Rosen & Barkin's 5-Minute Emergency Medicine Consult (771 page)

Read Rosen & Barkin's 5-Minute Emergency Medicine Consult Online

Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
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DIAGNOSIS
  • Categorize visual loss by the properties associated with the decrease in visual function
  • Transient (<24 hr):
    • Minutes:
      • Transient ischemic attack = amaurosis fugax (unilateral)
      • Vertebrobasilar artery insufficiency (bilateral)
    • Minutes to hours:
      • Migraine
      • Sudden BP changes
  • Persistent (>24 hr):
    • Painless: Sudden:
      • Retinal artery or vein occlusion
      • Vitreous hemorrhage
      • Retinal detachment
      • Optic neuritis
      • Giant cell arteritis
      • Cerebral infarct
    • Painless: Gradual (weeks to years):
      • Cataract
      • Presbyopia
      • Refraction errors
      • Open-angle glaucoma
      • Chronic retinal disease
      • Macular degeneration
      • Diabetic retinopathy
      • CMV retinopathy
      • CNS tumor
    • Painful:
      • Corneal abrasion, ulcer, burn, or foreign body
      • Angle-closure glaucoma
      • Optic neuritis
      • Iritis/uveitis/endophthalmitis
      • Keratoconus with hydrops
      • Orbital cellulitis/abscess
  • Monocular: Pathology anterior to optic chiasm
  • Binocular: Pathology posterior to optic chiasm
  • Associated with systemic neurologic symptoms of visual field defects:
    • CVA (especially posterior or occipital circulation)
    • Mass lesion (pituitary adenomas, aneurysm, meningioma, other tumors)
  • Malingering/hysteria
SIGNS AND SYMPTOMS
History
  • Decreased vision:
    • Loss of vision
    • Blurry vision
    • Double vision:
      • Horizontal or vertical
  • History of trauma
  • Use of corrective lenses:
    • Contacts
    • Glasses
  • Prior eye surgery or problems
  • Eye pain
  • Conjunctival redness or discharge
  • New floaters
  • Flashing lights
  • Pain with eye movement
  • Key elements to determine:
    • Acute or gradual onset
    • Length of symptoms
    • Transient vision loss or permanent
    • Binocular or monocular
    • Degree of vision loss
    • Painful or painless
    • Other comorbidities
Physical-Exam
  • Ophthalmologic:
    • Visual acuity
    • Pupil exam
    • Afferent papillary defect
    • Confrontational visual field exam
    • Extraocular muscle function
    • Slit-lamp exam
    • Intraocular pressure (Tonometry)
    • Fundoscopy:
      • Optic nerve swelling
      • Pale retina with a cherry-red spot
  • Cardiovascular:
    • Murmurs
    • Carotid bruits
    • Temporal artery tenderness
  • Neurologic exam:
    • Complete exam for other deficits
    • Optic chiasm and intracerebral lesions
    • Occipital and posterior circulation lesions
  • General:
    • Signs of immune, endocrine, or toxic disorders
ESSENTIAL WORKUP

