Advanced Trauma Life Support ATLS Student Course Manual 2018

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APPENDIX A n Ocular Trauma
stable patients. While awaiting patient transfer or
specialist consultation, follow this procedure:
1. Cover the affected eye with a rigid shield. If a
foreign body is sticking out of the eye, cut a
foam or paper cup to accommodate the foreign
body. Never place a pressure dressing, gauze,
or other soft material under the rigid shield
because pressure may force contents out of the
eye. Furthermore, gauze or soft eye pads can
stick to extruding iris or other ocular contents,
which might then be pulled out of the eye when
removing the pad.
2. Provide an IV antibiotic. Fluoroquinolones
are the only class of antibiotics that penetrate
the vitreous at therapeutic concentrations
when given by an intravenous or oral route.
Gatifloxacin and levofloxacin are preferred
over older fluoroquinolones due to higher
vitreous concentrations from oral dosing.
IV formulations are preferred for patients
with oral restrictions awaiting surgery. If
fluoroquinolones are unavailable, give IV
broad-spectrum antibiotics to cover both
gram-negative and gram-positive bacteria.
Be sure the patient is up to date with
tetanus immunization.
3. Explain to the patient the importance of
minimizing eye movement if possible.
Extraocular muscle movement can cause
further extrusion of intraocular contents.
Eye movements are linked in the brain, so
moving the good eye causes the injured eye
to move as well.
4. Treat pain, nausea, and coughing. Valsalva
maneuvers can increase pressure on the back
of the eye (through the venous system), so
reduce these activities to help keep intraocular
contents inside of the eye. If the patient is
intubated or has an airway in place, ensure
that he or she is not getting excessive positive
pressure or coughing.
5. Minimize manipulation of the eye. Do not
perform any examination beyond visual acuity
and observation. This is the extent of evaluation
necessary before the ophthalmologist arrives.
6. Order a CT scan (only if the patient will be
treated in your facility) with fine cuts through
the orbits to look for a foreign body or other
ocular injuries. Each hospital has a slightly
different orbital protocol for this, but generally
the cuts are 1 mm or less. IV contrast is
not required.
When you suspect there is an open globe, call the
ophthalmologist for immediate examination to make
a definitive diagnosis. These injuries should be treated
promptly once diagnosed.
SummARy
1. A thorough ocular exam in the secondary survey
can identify subtle ocular injuries that may threaten
loss of sight if not treated right away. In such cases,
immediately consult an ophthalmologist.
2. Other ocular concerns can often wait until the
hospital ophthalmologist is available during the
day for further exam and consultation.
3. When you are in doubt, consult immediately, and
the consulting ophthalmologist will determine the
timing of the eye exam.
Bibliography
1. Bagheri N, Wajda B, Calvo C, et al. The Wills Eye
Manual. 7th ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2016.
2. Hariprasad SM, Mieler WF, Holz ER. Vitreous
and aqueous penetration of orally administered
gatifloxacin in humans. Arch Ophthalmol
2003;121(3):345–350.
3. Hayreh SS, Jonas JB. Optic disk and retinal nerve
fiber layer damage after transient central retinal
artery occlusion: an experimental study in rhesus
monkeys. Am J Ophthalmol 2000;129(6),786–795.
4. Herbert EN, Pearce IA, McGalliard J, et al.
Vitreous penetration of levofloxacin in the
uninflamed phakic human eye. Br J Ophthalmol
2002;86:387–389.
5. Yung CW, Moorthy RS, Lindley D, et al. Efficacy
of lateral canthotomy and cantholysis in orbital
hemorrhage. Ophthal Plast. Reconstr Surg
1994;10(2),137–141.
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