Eye Trauma (Emerg Med Clin North Am 2008;26:199; Int J Clin Pract 2008;62:1776; Philos Trans R Soc Lond B Biol Sci 2011;366:251, CD004166)
• Corneal abrasion
• Traumatic defect in corneal epithelium
• Symptoms of pain, photophobia, tearing, foreign body sensation
• Topical anesthetic (proparacaine) can facilitate exam. Conjunctival injection (common), visual acuity usually normal. Very important to evert upper/lower lids
• Diagnosis made with topical fluorescein staining
• Treated with antibiotic ointment and +/- oral analgesics. Contact lens wearers need to have contact lens removed, pseudomonas coverage, and referral to ophthalmology. Eye patching is not recommended
• Traumatic hyphema
• Layering of blood in the anterior chamber
• Caused by blunt trauma directly to eye. May be associated with head trauma or fall
• Symptoms of pain, photophobia, visual loss, nausea and vomiting
• Remember ABCs and trauma evaluation. Often trauma can be seen with pen-light exam. Microhyphema requires slit lamp exam
• Apply eye shield immediately. Do not patch. Place on bed rest with head of bed elevated 30–45 degrees. Emergent ophthalmology exam
• Open globe injuries
• Full-thickness wound of eye wall
• Caused by sharp objects, BB guns, ball sports, MVAs
• Males 10–30 years old at greatest risk
• Symptoms of pain, diplopia, decreased visual acuity
• Do not touch the eye. Usually presents with sub-conjunctival hemorrhage, hyphema and teardrop pupil (narrow segment points toward rupture)
• Apply eye shield immediately. Can use bottom of Styrofoam cup as shield. Immediate referral to ophthalmology
• Pinna hematoma
• Often due to athletic injury, fall, blow to head. May cause disruption of perichondrial blood vessels causing cartilage necrosis
• Emergent evacuation to avoid cauliflower ear complication
• CSF otorrhea
• May be secondary to temporal bone fracture
• Do not use otoscope or other instruments. Place on bed rest and elevate head of bed
• Neurosurgical referral and head imaging
Nasal Trauma (Pediatr Clin North Am 2006;53:195; Pediatr Rev 1998;19:142; Int J Pediatr Otorhinolaryngol 2011;75:186)
• Epistaxis
• 90% due to anterior bleeding and usually arises from Kiesselbach’s plexus. Anterior bleeding is slow, persistent oozing
• Commonly due to trauma, nose picking, URI, allergic rhinitis, foreign body
• Management includes internal/external exam, then direct nasal pressure for
5–10 min while patient is sitting upright
• Posterior bleeds originate from sphenopalatine artery and bleed more profusely. May be associated with hemoptysis, hematemesis, blood in posterior pharynx, and failure to identify an anterior source of bleeding. Higher risk for airway compromise, aspiration of blood and hemorrhage. Requires ENT referral
• Nasal fractures and septal hematoma
• Children have more soft cartilage which can cause more soft tissue swelling with trauma. Septal hematoma develops when there is disruption of septal cartilage from perichondrium, which can develop pressure-induced avascular necrosis
• Require internal/external exam which may be difficult due to edema. Septal hematoma has septal asymmetry and swelling of nasal mucosa with obstruction of nasal passage. Size of mass does not change with topical vasoconstrictor
• Radiographs are not helpful
• If not septal hematoma, intracranial or ocular injury, should follow-up in 3–4 d when swelling has subsided
• Management of septal hematoma includes prompt surgical evacuation and antimicrobial therapy if nasal septal abscess is suspected.
• Improperly treated septal hematoma can lead to saddle nose deformity
• Clear rhinorrhea
• Differential is broad but think of CSF leak caused by skull base fracture
• Allow rhinorrhea to drip onto piece of paper and classic pattern is central area of blood with halo of clear CSF. Not a sensitive test
• If CSF rhinorrhea is suspected, place patient on bed rest and elevate head of bed 30 degrees. Consult neurosurgery and otolaryngology
Oropharyngeal Injuries (Pediatr Clin North Am 2006;53:195; Pediatrics 2010;126:e1578)
• Dental injuries
• Patients with a fracture, luxation, tooth pain, or discoloration should undergo dental radiography
• Uncomplicated fractures affect the outer enamel or dentin only. Patient can be seen by dentist in 48 hr
• Complicated fractures involve enamel, dentin, and pulp. Symptoms include tooth pain with pressure, temperature sensitivity, bleeding from core of tooth, and malocclusion. Requires immediate dental referral
• Avulsion refers to complete displacement of tooth from socket. If primary tooth, do not reimplant. Permanent teeth begin to erupt at age 6. If permanent tooth, handle by crown, rinse with water or normal saline and attempt reimplantation. If unable to reimplant, place in milk or other commercial product. Patients require immediate dental referral. Tooth survival outside oral cavity at 1hr is near 0
• Tongue and frenulum injuries
• Careful examination of teeth, oropharyngeal foreign bodies, bite for malocclusion (mandibular fracture) and TMJ (condylar fracture)
• Most frenulum injuries heal spontaneously and do not require repair
• Tongue lacerations <1 cm and non-gaping usually do not require repair
• Tongue lacerations >1 cm, into muscle or lateral tongue, large flaps, or do not achieve hemostasis usually require repair
• Palate injuries
• Superficial and puncture wounds to the central palate that are <2 cm usually do not need repair after careful exam for foreign body
• Injury to lateral aspect of palate, posterior pharyngeal wall, >2 cm, or with unknown depth or foreign body will likely need repair. These injuries carry a small risk of injury to the carotid arteries and jugular veins. Consider further imaging and close observation for neurologic deterioration. Obtain otolaryngology consult