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تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
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Open globe injury: Rapid overview of emergency management

Open globe injury: Rapid overview of emergency management
History
May accompany multiple trauma or serious head injury
Open globe laceration is considered a tetanus-prone wound
Open globe rupture may be occult
Clinical features
Inspection (with penlight or, preferably, a slit lamp):
  • Obvious corneal or scleral laceration
  • Volume loss to eye
  • Uveal (iris or ciliary body) prolapse
  • Other iris abnormalities (peaked pupil or eccentric pupil)
  • 360-degree, bullous subconjunctival hemorrhage (posterior rupture)
  • Intraocular or protruding foreign body
Decreased visual acuity by Snellen or handheld chart; assess counting fingers, hand motion, or light perception if unable to see chart
Relative afferent pupillary defect by swinging penlight technique
Diagnostic evaluation
Immediate ophthalmology consultation for comprehensive eye examination if suspicion of an open globe
CT scan: non-contrast with 1- to 2-mm cuts axial and coronal through the orbits
Other studies based on presence and degree of traumatic injury to other anatomical regions (eg, head, thorax, abdomen)
Initial treatment
Ensure nothing by mouth (NPO)
Assess and treat life-threatening injuries
Avoid ketamine if RSI is required
If RSI is necessary, rocuronium is preferred to succinylcholine for muscle relaxation, although succinylcholine may be used with dexmedetomidine premedication
Do not remove any protruding foreign bodies
Avoid eye manipulation that will increase intraocular pressure (eg, lid retraction, intraocular pressure measurement, ocular ultrasound)
If open globe is present on gross eye inspection, do not give any eye drops (eg, fluorescein, tetracaine, cycloplegics)
Place eye shield without applying pressure on the eye after initial eye examination
Put patient on bed rest with head of bed elevated to 30 degrees if hemodynamic condition allows
Treat nausea and prevent vomiting (eg, in adults, IV ondansetron 4 to 8 mg; in children, IV ondansetron 0.15 mg/kg per dose, up to 4 mg per dose)*
Provide sedation as needed (eg, lorazepam 0.05 mg/kg, maximum single dose: 2 mg)
Provide analgesia (eg, IV fentanyl or morphine); for adult and pediatric dosing, refer to drug monographs included within UpToDate
Begin IV antibiotics:
  • Vancomycin (15 mg/kg IV) plus either
  • Ceftazidime (50 mg/kg IV, maximum dose: 2 g) or
  • Fluoroquinolone for patients unable to tolerate ceftazidime (eg, ciprofloxacin 10 mg/kg IV, maximum dose: 400 mg)
Ensure definitive management by an ophthalmologist
Urgent surgical repair, ideally within 24 hours of injury

CT: computed tomography; ECG: electrocardiogram; IV: intravenous; RSI: rapid sequence intubation; SQ: subcutaneously.

* Ondansetron should be avoided in patients with congenital long QT syndrome. ECG monitoring should be performed for patients receiving ondansetron who also have the following conditions: electrolyte abnormalities (eg, hypokalemia, hypomagnesemia), congestive heart failure, or bradyarrhythmias; or are taking medications that prolong the QT interval.

¶ In adults, adjust subsequent vancomycin doses based on therapeutic monitoring. For children, the maximum single dose for vancomycin is 1 g.
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