10.2 Core Workflows and Decision Points

Ocular Workflows

** Begin immediate copious irrigation — do not wait for visual acuity, history, or even the provider. Use normal saline or lactated Ringer's, often via a Morgan lens for hands-free flow. Evert the lids and sweep the fornices for particulate matter (especially cement/lime). 4**, and you should recheck pH about 5 minutes after stopping to be sure it does not drift back. Alkali exposures commonly require much larger volumes and prolonged irrigation. Only after pH is neutral do you assess acuity and arrange ophthalmology.

Globe rupture / open globe. The instant rupture is suspected (markedly decreased acuity, teardrop/peaked pupil, prolapsed uveal tissue, positive Seidel sign, low intraocular pressure on history), stop manipulating the eye. Apply a rigid eye shield (Fox shield) — never a pressure patch, because external pressure can extrude intraocular contents. Give no eye drops or ointment, no tonometry, and no irrigation. Elevate the head of bed, control pain and prevent vomiting/Valsalva with antiemetics, start IV antibiotics and update tetanus, and keep the patient NPO for emergent surgery.

More Ocular Workflows

Central retinal artery occlusion (CRAO). Treat as an "eye stroke." Sudden, painless, profound monocular vision loss with a cherry-red spot at the macula and an afferent pupillary defect. Because infarction is irreversible in roughly 90-100 minutes, act emergently: ocular massage, measures to lower IOP, and immediate ophthalmology/stroke-pathway activation (many centers now evaluate for thrombolysis and a workup for giant cell arteritis in older adults).

Acute angle-closure glaucoma. A red, rock-hard, painful eye with a mid-dilated fixed pupil, blurred vision, halos around lights, headache, and nausea/vomiting. The goal is rapid IOP reduction, classically a bundle: topical beta-blocker (timolol), topical alpha-agonist (apraclonidine/brimonidine), topical pilocarpine (miosis to open the angle), plus systemic acetazolamide (oral or IV) and frequently IV mannitol for very high pressures. Definitive treatment is laser peripheral iridotomy.

Dental and ENT Workflows

Avulsed permanent tooth. Handle the tooth by the crown only; do not scrub or sterilize the root (this strips the periodontal-ligament cells needed for reattachment). If dirty, rinse briefly with saline. Best storage media are Hank's Balanced Salt Solution (HBSS), then cold milk, then saline or saliva (in the buccal vestibule) — plain water is the worst because it lyses cells. Reimplant within 5 minutes if feasible; survival drops sharply after 60 minutes of dry time. Primary (baby) teeth are NOT reimplanted.

Epiglottitis / Ludwig's angina (airway-first). For suspected epiglottitis (high fever, drooling, muffled "hot-potato" voice, tripod posture, stridor) and Ludwig's angina (bilateral submandibular swelling with a raised, displaced tongue), the rule is do not agitate and do not instrument the throat. Keep the patient upright, allow a position of comfort, minimize anxiety, give humidified oxygen, and have difficult-airway and surgical-airway (cricothyrotomy) equipment immediately available with the most experienced airway operator present before any attempt.

Epistaxis. For anterior bleeds, sit the patient upright and leaning forward, apply firm continuous pressure to the lower cartilaginous nose for 10-15 minutes, and consider a topical vasoconstrictor (oxymetazoline). Escalate to anterior packing, then suspect a posterior bleed if it does not stop — those need a balloon/posterior pack and admission.

CRAO, Foreign Bodies, and Packing Details

CRAO bridging measures. While ophthalmology is mobilized, classic temporizing maneuvers aim to dislodge an embolus and lower IOP so the retinal artery can perfuse: ocular digital massage (firm pressure for ~10 seconds, release, repeat), IOP-lowering agents (topical timolol, acetazolamide), and having the patient rebreathe into a paper bag or receive a carbogen mix to raise CO2 and dilate the retinal vessels. Because giant cell arteritis can cause CRAO in older adults, an ESR/CRP is drawn and high-dose steroids considered if temporal arteritis is suspected.

Foreign bodies. A corneal foreign body is removed under topical anesthetic with a moistened swab or needle by trained staff, followed by fluorescein to check for residual abrasion or a rust ring. For the ear, an insect is first immobilized with mineral oil or lidocaine before removal to stop painful movement; for the nose, a cooperative child may clear a soft object with positive-pressure ('parent's kiss') technique. Any button battery or paired magnets in the nose or ear is removed emergently because of rapid tissue necrosis.

Hyphema (blood layering in the anterior chamber) is managed with head of bed elevated 30-45 degrees, an eye shield, rest, and IOP monitoring, plus screening for sickle cell trait/disease, which raises the risk of dangerous IOP spikes and optic-nerve injury.