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Orbital Fracture in Emergency Medicine Treatment & Management

  • Author: Thomas Widell, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Oct 23, 2014
 

Prehospital Care

Airway, breathing, and circulation are the first priorities. Hold the airway open by jaw thrust or airway adjuncts, including endotracheal intubation. Because of the concern with intracranial placement of endotracheal tubes, severe facial injury is considered a relative contraindication to using the nasotracheal route of intubation.

Place patient on a backboard with a collar if cervical spine injury is a possibility.

Treat hypoventilation with intubation and bag ventilation.

Control actively bleeding wounds by applying direct pressure with a bandage.

If globe is open, cover it with a protective shield.

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Emergency Department Care

Airway, breathing, and circulation are the first priorities. Reassess airway frequently. Intubation performed early on, before swelling occurs, makes airway control much easier than waiting until a problem arises from obstruction.

Do not focus on the obvious deformity, thereby neglecting to perform a complete primary survey. Rapidly diagnose other life threats and undertake appropriate resuscitation.

Diagnosis of orbital fracture in the ED is part of the secondary survey. Diagnose other injuries to the eye as well by performing a complete slit-lamp examination of the eye and tests for visual acuity.

In one study, treatment of ocular emergencies in trauma centers and treatment in traditional community hospital emergency departments were compared. The records of 1027 patients with ocular emergencies between July 2007 and November 2010 were reviewed. The incidence of patients requiring ophthalmic intervention was 77.2 per 100,000 in the community hospitals and 208.9 per 100,000 in the trauma centers. Orbital fractures were found in 86% of all orbital contusion cases in trauma centers; and in 66.7% of patients with fall injuries and open globe diagnoses, the result was legal blindness.[9]

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Consultations

Depending on the institution, orbital fractures are cared for by an eye, ear, nose, throat (EENT) surgeon, oromaxillofacial surgeon, ophthalmologist, or plastic surgeon.

Patients with serious eye injuries and decreased visual acuity should have an ophthalmology consultation. Monitor minor injuries, such as corneal abrasions, on an outpatient basis.[4]

Provide care for the patient with multiple injuries in conjunction with a surgeon with experience in trauma care.

The incidence of posttraumatic stress disorder is high in patients with facial injuries, and a consultation with a psychiatrist should be considered.[10, 5, 7]

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Contributor Information and Disclosures
Author

Thomas Widell, MD Vice Chairman, Assistant Professor, Department of Emergency Medicine, Chicago Medical School at Rosalind Franklin University of Medicine and Science; Associate Residency Director, University of Chicago Emergency Medicine Program; Program Director, Emergency Medical Education, Attending Physician, Mount Sinai Hospital Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Legome, MD Chief, Department of Emergency Medicine, Kings County Hospital Center; Professor Clinical, Department of Emergency Medicine, State University of New York Downstate College of Medicine

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, Council of Emergency Medicine Residency Directors, American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Michelle Ervin, MD Chair, Department of Emergency Medicine, Howard University Hospital

Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. Hendler BH. Maxillofacial trauma. Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. Mosby-Year Book; 1998. 1093-1103.

  2. McGill J, Ling LJ, Taylor S. Facial trauma. Diagnostic Radiology in Emergency Medicine. Mosby-Year Book; 1992. 51-76.

  3. Smith RG. Maxillofacial injuries. Harwood-Nuss A, ed. The Clinical Practice of Emergency Medicine. Lippincott Williams & Wilkins Publishers; 1996. 408-418.

  4. Spoor TC, Ramocki JM, Kwito GM. Ocular trauma. Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. 2nd ed. Lippincott, Williams & Wilkins; 1996. 225-241.

  5. Sullivan WG. Trauma to the face. Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. Lippincott, Williams & Wilkins; 1996. 242-269.

  6. Hasan N, Colucciello SA. Maxillofacial trauma. Tintinalli JE, Gabor KD, Stapczynski SJ, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. McGraw-Hill Co Inc; 2004. chap 257, p1583-1.

  7. McKay MP. Facial trauma. Marx JA, Hockberger RS, Walls RM, eds. Rosen's Emergency Medicine, Concepts and Clinical Practice. 6th ed. Philadelphia, PA: Mosby Elsevier; 2006. Vol 1: 382-98/chap 39.

  8. Snell RS, Smith MS. The face, scalp, and mouth. Clinical Anatomy for Emergency Medicine. Mosby-Year Book; 1993. 206-241.

  9. Cheung CA, Rogers-Martel M, Golas L, Chepurny A, Martel JB, Martel JR. Hospital-based ocular emergencies: epidemiology, treatment, and visual outcomes. Am J Emerg Med. 2014 Mar. 32(3):221-4. [Medline].

  10. Glynn SM, Asarnow JR, Asarnow R, et al. The development of acute post-traumatic stress disorder after orofacial injury: a prospective study in a large urban hospital. J Oral Maxillofac Surg. 2003 Jul. 61(7):785-92. [Medline].

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Left orbital floor fracture. This patient presented with little motility disturbance; however, because of the large defect in the orbital floor, late enophthalmos was predicted. Surgical repair was undertaken. Note the pneumo-orbitum.
 
 
 
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