Paramedic National EMS Education Standard

NORTHWEST COMMUNITY EMERGENCY MEDICAL SERVICES

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EEyyee && EEaarr DDiissoorrddeerrss && TTrraauummaa Questions/comments are welcome. Please direct to Jen Dyer, RN, EMT-P EMS Educator NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 1

Paramedic National EMS Education Standard Integrates assessment findings with principles of pathophysiology to formulate a field impression and implement a treatment/disposition plan for patients with eye and ear disorders/trauma.

Objectives: Upon completion of the class and review of the independent study materials and post-test question bank, each participant will do the following with a degree of accuracy that meets or exceeds the standards established for their scope of practice: 1. Identify the anatomical structures of the eye and describe the corresponding physiologic function of each. (C) 2. Explain the physiology of normal vision. (C) 3. Identify the anatomic structures of the ear and describe the corresponding physiologic function of each. (C) 4. Explain the physiology of normal hearing. (C) 5. Explain the physiology of equilibrium. (C) 6. Select and discuss maneuvers for assessing eye structures and functions (C) and demonstrate a thorough EMS assessment of ocular structures, visual acuity, pupils and ocular movements. (P) 7. Distinguish abnormal assessment findings/conditions of the eye: blurred vision, diplopia, photophobia, changes in vision, flashing, pupil exam, Adie’s pupil, oculomotor nerve paralysis, Horner’s Syndrome, blindness, deviation/paralytic strabismus, orbit fracture, cataracts, conjunctivitis, color blindness, near sightedness, farsightedness, astigmatism, amblyopia, burns of the eye, corneal abrasions, foreign body, inflammation of the eyelid, glaucoma, hyphema, iritis, orbital cellulitis, macular degeneration and trauma. (C) 8. Associate pathophysiology with abnormal assessment findings for the eye. (C) 9. Distinguish abnormal assessment findings for conditions of the ear: drainage, deafness, foreign body; impacted cerumen, labarynthitis, Meniere’s disease, otitis externa and media; perforated tympanic membrane, and blast injury. 10. Associate pathophysiology with abnormal assessment findings for the ear. (C) 11. Discuss exam finings as aided by an otoscope. (C) 12. Predict eye injury/conditions as they relate to various mechanisms of injury or illness. (C) 13. Predict ear injury/conditions as they relate to various mechanisms of injury or illness. (C) 14. Interpret assessment findings to formulate EMS impression for diseases/injury to the eyes. (C) 15. Interpret assessment findings to formulate EMS impression for diseases/injury to the ears. (C) 16. Formulate a plan of care and establish care priorities for illness and/or injury to the eye. (C) 17. Formulate a plan of care and establish care priorities for illness and/or injury to the ear. (C) 18. Describe the etiology, clinical presentation and emergency management for patients with a retinal artery occlusion and acute glaucoma. (C) 19. Propose, value and defend modifications to EMS practice in response to challenges faced by elderly patients who experience changes in vision and/or hearing. (A) 20. List the necessary equipment and sequence the critical steps for the instillation of eye drops. (C) 21. State the action, dose, route, indications, contraindications, precautions, and side effects of Tetracaine (0.5% solution Pontocaine) topical eye drops. (C) 22. Identify indications for the procedure, list the needed equipment, and explain the process of irrigating an eye using traditional methods and using a Morgan lens. (C) 23. Describe the correct method to remove a contact lens based on the System procedure manual. (C) 24. Describe and demonstrate the correct method to shield an injured eye. (P) 25. Defend the need for a thorough EMS assessment of the eyes and ears to effectively identify conditions and injuries, minimize damage and loss of function, and ensure disposition to the most appropriate hospital. (A)

Key: C: Cognitive objective P: Psychomotor objective A: Affective objective

NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 2 Eye Anatomy and Physiology

Eye function is dependent on an exact maintenance of anatomical relationships between the eyelids, ocular structures, extraocular muscles, and nerves. Permanent deficit in any may result in altered visual acuity and possible eye loss. Complete information on eye A & P, which is assumed knowledge, is found in the Independent Study Materials document.

Goals of emergency care: 1 Protect intact portions of the visual system 2 Avoid further injury to undamaged parts 3 Accurately assess the eye for illness/injury 4 Transport for immediate definitive care/repair 5 Preserve optimal function 6 Optimal cosmetic results

Eye Assessment General examination of eye function begins with assessing the chief complaint and history while beginning the assessment of the ocular structures and function. The only exception to this is in the event of a chemical splash or burn to the eye where the only visual acuity required is to determine if the patient can see light before eye irrigation is immediately started.

Eye injuries are substantial distracting injuries, to both pt & caregiver. If MOI suggests potential for head or spine injury, spine motion precautions should be followed! Also, many eye and ear assessment findings may be due to CNS etiologies. Beware of the potential for not-so-obvious traumatic and neurologic emergencies.

