycosaminoglycans

Functions of the Cornea

• Acts as a barrier and offers protection
• Contributes to light refraction
• Supports immune functions
• Provides a surface for tears

Epithelial Layer

• Consists of 5-7 layers of cells
• Regenerates quickly, typically healing within 7-10 days

Bowman's Membrane

• Acellular structure composed of collagen and proteoglycans
• Maintains the shape of the cornea
• Does not regenerate, resulting in scarring upon injury

Corneal Abrasion Causes

• Mechanical trauma is the most common cause of corneal abrasions
• Foreign bodies, contact lens wear, chemical burns, flash burns, and keratitis can cause corneal abrasions

Corneal Abrasion Symptoms

• Eye pain
• Tearing
• Light sensitivity, especially after trauma

Patient Preparation for Eye Exam

• Position the patient seated or supine
• Darken the room to reduce photophobia
• Inform the patient about potential side effects, such as burning from anesthetic drops or yellow/orange vision from fluorescein

Materials Required

• Gloves for irrigation
• Vision chart for near and far vision, to be used before and after the procedure
• Anesthetic drops, normal saline, fluorescein dye, black or cobalt light
• Cotton-tipped applicators, magnification (Woods/slit lamp), tissues or washcloths
• pH paper
• Equipment for removing rust rings and corneal spud

History and Physical Exam

• Obtain the mechanism of injury, identify allergies, and assess tetanus status
• Conduct a physical exam, including a vision exam, first in the injured eye and then in both eyes
• Darkening the room may be necessary for the vision exam
• Examine the eye under magnification to assess any deformity, pupil reaction, extraocular movements, fundus abnormalities, or obvious foreign bodies

Trauma-Oriented Eye Exam Procedure

• Apply 1-2 anesthetic drops to the affected eye
• Moisten the fluorescein strip with anesthetic or saline
• Instruct the patient to look up
• Hold the lower lid down and apply the strip
• Have the patient blink to distribute the dye
• Visualize with cobalt or UV light
• Evert the lower and upper eyelids, especially if a foreign body is suspected

Special Considerations During Examination

• Foreign bodies may hide in the lateral fornices, necessitating swabbing with moistened cotton tips
• The pattern of abrasions can suggest the etiology

Abrasion Etiology

• Branching or dendritic patterns suggest a viral cause
• Linear patterns suggest a foreign body

Documentation

• Document the abrasion's shape, location, depth, and length

Everting the Upper Eyelid

• Instruct the patient to look downward but not close their eyes
• Apply a cotton-tipped applicator against the mid-portion of the eyelid parallel to the surface
• Gently grasp the eyelashes and lift upward, flipping the lid back over the cotton applicator

Foreign Body Removal

• Methods include irrigation with flushing, using a moistened cotton-tipped applicator, or a needle, spud, or burr

Flushing the Eye

• Use saline for irrigation, avoiding squirting
• Methods include using a saline bag with IV tubing, a saline bottle, or a syringe with an angiocatheter

Using a Needle for Foreign Body Removal

• Use a 25G needle on a 1 ml syringe
• Ensure the patient is comfortable, anesthetize the eye, and ensure direct gaze so that the foreign body is visible
• Use a parallel approach and stabilize the hand on the face
• Keep light out of the pupil and scoop the foreign body out

Instruments for Removal

• A corneal spud removes foreign bodies
• A corneal burr brushes away corneal rust rings

Post-Procedure Care

• Rinse the eye with normal saline to remove dye and debris
• Explain that the dye will drain through the tear ducts
• Recheck visual acuity and verify tetanus status
• Educate the patient on the importance of eye protection

Follow-Up Care

• Prescribe a topical antibiotic, such as erythromycin 0.5%
• Contact lens wearers need Pseudomonas coverage

Follow-Up Instructions

• Repeat fluorescein staining and visual acuity tests are required in 24 hours
• Advise against contact lens use for 5-7 days until the eye has healed
• Emphasize the importance of eye protection to reduce future occurrences

Long-Term Care

• Use ice compresses, apply eye drops as directed, and avoid rubbing or touching the eye
• Avoid bright light and consider pain control measures, like topical NSAIDs, sunglasses, or oral opioids if severe

When to Seek Medical Advice

• Patients should call if they experience increased pain, changes in vision, new discharge, or a failure of the eye to heal within 1-2 days
• Consult an eye care practitioner before prescribing topical steroids

Topical Medications

• Topical antibiotics, like Erythromycin 0.5% ointment
• Antipseudomonal antibiotics, like ciprofloxacin 0.3%

