Retrobulbar Hematoma - Council of Emergency Medicine ...

Barry Smith; 52 yo

4/26/1958


1




Author
s: Elliot Rodriguez, MD, FACEP/Brian Kloss, MD, JD


Reviewer:

Sharon Griswold, MD, MPH


Case Title:
“Can’t See the Forest Because of the Tree”


Target Audience:

Resident (EM1
-
3)


Primary Learning Objectives:

key learning objectives of the scenario


1. Perform an appropriately thorough and efficient trauma evaluation.

2. Identify the signs & symptoms of ocular compartment syndrome due to retrobulbar
hematoma.


3. Recognize the need for emergent lateral canthotomy.


4. Describe the steps for per
forming a lateral canthotomy.


Secondary Learning Objectives:

detailed technical goals, behavioral goals, didactic points


1. Consult Ophthalmology.

2. Recognize the cause of bradycardia is the oculo
-
cardiac reflex & does not require
treatment as patient

is not unstable.




Critical actions checklist

1. Perform primary survey & appropriate secondary trauma survey to identify injuries

2.
I
mmobilize cervical spine.

3. Perform visual acuity and IOP.

4. Diagnose orbital compartment syndrome.

5. Consult
ophthalmology immediately upon recognition of acute traumatic visual loss.

6. Identify need for emergent lateral canthotomy and describe procedure.


Environment

(if using as a simulation case)

1.

Room

Set Up
–

trauma bay

a.

Manikin Set Up
–

Full body mannequin,

needs clay & makeup to simulate left
periorbital swelling and bruising, needs eye with dilated pupil
,

no IV lines in
place, 1% lidocaine w/epinephrine

b.

Props
–

EKG (attached), CT images (attached), laceration tray

2.

Distractors
-

none


Actors

(optional)

1.

Roles
–

nurse,

ophthalmology
consultant

(will be limited to telephone
conversation)

2.

Who may play them
–

nurse can be played by anyone, consultant should be
played by confederate with foreknowledge of scenario.

3.

Action Role
–

nurse is helpful, consultant is

unhelpful (unavailable to come in
emergently due to currently in outpt surgery center with elective OR case
–

“ I can be
there in 2
-
3 hours”).




Barry Smith; 52 yo

4/26/1958


2



For Examiner Only


Author
s: Elliot Rodriguez, MD, FACEP/Brian Kloss, MD, JD


Reviewer:


Case Title:
“Can’t See the Forest Because of the Tree”


CASE SUMMARY



CORE CONTENT AREA



2009 Model of the Clinical Practice of EM

18.1 Trauma; Ophthalmologic; Retrobulbar Hemorrhage

Appendix 1. Procedures; Head & Neck; Lateral Canthotomy



SYNOPSIS OF HISTORY
/
Scenario Background



52 yo male was cutting trees down on his property 60 minutes prior to presentation.
He

was
struck in the left side of the face with a tree branch while using chainsaw.
He presents via
private vehicle with friend. He complains of sev
ere
left side face & eye
pain, poor vision

from left eye
, nausea, dizziness. He denies LOC or neck pain. He was not injured by
the chainsaw and has no other injuries. He has a retrobulbar hematoma with orbital
compartment syndrome that requires emergent

lateral canthotomy.


Chief Complaint
–

“I got hit in the face with a tree branch”


Triage note
–

While cutting down trees got hit with branch to left side of face 60 minutes
ago. He c/o pain & blurry vision.


Past medical history
-

HTN

Medications and
allergies
–

atenolol 50mg daily

Family and social history
–

married, 2 adult children, drinks alcohol socially, smokes ½
ppd. No significant family history.



SYNOPSIS OF PHYSICAL

Initial s
ce
nario conditions: Vital signs, initial physical examination, any

pertinent patient
physiology


Initial triage VS
–

BP 130/80, HR 42, RR 20, T 36.8 C (oral)


Abnormal PE findings limited to left side of face which reveals proptosis of left eye with
associated left periorbital swelling & ecchymosis, VA OS has light perce
ption only,
+RAPD, IOP=80.


Patient is bradycardic due to oculo
-
cardiac reflex from his ocular compartment
syndrome but his blood pressure remains stable.

Barry Smith; 52 yo

4/26/1958


3



For Examiner Only




CRITICAL ACTIONS

SCENARIO BRANCH POIN
TS
/ PLAY OF CASE GUIDELINES



1.