Chief Complaint Perform simultaneously w/ eye exam. Nature of complaint: traumatic vs. non-traumatic Non-traumatic: Usually divided into complaints of vision, appearance or sensation. Obtain details regarding the rapidity of onset, duration, intermittence and frequency. Note associated symptoms. Traumatic: Blunt, penetrating, sharp or explosive; thermal, UV; time and course of events. Ask about any change in vision, and if so, was it immediate, sudden or gradual? If chemical burn, ask if it was toxic, acid or alkali. Determine any treatment rendered prior to arrival. Caveats ¾ Blunt MOI often leaves soft tissues intact –may be no evidence of internal trauma in prehospital environment ¾ Visual disturbances may be an early indicator of stroke, tumor, or other CNS disorder

SAMPLE History Signs/symptoms: Obtain details about onset, provocation (what object or item caused the injury - magnetic?)/palliation, quality, region/recurrence, severity, and date and time of injury. Ocular pain; redness; burning; spots; change in vision; blurred; diplopia; halos; excessive tearing; crusting; discharge. If applicable, occupational history: dust, chemicals, metalwork, use of protective devices. Symptoms in one or both eyes? Eye injuries may be difficult to identify in patients w/ normal vision. The following should be approached w/ a high index of suspicion for serious ocular trauma. y Obvious trauma w/ eye injury y Vision loss or blurred vision that does not improve w/ blinking Diplopia (double vision) y Diplopia may indicate trauma to the globe with muscle entrapment or nerve deficit, peripheral or central y Monocular diplopia usually indicates a refractive error in the eye itself y Binocular diplopia, present only when both eyes are open, is the result of a deficiency in the movement of the eye Allergies NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 3 Medications: y Regular use of eye medications or over-the-counter remedies including drops or ointments y Use of anticoagulants y Recreational drug use - they can affect pupil size and reactivity

Past ocular history: y Photophobia y Ocular disease or visual loss? Glaucoma? Cataracts? y Blurred vision that does not improve with blinking y Diplopia y Sectorial visual loss y Spots before eyes, curtain over the visual field? y Halos or rings around lights y Eye injury/surgery Baseline visual acuity; Corrective lenses or contacts? How long? If contacts are worn: hard, soft, extended wear? For reading, driving, distance? Past medical history in self or family y Heart disease, hypertension y Diabetes y Sickle cell disease y Liver disease y Vascular disorders Last oral intake Events surrounding the incident: Details regarding probable size, velocity, and chemical constituency of pellets or projectiles; determine treatment rendered prior to arrival.

Contact Lens Removal – See procedure manual for all steps Lenses should only be removed if irrigation is required or if eye drops will be administered, and in the case of burns. Unnecessary removal in the prehospital environment may cause additional trauma or irritation.

y Prepare equipment: BSI; Sterile NS; lens case; towel or 4X4s; suction cup (optional) y Remove external loose debris by gently touching adhesive tape against closed lids. Remove dirt, blood or makeup from lids. Do not dislodge clots. y Place 2 mL sterile saline into each specimen cup. Label containers L & R. y If eye appears dry, instill several drops of preservative free saline and wait a few minute before removing the lens, to help prevent corneal damage. y Locate the lens. It can be seen moving on cornea when pt blinks or by looking sideways across the eye y Position lens totally on sclera or cornea. It is safer for the lens to be entirely on the sclera or cornea than partially on each. If unable to remove, slide to either position. y With index finger, raise and hold upper lid against orbital rim. Gently pull lower lid down w/ thumb Soft lenses: y Have pt look up. y Slide the lens downward onto the sclera w/ index finger of your free hand. y Compress or pinch lens gently between index finger and thumb Hard lenses: y Pull upper lid towards ear w/ one thumb y W/ other thumb on lower lid, index finger on upper lid, move lids toward each other to trap lens edges & break suction y Gently press lids together toward lens. Pop or slide lens out between the lids y Remove the lens and place it in the prepared container. If using suction cup for hard lenses: y Wet suction cup w/ saline y Raise upper lid w/ index finger & lower bottom lid w/ thumb y Press suction cup gently to center of lens & pull cup and lens directly away from eye NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 4 Physical exam of the eye

Eye position and alignment: Stand in front of patient and inspect external eye from top to bottom and medial to lateral Bony structures: Palpate entire orbital rim for S&S of fracture Eyelids Examine lids closed & open. Inspect for symmetry. They should spontaneously lift & close to cover superior limbus (point where cornea connects to iris) by 1 -3 mm

y Ptosis: If lid cannot open and covers more of one iris than the other side or extends over the iris, this indicates congenital or acquired weakness (paresis) of the levator muscle (branch of CN III – Oculomotor nerve) y If lid cannot close, suspect trauma or dysfunction of CN VII (Facial nerve), which innervates the orbicularis muscle (ex: Bells palsy, stroke) y Inspect for edema, discoloration, lesions, drainage and lacerations (can be assoc w/ penetrating trauma to globe; assess carefully!) Lashes and sebaceous glands: Assess for crusting, scaling, hair loss, pus, blood, CSF Ask patient to look up. Depress both lower lids w/ thumbs. Conjunctiva: Using a penlight, inspect for redness, inflammation, foreign body, rust ring, drainage, laceration, pus, bleeding, or chemosis Chemosis: Abnormal swelling of the mucous membrane covering the eyeball and lining the eyelids (conjunctiva). Usually due to local trauma or infection. May also occur in acute conjunctivitis. Rust rings occur when a metal FB attaches to the surface of the eye and rusts. The ring should be removed by a physician as soon as possible, as it may retard healing.

