CC: fall

HPI: 64 y/o M BIB EMS s/p fall after drinking. Well known to EMS as a chronic EtOH abuser. Witnesses say he fell forward onto his face after appearing to pass out while standing. +LOC without seizure or myclonus. LOC lasted <1 min and pt did not return to baseline. GCS in the field was 12 (E2V4M6). Transported for further eval on backboard with c-collar in place.

Upon arrival: Pt arrives on gurney alert, oriented to person and place, unsure of time. Slurring speech. Vitals unremarkable.

Primary survey: no airway, breathing or obvious hemorrhage. Pelvis stable. Pt was rolled, had no step-off or spinal tenderness, normal rectal tone, backboard removed. C-collar was kept in place.

Secondary survey: Pt had obvious facial swelling and was unable to open his right eye because of this. There were multiple abrasions and contusions about the face. TTP L wrist with obvious deformity, strong pulse, neurovasc intact with brisk cap refil in all digits. No other injuries identified.

Ddx up to now: Retrobulbar hematoma, orbital fx with entrapment, intracranial hemorrhage/contusion, open globe, corneal laceration, traumatic iritis, CVA.

As part of the secondary survey lid retractors were used to evaluate the eye which appeared proptotic. Pt noted hand waving perception OD, had not deficits OS. Pupil OD was 5mm and minimally reactive. Pupil OS was 3mm and briskly reactive. APD present OD. Cornea stained OU without evidence of uptake and had negative Seidel’s sign.

IOPs obtained and were 42 OD and 17 OS.

Dx: Retrobulbar hematoma with orbital compartment syndrome

What now? Cut to cure!

Procedure: Lateral canthotomy, lateral cantholysis

Equipment needed: Iris scissors, hemostat, lidocaine, needle and syringe to inject, cleansing/scrub

Procedure: Inject local and clean the area. Using the hemostat crush the tissue of the lateral eye. It is important to keep inserting the medial part of the hemostat posteriorly until you reach the orbital rim. Crush the tissue for 5-10 seconds. Now use the iris scissors to incise the tissue that you have crushed (canthotomy complete). Now peel the lower lid down and find the inferior canthal tendon, feels like a guitar string. Cut that (cantholysis complete). Recheck the pressure and the pt’s vision. If still abnormal find the superior canthal tendon and cut that. Recheck the pressure, should be relieved. High 5’s all around and call ophtho.

Note: you probably will not see a large or reassuring evacuation of blood but will still have relieved the pressure behind the eye and underlying compartment syndrome. There is no need to worry about closing the wound you’ve created in the ED, that’s for ophtho to do.

This patient received a CT head, max/face, and c-spine along with L wrist radiographs. His other injuries included a lower floor fracture OD and colle’s fracture of the L wrist. Ophtho, gen surg and ortho were consulted. His wrist was reduced and splinted in the ED, c-collar was removed and he was admitted to the trauma service for monitoring. By the end of his hospital stay his vision was back to baseline without the need for further ocular intervention.

**Not all retrobulbar hematomas require evacuation, but may threaten the patient’s vision.  Rapidly check acuities, IOPs, and look for tenting of the globe on CT.  If these are relatively okay, you may be able to watch this patient.  Also get ophthalmology involved early.

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Additional Resources:

https://em.umaryland.edu/page/education/residency/videos_procedures

Procedure: Lateral Canthotomy

 

 

 

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