Pediatric emergency medicine trisk 923
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can be more difficult to “trick.” Sometimes, by placing a drop of saline or topical
anesthetic in the eye while giving the child the suggestion that these “magic
drops” will cause a return of vision, the child then begins to see better. The
pinhole test (discussed above) can also be used in this manner. Ophthalmology
consultation is sometimes critical in discovering whether a child has truly
sustained visual loss.
Rarely, transient cortical visual impairment/blindness can result following
direct or contrecoup blunt occipital head trauma. Despite an otherwise normal eye
examination, centrally mediated vision loss may occur. Though the vision loss
may be transient, ophthalmology should be consulted. Traumatic cataract,
vitreous hemorrhage, commotio retinae (bruising and edema of the retina from
blunt injury), retinal detachment, and optic nerve injury may also cause acute
traumatic vision loss. For these injuries, ophthalmology consultation is also
required. The most effective screening tests for severe intraocular injury remain
visual acuity testing, evaluation of the pupils for direct, consensual responses as
well as relative afferent pupillary defects, inspection of the anterior segment, and
examination of the red reflex (with or without direct ophthalmoscopy).
Child Abuse
Virtually, any eye injury can be the result of child abuse. Perhaps the most
common ocular manifestation of child abuse is the finding of retinal hemorrhages
associated with the abusive head injury ( Fig. 114.11 ). Although these
hemorrhages can be seen with the direct ophthalmoscope, ophthalmology
consultation is required. Children who present to the ED before the age of 5 years
with significant intracranial hemorrhage, unexplained skeletal fractures, or
sudden, unexplained cardiorespiratory arrest should have a full dilated
examination conducted by an ophthalmologist to look for retinal hemorrhages
that may indicate that a nonaccidental injury has occurred.
Suggested Readings and Key References
General Approach to Ocular Trauma
Chapter 8: Pediatrics. In: Bagheri N, Wajda BN, eds. The Wills Eye Manual—
Office and Emergency Room Diagnosis of Eye Disorders. 7th ed. Philadelphia,
PA: Wolters Kluwer; 2017:177–203.
Levin AV. Eye emergencies: acute management in the pediatric ambulatory
setting. Pediatr Emerg Care 1991;7:367–377.
Levin AV. General pediatric ophthalmic procedures. In: King CK, Henretig FM,
eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2008:531–544.
Levin AV. Slit lamp examination. In: King CK, Henretig FM, eds. Textbook of
Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2008:545–549.
Ultrasound
Jank S, Deibl M, Strobl H, et al. Interrater reliability in the ultrasound diagnosis
of medial and lateral orbital wall fractures with a curved array transducer. J
Oral Maxillofac Surg 2006;64(1):68–73.
Kilker BA, Holst JM, Hoffmann B. Bedside ocular ultrasound in the emergency
department. Eur J Emerg Med 2014;21(4):246–253.
Ruptured Globe
Bunting H, Stephens D, Mireskandari K. Prediction of visual outcomes after open
globe injury in children: a 17-year Canadian experience. J AAPOS
2013;17(1):43–48.
Maw M, Pineda R, Pasquale LR, et al. Traumatic ruptured globe injuries in
children. Int Ophthalmol Clin 2002;42(3):157–165.
Blow-Out Fracture
Burnstine MA. Clinical recommendations for repair of isolated orbital floor
fractures: an evidence-based analysis. Ophthalmology 2002;109:1207–1213.
Coon D, Kosztowski M, Mahoney NR, et al. Principles for management of orbital
fractures in the pediatric population: a cohort study of 150 patients. Plast
Reconstr Surg 2016;137(4):1234–1240.
Corneal Abrasion
Calder LA, Balasubramanian S, Fergusson D. Topical nonsteroidal antiinflammatory drugs for corneal abrasions: meta-analysis of randomized trials.
Acad Emerg Med 2005;12(5):467–473.
Lim CHL, Turner A, Lim BX. Patching for corneal abrasion. Cochrane Database
Syst Rev 2016;7:CD004764.
Hyphema
Gharaibeh A, Savage HI, Scherer RW, et al. Medical interventions for traumatic
hyphema. Cochrane Database Syst Rev 2019;1:CD005431.
Child Abuse
Levin AV, Christian CW, Committee on Child Abuse and Neglect, Section on
Ophthalmology. The eye examination in the evaluation of child abuse.
Pediatrics 2010;126:376–380.
CHAPTER 115 ■ THORACIC TRAUMA
MATTHEW EISENBERG, JOY L. COLLINS
GOALS OF EMERGENCY THERAPY
The initial goals of emergency therapy for the child with thoracic trauma, just as
for all forms of major trauma, are assessment and stabilization of airway,
breathing, and circulation, all of which are at increased risk due to the location of
vital structures within the thorax. A thorough primary trauma survey, with
immediate steps to correct any deficits in airway, breathing, and circulation
before moving on to the next element of assessment, is critical. The provider
should be prepared to emergently intubate the trachea, provide mechanical
ventilation, administer both intravenous fluids (IVFs) and blood products, and
perform other emergency interventions such as thoracentesis, thoracostomy, and
pericardiocentesis as indicated.
Respiratory compromise in children with thoracic trauma may be due to
obstruction of the airway, injury to the chest wall, lung parenchyma, or central
nervous system, or shock. Thoracic hemorrhage, obstruction of venous return, or
direct injury to the heart may lead to circulatory compromise and shock.
The evaluation of the child with thoracic trauma is complicated by both
physical and developmental differences from adults. Detailed further in the
sections that follow, these include increased compliance of the thoracic cage,
greater susceptibility to air and fluid in the pleural space, a shorter, narrower
trachea at greater risk of obstruction, and greater sensitivity to hypoxia. Due to
fear, pain, separation from caregiver and/or young age, an injured child may not
be able to articulate his/her complaints or comply with the examination.
Therefore, attention to nonverbal cues, vital signs, and careful observation of
respiratory and circulatory status are crucial. Because approximately 80% of
thoracic trauma occurs as part of a multisystem injury, the physician must also
consider head, neck, and intra-abdominal injuries when evaluating a child with
chest trauma. An overview of the approach to the child with blunt thoracic trauma
is shown in Figure 115.1 .
KEY POINTS
