Pearls & Pitfalls from the Fast Track Room

By Kane Guthrie

Case Study

• 18 male plaster• Mixing cement 20mins ago• Splashed up into L eye• Developed burning sensation to eye• Irrigated for 5mins before presenting to ED• ATS ? to FastTrack

A True Ocular Emergency

• ATS 2

Eye Anatomy

Chemical Burns to the Eye

Severity of Chemical Burns

Minor Minor irritation, typified by redness,

lacrimation and mild oedemaModerate Moderate irritation, such as irritation to corneaSevereSevere irritation, such as corneal ulceration or

perforation, can lead to blindness

Chemicals

Acids Alkalis Natural Chemicals

Toilet cleaner Lime Solvents

Car battery fluid Mortar & plaster

Detergents

Pool cleaner Drain/oven cleaner

Aerosols and irritants (mace, pepper spray)

Ammonia

Alkaline chemicals are particularly harmful to eyes and can lead to necrosis

Why are Alkalis so Bad!!

• Cause disruption of eye’s protective permeability barrier (cornea)

• Once alkali rapidly penetrate the cornea they release collagenase that then enters the anterior chamber

• 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.

“Hydrofluoric acid is the exemption, tends to work the same as an alkali”

History

• When did it occur?• What is the chemical? (acid/alkali)• Any first aid administered and how soon after

the incident.• Symptoms? E.g. loss of vision, redness,

tearing, pain, photophobia,• Associated injuries? E.g. skin exposure

Assessment

• Look for Red eye(severe alkali burns alkali burns can present as

eye completely white due to total loss of conjunctival blood vessels)

Signs of severe burn• Decreased visual acuity• Cloudy cornea• Epithelial defect with fluroscein

Acute Burn

Acute Severe Burn

Pre-Hospital Care

• Copious irrigation for at least 30mins• Neutral fluid (CSL or N/saline)• Try and remove foreign bodies first• Main need topical anaesthetic

Emergency Department Management

• Irrigation ? CSL is better • Morgan's Vs Nasal Oxygen• Analgesia• Same day Opthal r/v

Emergency Department Management

• Pain relief• Topical is better • Helps relieve blepharospasm• Assist with irrigation• “Tetracaine Hydrochloride 1%”• Avoid repeated application

Emergency Department Management

Irrigation > ASAP>Time is EYE sightObjectives of Irrigation1 Immediate dilution of offending agent2 Removal of agent3 Removal of foreign bodies4 Normalisation of anterior chamber pH

Irrigation

Which fluid is best?Pre-Hosp any fluid better than nothingN/saline can cause more stinging compared to

CSL, generally recommend in most textsNew literature heading towards CSL as has

closer pH to the eye. Some studies showed warmed fluids were

better toleratedBottom line, not enough evidence yet!!

How long for? When do I stop?

• Literature recommends at least 20-30minsStop when:• When normalisation of pH,( ?7.3)• Use litmus paper• If pH deranged continue for another 20-

30mins• Symptoms improved• Keep patient warm

Morgan’s Lens “Friend or Foe”?

Is the a better way to Irrigate

Emergency Department Management

• Ophthalmology review• Urgent once irrigation has been completed• Can be sent to clinic• May require ongoing management in OT,

debridement, transplant• Keep NPO

The End

• Questions