visual diagnoses in the ed

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?