Ocular Emergency

Ocular Emergency is a systematic, symptom based reference book for clinical practice guidance. This book aims to provide the most thorough knowledge and standard process to clinical practitioners, such as the nurses, medical students, residents, fellows and even ophthalmologists, to help them make the most appropriate decision on the management of patients who have suffered from urgent ocular conditions.

The first three chapters provide the audiences general information of ocular emergency and the emergency room (ER), which will help them generate a clinical thinking. The following four chapters are symptom based discussion of common complaints of ocular emergency. These chapters contain almost all the symptoms the audiences will meet in the ER and covers hundreds of diseases the audiences may or may not think of which fits the symptom. They will help the readers to make the right diagnose and offer the best advice or treatment to the patients. The last two chapters provide the audiences the information of most urgent ocular traumas. For each disease, definition, etiology, clinical presentations and signs, treatment and typical clinical case with pictures or illustrative figures will be provided. In addition, each chapter will be provided with an algorithym(s) for differential diagnosis and treatment as a summary of the chapter. Hopefully this book may help the clinical practitioners to be fully prepared for any challenge of ocular emergency cases.

• Language: English
• Publisher: Springer
• Release date: Jan 16, 2018
• ISBN: 9789811068027

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© Springer Nature Singapore Pte Ltd. 2018

Hua Yan (ed.)Ocular EmergencyOcular Traumahttps://doi.org/10.1007/978-981-10-6802-7_1

1. General Guideline of Ophthalmic Emergency

Hong Yan¹, ²   and Song Wang²

(1)

Department of Ophthalmology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China

(2)

Department of Ophthalmology, Tangdu Hospital, Xi’an, China

Hong Yan

Email: [e-mail]

Abstract

In the situation of ocular emergency, rapid diagnosis and proper treatment are the key to success. First of all, the doctor should be familiar with common symptoms and signs in ophthalmic emergency, which include acute red eye, acute visual loss, acute ocular pain, ophthalmic trauma, and so on. From typical symptoms and signs, the doctor can make a quick judgment about the diagnosis. Then, the doctor needs to perform further examination to confirm the judgment. Evidence taken from patient history and specific ocular examination will support the doctor to make a correct diagnosis. Finally, in pursuit of the best prognosis, the doctor should make prompt and appropriate treatment. According to our experience, we have summarized the initial treatment for typical ocular emergencies as a reference. In conclusion, this chapter displays the standard procedure of dealing with ophthalmic emergency and tries to help doctors to build the pattern of clinical thinking.

Keywords

Ophthalmic emergencyDiagnosisExaminationTreatmentClinical thinking

The subjects of ophthalmic emergency include acute illness, acute poisoning, and ophthalmic trauma. The research of etiology, pathogenesis, diagnostics, and treatment has significantly improved the outcome of ophthalmic emergency patients.

Rapid diagnosis and proper treatment are crucial for ophthalmologist to deal with ophthalmic emergency. In pursuit of the best prognosis, there are several basic principles to follow:

1.

Immediate assessment of the patient’s general and ocular conditions.

2.

Making a correct diagnosis rapidly.

3.

Developing a therapeutic strategy.

4.

Proper medication.

5.

Get ready for the patients with operation indications.

6.

Mastering the principles and procedures of emergency surgery.

7.

Consultation with doctors from related professions.

8.

Be familiar with the laws that apply for emergency medicine.

1.1 Common Symptoms and Signs in Ophthalmic Emergency

1.1.1 The Acute Red Eye

The red eye is red because its conjunctival vessels are engorged. These vessels may be engorged for many reasons, including inflammation of the eye or its surrounding structures or increased backflow pressure in its draining veins. In other words, a red eye could signify a problem with the eye, eyelids, lacrimal system, orbital soft tissues, or cavernous sinus. To sort through these conditions, use the diagnose tree in Fig. 1.1.