Key Takeaways

• Identify ocular emergencies like hyphema or globe rupture
• Check visual acuity before and after any procedure
• Irrigate using a drip approach, not a direct spray
• Close follow-up is necessary for patients with concerning eye symptoms
• Eye patches are unnecessary unless there is a globe rupture
• Maintain a low threshold for referral if there is reduced visual acuity or notable photophobia
• Contact lens wearers with abrasions or conjunctivitis require Pseudomonas coverage

Cerumen (Earwax) Removal Indications

• Symptomatic cerumen impaction
• Need to visualize the tympanic membrane (TM)
• Presence of a foreign body

Cerumen Removal Techniques

• Irrigation
• Use of an instrument or tool

Patients Most Likely to Benefit

• Elderly individuals due to hearing loss
• Those who wear hearing aids
• Those with a history of excessive earwax

Contraindications for Ear Irrigation

• Current or past TM perforation
• History of prior ear surgery
• Sudden onset of severe pain or dizziness during the procedure
  • May indicate TM perforation or trauma
• Presence of a disk battery
• Cholesteatoma
• Unilateral hearing loss in the opposite ear of impaction

General Contraindications Requiring Referral

• The above-listed conditions
• Difficult anatomy
• Preexisting infection
• Trauma
• Hard, round objects against the TM
• Hard objects wedged deep in the canal
• Sharp foreign bodies
• Previous unsuccessful attempts

Potential Complications

• Minor complications include discomfort, brief vertigo or tinnitus, nausea, dizziness, and superficial abrasion of the ear canal
• Severe complications include tympanic membrane perforation, trauma-induced otitis externa, and alkaline necrosis of the canal from a disk battery

Rare Complications

• Trauma to ossicles or round window, leading to permanent hearing loss, tinnitus, or vertigo

Patient Preparation

• Review the procedure, associated risks, discomforts, and potential complications
• Obtain informed consent
• Position the patient comfortably in a supported, upright position
  • Children should be supine and restrained on a parent's lap or wrapped in a sheet
• Refer if the child is severely agitated
• Advise the patient to remain still and to report any pain or dizziness immediately

Impacted Cerumen

• Cerumen impaction is more common in the elderly or handicapped patients
• Can be worsened by hearing aids, Q-tips, and earplugs
• Eardrops at home, like carbamide peroxide (Debrox) or hydrogen peroxide, may be effective

Patient Symptoms

• Hearing loss
• Ear pain or a feeling of fullness
• Itching
• Reflex cough or hiccups
• Some patients may be asymptomatic

Equipment

• Otoscope or ear speculum, with a bright light or headlamp light source
• Towels and plastic drapes
• Syringe or ear irrigation system, such as:
  • A 30-60 mL syringe with an 18G angiocatheter
  • Elephant ear wash
  • Ear basin
• Tools like cerumen spoons, loops (curettes), or alligator forceps

Irrigation Procedure Steps

• First check for contraindications
• Consider pretreating with water, saline, or an earwax preparation
• Position the patient comfortably
• Use a plastic drape, towel, or chucks to protect the patient from splashing
• Have the patient hold an ear basin
• Fill the syringe or system with body temperature (98.6F) water
• Straighten the ear canal by pulling the pinna outward, up, and back; for children, pull down and back
• Aim a jet of water at the superior canal, not directly at the tympanic membrane
• Repeatedly inject water until the cerumen is expelled Successfulness of Irrigation
• In cases of unsuccessful attempts, send the patient home with instructions, and have them soften earwax drops for 2–3 days before it returns for ear lavage

Post-Procedure Care

• Perform an otoscopic exam to check the integrity of the tympanic membrane and assess for residual wax, abrasions, or erythema, which would warrant antibiotic prescription
• Dry the external canal using a hairdryer on a low setting or with a few drops of isopropyl alcohol

Curette Procedure

• Perform procedure under direct visualization with an otoscope
• Never insert a curette or instrument without visualization
• Position the curette at one edge of the impaction
• Gently pull the curette out without abrading the canal wall, stabilizing your hand

Curette Procedure Pros

• It is quicker than the other methods
• Can be used when the tympanic membrane status is unknown
• Can be used when lavage is not possible

Curette Procedures Cons

• Not safe if cerumen is near the tympanic membrane (TM)
• May be painful, especially if the wall of the canal is touched
• Adherent cerumen can be pulled off the canal

Otic Foreign Body Removal

• More common in children under 8 years old

Common Foreign Bodies

• Q-tips
• Beads
• Plastic toy parts
• Pebbles
• Insects
• Seeds
• Popcorn kernels
• Cotton
• Paper objects

Higher Risk Complications of FB Removal

• Hard, round objects
• Sharp objects
• Previous unsuccessful attempts
• Age less than 4 years

Key Elements to Successful Removal

• Good lighting and visualization
• Appropriate equipment
• Patient cooperation or physical restraint