Sclera: Should be white [Abnormal findings: jaundice; bluish (may suggest Marfan’s Syndrome)] Assess for redness, drainage, inflammation, laceration, hemorrhage, FB, black defect (choroid prolapse)

Cornea Should be smooth, round, clear, glistening, free of lesions Inspect for blood in the anterior chamber under the cornea (hyphema); abnormal pigmentation; retained FB Clouding/opacities may be due to glaucoma; edema; foreign body (FB); or infection Corneal lacerations/abrasions not necessarily evident on gross exam – usually identified w/ fluorescien staining and exam with blue light at the hospital

Iris Should be round, flat and smooth. In trauma, may show tears and holes. These may cause pupil irregularities. If torn, suspect ruptured globe. Visual acuity “Vital sign” of the eye - allow patient to use contacts / glasses Exception to detailed exam: chemical burn to eye Assess best vision in each eye separately using a Rosenbaum near card y Shield eye not being tested (all methods of testing) y Assess injured eye first y Hold card in good light; 14 in. from eye y Note smallest line pt can read without squinting or straining y Must have minimum 50% correct to read line correctly If pt unable to read any lines on Rosenbaum card, test ability to count your fingers held at a distance of 12 inches from the eyes y Change number of fingers displayed each time y Note distance at which pt is able to correctly identify fingers If pt unable to see/count fingers, assess ability to detect hand motion at 12 inches y Move hand back and forth, up and down y Note distance at which pt is able to correctly see movement If pt is unable to detect hand motion, wave a light back and forth in front of pt (test each eye separately). If pt is able to see light, document visual acuity as “LP” (light perception). If they cannot see light, document “NLP” (no light perception or blind eye).

NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 5 Visual fields y Test eyes separately; one eye covered y Pt focuses on examiner’s nose y Move a different number of fingers into each of the R & L upper and lower visual fields y Pt identifies number of fingers displayed y Note any field without vision Extraocular movements (EOMs) y Assesses 6 cardinal positions of gaze y Instruct pt to focus on your finger, and follow it w/ only his/her eyes y Move finger in an H pattern: center, left, right, upward, downward y Both eyes should move equally and completely through all quadrants

Pupil assessment y Simultaneously assess pupils for size, shape, and equality prior to light response assessment y Normal size is 3-7 mm; EMS may report as midpoint, small or pinpoint, large or dilated y Shape: should be round; note if other shape (keyhole, teardrop, oval) y Equality: should be roughly equal size when viewed simultaneously Reactivity to light – direct y Assess each eye separately y Should be done in as dim light as possible y Instruct pt to look straight ahead at a distant point y Beam light into the pupil from the side (not straight on ) y Constriction should be brisk and at least 1 mm y Note if reaction is brisk, sluggish, or nonreactive Consensual light response: y Beam light into one pupil y Assess the OPPOSITE pupil for constriction (should match examined eye)

Accommodation – not usually assessed by EMS y Instruct patient to focus on your finger held at a distance y Move the finger towards their nose y Observe that the eyes should converge and the pupils should constrict when focus changes from far to near y Done in ambient light

Eye Assessment Findings and Management

Pain Common causes • Chemical splash/burn • Particles/FB • Corneal abrasions • Penetrating injuries • Infection/inflammation of ocular structures • Glaucoma with high intraocular pressure Management: Depends on MOI & injury / condition

Tetracaine – see drug profile at back of SOP y Topical anesthetic y Indications: Pain due to superficial eye injury (corneal abrasion); prior to eye irrigation y Contraindications: Penetrating globe injury y Dose: 1-2 gtt in affected eye; repeat prn y Onset: 25 sec. y Duration: 15 min. or longer y Caution pt not to rub or manipulate eye or lid! NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 6 Instillation of eye drops - procedure • 6 Rights of Med Administration • Gross visual acuity done? • Lenses removed? • BSI • Examine package for integrity • Check solution for color, clarity, exp. date • CONFIRM: absence of penetrating/perforating injury • Grasp container upside down w/ dominant hand • Steady hand against pt’s forehead • W/ free hand, pull down lower lid, creating a reservoir (conjunctival sac) • Instruct pt to look up & to side • Instill drops into conjunctival sac, NOT onto eyeball • Instruct to blink if possible • Blot around eye w/ clean gauze or tissue Fentanyl – see drug profile in SOPs • Dose: 1 mcg/kg (max 100 mcg) IV IO IN IM • May repeat 0.5 mcg/kg (max 50) in 5 min. • Elderly (> 65 y/o) or debilitated: 0.5 mcg/kg (max 100 mcg) IV/IN/IM/IO • Add’l doses require OLMC: 0.5 mcg/kg q 5 min. up to total of 300 mcg • Onset: minutes • Peak: 3-5 min. • Duration: 30-60 min. • Contraindications: o Allergy o Resp depression o Hypotension o Myasthenia gravis o Acute/severe asthma o AMS

