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