Critical Action


Perform primary survey & appropriate secondary trauma survey to identify injuries


Cueing Guideline
: Consider having patient complain of additional areas of pain (eg, neck,
extremity) to prompt candidate to search for other potential inj
uries.


2.

Critical Action


Immobilize cervical spine initially. As patient did not come into ED via EMS, candidate must
recognize mechanism of injury could involve cervical spine.


Cueing Guideline
: Have patient complain of neck pain. Alternatively have

patient comment
on how severe his pain is to prompt candidate to consider facial trauma as distracting injury.


3.

Critical Action


Identify presence of ocular compartment syndrome, including assessment of visual acuity &
measurement of intraocular pressure
.


Cueing Guideline
: Have nurse question candidate as to why patient’s vision is being
affected by this injury.


4.

Critical Action


Consult ophthalmology immediately upon recognition of acute traumatic visual loss.


Cueing Guideline
: Have nurse comment that CT will be delayed if consult not requested
prior to imaging ordered.


5.

Critical Action


Identify need for emergent lateral canthotomy and describe procedure. At completion of
procedure patient’s pain improves, VA OS improves
to finger count & heart rate increases to
70 bpm.



Cueing Guideline
: Have nurse & patient question whether it is safe to wait the 2
-
3 hours
before the ophthalmology consultant arrives.



Barry Smith; 52 yo

4/26/1958


4





SCORING GUIDELINES

1.

Perform primary survey & appropriate
secondary trauma survey to identify injuries

2.

Immobilize cervical spine.

3. Perform visual acuity and IOP.

4. Diagnose orbital compartment syndrome.

5. Consult ophthalmology.

6. Identify need for emergent lateral canthotomy and describe procedure.












































Barry Smith; 52 yo

4/26/1958


5




For Examiner Only



HISTORY

Onset of Symptoms:

One hour prior to presentation.


Background Info:

52 year old male with left eye & face pain


Chief Complaint:

“I got hit in the face with a tree branch.”


Past
Medical Hx:

Hypertension


Past Surgical Hx:

None


Medications
:

Atenolol 50 mg daily


Allergies:

None


Habits:

Smoking: ½ pack/day


ETOH: social;


Drugs: None


Family Medical Hx:


None


Social Hx:

Marital Status: Married


Children: 2 adult children
(healthy)


Education: High school



Employment: Security guard


ROS:

List pertinent positives and negatives:



Positives:




Headache
–

left sided




Eye pain
–

left sided




Acute visual loss OS
–

light perception only




Nausea without vomiting




Dizzi
ness



Negatives:




Loss of consciousness




Neck/back pain




Numbness or weakness




Chest pain




Dyspnea




Syncope




Abdominal pain




Extremity pain



Barry Smith; 52 yo

4/26/1958


6



For Examiner Only



PHYSICAL EXAM



Patient

Name
:

Barry Smith

Age & Sex
:

52 yo, male


General Appearance:
Well
-
developed, well
-
nourished male in moderate distress
, obvious left
sided facial trauma


Vital Signs:

BP 130/80, HR 42, RR 20, T 36.8 C (oral)


Head:

Left sided periorbital

ecchymosis, swelling
, abrasion


Eyes:

Proptotic left
eye with fixed dilated pupil (+ Relative Afferrent Pupillary Defect (RAPD));
lateral subconjunctival hemorrhage; cornea, clear; anterior chamber clear; visual acuity OS
–

light perception only, OD
–

normal; IOP = 80


Ears:
normal


Mouth:
normal


Neck:
no

m
idline cervical
tender
ness
, no masses


Skin:
no rashes


Chest:

normal


Lungs:

normal


Heart:
normal


Back:
normal


Abdomen:
normal


Extremities:
non tender


Rectal:

deferred


Pelvic:

non tender


Neurological:
5/5 motor in all

extremities

with

intact sensation
, speech clear


Mental Status:
alert
, no confusion
,

follows commands




Barry Smith; 52 yo

4/26/1958


7



For Examiner Only



STIMULUS INVENTORY



#
1

Emergency Admitting Form


#2

CBC
-

included


#3

BMP
-

included


#4

Cardiac Enzymes
-

included


#5

CXR report included


#6

CT head report


#7

CT Cervical spine report


#8

CT maxillofacial images


#9

EKG
–

image attached


#10

Debriefing materials
–

article attached





























Barry Smith; 52 yo

4/26/1958


8




For Examiner Only



LAB DATA & IMAGING RESULTS



Stimulus #
2







Complete Blood Count (CBC)