Soft Tissue Injury (Contusion) AKA “Black Eye” Potential for other serious injuries Unilateral - may indicate orbit floor fx Bilateral - may indicate basilar skull fx Complete ocular exam indicated! Management: Cold pack if closed injury; pain management

PUPIL Abnormalities Blunt trauma etiology: direct trauma to iris sphincter muscle (suspect serious injury to optic nerve, globe) Non-traumatic etiologies: Drug use, CNS disease, history of ocular surgery, anisocoria, stoke, previous injury, cataracts, hypothermia Pupil Asymmetry Anisocoria: About 15% of the population has “physiologic” anisocoria (normal) where the pupil size may vary by 20%. In fully conscious patients, without injury or previous eye condition, size difference without other findings seldom suggests emergent pathology. If “physiologic”, the pupils should be asymmetric in both bright & dim lights. BEWARE: A >1 mm pupil size difference in patients w/ AMS is significant for neuro emergency! Pathologic etiologies • Direct blunt eye trauma • Intraorbital trauma • 3rd cranial nerve palsy • Unilateral blindness • Intraocular inflammation • Inflammation of iris • Stroke NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 7

Adie’s Pupil: NEW in the EMS Education Standards. In this condition, the affected pupil is larger than the non-affected side and constricts slowly in bright light (tonic pupil). The patient experiences neuro/Sympathetic nervous system S&S: absence of Achilles tendon reflexes, excessive sweating on affected side Etiology: Possibly viral infection causing damage to neurons in the area of the brain that controls eye movements & area of spinal cord involved in Autonomic nervous system (ANS) response Most common in young women

Horner’s Syndrome – NEW in the EMS Education Standards Rare disorder due to Sympathetic nerve damage in stroke, tumor or high spinal cord injury (SCI). The pupil size on the affected side is small or pinpoint accompanied by ptosis (drooping upper eye lid) and slight elevation of the lower eyelid. These changes are more noticeable in dim light. Decreased or absent sweating on affected side of face.

Oval-shaped pupil: Usually indicates impending brain herniation. Increasing intracranial pressure exerts pressure on CN III (Oculomotor nerve) which regulates pupil size and shape. A thorough neuro assessment is important unless EMS notes obvious physical trauma to the eye. Watch for the pupil to rapidly dilate and constrict like it is jiggling up and down when tested for the light reflex. This finding is known as hippus. If seen in both eyes, herniation has occurred Management: request OLMC order for controlled hyperventilation

Anterior chamber abnormalities: Hyphema Definition: Vessels rupture allowing blood to accumulate in the anterior chamber under the cornea. Red blood indicates a new bleed and brown indicates an older event. Bleeding is limited as vascular pressures and intraocular pressures equilibrate. Allowing the patient to sit up will eventually result in gravity causing the blood to settle inferiorly (hence crescent shape) Clinical significance: This usually results from severe blunt trauma to the eye, but could also suggest a perforating injury or open globe. It may also indicate significant force applied to the eye – suspect spine injury Presentation: y ↓ visual acuity (visual acuity is impaired when blood obscures the pupil opening). The hospital will score the severity according to how much of the iris and pupil are covered, 4 being near total coverage, known as an “8- ball hyphema” • C/O “seeing red” • Pain, N&V which may signal increasing intraocular pressure (IOP) An increase in IOP in the anterior chamber will pose a threat to vision. Also a concern if blood clots in the canals connecting the anterior and posterior chambers. A clot may cause an acute rise in intraocular pressure Management: y HOB up 30° - 45° (facilitates settling of hyphema away from the visual axis) y Shield involved eye with a paper cup (prevents re-bleeding); DO NOT apply pressure to the eye! y Do not allow pt to read y Sedate if overly anxious (OLMC order) y Note & record “height” of hyphema y Medicate for pain & nausea

NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 8 Extraocular Movement (EOM) Abnormalities May be related to orbital fx resulting in orbital content trauma or cerebral edema, &/or cranial nerve dysfunction Note! If related to head trauma - consider: • Need for spine motion restriction • Assessment for basilar skull or facial fx • Need to maintain CPP w/ minimum SBP 110 • AMS? check glucose • Thorough neuro assessment • Sedation or restraint prn • Seizure precautions • Watch for S&S of ↑ ICP

