POTD: Trauma Tuesday - Eye trauma review

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Dr. Marshall's only request for POTD is that we touch on a trauma topic on the most alliterate day of the week related to trauma.  That being.... trauma Tuesday.  So here goes....

This guy comes in.  

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Physical exam is key!!!

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Use your tool.   Use POCUS if eye is swollen shut.  Tegaderm first, lots of U/S jelly.  Is there a pupillary response to light?  Is there a consensual response?  Is the anterior chamber present?  Is the posterior chamber normal appearing (black/round/smooth throughout)?  Is there retinal detachment or vitreous hemorrhage?  What is the overall shape of the globe? (guitar pick = bad = suspicious for retrobulbar hematoma).  

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 Normal Eye U/S:

 

Retrobulbar Hematoma on U/S ( measure that pressure and think about clipping that lateral canthus):

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Traumatic ocular injuries seen in ED:

Globe rupture

Hyphema

Retrobulbar Hematoma

Lens dislocation

retinal detachment

corneal abrasion/ulceration

Lid Lacerations

Globe Rupture:  Prevent increased IOP (elevate HOB, avoid eye manipulation), Seidel test, cover with eye shield, pain meds, topical and systemic antibiotics and Optho consult.  

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Hyphema: Blood in anterior chamber, Elevate HOB, consult optho, patients at highest risk:  sicklers, trauma, bleeding diathesis, the anticoagulated

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Retrobulbar Hematoma:  Usually 2/2 trauma, can cause optic nerve and retinal ischemia leading to permanent blindness if untreated, A lateral canthotomy is indicated if: proptosis, decreased visual acuity or pain on EOM, afferent pupillary defect or IOP > 40 mmHG

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Lens dislocation (aka ectopic lensis): typically 2/2 blunt trauma (less common mechanisms are electrocutions/lightning strike or in Marfan's patients.  Painful, + or - lens tremor on exam.  Emergent optho consult if elevated IOP.

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Retinal Detachment:  patient says they see "floaters, black dots and flashes of light." Typically acute painless vision loss.  Seen as undulated highly reflective membrane (wavy white line) on U/S.  Consult optho.

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Corneal Abrasion/Ulceration:  fluorescein and woods lamp.  Flip eyelid -  multiple linear abrasions often imply retained foreign body under eyelid.  Antibiotics and analgesia.  

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Can anyone guess what caused this corneal abrasion?!?!?




(an airbag impact on car accident)

Lid Lacerations:  What can we(as ED providers) safely repair in the ED?

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POTD: When the heart fails.... congestively

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Per Medscape: CHF is when "the heart, via an abnormality of cardiac function (detectable or not), fails to pump blood at a rate commensurate with the requirements of the metabolizing tissues or is able to do so only with an elevated diastolic filling pressure"

Some Generalities:

S3 = most specific exam finding (Ken-tucky, Ken-tucky)

Edema = most specific CXR finding . .


BNP : below 100 pg/ml?? -- > basically rules out CHF (90% specificity)

above 500 pg/ml? --> most likely acute decompensated CHF (87% specificity) .


Scenarios:

Isolated left sided failure --> dyspnea, fatigue, orthopnea (WITHOUT peripheral edema or JVD).

Isolated right sided failure --> JVD, hepatojugular reflex, peripheral edema (with clear lungs sounds/CXR).

Right sided failure most common caused by left sided failure.

Systolic failure = poor contraction (low EF) and less forward blood flow

Diastolic failure = Good contractility (normal ish EF) with poor filling 2/2 stiff ventricles

NYHA Classes

  1. No symptoms

  2. Symptoms with every day activity

  3. Severely limits activity or symptoms with minimal activity

  4. Symptoms at rest


Test Pearls:

Acute CHF with STEMI on EKG --> go directly to Cath lab

Acute CHF with new systolic murmur (particular after an inferior or posterior MI) --> think Cordae Tendinae rupture --> mitral valve regurgitation 2/2 posterior leaflet of valve supplied by right coronary artery (this patient needs cardiothoracic surgery ASAP!!)

Acute CHF with syncope and/or heart murmur --> think aortic stenosis in elderly, think HOCM in the young.

Acute CHF with right sided MI --> concern for RV infarct --> fluids and/or dobutamine only if hypotensive (DO NOT TREAT LIKE TYPICAL CHF aka Nitrites and diuretics)

Acute CHF in dialysis patient with AV fistula --> think high output failure through fistula --> compress fistula site manually to decrease shunting of blood through fistula. Other types of high output failure can be seen in pregnancy, hyperthyroidism, beriberi

Obviously a tremendous topic, just scratching the surface here. Stay tuned for more POTD coming up.


Sources: In training prep video - Cardiology

https://emedicine.medscape.com/article/354666-overview#a2

https://emedicine.medscape.com/article/163062-overview

https://wikem.org/wiki/Congestive_heart_failure

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Targeted Temperature Management

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Targeted Temperature Management

What is it: the purposeful cooling of a patient post-cardiac arrest. Target of 32°C to 34°C (Some studies say 36, but debatable and prevent any hyperthermia) for at least 24 hours. 

Why: To improve the chance of survival and neurologic recovery, international guidelines recommend use of targeted temperature management (TTM), together with urgent coronary angiography and percutaneous coronary intervention when appropriate

Who: 

  • Post cardiac arrest (any cause but most evidence supports from VF/VT shockable causes of cardiac arrest)

  • ROSC < 30 mins from team arrival

  • Time < 6 hours from ROSC

  • Patient is comatose, GCS <8 (this is try and improve neurological outcome, so someone who is neurologically intact does NOT need TTM)

  • MAP >= 65mmHg

  • depends on your hospital protocol

When: Initiate within 6 hours of ROSC and maintain for 24 hours

How: 

  • cold IVF at 2-3 mL/kg stat

  • cooling vest and cooling machine

  • sedation and paralysis

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Complications:

Shivering, electrolyte abnormalities, cold diuresis, infection. 

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So, for post cardiac arrest patients with depressed neurological function - Keep this in mind, but consult your ICUs and plan this patient's care together for best management. TTM needs an ICU level care admission. 

Happy Learning!

References:

https://jamanetwork.com/journals/jama/fullarticle/2645105

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4578199/
https://lifeinthefastlane.com/ccc/therapeutic-hypothermia-after-cardiac-arrest/

http://www.ijccm.org/article.asp?issn=0972-5229;year=2015;volume=19;issue=9;spage=537;epage=546;aulast=Saigal

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