Visual Diagnoses in the ED
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This document provides information on various visual stimuli and their significance in emergency medicine. It describes several cases presenting with different eye conditions like hypopyon, dendritic ulcer, retinal detachment, unequal pupils, and Hutchinson's sign. For each case, it summarizes the visual stimulus, associated risks, importance of urgent referral to ophthalmology or other specialists, and potential sight-threatening implications if not properly managed. The document aims to teach healthcare providers about identifying and interpreting important visual clues in emergency patient presentations.
Visual Diagnoses in the ED
- 1. 23/02/17 Visual Stimuli In Emergency Medicine CME Teaching
- 2. 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
- 6. 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
- 8. Seatbelt sign ✤ Increased risk of underlying visceral injuries ✤ Low threshold for CT
- 10. 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
- 12. 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
- 13. A 26 year old man presents to ED with a 2 day history of a red, painful eye with blurred vision
- 15. Hypopyon ✤ Visible accumulation of white cells in the anterior chamber ✤ Indicates severe anterior uveitis ✤ Needs urgent ophthalmology referral ✤ Can be sight threatening
- 16. A 38 year old lady presents to hospital with a one day history of pain and irritation in her right eye
- 18. Dendritic ulcer ✤ Herpes simplex keratitis ✤ Treated with topical anti-virals and needs urgent ophthalmology referral ✤ Can be sight threatening
- 19. A 78 year old lady with a background of hypertension and type 2 diabetes presents with painless visual loss in her right eye
- 21. 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
- 22. A 63 year old man presents with sudden loss of vision in his left eye
- 24. Central retinal artery occlusion ✤ Visual acuity always reduced <6/60 ✤ Need to rule out Giant Cell Arteritis ✤ Needs urgent ophthalmology referral
- 25. A 32 year old lady presents with severe headaches and blurred vision
- 27. Papilloedema ✤ Assess with full neurological and ophthalmological examinations ✤ Needs urgent neurological imaging ✤ Neurology/opthalmology input depending on cause
- 28. A 56 year old man presents with loss of vision in one after complaining of flashes and floaters over the last couple of days
- 30. Retinal detachment ✤ Direct fundoscopy can’t always rule out a detachment ✤ Ultrasound is a useful tool for diagnosis ✤ Needs urgent ophthalmology referral
- 31. A 68 year old man in brought into ED following a collapse at home. He is GCS 6/15
- 33. Unequal pupils ✤ Injury or compression of the third cranial nerve and upper brainstem ✤ Suggests severe inter cranial pathology ✤ Needs urgent CT head to assess
- 34. A 45 year old smoker presents to ED complaining that her left eye is ‘droopy’
- 36. Horner’s Syndrome ✤ Ptosis, miosis and anhidrosis ✤ Interruption of the sympathetic nerve supply to the eye ✤ Painful Horner’s - need to consider dissection
- 37. A 70 year old man presents to hospital with a painful rash and redness in his right eye
- 39. 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
- 40. A 72 year old man with a background of lung cancer presents to hospital complaining of increasing shortness of breath
- 43. SVC obstruction ✤ Pemberton’s sign ✤ Most common cause is lung cancer ✤ Treated with chemotherapy/radiotherapy or stenting
- 44. A 54 year old man presenting to hospital with abdominal pain and distention
- 46. Distended abdominal veins ✤ IVC obstruction vs caput medusa ✤ Caput medusa signifies severe portal hypertension
- 48. Spider Naevi ✤ Dilation of arterioles caused by increased oestrogen levels ✤ Multiple spider naevi is a common sign in liver disease ✤ Also common in pregnancy
- 49. A 46 year old alcoholic man presents to hospital with severe abdominal pain and vomiting
- 52. Retroperitoneal bleed ✤ Trauma, ectopic pregnancy rupture or pancreatitis ✤ Signifies necrotizing pancreatitis ✤ Associated with very high mortality
- 53. A 78 year old lady with a history of COPD presents to hospital with respiratory distress
- 55. Peripheral cyanosis ✤ Caused by excessive deoxyhaemoglobin in the blood ✤ Inadequate or obstructed circulation ✤ Anaemic patients may be hypoxic without cyanosis
- 56. A 42 year old IVDU presents to hospital feeling generally unwell with high fevers
- 59. Infective endocarditis ✤ Vascular and immunologic phenomena ✤ Most commonly caused by Staph aureus ✤ Modified Dukes criteria for diagnosis
- 61. A 72 year old man presents to ED with SOB which has been getting worse over the last few months
- 63. Clubbing ✤ Many associated diseases ✤ Schamroth’s test used to identify subtle clubbing ✤ Needs further investigation if not known to have a causative disease
- 64. A 38 year old man presents to hospital with a painful rash on his chest
- 66. HSV ✤ Cause by the varicella zoster virus ✤ Never crosses the midline ✤ Infective until lesions have crusted ✤ Often complicated by post-herpetic neuralgia
- 67. Any Questions?