Pediatric emergency medicine trisk 919
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FIGURE 114.4 Open-globe injury. The scleral laceration (green arrow ) appears as a linear,
maroon line on the white of the eye. The pupil has a teardrop shape, the apex of which points in
the direction of the rupture. A 360-degree subconjunctival hemorrhage is present. There is a
diffuse hyphema in the anterior chamber, which partially obscures the pupil.
FIGURE 114.5 Open-globe injury caused by a corneal laceration. Note iris protruding through
wound (arrow ) and teardrop-shaped pupil pointing in direction of laceration.
FIGURE 114.6 Patient shielded for right open-globe injury that was caused by a thrown pen.
Triage Considerations
Children with eye injuries associated with severe mechanisms, extreme pain,
significant eyelid swelling, or visual disturbance may have an open-globe injury.
These patients should undergo prompt evaluation in the ED with minimal
interventions.
Management
If an open-globe injury is suspected, no eye drops should be instilled. A shield
should be placed over the eye such that the edges contact the bony prominences
of the orbit above and below the globe ( Fig. 114.6 ). If a commercial shield is not
available, the clinician should cut off the bottom of a Styrofoam or plastic cup,
and use it as a shield, resting it against the bony prominences ( Fig. 114.7 ). For
multisystem trauma patients, a shield should even be placed over an obviously
injured eye while other resuscitative efforts are ongoing to prevent further
accidental injury or contamination by the medical staff. A patch does not provide
firm protection, may place pressure on the globe, and should not be used in this
circumstance.
FIGURE 114.7 The bottom of a drinking cup is used as an eye shield.
Severe eye trauma may cause sedation or vomiting without concurrent head
injury. Crying and Valsalva maneuvers such as vomiting can result in further
extrusion of intraocular contents through the eye-wall opening. Every attempt
should be made to keep the child calm, including analgesia and antiemetic
medications. If inter-hospital transport is needed or if calming cannot be
achieved, tracheal intubation, sedation, and paralysis can be helpful to keep
intraocular pressures as low as possible.
Broad-spectrum intravenous antibiotic coverage is desirable, but this treatment
must be weighed against the potential aggravation of the child with intravenous
catheter placement. If an intraocular foreign body is suspected, the clinician must
establish by history whether it is metallic as this may influence the choice of
imaging and treatment. Even if an open-globe injury is not seen clearly on
examination, any patient who has a high-risk history, severe eyelid swelling, and
extreme resistance to examination should be given an eye shield and referred to
an ophthalmologist as if an open-globe injury was confirmed.
BLOW-OUT FRACTURE