Orbital (“Blowout”) Fracture Definition: Blunt ocular trauma causes thin inferior & medial orbital bones to fracture. The fractured bones separate briefly while pressure is applied and then realign allowing orbital contents (esp. ocular muscles) to drop through fx at time of injury to become entrapped in maxillary sinus. About 1/3 have associated eye injury. May be seen with other facial fractures. Clinical S&S • Swelling; ecchymosis • Inability to look upward (indicates possible EOM entrapment) • Pain upon attempted upward gaze • Chemosis • Visual changes possible (clot around optic nerve or retinal damage); diplopia due to abnormal positioning of eye • Tender upper orbital ridge; possible crepitus • Subconjunctival hemorrhage • Enophthalmos (sunken appearance to eye) if orbital fat entrapped • Nosebleed on affected side • Hyperacute or no feeling in cheek or upper lip on affected side (indicates significant stretching or tearing of infraorbital nerve – see area in yellow on image) Management y Apply cold pack if no globe rupture; pain management with Fentanyl y Caution pt against blowing nose, sneezing, etc.

Oculomotor Nerve (CN III) Paralysis CN III moves the eye up, down, and in to the nose; and lifts the eyelid It controls pupil size, shape, and equality Dysfunction is evidenced by ptosis, gaze palsy (eye is pulled to ear), diplopia, and pupil on affected side dilates. These findings can be seen in patients with a cerebral aneurysm or brain shift

Ruptured (open) Globe Any full-thickness injury to the cornea, sclera, or both is considered an open globe injury y Penetrating injury: disruption of outer coats of eye, w/o interrupting the anatomic continuity of the entire eye y Perforating injury: complete anatomic disruption of sclera or cornea; may / may not be assoc. w/ prolapse of internal structures Management: • Assess and treat pain (tetracaine contraindicated!) • Do not remove impaled objects – stabilize them in place • Do not irrigate eye NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 9 • Shield injured eye to prevent pressure on globe. Cup should rest on the bones of the brow & cheek • DO NOT patch eye directly under shield • Pt must not be able to touch or rub eye • DO NOT shield the uninjured eye • Elevate head of stretcher 45° • Discourage sneezing, coughing, straining, bending • Vomiting precautions

Vision Abnormalities:

Blurred vision or double vision (Diplopia) A thorough history of present illness is essential! Any hx of trauma? Pay special attention to onset – acute, gradual, or slow/chronic? One eye or both? Cover one eye – does the diplopia resolve or not? Many of these will be time-sensitive patients Acute onset etiologies: y Retinal detachment y Ocular trauma y Stroke (refer to stroke SOP)

Retinal Detachment Separation of retina from blood supply (choroid) due to tear, fold or rent These tissues are paper thin & tear easily w/ significant trauma. This allows the accumulations of subretinal fluid under the neurosensory layer Etiology: 15% due to trauma; chronic disease (HTN, DM) More common in people > 40 y/o S&S: • Painless vision or visual field deficit • Blurred vision • Darkening or haziness • Curtain being drawn over visual field • Photopsia (flashes of lights or sparks) • “Floaters” or black dots • In the absence of trauma hx, there is nothing on external exam to alert you to the problem except awareness of S&S! Management • Keep pt quiet, supine • Definitive treatment: surgery • Limiting time to treatment ↓ risk of permanent vision loss • May be asked to cover both eyes to minimize movement – DO NOT apply pressure patch!

Vision Loss Causes: • Lid swelling • Blood or F/B covering cornea; corneal damage • Hyphema • Vitreous hemorrhage • Traumatic cataract • Injury to lens • Central retinal artery occlusion (CRAO) • Retinal edema/hemorrhages • Acute angle closure glaucoma (The iris bulges forward & either narrows or blocks the drainage of aqueous humor from the drainage system at the angle formed by the cornea and the iris. As a result, the pressure in the anterior chamber increases abruptly. Angle-closure glaucoma usually occurs suddenly, but it can also occur gradually (chronic angle-closure glaucoma). • Damage to Optic nerve (CN II) NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 10 • Hysteria (physical symptoms that do not have a physical cause), malingering (intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs), loss of contact lens Management • Be alert for time-sensitive cause • Supportive care unless ordered by OLMC to provide intervention – as in CRAO (give NTG to dilate vessels; ocular massage) • Protect from further injury (falls, etc.)

Ocular Foreign Body Usually involves cornea or conjunctiva and are caused by dirt, dust, glass, cinders, metal fragments Most do not completely penetrate globe, but create irritation or a retained FB Possible indicator of intra-ocular trauma, esp. in setting of metal working w/o protective eyewear Always suspect penetration in higher velocity injuries S&S y Pain y FB sensation ((may be worse w/ blinking) y Photophobia y Blurred vision y Eyelid edema Management • Remove only loose debris from brows or lashes • Evert lids – check for FB • Tetracaine 0.5% 1 gtt as long as no evidence of open globe • Fentanyl if pain is severe • Non-embedded FB only: Irrigate or remove w/ moistened cotton-tipped applicator