WBC

17,000/mm
3






Hgb

15 g/dL






Hct

45
%






Platelets

350,000
/mm
3




Differential


Segs

65
%






Bands

0
%






Lymphs

20
%






Monos

10
%






Eos

5
%









Stimulus #
3







Basic Metabolic Profile (BMP)



Na
+


140 mEq/L




K
+


4.5 mEq/L




CO
2


30
mEq/L




Cl
-


100 mEq/L




Glucose

150
mg/dL

BUN

15
mg/dL




Creatinine

1.1
mg/dL













Stimulus #
4







Cardiac Enzymes







Troponin

0.0 ng/ml




















Diagnostic Imaging


Stimulus #5

CXR:


Negative









Stimulus #6







Head CT:


Negative






Stimulus #7

Cervical spine CT:


Negative


Stimulus # 8

Maxillofacial CT:



Orbital floor & medial wall fractures with retrobulbar hemorrhage &
proptosis (images attached)


Stimulus #9

EKG:

sinus bradycardia (image attached)

Barry Smith; 52 yo

4/26/1958


9







Learner
Stimulus #1



ABEM General Hospital


Emergency Admitting Form


Name:


Barry

Smith

Age:


5
2 years

Sex
:



M
ale

Method of
Transportation
: P
rivate car

Person giving information
:

Patient

Presenting complaint
:

Hit with branch to left face


Background:
Patient was
struck in the left side of the face with a tree branch while using
chainsaw. Nei
ghbor brought patient into ED via car. Patient complains of left side face & eye
pain with poor vision.


Triage or Initial
Vital Signs


BP
:


130/80


P
:


42


R
:


20


T
:


36.8 C (oral)















Barry Smith; 52 yo

4/26/1958


10







Learner
Stimulus #
2



Complete Blood Count (CBC)



WBC

17,000/mm
3





Hgb

15 g/dL






Hct

45
%






Platelets

350,000
/mm
3




Differential


Segs

65
%






Bands

0
%






Lymphs

20
%






Monos

10
%





Eos

5
%


































Barry Smith; 52 yo

4/26/1958


11




Learner
Stimulus

#3









Basic Metabolic Profile (BMP)



Na
+


140 mEq/L




K
+


4.5 mEq/L




CO
2


30
mEq/L




Cl
-


100 mEq/L




Glucose

150
mg/dL

BUN

15
mg/dL




Creatinine

1.1
mg/dL




Barry Smith; 52 yo

4/26/1958


12





Learner Stimulus #6



Cardiac Enzymes

Troponin 0.0





Barry Smith; 52 yo

4/26/1958


13





Learner Stimulus #8



Chest Xray Report

Normal CXR









Barry Smith; 52 yo

4/26/1958


14





Learner
Stimulus #9



Head CT Report

No acute intracranial abnormalities.



Barry Smith; 52 yo

4/26/1958


15





Learner
Stimulus #10



Cervical spine CT Report

No acute fracture or subluxation.






Barry Smith; 52 yo

4/26/1958


16





Learner
Stimulus #11



Maxillofacial CT images

(2 images)











Barry Smith; 52 yo

4/26/1958


17





Stimulus #12



EKG




Barry Smith; 52 yo

4/26/1958


18








Feedback
/ Assessment

Form


“Can’t See the Forest Because of the Tree”



Candidate

________________________

Examiner
_________________________




Critical Actions:





Critical Action #1
Perform primary survey & appropriate secondary trauma survey to
identify injuries



Critical Action #2

Immobilize cervical spine.



Critical Action #3

Perform visual acuity and IOP.



Critical Action #4

Diagnose orbital compartment
syndrome.



Critical Action #5

Consult ophthalmology

immediately upon recognition of acute traumatic
visual loss.



Critical Action #6
Identify need for emergent lateral canthotomy and describe procedure.


Dangerous Actions:

(Performance of one dangerous acti
on results in failure of the case)




Dangerous Action #1

Treating bradycardia with atropine despite normal blood pressure.



Dangerous Action #2 Waiting for ophthalmologist to come in and perform procedure.


Overall Score:




Pass



Fail













Barry Smith; 52 yo

4/26/1958


19





For Examiner


Date:





Examiner:





Examinee(s):

Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)


The learner should be scored (based on level of training) for each item above with one
of the following:


NI =

Need
s Improvement


ME =

Meets Expectations


AE =

Above Expectations


NA=

Not Assessed


Critical Actions

NI

ME

AE

NA

Category

Perform primary survey & appropriate
secondary survey to identify injuries





PC, MK

Immobilize cervical spine





PC, MK

Perform visual acuity and IOP





PC, MK

Diagnose orbital compartment
syndrome





PC, MK, PBL

Consult ophthalmology





PC, ICS, SBP

Identify need for emergent lateral
canthotomy and describe procedure
#
#





PC, MK, PBL
,
SBP


##

EM1 &

2 can request review of procedure using text or electronic reference, however
EM3 must describe the procedure accurately without a reference.


