created 14/11/10 by S.R. Bruijns, version 1.0
E M E R G E N C Y D E P A R T M E N T J U N I O R T E A C H
Eyes, ears, teeth and everything in between
Objectives
• Eyes
• Ears
• Teeth
• Maxilla- facial
EYES
Approaching the eye
Approaching the eye: History
Occupation
Previous eye or other medical problems
Use of glasses or contact lenses
If due to injury, what happened? Sharp or blunt injury
Chemical splashes
Exposure to bright light
Change in vision/ pain/ itch/ discharge
Sensation of something in the eye
Photophobia
Approaching the eye: Examination
Visual acuity Look at
Lids & external eye Redness, discharge, foreign body Cloudiness
Examine Iris and pupil Anterior chamber Under the upper and lower eyelids
You may need to numb the eye To colour the eye
Eyes: acute loss of vision
Vitreous haemorrhage
Complains of new multiple floaters, visual haze, smoke, shadows, or cobwebs
Variable loss of fundus detail with floating debris
Eyes: acute loss of vision
Retinal detachment
Sensation of a flashing light accompanied by a shower of floaters.
Evidence of vitreous haemorrhage and large detachment of the posterior pole
Eyes: loss of vision
Optic neuritis
Rapidly developing impairment of vision in one eye
Pupillary light reaction is decreased (Marcus Gunn pupil)
Eyes: loss of vision
Retinal artery occlusion
Painless loss of monocular vision
Pale retina with a cherry red macula
Eyes: Acute Angle Closure Glaucoma
Typical complaint
Ocular pain,
nausea/vomiting,
and intermittent blurring of vision with halos
ED finding
Conjunctival injection,
mid-dilated nonreactive pupil
In a large percentage of patients, extraocular symptoms are the chief complaint
Headache, abdominal pain from vomiting
Eyes: Trauma slideshow
Eyes: Trauma slideshow
Eyes: Trauma slideshow
Typical teardrop sign
Represents the herniated orbital contents, peri-orbital fat and inferior rectus muscle
Eyes: Trauma slideshow
With inferior rectus trapped the patient is unable to look down
EARS
Ears: Otitis Media
Exceedingly common in paediatric population
Diagnostic criteria is Acute onset
Middle ear effusion
Middle ear inflammation
Severe illness Severe otalgia
Temperature > 39o
Treatment < 6 months: always treat if suspected
6 months to 2 years: treat if all criteria present/ severe illness
> 2 years: can be observed if no signs of severe illness
Ears: Otitis Externa
1-2 days of progressive ear pain
Symptoms may include Pruritus within the ear canal
Purulent discharge
Conductive hearing loss/ feeling of fullness or pressure
Examination The main finding is pain on gentle traction of the external ear
Erythema, oedema, and narrowing of the external auditory canal
Treatment
Topical antibiotic/steroid mix (Sofradex)
Foam or gauze wick aids delivery of drops to affected area
Ears: tympanic perforation
Most will heal without intervention
Consider antibiotics with pain or discharge
Advise not to get water in their ear
Arrange follow-up
DENTAL
Dental: Basics
There are up to 20 primary teeth replaced by
Up to 32 permanent teeth from 6 yrs of age
That’s 32 teeth in 4 quadrants
UR 1-8 UL 1-8
LR 1-8 LL 1-8
Numbered from front to back
Dental: Basics
Dental: Post Extraction Bleeding
Bite on a dry gauze pack placed in socket
Attempt the same but using a medicated pack
Adrenaline
Tranexamic acid
With failure will need referral for suturing of socket
Dental: Fractures
Dental: Avulsion
Best replaced in the first hour
Transport medium
Re-implanting procedure
Handle tooth minimally (touch only the crown)
Clean in saline
Orientate and re-implant with firm pressure
Needs antibiotics and referral for stabilisation
MAXILLO- FACIAL
MaxFax: Nasal fractures
Obvious deformity
Palpate for deformities/tenderness
Cerebrospinal fluid rhinorrhoea
Look for
Septal deviation,
Mucosal tears,
Septal haematoma
Treatment delayed
Epistaxis advise sheet
Follow up with Maxfax
MaxFax: Mandible anatomy
BODY
MaxFax: Mandible fractures
MaxFax: TMJ dislocation
May be traumatic or with minimal movement with a lax joint capsule (laughing/ yawning)
No need for x-ray with good history and no trauma
Treatment is to reduce the dislocation
Use gloves and gauze for protection
Sit patient up in a chair with head back against a wall
Down and backward force whilst rotating jaw anteriorly
Patient comfort and relaxation is the key (may need some form of sedation)
MaxFax: Mid-face fractures
High-energy blunt force
Often part of an injury complex
Priority is to establish that the airway is patent With airway adjuncts (intubation)
Without airway adjuncts (patient able to maintain own airway with no concern for impending obstruction)
Clinical picture
Soft tissue swelling, ecchymosis, blood and haematoma
Less often seen is flattened appearance (dish/ pan-face)
MaxFax: Mid-face fractures
QUESTIONS
Summary
Eyes
Vitreous haemorrhage
Retinal detachment
Optic neuritis
Retinal artery occlusion
Glaucoma
Hyphema
Lens dislocation
Orbital blow out
Ears
Otitis Media & Externa
TM perforation
Dental
Post extraction bleed
Dental fracture
Tooth avulsion
MaxFax
Nasal fracture
Mandible fracture
TMJ dislocation
Midface fractures
Key is (ALS priorities) recognition and referral