Hyphema

Facial Trauma: Hyphema

Hyphema

Hyphema results from ocular trauma that causes bleeding into the anterior chamber. The bleeding originates from vessels in the ciliary body or iris. The blood tends to layer over time, and left undisturbed, will form a visible meniscus when the patient sits upright. Patients typically complain of pain, photophobia, and possibly blurred vision secondary to obstructing cells. Intraocular pressure should be measured because acute glaucoma may be caused by RBC clogging of the trabecular meshwork with impedance to aqueous outflow. Prevention of further hemorrhage is the principal treatment goal. Most rebleeding occurs within the first 72 hours and, when present, tends to be more extensive than the initial event. Patients should be instructed to rest in the supine position with their head slightly elevated. In addition, carbonic anhydrase inhibitors should be avoided in patients with sickle cell anemia because they can cause RBCs to sickle in the anterior chamber, which can lead to increased IOP.

There are 4 grades of Hyphema. Below is an image showing the grades and 

 

 

Evaluation - Best done under a slit-lamp exam. Watch the videos below for  

 

Dr. Anna Pickens has great videos on the slit-lamp exam and hyphema, please watch below: 

 

1. Slit Lamp: https://emin5.com/2016/02/07/slit-lamp-anatomy/

2. Hyphema: https://www.youtube.com/watch?v=vQG9kL7mpyA 

• Blood in anterior chamber
  • May only see difference in color of irises if patient is supine because blood layering is gravity dependent
  • Blood in anterior chamber only visible on slit lamp is a microhyphema
• Vision loss / Acuity changes
• Inspect the lids, lashes, lacrimal ducts, and cornea
  • Corneal abrasions often co-exist
• Assess direct and consensual pupillary response for the presence of a relative afferent pupillary defect
• Assess for Ruptured Globe which is associated with high energy mechanisms (shrapnel, BB guns, paint balls, etc)
• Check intraocular pressure after Globe Rupture is excluded
• Inquire about bleeding diathesis, anticoagulant/NSAID/aspirin use

 

Management

 

• Elevate head of bed and upright position to layer blood by gravity, open visual field while blood resorbs
• Eye shield
• Pharmacologic control of pain and emesis
• Weigh risks and benefits of stopping NSAIDs, ASA, anticoagulants
• If IOP elevated (>22) the treatment is similar to glaucoma management except if there is also a concern for a retrobulbar hematoma as a result of trauma. Topical and oral treatments include
  • Timolol
  • Topical α-adrenergic agonist
  • Carbonic anhydrase inhibitors
• Consult ophtho regarding:
  • Dilation of pupil to avoid "pupillary play" -constriction and dilation movements of the iris in response to changing lighting, which can stretch the involved iris vessel causing additional bleeding
  • Use of topical α-agonists and/or acetazolamide to decrease intraocular pressure
• Cycloplegic can be given for comfort and to decease pupillary play if globe rupture has been excluded. Options include:
  • Tropicamide (Mydriacyl)
  • Homatropine
  • Cyclopentolate (Cyclogyl, Cylate, Pentolair)
  • Scopolamine
• Topical steroid
• Treat any underlying coagulopathy

Disposition

• Should be made by the ophthalmologist after examining the patient
  • Hyphemas <33% of anterior chamber are frequently managed as outpatients
• Patients being managed as an outpatient should have ophthalmologist referral and consider outpatient screening for spontaneous hypthemas due to the association with sickle cell disease and hemophilia
• Patients on anticoagulation or anti-platelets agents should be admitted for reversal and observation.

Discharge Instructions

• No reading (accommodation may further stress injured blood vessels)
• Avoid NSAIDs
• Wear hard shield at all times
• Return to ED if rapid increase in size of hyphema or large increase in pain

Prognosis

• Rebleeding worsens prognosis as patients are at higher risk of permanent vision loss.
  • Occurs 3-5 days after initial incident
  • Complicates ~30% of cases
  • Populations at highest risk:
    • Sickle cell disease or sickle cell trait
    • Bleeding dyscrasia (including aspirin, NSAID, or anticoagulant use)
    • Initial intraocular pressure >22 mmHg
    • Pediatric patients

Grade	Anterior Chamber Filling	Normal Vision Prognosis
I	<33%	90%
II	33-50%	70%
III	>50%	50%
IV	100%	50%

Sources: EM in 5, Rosh Review, Wikem.

