S1E12: Orbital Compartment Syndrome - Silver Trauma | Ophthalmic POCUS | Tips for CSTEM Applicants

We’re back with another episode of The Case.Report.

This month, it’s trauma and to guide us along with our case is Dr Fran O’Keefe, consultant in Emergency Medicine.

Our friendly in-house EM registrar Orla also provides some invaluable tips for CSTEM applicants for this year’s interviews.

Silver Trauma

Silver trauma is not straight forward. In fact, it’s the the opposite. Often these patients have multiple co-morbidities and present a real challenge to emergency medical teams. Here’s a few things to consider with trauma in elderly patients…

• Previous Medical History

  • Get a collateral history as early as possible

  • Cardiac disease

  • Medications blunting physiological response to trauma

  • Medications putting patients at higher risk for severe injuries e.g. anticoagulation therapy increasing chances of intracranial haemorrhage

• Fragility fractures

  • Think ribs, hips and spinal

• Impaired thermoregulation

• Consider what is “normal” for an elderly patient

  • A BP of 120/70 could very well by hypotensive for your patient

• Application of stiff spinal collars in spondylotic spines

Where to Start?

• Zero-point survey to prepare yourself and the team

• Consider how and where the patient was found- preparing your environment in advance is important. Put out the trauma call and consider rewarming methods.

• Prepare for massive transfusion.

• Large bore IV cannulae x 2

• Monitors and ECG

• Baseline bloods: FBC, U&E, CK, G+CM, Coag, Fibrinogen, Calcium.

  • A VBG can be helpful in establishing many of these early including those all important glucose and lactate values

• Early blood transfusion

• Active rewarming- warmed fluids and Bair-hugger.

C-spine Immobilisation in an Elderly Patient

This is a tricky one. Elderly cervical spines are not set for being forced into a stiff collar. They’re generally poor fitting and can cause more damage in patients with stiff, kyphotic necks. Consider manual-in-line stabilisation and applying a Miami-J early. A position of comfort in a conscious geriatric patient is crucial.

Lateral Canthotomy and Inferior Cantholysis

Orbital compartment syndrome is ultimately a clinical diagnosis. Do not wait for a CT to confirm this. At the end of the day, a lateral canthotomy and inferior cantholysis is a vision-saving procedure that we can carry out at the bedside.

Signs and Symptoms

• Decreased visual acuity (in an awake patient)

• Proptosis (best visualised in perpendicular plane with the patient in semi-reclining position)

• Eccymosis of eyelid- “Shiner”

• Chemosis- conjunctival swelling

  • Easy to identify in that the conjunctiva looks almost like a blister

• Tense orbit (helpful in unconscious patients)

  • Increase resistance when pushing down on the eyelid

  • Tender, hard eyeball

• Opthalmoplegia

• Relative afferent pupillary defect (RAPD)

• … and those best assessed by our colleagues in opthalmology

  • Increased intraocular pressure

  • Papilloedema

  • Central retinal artery pulsation

  • Pale optic disc (late)

  • Cherry-red macula (rare)

So when should I start thinking about performing it?

• Without delay! Get prepared as soon as the diagnosis is made.

• Increasing pressure can cause retinal and optic nerve ischaemia and as such this is a time-critical, vision-threatening emergency,

• Perform it right where you are in resus. This is not something to be deferred for theatre management.

Who should perform these?

• Ideally, the most experienced person on the floor.

• This is not just an opthalmology job. They will gladly fix anything we do to the eyelid. The priority is ensuring the patient keeps their vision.

So it’s me… I’m the most experienced. Any tips and tricks on method?

• #EM3 has an excellent video and breakdown of the equipment needed and best methods for the procedure.

• Do your best to make the patient as comfortable as possible

  • Local anaesthetic

  • Adequate analgesia

  • Consider light sedation to ease their nerves (not yours!)

  • Keep it as sterile as possible

Remember: The most difficult part of a lateral canthotomy and inferior cantholysis, as with many emergency medical procedures, is to make the decision to perform the procedure. This is a vision-saving procedure and should be done without delay. The results can be seen within minutes.

References

• Zero Point Survey- St Emlyn’s Blog

• Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment, Vitreous Hemorrhage, and Vitreous Detachment in the Emergency Department- Lahham et al. (2019)

• Ocular Ultrasound “EM in 5”- Anna Bargren (YouTube)

• Sonography of the Optic Nerve Sheath Diameter for Detection of Raised Intracranial Pressure Compared to Computed Tomography: A Systematic Review and Meta-analysis- Ohle et al. (2015)

• CoreEM- Ocular Ultrasound

• WikiEM- Ocular Ultrasound

Page last updated:

08/02/2021