Severe eye injury is a rare call for EMS, but when the severity of the injury triggers a 9-1-1 call, your rapid assessment and care, along with transport to an appropriate facility, can mean the difference between permanent disability and the return to normal life.

Basic Anatomy & Physiology

• The orbit is the bony socket that provides surrounding support for the eye.
• The globe sits inside the orbit and is commonly referred to as the “eyeball.” Covering the front of the orbit is the cornea, a transparent piece of skin. Behind the cornea is the iris, the colored part of the eye, which is made up of muscles that control the amount of light that enters through the pupil.
  
• Directly behind the pupil is the lens, a transparent structure that focuses light rays to form an image on the retina. Located on the posterior aspect of the inside of the globe, the retina converts light into color and transmits electrical images down the optic nerve.
• Behind the lens is a jelly-like substance called the vitreous humor, which fills the inside of the globe. The white part of the globe is called the sclera.

https://www.jems.com/2008/07/31/keep-your-eye-ball-assessing-m/

Sydney Ryan, Assistant Professor, MD

Department of Pediatrics, Division of Emergency Medicine

Background

Globally, more than 250,000 children present to hospitals with serious ocular injuries. These injuries, if not addressed and treated, can lead to infection and loss of vision. Common causes for injury include projectiles (20%), blunt objects (10%), body parts (i.e., fingers, fist) (12%), sharp objects (9%), and motor vehicle accidents (4%). More serious eye injuries were encountered as a result of all-terrain vehicle (ATV) crashes, paintball injuries, and fireworks. Brophy et al. studied pediatric eye-related hospitalization and found there were more than 7,500 admissions in the United States as a result of eye injuries in 2001.

Emergent Ocular Injuries

Ocular chemical injury

Exposure to alkali or acidic chemicals can cause permanent vision loss. Alkali exposure (cleansers, fertilizer, hair dyes, cement, plaster, oven cleaners, drain cleaners, bleach, dishwasher detergent) tends to be worse than acids (grout cleaner, toilet bowl cleaner, glass etching, rust remover, car battery fluid). If you suspect exposure, continuous and copious irrigation with water is indicated to neutralize the pH of the eye. The process can take about 3-60 minutes and often requires sedation. However, getting started early can be helpful in the outcome.

Open Globe Injury

This eye injury is generally related to a traumatic event and can result in obvious corneal or scleral laceration, volume loss to the orbit itself, 360-degree bullous subconjunctival hemorrhage, or iris abnormalities/teardrop pupil.

In this setting:

• Keep patient NPO
• Avoid Ketamine for sedation
• Avoid eye manipulation
• Raise the head of the bed to 30 degrees
• Treat nausea/vomiting
• Secure a protective shield over the eye
• Leave any protruding object in place

Traumatic Hyphema

This occurs generally with blunt force trauma directly to the eye, but sometimes can occur spontaneously. The patient usually presents with decreased visual acuity, eye pain, photophobia, and blood in the anterior chamber. In case the pressure is high in the eye, avoid Ketamine. If you are able, place a shield over the eye and elevate the head of the bed to 30 degrees. Pain control and treating nausea and vomiting is important.

Vitreous Hemorrhage

Following trauma to the eye/face, patient may have vitreous hemorrhage which may indicate retinal tears or detachment. It is commonly associated with abusive head trauma in children. The patient may report hazy vision, and black spots or “floaters” within the visual fields. Patients will need to be evaluated quickly by an ophthalmologist.

Retinal Trauma

Complete or partial retinal detachment can occur following direct or indirect trauma to the eye. Usually this will cause cause light flashes, floaters, visual disruption (shadow or "like a curtain being pulled down"), visual field defect, and loss of peripheral and/or central vision. The defect requires surgical repair.

Orbital Compartment Syndrome

Orbital compartment syndrome can occur in the setting of trauma to the eye and involves elevated eye pressures (orbital fracture, swelling, etc.) that result in poor perfusion to the optic nerve. This is an ophthalmologic emergency and requires a later canthotomy in the emergency department. Physical findings include afference pupillary defect, proptosis, diffuse subconjunctival hemorrhage, and tight/”rock hard” eyelids.

Other Eye Injuries

Corneal abrasion:

Patients generally present with photophobia with reluctance to open eyes and sensation of a foreign body. A flourescin exam is done once pain is managed and the eye is screened for signs of traumatic hyphema or penetrating globe injury. The area under each eyelid is explored to confirm no continued foreign body exists. The patient requires antibiotics and close follow up.

Some exciting news! The 2020 update of the Utah EMS Protocol Guidelines has been released!

Training Opportunities

Peds Resuscitation Training - Free

There is an opportunity for free pediatric resuscitation training for any health care professional (physician, nurse, paramedic, EMT) working in a non-pediatric-specialized ED or hospital setting. https://redcap.chop.edu/surveys/?s=4D39HWCFX3

Free Webinar Series on the Impacts of Covid-19 on Children

ASPR TRACIE and ASPR’s Pediatric Centers of Excellence are collaborating on a webinar series focused on the impact of the COVID-19 pandemic on children. Topics will include impacts on child health and wellness, child emotional and social effects, the impact of COVID-19 on children with special healthcare needs, and how secondary/other disasters may affect children during the pandemic.