Pelvic Binder Placement

We recently had a sim where only one person was confident in placing a pelvic binder. So this is basic but it should be reviewed, particularly for interns, in a trauma you may be asked to place one. So if you don't read anything, please watch the 2 very short videos below: a 1 minute video on pelvic binder placement - this I believe is the same binder we have in our ed, and a 3 min video on pelvic fractures. Afterward go find the pelvic binder on your next Northside shift and take a look at it.

 

1. Pelvic Binder Placement: https://www.emrap.org/episode/pelvicbinder/pelvicbinder

2. Pelvic Fractures: https://www.emrap.org/episode/pelvicfractures/pelvicfractures

 

For binders classically an open book fracture and an unstable patient will require a binder. A open book fracture results from Anteroposterior (AP) compression forces, which cause disruption near the symphysis pubis and sacroiliac joint opening resulting in the “open-book” pelvic injury. This injury can be diagnosed on an AP pelvic X-ray if the diastasis of the pubic symphysis is >2.5 cm. The high-forces from the injuries cause shearing and tearing of blood vessels leading to hemorrhagic shock. Examination of the pelvis will reveal gross instability. “Rocking” of the pelvis is discouraged as this force may dislodge clots that have formed. Instead, the greater trochanters should be grasped with both hands and gently squeezed together. Any movement with this procedure indicates an unstable pelvic fracture. Once an unstable pelvic fracture is recognized, it should immediately be stabilized with either a properly applied sheet and towel clamps or a commercial pelvic binder -over the greater trochanters not iliac crests. Patients who have immediate stabilization have been found to have lower transfusion requirements. Additionally, the AP injury pattern stands to benefit the most from external stabilization.

 

 

More on Pelvic Fractures, types, evaluation, and management:

 

Pelvic Fractures. There are 3 types based on mechanism. 

1. Lateral Compression

• Most common
• Often T-bone MVC/pedestrian hit from side
• Usually stable as affected hemipelvis is crushed inward, reducing pelvic volume
• Associated with the unstable wind-swept pelvis fracture
• Severe cases usually associated with bladder rupture; consider CT or retrograde cystography

2. Anteroposterior Compression

• Usually unstable as the iliac wings are forced outward, increasing pelvic volume
• Often head on MVC
• Often assocciated with pelvic and retroperitoneal hemorrhage
• Coincident injuries of the thorax and the abdomen are the rule
• Associated with the unstable open book fracture
• Urethral disruption should also be considered

3. Vertical Shear

• Result from vertically oriented force (fall) delivered to the pelvis via the extended femurs
• Unstable; pelvic volume is increased
• Associated with the unstable Malgaigne fracture or bucket handle fracture

 

Evaluation: 

XR, US, CT/MRI, Retrograde cystourethrogram

1. CXR: AP - Obtain in all unconscious blunt trauma patients

2. CT

• Obtain in all hemodynamically stable blunt trauma patients with pelvic fracture on x-ray
• Exceptions include isolated pubic rami fracture, avulsion fracture

3.Retrograde cystourethrogram

• Obtain (before foley) if blood at meatus, high riding prostate, or gross hematuria

 

Management: 

Classify fracture pattern as "stable" or "unstable"

• • If unstable pelvis:
    • Wrap with sheet or pelvic binder: Place pelvic binder over greater trochanters
    • Do not over-reduce a lateral compression fracture (places increased strain on post pelvis)
    • Placing pelvic binder in vertical shear injury may worsen fracture
• Anticipate hypotension: 80-90% Venous plexus bleeding, 10-20% Arterial bleeding

 