Krazy Glue (Cryanoacrylate) Management y Irrigate w/ warm water 15 minutes minimum (warmed NS for IV, or warm tap water are OK) y Do not pry lids open or try to remove residual glue y Do NOT apply acetone, ethanol solutions y Mineral oil can be applied if available y Corneal abrasion may result from removal

Corneal Abrasions – One of the most common eye injuries Etiology: Superficial trauma (abrasion) to corneal epithelium; Esp. common w/ contact lenses S&S: • FB sensation • Pain (worse w/ light, air) • Photophobia • Excessive tearing • Lid spasm • Diffuse conjunctival redness • Possible ↓ visual acuity Management • Evert upper lid to evaluate for retained FB • Elevate head of stretcher 45° • Tetracaine if no suspicion of penetrating injury • Apply pressure patch to affected eye to help alleviate pain w/ eyelid movement: 2 pads w/ tape running from bone to bone diagonally; lift cheek prior to placing 2nd strip of tape and then release to create pressure over patch. • DO NOT PATCH if pt wears contacts!

NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 11 Ocular Burns The eyelids offer some protection from ocular burns associated w/chemicals & heat. That protection is lost w/ burns involving light and radiation. Sources of ocular burns: acids, alkalis, irritants, radioactivity, light, and heat.

Chemical Splash / Burns Acids: Acid contacts eye → tissue proteins released → protective barrier → prevents further penetration of eye tissue. Injury usually limited to external surface with no ongoing tissue destruction or collagen swelling Alkali - Worse than acid burn • Breaks down surface cells → denatures proteins of lids & conjunctiva → rapid penetration of cornea and anterior chamber • pH > 8 → chemical keratitis • pH > 11.5 → intraocular penetration & irreversible damage S&S • Severe pain • Diminished or blurred vision • Chemosis • Possible limbal blanching • Localized redness and edema • Sloughing of corneal epithelium • Corneal clouding after acute phase Always bring MSDS or product label! Note exposure time; pH & concentration of substance if known; time to initial irrigation

Management • Do not delay treatment while trying to determine nature of substance • Remove contact lenses • Rapid visual acuity for light perception only • Tetracaine drops if severe pain or spasm • Immediate and profuse eye irrigation • Do not attempt to neutralize the chemical

Eye Irrigation – see procedure manual Equipment: NS, regular IV tubing, tetracaine drops, towels, gauze pads, bath basin Procedure y Remove contact lenses y Explain procedure y Instill tetracaine y Position w/ affected eye downward y Towel around neck, gauze above/below lids y Basin to collect fluid y Instruct pt to look up; pull down lower lid y Aim fluid: inner canthus to outer y Ask pt to look down; retract upper lid & irrigate y Repeat tetracaine as needed Morgan Lens – NEW INFO • Molded lens fins, tubing & adaptor • Lens inserts under upper lid, then lower • Required to cover by new EMS Education Standards although use is becoming controversial • Allows for continuous hands-free eye irrigation • Will not be used in NWC EMS System

NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 12 Eye Irritants - pH 7 → ~ 10 Includes most household detergents; produces discomfort but usually no actual damage Pepper spray - significant temporary pain and tearing but usually does not permanently affect vision; rarely causes any damage to the eye. See clinical alert sent out before NATO summit in May 2012. Apply baby shampoo to face and eyelids to break down chemical. Then irrigate.

Thermal Ocular Burns - Usually w/ facial burns Sources: • Flash burn • Fiery explosion (R/O perforating injuries, FB) • Hot liquids • Molten metal Management • Cool the burn • Moist, sterile dressing over eye only • Leave contact lenses in place

The EAR The ear is the primary structure for hearing and balance, but it is also integral to self-protection. Disorders and injury can leave the person unable to communicate and develop social skills, react and maintain equilibrium. A&P: Assumed knowledge and can be reviewed in the ISM document. Assessment Assessment of the ear canal and middle ear cannot be done adequately in the prehospital environment. Fortunately, conditions involving the ears are not life threatening unless they are a symptom of a much more serious problem y When obtaining H&P, note presence of hearing aid y Inquire whether S&S are related to swallowing, sneezing, coughing, bending y Ask about recent ear popping, itching, recent URI, flying, or scuba diving y Inspect for Deformity, Contusion, Abrasion, Penetration/Puncture, Burns, Tenderness, Laceration y Inspect ear for drainage; mastoid area for discoloration (Battle sign) y Palpate skull & facial bones around the ear Otoscope NEW in the National Education Standards Instrument that allows examination of the ear canal and tympanic membrane (TM) for discharge, foreign bodies, and conditions indicating illness. Is not being added to NWC EMSS practice at the present time. Normal exam: • Ear canal should be free of inflammation (signals infection) • Tympanic membrane should be translucent or pearly gray (pink/red indicates inflammation)

Hearing y Softly whisper a phrase, word or number in each ear. Ask the pt to repeat it. y Note whether pt is experiencing any abnormal sound or auditory sensation (ex: tinnitus or ringing in the ears) y OPQRST hx

Ear trauma MOI y Blunt: MVC, sports, interpersonal violence y Penetrating: gunshot, laceration, FB, puncture y Temperature: Because of its position, the ext. ear is prone to injury from temperature extremes, such as frostbite & burns y Blast: explosion y Pressure: underwater diving

NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 13 Signs of infection (Infection can occur inside the ear and on the outside) y Pain y Redness, swelling, tissue warmth and/or fever y Irritation; drainage y Hearing deficit

Ear drainage What injury should be suspected in pts w/ bloody or serous ear drainage (Otorrhea)? Management • Cover loosely (4X4s) • Do not pack or attempt to slow/stop drainage Note: Checking to see if drainage is CSF by collecting it on a 4X4 and looking for a halo is not a reliable finding.