Thorough history and physical exam

DIAGNOSIS TESTS & NTERPRETATION
Lab
  • May be obtained to determine extent of other comorbidities in association with vision loss (i.e., diabetes, cardiovascular disease)
  • Erythrocyte sedimentation rate if giant cell arteritis is suspected
Imaging
  • Tests should be directed toward the suspected etiology of visual loss
  • Dilated fundus exam may be performed to assess for posterior segment disease
  • Temporal artery biopsy may be obtained if giant cell arteritis is suspected
  • Brain CT, MRI, MRA, and transcranial Doppler may be used to evaluate neurologic symptoms and vertebrobasilar artery
  • Urgent cardiac and carotid US if a retinal artery occlusion is diagnosed
  • Facial CT may be used to evaluate extent of traumatic injuries
DIFFERENTIAL DIAGNOSIS
  • Trauma
  • Neurologic lesion
  • Infectious
  • Cardiovascular
  • Toxic/metabolic
  • Autoimmune
TREATMENT
PRE HOSPITAL
  • Chemical burns:
    • Begin copious irrigation with water or saline
ED TREATMENT/PROCEDURES
  • Direct therapy toward cause of visual loss
  • Ophthalmology consultation for visual loss with an uncertain diagnosis
  • 3 conditions for which identification and treatment must begin within minutes:
    • Central retinal artery occlusion
    • Chemical burn
    • Acute angle-closure glaucoma
Central Retinal Artery Occlusion
  • Clinical criteria:
    • Unilateral, painless, dramatic vision loss
    • Afferent pupillary defect
    • Pale fundus with a cherry-red spot (macula)
    • Counting fingers to light perception in 94% of patients
  • Therapy:
    • Immediate ophthalmology consultation
    • Maneuvers and medications to lower intraocular pressure, allowing the embolus to move to the periphery:
      • Ocular massage: Direct pressure to eye for 5–15 sec then sudden release, repeat for 15 min
      • Acetazolamide: 500 mg IV or PO
      • Topical β-blocker
      • Anterior chamber paracentesis by an ophthalmologist
    • Referral for cardiac and carotid artery workup
    • Rule out giant cell arteritis
Chemical Burn
  • Clinical criteria:
    • Alkali worse than acids
    • White eye (vessels have already sloughed) worse than red eye (vessels are intact)
    • Examples: Mace, cements, plasters, solvents
  • Therapy:
    • Topical anesthetic
    • Copious irrigation of the eyes with LR or NS (nonsterile water is acceptable if others not available); minimum of 30 min
    • Goal: Neutral pH at 5–10 min after ending irrigation
    • Do not try to neutralize acids with alkalis or vice versa
    • Evert lids and use moist cotton-tipped applicator to sweep furnaces for residual chemical precipitants
    • Dilate with cycloplegic (atropine, cyclopentolate, tropicamide)
    • Do not use phenylephrine; vasoconstricts already ischemic conjunctival blood vessels
    • Erythromycin ointment q1–2h
    • Artificial tears q1h
    • Check intraocular pressure
Acute Angle-closure Glaucoma
  • Signs and symptoms:
    • Unilateral, painful vision loss
    • Nausea, vomiting, headache
    • Cornea injected, edematous
    • Mid-dilated, sluggish/nonreactive pupil
    • Swollen, “steamy” lens
    • Cell, flare in a shallow anterior chamber
    • Increased intraocular pressure (>20 mm Hg)
  • Therapy:
    • Topical β-blocker
    • Topical prostaglandin analog
    • Acetazolamide
    • Topical α-2 agonist
    • Pilocarpine
    • Mannitol: If no decrease in IOP after 1 hr
MEDICATION
  • Antibiotic drops:
    • Ciprofloxacin 0.3%: 1–2 gtt q1–6h
    • Gentamicin 0.3%: 1–2 gtt q4h
    • Ofloxacin 0.3%: 1–2 gtt q1–6h
    • Levofloxacin 0.5%: 1–2 gtt q2h
    • Polymyxin (Polytrim) 1 gtt q3–6h
    • Sulfacetamide 10%, 0.3%: 1–2 gtt q2–6h
    • Tobramycin 0.3%: 1–2 gtt q1–4h
    • Trifluridine 1%: 1 gtt q2–4h
  • Antibiotic ointments:
    • Bacitracin 500 U/g 1/2 in ribbon q3–6h
    • Ciprofloxacin 0.3%: 1/2 in ribbon q6–q8h
    • Erythromycin 0.5%: 1/2 in ribbon q3–6h
    • Gentamicin 0.3%: 1/2 in ribbon q3–4h
    • Neosporin 1/2 in ribbon q3–4h
    • Polysporin 1/2in ribbon q3–4h
    • Sulfacetamide 10%: 1/2 in ribbon q3–8h
    • Tobramycin 0.3%: 1/2 in ribbon q3–4h
    • Vidarabine 1/2 in ribbon 5 times per day
  • Mydriatics and cycloplegics:
    • Atropine 1%, 2%: 1–2 gtt/day to QID
    • Cyclopentolate 0.5%, 1%, 2%: 1–2 gtt PRN
    • Homatropine 2%: 1–2 gtt BID–TID
    • Phenylephrine 0.12%, 2.5%, 10%: 1–2 gtt TID–QID
    • Tropicamide 0.5%, 1%: 1–2 gtt PRN dilation
  • Corticosteroid–antibiotic combination drops (with ophthalmology consultation):
    • Prednisolone (Blephamide) 1–2 gtt q1–8h
    • Hydrocortisone/neomycin/bacitracin/polymyxin B (Cortisporin) 1–2 gtt q3–4h
    • Dexamethasone/neomycin/polymyxin B (Maxitrol) 1–2 gtt q1–8h
    • Prednisolone/gentamicin (Pred-G) 1–2 gtt q1–8h
    • Dexamethasone/tobramycin/chlorobutanol (TobraDex) 1–2 gtt q2–26h
  • Glaucoma agents (always with ophthalmology consultation):
    • α-2 agonists:
      • Brimonidine 1% 1 gtt TID
      • Apraclonidine 1% 1 gtt TID
    • β-blocker:
      • Betaxolol 0.25%, 0.5%: 1–2 gtt BID
      • Carteolol 1%: 1 gtt BID
      • Levobunolol 0.25%, 0.5%: 1 gtt QD–BID
    • Carbonic anhydrase inhibitor:
      • Acetazolamide 500 mg PO/IV QD–QID
    • Miotic (parasympathomimetic):
      • Pilocarpine 0.25%, 0.5%, 1%, 2%, 3%, 4%, 6%, 8%, 10%: 1–2 gtt TID–QID
    • Osmotic agent:
      • Mannitol 1–2 g/kg IV over 45 min
    • Prostaglandin analog:
      • Latanoprost 0.005%: 1 gtt QD
  • Only if mechanical closure is ruled out:
    • Timolol 0.25%, 0.5%: 1 gtt BID
FOLLOW-UP

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