Patient Preparation

• Position the patient upright
• Attempt irrigation first for inorganic foreign bodies
• Never irrigate absorbent materials
• Manual removal with an instrument
• Small, unwedged objects can be handled with irrigation
• Non-swellable and non-water absorbing objects can be handled using irrigation
• Disk batteries are contraindicated using irrigation
• Wooden or plant objects are contraindicated using irrigation

Instrument Techniques

• Aided by graspable objects
• Insects must be killed before an attempt at removal
• Use 2% lidocaine, alcohol, mineral oil, or olive oil to kill insect

Additional Equipment

• Mosquito forceps
• Alligator forceps
• Right-angle hook
• Magnetic probe, for metallic FBs of the ear and nose
• Applicator stick, with cyanoacrylate
• Cup-shaped instruments, with more spherical objects

Post-Instrument Removal

• Make sure canal is clear of FB
• If an inflammatory response is seen, prescribe an antibiotic otic drop
• Referral to an ENT is recommended if not easily accessible

Potential Complications

• Severe pain
• Bleeding
• Injury to the canal or tympanic membrane

Nasal Foreign Body

• One of the most prominent complaints of foreign bodies is mucopurulent nasal discharge
• Foul odor, epistaxis, and nasal obstruction are found as well
• Pro-tip - unilateral rhinorrhea

Nasal Foreign Body Causes

• Usually, a children disorder
• Adults are also found, usually with a compromised mental state and/or disability

Common Items

• Toys, beads, seeds, paper, pills, and rocks
• Foods, which include popcorn, peas, nuts, candy, and raisins
• Screws and small metal batteries are emergent

Contraindications

• An airway that can’t be protected needs the surgical setting

Materials

• Topical 1% lidocaine/epinephrine and afrin
• Nasal speculum
• Right-angled hook, a bayonet, alligator forceps, a small suction catheter, cyanoacrylate glue, Katz extractor, a thin balloon-tip catheter, and an Ambu bag

Instruments

• Non-occlusive, compressibly (use bayonet or alligator forceps)
• Smooth, firm (use right-angle hook, any thin balloon catheter, Katz extractor, an Ambu bag, or cyanoacrylate glue)

Removal

• Close open nostril, blow out the occluded

Removal process

• Apply Oxymetazoline and lidocaine/epi
• Manipulate to be removed from area
• 45-degree angle of patient (FB, if dispelled, doesn’t compromise airway)

Special Considerations

• If you can’t visualize, refer it
• If you attempted and failed twice, refer it
• Chronic nasal issues
• Granulation tissue

Potential Complications

• Trauma to mucous membrane
• Displacement of the FB
• Aspiration
• If the procedure is delayed or incomplete, the patient could develop sinusitis and/or meningitis

If Glue is Used

• Mucosa Abrasion
• Dripping the glue
• Irritation from removal

Patient Instructions

• Watch for infections
• 2-3 Days Saline Irrigation
• Possible follow-ups of 1-2 days
• If the patient has infections, then refer in to provider

Epistaxis

• Typically peaks at the ages of 2-10 years
• Typically peaks again at ages 50-80
• More severe at 50-80 years

Epistaxis Causes

• Nose-picking
• Foreign body
• Trauma
• Medication irritants resulting in sinus
• Indoor air
• URI

Systemic Conditions

• Coagulopathies
• Hepatic/renal disruption
• Medications like NSAIDs/anticoagulants

Relevant Anatomy

• Kiesselbach Plexis (anterior)

Review

• 90% are from anterior bleeds
• Less Site Visualization, Nasal Endoscopy, Hemopytsis, Life Threatening, Coagulopathies

1st Treatment

• Flex the neck for 10 min

Direct Pressure Issues

• Use afrin
• Liquid Cocaine and LET
• silver nitrate
• Cauterize after bleeding
• No-No for bi-laterally

Intervention Causes

• Lasting longer than 10 min
• High conditions
• Frail patient

First Priorities

• ABC’s
• Stability Vitals

Processes

• Timeline, risks, factors, high history
• Head at 45
• Confirm source is from
• Confirm location and needs for procedure

What to suspect

• Oozing, the need for packing system, and recurrent bleeds

Follow Precautions

• Gloves and Gown
• Face Shield
• Otoscope
• Vasoconstriction in Afrin

Steps

• Insert foam that is compressed
• Constant Pressure
• Anesthesia, lubricant, incision, and saline/water in 1-3 days