Ear lacerations

y Earlobes are highly vascular but ear cartilage is not – heal well when avulsed lobes reattached y Where should this patient be transported? (closest Level I or II) Management • Bleeding control – hemostatic dressings may be needed • Bandage ear gently; • Cold pack • If partially detached, tape in place under bandage • Total avulsion: Package and transport the amputated part wrapped in gauze barely moistened with NS, cover w/ water-proof barrier, place on cold packs

Foreign Bodies: Assessment in the prehospital setting is limited to visual clues from external inspection only • Mostly seen in the peds population • FB are usually solid, but kids may put vegetative matter in their ears, and insects really do crawl into ear canals • To inspect for FB: gently pull earlobe back, and shine a penlight into the ear canal • Commonly encountered objects in the ear: beads, small toys, pebbles, buttons, vegetables, crayons, bolts, screws, sticks, paper, insects S&S: Sensation of fullness, pain or discomfort, or something in the ear ↓ hearing in affected ear Swelling of external ear Drainage (bloody, purulent) Foul-smelling discharge Most FB’s in the ear are not medical emergencies. Exceptions: y Button-type batteries must be removed ASAP as they cause chemical burns y Food and plant material can swell from the moist environment, and become difficult to remove y Presence of insect in the ear may be very upsetting or unpleasant – OLMC for possible sedation Management • Never attempt to remove a FB lodged within the ear canal • Stabilize protruding object; transport w/ supportive care

NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 14 Otitis Media Infection or inflammation in the middle ear, between the eardrum and inner ear, and involves the eustachian tube y Most commonly seen in pediatric pts y Often follows URI y Be alert to subtle S&S in young pts w/ limited communication skills S&S: • Chills, fever • Severe pain; ear tugging • Ear noise or hearing loss • Malaise; irritability; poor feeding • N&V Management y Supportive care only; may be dehydrated from fever and poor fluid intake y Not usually an emergency, but a risk for meningitis if untreated. Infection can travel from the middle ear to the brain and may lead to permanent hearing loss

Ruptured Tympanic Membrane Common causes • Pressure (diving, water skiing) • Direct blows • Explosion/barotraumas • Foreign objects • Often assoc. w/ infection/otitis media S&S • Pain (may dissipate after rupture) • Hearing loss • Hemorrhagic otorrhea Management • Supportive care • Loose dressing to absorb otorrhea • Pain management

NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 15

NWC EMSS Skill Performance Record CONTACT LENS REMOVAL: HARD LENSES

Name: 1st attempt: Pass Repeat Date: 2nd attempt: Pass Repeat

Instructions: An adult has experienced ocular trauma but the globe appears intact. You are asked to remove the hard contact lenses.

Performs Performs Needs Performance standard w/o w/ additional coaching coaching practice *Obtain rapid gross visual acuity Can read name badge Sees shape/shadow/motion Can count fingers Sees light projection only NLP *Prepare and assemble equipment Contact lens storage case or 2 containers w/ lids Suction cup - optional Sterile saline without preservatives Towel or 4X4s * Apply BSI (gloves) Prepare patient Remove external debris by gently touching adhesive tape against closed eyelids. Gently remove dirt, blood, or makeup from eyelids with 4X4s moistened with saline or cotton applicators. Do not dislodge clots. Place 2 mL. of sterile saline into each specimen cup and label containers L & Rt. If a lens case is used, place a few gtts of saline into each compartment. If eye appears dry, instill several drops of preservative-free sterile saline solution and wait a few minutes before removing the lens to help prevent corneal damage. Locate the lens in each eye: Can be seen moving on cornea when pt. blinks or by

looking sideways across eye - shine a penlight across the eye. Critical steps: It is safer for the lens to be entirely on sclera (white) or cornea (color) then

partially on each. So if unable to remove, slide to either position. Using one thumb, pull the pt's upper eyelid towards the lateral orbital rim (towards ear) With other thumb on lower lid, and index finger on upper lid gently move the lids towards

each other to trap the lens edges and break the suction. Gently press eyelids together toward lens. Use slightly more pressure on lower lid when

moving it toward bottom edge of lens. Pop or slide the lens out between the lids Remove the lens and place it in prepared container Remove and care for the opposite lens in the same manner Examine the eyes for redness or irritation Optional approach: Suction cup removal of hard lenses Wet the suction cup with a drop of saline Gently pull up the upper lid with index finger and pull lower lid down with thumb

