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23/02/17
Visual Stimuli In Emergency MedicineCME Teaching
A 50 year old man is BIBA following an MVA - the driver of a car travelling 80km/hr that was hit head on by a car travelling roughly the same speed
Basilar skull fracture
✤ Bleeding from the fracture site into the surrounding structures
✤ Clinical manifestations of basilar skull fracture may take hours to fully develop
✤ Needs urgent CT to evaluate and identify any underlying brain injuries
Seatbelt sign
✤ Increased risk of underlying visceral injuries
✤ Low threshold for CT
Septal haematoma
✤ Risk of avascular necrosis or secondary infection/abscess formation
✤ Can cause permanent deformity if left untreated
✤ Needs ENT input for urgent aspiration/drainage
Hyphaema
✤ Collection of red blood cells within the anterior chamber
✤ Usually managed conservatively with close ophthalmology follow up
✤ Can be complicated by obstruction of the trabecular meshwork leading to raised intraoccular pressure
A 26 year old man presents to ED with a 2 day history of a red, painful eye with blurred vision
Hypopyon
✤ Visible accumulation of white cells in the anterior chamber
✤ Indicates severe anterior uveitis
✤ Needs urgent ophthalmology referral
✤ Can be sight threatening
A 38 year old lady presents to hospital with a one day history of pain and irritation in her right eye
Dendritic ulcer
✤ Herpes simplex keratitis
✤ Treated with topical anti-virals and needs urgent ophthalmology referral
✤ Can be sight threatening
A 78 year old lady with a background of hypertension and type 2 diabetes presents with painless visual loss in her right eye
Central retinal vein occlusion
✤ Predisposing factors include age, HTN and Diabetes
✤ Visual acuity varies depending on the severity of the bleed
✤ Needs urgent ophthalmology referral
A 63 year old man presents with sudden loss of vision in his left eye
Central retinal artery occlusion
✤ Visual acuity always reduced <6/60
✤ Need to rule out Giant Cell Arteritis
✤ Needs urgent ophthalmology referral
A 32 year old lady presents with severe headaches and blurred vision
Papilloedema
✤ Assess with full neurological and ophthalmological examinations
✤ Needs urgent neurological imaging
✤ Neurology/opthalmology input depending on cause
A 56 year old man presents with loss of vision in one after complaining of flashes and floaters over the last couple of days
Retinal detachment
✤ Direct fundoscopy can’t always rule out a detachment
✤ Ultrasound is a useful tool for diagnosis
✤ Needs urgent ophthalmology referral
A 68 year old man in brought into ED following a collapse at home. He is GCS 6/15
Unequal pupils
✤ Injury or compression of the third cranial nerve and upper brainstem
✤ Suggests severe inter cranial pathology
✤ Needs urgent CT head to assess
A 45 year old smoker presents to ED complaining that her left eye is ‘droopy’
Horner’s Syndrome
✤ Ptosis, miosis and anhidrosis
✤ Interruption of the sympathetic nerve supply to the eye
✤ Painful Horner’s - need to consider dissection
A 70 year old man presents to hospital with a painful rash and redness in his right eye
Hutchinson’s sign
✤ Supplied by the nasocilliary branch of the trigeminal nerve
✤ Highly predictive of eye involvement
✤ Needs urgent ophthalmology referral - can be sight threatening
A 72 year old man with a background of lung cancer presents to hospital complaining of increasing shortness of breath
SVC obstruction
✤ Pemberton’s sign
✤ Most common cause is lung cancer
✤ Treated with chemotherapy/radiotherapy or stenting
A 54 year old man presenting to hospital with abdominal pain and distention
Distended abdominal veins
✤ IVC obstruction vs caput medusa
✤ Caput medusa signifies severe portal hypertension
Spider Naevi
✤ Dilation of arterioles caused by increased oestrogen levels
✤ Multiple spider naevi is a common sign in liver disease
✤ Also common in pregnancy
A 46 year old alcoholic man presents to hospital with severe abdominal pain and vomiting
Retroperitoneal bleed
✤ Trauma, ectopic pregnancy rupture or pancreatitis
✤ Signifies necrotizing pancreatitis
✤ Associated with very high mortality
A 78 year old lady with a history of COPD presents to hospital with respiratory distress
Peripheral cyanosis
✤ Caused by excessive deoxyhaemoglobin in the blood
✤ Inadequate or obstructed circulation
✤ Anaemic patients may be hypoxic without cyanosis
A 42 year old IVDU presents to hospital feeling generally unwell with high fevers
Infective endocarditis
✤ Vascular and immunologic phenomena
✤ Most commonly caused by Staph aureus
✤ Modified Dukes criteria for diagnosis
A 72 year old man presents to ED with SOB which has been getting worse over the last few months
Clubbing
✤ Many associated diseases
✤ Schamroth’s test used to identify subtle clubbing
✤ Needs further investigation if not known to have a causative disease
A 38 year old man presents to hospital with a painful rash on his chest
HSV
✤ Cause by the varicella zoster virus
✤ Never crosses the midline
✤ Infective until lesions have crusted
✤ Often complicated by post-herpetic neuralgia
Any Questions?