Bleeding

• Apply pressure by using petroleum or vaseline which is abx

Next Steps

• Remove packing in 48 hours and watch the risks

More interventions

• Packing infection
• Cellulin and amox-clav

Packing CIs

• Nasal Bones
• Shock
• Advanced COPD
• Untreaded

Prevention

• Co-morbid and educate pressure

Oxygen Therapy

• Oxygen, gas
• Clear color and taste
• Component cells and drugs

Indications

• Not Enough Oxygen
• Pulse and Blood
• Shock, ischemia, surgical recovery

Ideas for Therapy

• Volume per time
• Partial to 100% Rate

Sources

Wall - Green and Yellow Flowmeters - ball adapter

Oxygen Concentrates

• Battery and Electric Scrubber
• Small Back Up

Liquid Form

• Cylinder or E
• 10L per min

Gas and Flow

• Regulator
• PSI consideration
• Constant flow of flame/heat is a safety problem

Oxygen Delivery

• Low flow is typically 1-6 liters/minute
• Can dry mucosa

Rates

• 1 liter = 24%
• Increase each liter by increments of 4
• No less than 6 and room to mix-in

Venturi

• Airflow mixer
• Fixed airflow mix and slow titration
• COPD (Can retain Oxygen)

The Air Flow/High Flow

• High concentrations through reservoir bag
• No expired and rubber flaps
• Rates = 10 - 15 liters

Oxygen Devices

• High Flow
• Body Heat
• Good pressure
• Easily tolerance with face

Airway Instructions

• Or-over tongue
• Unconcious
• Measuring from corner and Earlobe
• Secretions, Inhalation, Noses and Ears are Measured

Positive Pressure

• Ambu - 1 and 1 way
• Syringe adjustments
• Sealing, thumbs, ring seal, and all around sides

Pre-Intubation Assessment

• Mallampati Classification
• Predict Difficulty with
  • Limited Joint Ability
  • Jaw disorder
  • Assessment can be visual

Direct Laryngoscopy

• Emergency or Difficult Access with Hypoxia Opening is not possible

Laryngoscopy Blades - Straight

• Pick up Epiglottis
• More in Peds
• Typically, #2, #3

McIntosh Blades, Curved

• More adult situations
• Put into Valeculla with, generally
• #3 and #4
• Silastic Tube
• Mid tracky

Airways

• #7 for Female
• #8 For Ma
• 60 cm Tube, Pass Through VCs
• Laryngeal Mask
• Can’t be intubated normally

Procedure

• Support blade and team
• Oxygenate in minutes
• Position
• Listen for results

Next Steps

• Remove and secure the tubes
• Use oxygen and drugs
• Note when the results change

Side Effects

• BP, HR, Cathacholamine
• Emesis, and Ventilatin

Key Concepts - An ABCs Look

• Unconscious - Indication
• Paralysis - Blocking
• Pretreatment - Plan
• Positioning

Drug Onset

• Fast and Slow, HR
• Give all meds in mind of the patients
• Fast 1- 3
• Slow 2 - 4

Blocking Drug - Key Concepts

• Depolarize
• High Potent
• Burns, failures, increased everything

Sedatives

• Inhibited and blocked
• Cannot intubate, the patient has no air

Post Operation

• Selection, Reduce
• Early Re-dose
• Don’t Paralysed
• Check everything ahead

Steps

• Preparation First
• Give and Admin meds and sedatives
• Put tube in with support
• Monitor

Thoracentesis

• Lung Procedure
• In the Plerual Space
• Chest and Lungs
• Lungs are Fluid

Indications

• Difficult breathing
• Analyze
• Transudate
• Exudate

High Risks and Precautions

• Coagulopahty
• Respiratory Compromised
• Hard Skin

Equipment

• Needle
• Gatheler
• Syringe
• Device
• One way with spring-loaded
• Built-in site

Steps

• Obtain Patients Identity
• Make sure skin isn’t used
• Avoid Air going into the Lung

Obtain 2 positions

• Seated for Post
• Check Level of Results + Scapula
• Hemithorax

More Steps

• Draw the site
• Walk on other lung
• Inter spaces below
• Put it through and feel to check and aspirate

Don’t

• Go through other rib
• Expiration is critical
• Hold Breaths
• Guages and Pressures

Fluids

• Analyzed by testing
• Exudate for testing for what is found inside

Additional

• The high numbers and lowers can help you see the different levels of the lung and fluids

Post Operation

• Can Aspirate in air
• Multi passes is always a no-no

Complications

• Infection
• PTX
• Lowers lung

Preventing

• Damage Lung with all

Check and Look for

• Needle to pull with the operation

Thoracotomy

• All time needs to be ready for in case of procedure
• Put Oxygen on and Syringe for Air
• Betadyne and Chlorohexidines

Midclavicula Space

• Second Intercostal space straight down on Mid 3rd Rib side
• Assess EKG , pulse ,and oxygen

Obtain follow up

• Blood test and levels for ABGs
• Patient oxygen
• Potential for all high risks to occur
• Put Gaths and need oxygen

Other Items

• It is important to obtain
• You can’t have a compromisation
• Put catheter inside