FAST Exam

• • If hemoperitoneum is present→ OR
  • If vital signs are unstable→ OR for damage control laparotomy, not CT
  • If vital signs are stable and no hemoperitoneum→ CTAP with IV contrast
    • Contact IR for possible pelvic angiographic embolization
• Pre-peritoneal packing can rescue failed angiography (usually in venous bleeding)
  • Also an option for primary hemorrhage control
• Look for vaginal or rectal bleeding, suggests open fracture (uncommon)

 

Specific Fractures

Open Book:

• Disruption of pubic symphysis >2.5cm and the pelvis opens like a book and may be accompanied by sacroilial joint disruption
• External rotation of the hemipelvis requires binding and likely surgical fixation

Straddle Pelvic Fracture: 

• Unstable
• Both rami fractured on both sides or both rami on one side with pubic symphysis diastasis
• High rate of urinary tract and bowel injury

Pelvic Avulsion Fracture: 

• Anterior superior iliac spine
  • Occurs from forceful sartorius muscle contraction (adolescent sprinters)
  • Bed rest for 3-4 wk with hip flexed and abducted, crutches, ortho follow up in 1-2wk
• Anterior inferior iliac spine
  • Occurs from forceful rectus femoris muscle contraction (adolescent soccer players)
  • Bed rest for 3-4 wk with hip flexed, crutches, ortho follow up in 1-2wk

Sources: Rosh Review, Uptodate, EMRAP, Wikem

Management of Calf DVT

We had an interesting discussion on Calf DVT at conference this morning. Wanted to share some papers on calf DVT management that may help guide your practice. Here are two recent papers discussed in emrap Paperchase, which gives a to the point summary, from May & Feburary this year looking at management vs. risk of calf DVT management.

Feburary 2017 (The May 2017 is below and follows up on this with another study)

Paper Chase 2 - Calf Clot Demystification

Sanjay Arora MD and Michael Menchine MD

Take Home Points

❏ Therapeutic anticoagulation for isolated calf DVT is associated with a reduction in proximal DVT extension and pulmonary embolism but increased risk of bleeding.

❏ Patients should be given anticoagulation for isolated calf DVT unless they have increased risk of bleeding or very low risk features.

❏ The number needed to treat to prevent clot extension or PE is 16.

● Utter, GH et al. Therapeutic anticoagulation for isolated calf deep vein thrombosis. JAMA Surg. 2016 Sep 21;151(9):e161770.PMID: 27437827

● The bottom line: therapeutic anticoagulation for isolated calf DVT was associated with a reduction in proximal DVT extension and pulmonary embolism but with increased risk in bleeding. The study supports anticoagulating patients with calf DVT unless they have very low risk features or high bleed risk.

● Sometimes the work-up for DVT identifies clot in the calf (the veins distal to the knee). It is important to know whether your ultrasound tech actually is looking in the calf. You may have to tell them to look there as it is not routine. How should these be managed?

● This is a common problem and there are few studies available to guide therapy. Those who support anticoagulation cite increased risk of pulmonary embolism. Those against anticoagulation say clot progression and subsequent pulmonary embolism is rare.

● This was a single center, retrospective cohort study which reviewed all lower extremity venous duplex ultrasounds over a 3 year period and identified patients with isolated DVT to the calf. They excluded patients with chronic DVT or prior diagnosis of pulmonary embolism. This was not a randomized controlled trial. Anticoagulation was determined by the physician. Anticoagulated patients were grouped together regardless of agent used.

● They looked at the rate of DVT and PE as well as safety. 697 patients with isolated calf DVT were identified from over 14000 lower extremity venous duplex studies. 313 patients were excluded leaving 384 patients. 243 patients (63%) were anticoagulated and 141 patients were not.

● 5% of the control group developed proximal DVT compared to 1.6%. 4.3% of patients developed a PE in control group compared to 1.6% in the anticoagulated group. Combined, the absolute difference was 6 with a number needed to treat of 16.