• Child Emotional and Social Effects: The second webinar in this series will focus on the emotional and social effects of COVID-19 on children. Panelists will discuss food and financial insecurity, racial disparities, the impact of social determinants on children’s health, return to school and daycare, and alternate child care. This webinar will take place on Friday, October 16, 2020 from 1:00-2:15 PM ET. Register today.

• The Effects of Secondary Disasters on Children: The third webinar in this series will focus on how secondary disasters may affect children during the COVID-19 pandemic. Panelists will discuss sheltering in place versus mass sheltering; family preparedness considerations; wildland fire preparedness and response; the potential impact associated with the 2020-2021 influenza season; planning for pediatric surge; multisystem inflammatory syndrome in children (MIS-C): epidemiology, clinical features, laboratory findings and outpatient approach; and pharmacy and supply chain considerations. This webinar will take place on Friday, October 23, 2020 from 1:00-2:30 PM ET. Register today.

• Impact of COVID-19 on Children with Special Healthcare Needs: The fourth and final webinar in this series will focus on the impact of the COVID-19 pandemic on children with special healthcare needs. Panelists will discuss related programs, the impact of COVID-19 and social determinants on this population of children, behavioral health/ psychological effects, child neglect/abuse, and secondary disaster preparedness planning considerations. This webinar will take place on Thursday, October 29, 2020 from 1:00-2:00 PM ET. Register today.

New CDC study from Utah shows kids in daycare can spread COVID-19

Twelve children who likely caught COVID-19 at three child care centers in Utah went on to spread the virus elsewhere and infected some parents and siblings, according to a new study published last week by the Centers for Disease Control and Prevention (CDC). Previous studies have shown that children age 10 and older could spread the virus in schools. The new Utah study is evidence that even younger kids, including an 8-month-old baby, can still spread the virus, despite not getting severely sick from COVID-19.

How can you protect your family? The study's authors and Intermountain experts recommend all child care facility staff members and children 2 years and older wear masks. Good hand hygiene, frequently cleaning and disinfecting high-touch surfaces, and staying home when ill will also help reduce SARS-CoV-2 transmission. Read the full study.

Current pediatric stats

On October 1, the age distribution of reported COVID-19 cases was provided on the health department websites of 49 states, New York City, the District of Columbia, Puerto Rico, and Guam. While children represented only 10.6% of all cases in states reporting cases by age, over 657,000 children have tested positive for COVID-19 since the onset of the pandemic.
A smaller subset of states reported on hospitalizations and mortality by age, but the available data indicated that COVID-19-associated hospitalization and death is uncommon in children.

At this time, it appears that severe illness due to COVID-19 is rare among children.

Coronavirus Avoidance, a few things teachers can learn from healthcare workers

Utah EMSC put together a training toolbox for teachers entitled Coronavirus Avoidance, a few things teachers can learn from healthcare workers. The toolbox includes posters and signage from PCH/Intermountain on the following topics:

• Six steps to stop the spread of germs
• Cleaning your workspace
• Keeping safe in the break room
• The right way to wear a mask
• Keeping your family safe
• Transitioning from work to home.

There is also a 40-minute recorded zoom training from our Nurse Clinical Consultant Tia Dickson on the topic. Feel free to share the training with your teachers. Access through the link below or contact Tia Dickson at tdickson@utah.gov

https://drive.google.com/drive/folders/1cJbzPOc-D0B-PI1fK-HTJUvaxG_lCAns?usp=sharing

Covid-19 Trackers

Johns Hopkins Global tracker (desktop)

Johns Hopkins Global tracker (mobile)

Utah Department of Health

Effective September 1, 2020 a new collaboration between Primary Children's Hospital (PCH) and the University of Utah burn center started. PCH will now take any pediatric patient FROM THE SCENE with burn +/- trauma. Burn injury in itself is a trauma. These patients will be coming to PCH first for a trauma evaluation. This will include children for whom EMS has concerns of significant inhalational injury. The trauma team will work with a burn team to run the initial resuscitation at PCH and, depending on other trauma-related injuries and potential need for ECMO, the child will either be kept at PCH or transferred to the Burn Unit after stabilization.

Do you have a question for our EMSC Medical Director, Hilary Hewes, MD, PCH, ER Attending Physician about this newsletter topic or anything related to pediatrics? Shoot an email to the address below.

tdickson@utah.gov

Contact PCH EMS Liasion Lynsey Cooper at Lynsey.Cooper@imail.org

OR use the dedicated EMS follow up email

PCH-EDRTU-EMS@imail.org

If you are a pediatric advocate within your agency, we need you. Please contact our program manager, Brianne Glenn (brianneglenn@utah.gov) to find out how you can help.

Pediatric Education for the Prehospital Provider

Register online at peppsite.org. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($18.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at eandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, no matter where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth