Corneal foreign body and abrasion

Indications for emergent ophtho consultation:
-Globe rupture

Indications for day-of ophtho referral:
-Ulceration or large defect
-FB that cannot be removed
-Hypopyon or purulent discharge

Indications for urgent ophtho referral:
-Drop in vision more than 2 lines on snellen chart
-Lack of healing after 3-4 days
-Child/infant with persistent discharge and poor cooperation with exam

Tetanus prophylaxis? Only for penetrating injuries

Primary risk for abrasion with contaminated material?  Bacterial keratitis

Bacterial keratitis

Bacterial keratitis characterized by a large corneal infiltrate and a small hypopyon

 

Primary pathogen for infected corneal body? Coagulase negative staph

Rust rings: generally resorb without complication.  They need not be removed immediately after removal of FB and can be treated as abrasions.  Routine removal risks damage to Bowman’s membrane and scarring.  If after 2-3 days they are still present, they should be debrided.

While evidence lacks, expert consensus supports use of abx for abrasions and FBs:
First line, non-contact wearers
-erythromycin ointment, 0.5 inch ribbon QID x3-5 days
-sulfacetamide 10% ointment, 0.5 inch ribbon QID x3-5 days
-sulfacetamide (bleph-10) 10% ophthalmic soln, 1-2 drops QID x3-5 days
-TMP-polymyxin (polytrim) 0.1%, 1 drop QID x3-5 days
Contact wearers
-ciprofloxacin 0.3% ointment, 0.5 inch ribbon QID x3-5 days
-ciprofloxacin 0.3% soln, 1-2 drops QID x3-5 days
-olfloxacin 0.3% soln, 1-2 drops QID x3-5 days
-gentamicin 0.3% ointment, 0.5 inch ribbon BID x3-5 days
-gentamicin 0.3% soln, 1-2 drops QID x3-5 days
Topical cycloplegics
Useful for ciliary spasm, which manifests as photophobia.  Will not help with FB sensation
-cyclopentolate 1% soln, 1 drop, may repeat in 5 minutes, in-office only (onset 30-60 min, duration 24-36 hours)
-homatropine 2 or 5% soln, 1 drop, may repeat in 5 minutes, in-office only (onset 30-60 min, duration 1-3 days)

Patching? Controversial.  Never for contact users, can mask progression of infection.  Can provide relief to very large (>50%) corneal abrasions, however doesn’t seem to provide much benefit to small abrasions and can lead to increased fall risk.

Vital signs by age

 

Vital sign chart Peds

HR and RR data based on 10th-90th percentile data from:
Fleming S, et al. Normal ranges of heart rate and respiratory rate in children from birth to 18 years: a systematic review of observational studies. Lancet. 2011;377(9770):1011-1018.

Meta-analysis of 69 studies including 134,346 children age birth to 18 years

BP data represents lowest 5th percentile based on PALS and APLS

ECG in pulmonary embolism

Sinus tach (30-50%)
Right axis (S1QIIITIII)
RBBB
Ventricular or supraventricular arrhythmia
STD or STE
Anterior +/- inferior TWI

Associated with hemodynamic instability:
TWI in V1-V2
STE in aVR, V1-V2
Any STE/STD
Tachycardia (sinus, fib, flutter)
Signs of RH strain

 

Shopp JD, Stewart LK, Emmett TW, Kline JA. Findings From 12-lead Electrocardiography That Predict Circulatory Shock From Pulmonary Embolism: Systematic Review and Meta-analysis. Acad Emerg Med 2015;22(10):1127–37. PMID:26394330