● What was the number needed to harm? 2.6% of controls experienced bleeding compared to 8.6% of the anticoagulated group. These groups were different at baseline but additional analysis determined it probably didn’t affect results. It is possible increased testing in the control groups led to increased identification of clots.

● What does this mean? You need to consider the risk of bleeding. However, if the patient is symptomatic and you found a distal DVT, just treat them like a proximal DVT and give them anticoagulation. If they are asymptomatic or the clot is an incidental finding, you can either give them anticoagulation or if they are very low risk (small clot, very distal to the knee, no risk factors like cancer or prolonged immobilization) you could consider surveillance on these patients and repeat the study in two weeks and defer anticoagulation pending progression.

● The recent 2015 CHEST guidelines recommended serial imaging over two weeks rather than anticoagulation for acute isolated distal DVT without severe symptoms or risk factors for progression. This is not just repeat study in two weeks but rather surveillance over two weeks. If there are severe symptoms or risks factors for extension, the guidelines recommend anticoagulation over serial imaging.

○ What is high risk? Cancer or unprovoked clot.

○ Kearon, C et al. Antithrombotic therapy for VTA disease: CHEST guideline and expert panel report.Chest. 2016 Feb;149(2):315-52.PMID: 26867832

May 2017

Paper Chase 4 – CACTUS and The Calf Clot

Sanjay Arora MD and Michael Menchine MD

Take Home Points

▪ Anticoagulation of low risk patients with isolated calf DVTs results in higher bleeding risk without measurable clinical benefit.

▪ Bleeding occurred in 4% of the anticoagulated group.

● Righini, M et al. Anticoagulant therapy for symptomatic calf deep vein thrombosis (CACTUS): a randomised, double-blind, placebo-controlled trial. Lancet Haematol. 2016 Dec;3(12):e556-e562. PMID: 27836513

● The bottom line: anticoagulating low risk patients with isolated calf DVTs resulted in a higher bleeding risk without measurable clinical benefit.

● We recently discussed a paper on the topic of DVT of the calf. This is a common problem. Benefits to anticoagulation include possible decreased risk of pulmonary embolism in the future. However, very few of these clots propagate and if they do, it usually happens within a few weeks. It may be better to watch and wait.

o The prior paper suggested most should be treated if they are symptomatic unless they have low risk features. However, it was not randomized controlled trial.

o Utter, GH et al. Therapeutic anticoagulation for isolated calf deep vein thrombosis. JAMA Surg. 2016 Sep 21;151(9):e161770.PMID: 27437827

● This was a study spread out over 23 centers in 3 countries of patients and included patients with a clot in the deep veins distal to the popliteal vein (not the superficial veins). Patients with chronic DVTs, recent DVT or PE, contraindications to anticoagulation, current anticoagulation and pregnant patients were excluded.

o Patients were randomized to injections of nadroparin (a subcutaneous factor Xa inhibitor) or placebo for 42 days.

o The primary efficacy outcome was a composite endpoint of extension of the calf DVT to the proximal veins, contralateral proximal DVT or symptomatic pulmonary embolism at day 42.

o They enrolled a total of 259 patients over 6 years.

o They looked at a primary safety outcome was bleeding.

● What did they find?

o The primary composite efficacy outcome was 3% in anticoagulated patients and 5% in placebo. This is a nice reminder that the overall progression rate in this study was low in patients who were followed very closely and received a follow-up scan. No one in either group died from pulmonary embolism.

o Bleeding occurred in 4% of the anticoagulated group and 0% of the placebo group.

● What does it mean? These results are in contrast to most of the previous opinion pieces and observational data favoring treatment. They suggest extension is rare. Treatment has minimal impact and can result in clinically significant bleeding. Serial ultrasound is ok for asymptomatic patients and low risk patients with a symptomatic clot.

● There is still no guidance on high risk patients. They should likely be treated unless there is a contraindication to anticoagulation.

● If a clot is going to propagate, it will do so quickly. If you are sending these patients home, make sure they have follow-up within two weeks.

Source: emrap