N/A= not assessed.


Barry Smith; 52 yo

4/26/1958


20





Category: One or more of the ACGME Core Competencies as defined in the SDOT




PC
=

Patient Care

Compassionate, appropriate, and effective for the treatment of health problems and the promotion
of health


MK
=

Medical Knowledge

Residents are expected to formulate an appropriate differential diagnosis with special attention to
life
-
threate
ning conditions, demonstrate the ability to utilize available medical resources effectively,
and apply this knowledge to clinical decision making


PBL
=

Practice Based Learning & Improvement

I
nvolves investigation and evaluation of their own patient care,
appraisal and assimilation of
scientific evidence, and improvements in patient care


ICS
=

Interpersonal Communication Skills

Results in effective information exchange and teaming with patients, their families, and other health
professionals


P=

Profession
alism

Manifested through a commitment to carrying out professional responsibilities, adherence to ethical
principles, and sensitivity to a diverse patient population


SBP
= Systems Based Practice

Manifested by actions that demonstrate an awareness of and re
sponsiveness to the larger context
and system of health care and the ability to effectively call on system resources to provide care that
is of optimal value


Barry Smith; 52 yo

4/26/1958


21




K
eywords for future searching functions

Orbital Compartment Syndrome

Retrobulbar Hematoma

Lateral Canthotomy



References



Innes G, Howes D. Lateral canthotomy and cantholysis: A simple, vision saving procedure.
Canadian J
o
urnal
o
f Emergency Medicine (2002); 4(1), p 49
-
52


(Need permission if published)
Thomas J. Walsh, M.D. Relative Afferent

Pupillary Defect.

Reference taken from
http://www.cybersight.org/bins/volume_page.asp?cid=1
-
13
-
161
-
987
.
Retrieved February 2, 2011


Hoffman JR
,
Wolfson AB
,
Todd K
,
Mower WR
.Selective cervical spine radiography in blunt
trauma: methodology of the Na
tional Emergency X
-
Radiography Utilization Study (NEXUS).
Ann Emerg Med. 1998 Oct;32(4):461
-
9.


Has this work been previously published
?

No


Simulation Flowchart


-

patient physiologic status does not change during the scenario except
at completion of canthotomy procedure
–

pain improves, VA OS improves to finger count, heart
rate improves to 70 bpm.



Simulation Equipment Checklist

ENVIRONMENT

This scenario requ
ires (checked boxes):


Simulator

Type:


Standardized Patient

X

Non
-
Invasive BP Cuff


ETT


X

2 lead EKG


LMA


X

Pulse Oximeter


Laryngoscope



Arterial Line


Fiberoptic scope



CVP


Gum Bougie



PA Catheter





Temperature Probe


Crash Cart



Capnograph


Central line set up


X

Resp Rate Monitor


Chest tube set up





Ultrasound Machine




SP for family member


X

Additional nurse SP



Other SP



Barry Smith; 52 yo

4/26/1958


22



Debriefing
Stimuli
:



The following article attached in a separate pdf is an excellent
review of lateral
canthotomy procedure.



Innes G, Howes D. Lateral canthotomy and cantholysis: A simple, vision saving
procedure. Canadian J
o
urnal
o
f Emergency Medicine (2002); 4(1), p 49
-
52


Relative Afferent Pupillary Defect







Room Light

OD 20/20

OS 20/20




Bright Light OD = Both pupils constrict




Move light rapidly to OS,

both eyes stay constricted


Normal pupillary response to rapid shift of bright light from one eye to the other indicates
equal

optic nerve
function.







Room Light

OD
20/20

OS 20/200




Bright light OD = Both pupils constrict




Move light rapidly to OS,

both eyes dilate equally


Positive RAPD left eye confirms optic nerve disease is cause of decreased visual acuity.

Thomas J. Walsh, M.D.

(
Permission requested
)
Thomas J. Walsh, M.D. Relative Afferent Pupillary Defect.

Reference
taken from
http://www.cybersight.org/bins/volume_page.asp?cid=1
-
13
-
161
-
987
. Retrieved
February 2, 2011.