Pearls and pifalls from the fast track room


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Pearls and pifalls from the fast track room

  1. 1. Pearls & Pitfalls from the Fast Track Room<br />By Kane Guthrie<br />
  2. 2. Case Study<br />18 male plaster<br />Mixing cement 20mins ago<br />Splashed up into L eye<br />Developed burning sensation to eye<br />Irrigated for 5mins before presenting to ED<br />ATS ? to FastTrack<br />
  3. 3. A True Ocular Emergency<br />ATS 2<br />
  4. 4. Eye Anatomy<br />
  5. 5. Chemical Burns to the Eye<br />
  6. 6. Severity of Chemical Burns<br />Minor<br /><ul><li> Minor irritation, typified by redness, lacrimation and mild oedema</li></ul>Moderate<br /><ul><li> Moderate irritation, such as irritation to cornea</li></ul>Severe<br /><ul><li>Severe irritation, such as corneal ulceration or perforation, can lead to blindness </li></li></ul><li>Chemicals<br />Alkaline chemicals are particularly harmful to eyes and can lead to necrosis<br />
  7. 7. Why are Alkalis so Bad!!<br />Cause disruption of eye’s protective permeability barrier (cornea)<br />Once alkali rapidly penetrate the cornea they release collagenase that then enters the anterior chamber<br />Acid’s don’t seem to penetrate the cornea as much as alkalis, and tend to coagulate on the surface of the eye, limiting there damage.<br />“Hydrofluoric acid is the exemption, tends to work the same as an alkali”<br />
  8. 8. History<br />When did it occur?<br />What is the chemical? (acid/alkali)<br />Any first aid administered and how soon after the incident.<br />Symptoms? E.g. loss of vision, redness, tearing, pain, photophobia,<br />Associated injuries? E.g. skin exposure<br />
  9. 9. Assessment<br />Look for Red eye<br />(severe alkali burns alkali burns can present as eye completely white due to total loss of conjunctival blood vessels)<br />Signs of severe burn<br />Decreased visual acuity<br />Cloudy cornea<br />Epithelial defect with fluroscein<br />
  10. 10. Acute Burn<br />
  11. 11. Acute Severe Burn<br />
  12. 12. Pre-Hospital Care<br />Copious irrigation for at least 30mins<br />Neutral fluid (CSL or N/saline)<br />Try and remove foreign bodies first<br />Main need topical anaesthetic <br />
  13. 13. Emergency Department Management<br />Irrigation ? CSL is better <br />Morgan's Vs Nasal Oxygen<br />Analgesia<br />Same day Opthal r/v<br />
  14. 14. Emergency Department Management<br />Pain relief<br />Topical is better <br />Helps relieve blepharospasm<br />Assist with irrigation<br />“Tetracaine Hydrochloride 1%”<br />Avoid repeated application<br />
  15. 15. Emergency Department Management<br />Irrigation > ASAP>Time is EYE sight<br />Objectives of Irrigation<br />Immediate dilution of offending agent<br />Removal of agent<br />Removal of foreign bodies<br />Normalisation of anterior chamber pH<br />
  16. 16. Irrigation <br />Which fluid is best?<br /><ul><li>Pre-Hosp any fluid better than nothing
  17. 17. N/saline can cause more stinging compared to CSL, generally recommend in most texts
  18. 18. New literature heading towards CSL as has closer pH to the eye.
  19. 19. Some studies showed warmed fluids were better tolerated</li></ul>Bottom line, not enough evidence yet!!<br />
  20. 20. How long for? When do I stop?<br />Literature recommends at least 20-30mins<br />Stop when:<br />When normalisation of pH,( ?7.3)<br />Use litmus paper<br />If pH deranged continue for another 20-30mins<br />Symptoms improved<br />Keep patient warm<br />
  21. 21. Morgan’s Lens “Friend or Foe”?<br />
  22. 22. Is the a better way to Irrigate <br />
  23. 23.
  24. 24. Emergency Department Management<br />Ophthalmology review<br />Urgent once irrigation has been completed<br />Can be sent to clinic<br />May require ongoing management in OT, debridement, transplant<br />Keep NPO<br />
  25. 25. The End<br />Questions<br />