Press the suction cup gently to the center of the lens Pull the suction cup and lens away from the eye in a straight line Place the lens in the prepared container State one complication of the procedure:

Trauma after touching cornea w/ suction cup or attempting to remove dry lenses

Scoring: All starred (*) items must be answered/performed correctly in order for the student to complete this station. Any errors or omissions of these items will require a repeat. Recommendation: Excellent knowledge of material; no coaching needed. Satisfactory knowledge of material: minimal coaching needed. Could not perform some points even with coaching; recommend practice/repeat. NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 16

NWC EMSS Skill Performance Record CONTACT LENS REMOVAL: SOFT LENSES

Name: 1st attempt: Pass Repeat Date: 2nd attempt: Pass Repeat

Instructions: An adult has eye trauma but the globe appears intact. You are asked to remove the soft contact lenses.

partially on each. So if unable to remove, slide to either position. Raise upper eyelid with index finger and hold it against the upper orbital rim. Place thumb

on lower lid and gently pull down. Have patient look up and slide the lens downward onto sclera (white of eye) with index

finger of other hand Compresses or pinch lens gently between index finger and thumb Remove lens from eye and place in separate, clearly marked ("right" and "left") containers

filled with sterile saline solution State one complication of the procedure:

Trauma as a result of touching the cornea while attempting to remove the lenses.

Evaluator

CJM 2/10 NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 17

NWC EMSS Skill Performance Record EYE IRRIGATION

Name: 1st attempt: Pass Repeat Date: 2nd attempt: Pass Repeat

Instructions: An adult has experienced a chemical splash to their eyes. You are asked to assemble the equipment and perform eye irrigation.

Determine care provided prior to EMS arrival * Prepare and assemble equipment 1000 mL NS IV Gauze pads Towels Regular IV tubing Tetracaine gtts Bath basin * Apply BSI (gloves) Prepare patient – move as quickly as possible

Obtain history for contact use; remove contact lenses if in place Explain procedure to patient if awake * Ask patient to look up, pull lower eyelid downward and instill 1-2 gtts of tetracaine in the conjunctival cul-de-sac. Ask patient to roll eyes back and forth if possible to distribute gtts. Position patient on side with affected eye downward or turn head to side

Place towel around neck; position bath basin to collect liquid Perform procedure * Apply dry gauze above and below eyelids * Ask patient to look upward and gently pull down lower lid * Irrigate, aim fluid from inner to outer canthus, avoid direct stream on cornea Remove any particulate matter with a moistened cotton applicator * Ask patient to look down and gently retract upper lid. Irrigate under upper lid. Continue irrigation enroute, repeating installation of tetracaine prn

Evaluator

CJM 7/10 NWC EMSS Con-Ed Eye and Ear Disorders and Trauma September 2012 – page 18

NWC EMSS Skill Performance Record EYE PRESSURE PATCH

Name: 1st attempt: Pass Repeat Date: 2nd attempt: Pass Repeat

Instructions: An adult has sustained a possible corneal abrasion. You are asked to pressure patch the affected eye.

Performs Performs Needs Performance standard w/o w/ additional coaching coaching practice *Obtain rapid gross visual acuity Can read name badge Sees shape/shadow/motion Can count fingers Sees light projection only NLP * Inspect the eye for signs of perforation or penetration *Prepare and assemble equipment Tetracaine eye drops Oval eye patches (2) or 4x4 gauze (2) for each eye to be patched Tape - at least three 9" lengths Towel or 4X4s *Apply BSI (gloves) State one contraindication to the procedure: Eye irritation as a result of infection

Suspected open globe evidenced by hyphema, leak of aqueous or vitreous humor, teardrop shaped pupil etc. Prepare patient *Instill several drops of tetracaine and wait a few sec before applying the patch Cleanse skin around eye to remove debris, drainage, or residual eye medications

Critical steps: Ask patient to close eyes Determine the number of eye pads needed to fill the depth of patient's eye socket *Fold oval eye patch in half or 4x4 in quarters *Position folded patch or 4x4 against closed lid. Cover first patch with one or more flat eye

patches angled across eye to fill socket. *Tape snugly in place with parallel strips of tape extending from central forehead to lateral cheek on both sides of patch.

Before securing tape to cheek, lift cheek up, apply tape, and then release cheek. Avoid placing tape over side of nose or nasolabial fold. *State one complication of the procedure: Eye patches applied too tightly can result in eye damage Further trauma due to lid motion under a loose patch

Scoring: All starred (*) items must be answered/performed correctly in order for the student to complete this station. Any errors or omissions of these items will require practice/repeat. Recommendation: Excellent knowledge of material; no coaching needed. Satisfactory knowledge of material: minimal coaching needed. Could not perform some points even with coaching; recommend practice/repeat. Comments

Evaluator