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Fig. 1.1

Acute red eye

1.1.2 Acute Visual Loss

Acute visual loss that persists beyond 1 h requires immediate attention. The differential diagnosis includes keratitis, acute glaucoma, endophthalmitis, vitreous or retinal hemorrhage, retinal detachment, acute maculopathy, retinal artery occlusion, retinal vein occlusion, optic neuritis, ischemic optic neuropathy, occipital (visual) cortex infarction, and psychogenic visual loss. Table 1.1 compares symptoms, signs, and urgency of treatment for these conditions.

Table 1.1

Differential diagnosis of acute visual loss

Emergent = within 24 h; urgent = within 48 h

1.1.3 Acute Ocular Pain

Ocular pain may result from stimulation of trigeminal nerve fibers anywhere within the eye, the surrounding orbital tissues, and the base of the anterior or middle cranial fossa. If the pain arises from the eye itself, the eye (really the conjunctiva) will often be red. Pain that comes from a corneal epithelial defect feels like a grain of sand in the eye (foreign body sensation). If the pain arises from the eye’s surrounding orbital tissues, eyelid swelling or proptosis is often evident. Deep orbital and intracranial processes causing pain, which often produce no external swelling, may cause Horner syndrome and impairment of the third, fourth, or sixth cranial nerves.

In ophthalmic emergency, acute ocular pain is usually associated with conditions from these categories:

1.

Corneal or eyelid abnormality and diffuse conjunctival congestion

2.

Drastic increase in intraocular pressure such as acute angle-closure glaucoma, traumatic glaucoma, pigmentary glaucoma, uveitis, and hyphema

3.

Ciliary injection such as scleritis, uveitis, and endophthalmitis

1.1.4 Ophthalmic Trauma

Quick action is often called for in managing ocular injury. Some cases should be treated on the spot. Other cases should be referred promptly because of the difficulty in diagnosis and management and the potential threat to sight.

Ophthalmic trauma in emergency could be classified as below:

1.

Mechanical injuries which include blunt injury, lamellar laceration, rupture of the globe, penetrating injury, intraocular foreign body, and perforating injury.

2.

Nonmechanical injuries like chemical burn, thermal burn, and radiation injury.

1.2 The Clinical Thinking of Ophthalmic Emergency

In all the situations of ophthalmic emergency, there are only two conditions that need to be treated within minutes—chemical burn and retinal artery occlusion—while in some conditions like endophthalmitis, intraocular foreign body, and orbital cellulitis, medical intervention should be introduced within hours. In certain cases, consultations with other professionals (radiologist, otolaryngologist, and neurologist) are necessary.

Ocular trauma is very common in emergency room. When dealing with trauma patients, ophthalmologists should check the patient’s general conditions thoroughly. Combined injuries and multiple injuries are quite normal among patients suffering from car accidents and explosive injuries. The top priority in treating these patients is to check their vital signs and organs. If the patient’s signs are critical, ophthalmologists should quickly transfer the patient to a surgeon for further inspection. When the patient’s injuries are confined to the ocular, emergency doctors need to be careful with wounds caused by foreign body whose physical signs may be slight but may seriously threaten vision if left in place.

In general hospital, trauma patients that require multiple specialists from different professions are not unusual. In these cases, doctors must cooperate as a team in order to do their work efficiently. Emergency consultations with ophthalmologists can be decisive in the diagnosis of certain diseases such as papilledema, craniofacial trauma, vascular disease, and toxemia of pregnancy.

Figure 1.2 is the routine procedure of ophthalmic emergency. It will help the doctor to get a general assessment of the emergency patient.

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Fig. 1.2

Routine procedure of ophthalmic emergency

1.3 Key Points of Examination in Ophthalmic Emergency

1.3.1 History

In most circumstances, the first step of treating an emergency patient is to acquire the patient’s detailed medical history. Information like visual acuity prior to and immediately following the injury, the time of injury, the mechanism of injury, and previous history is crucial for further inspection and treatment.

The details of the injury are very important for the assessment of ocular trauma patients. The questions below are helpful for ophthalmologists in the process of history taking:

Did the patient feel a sudden impact on the eyelids or eye?

Was the patient wearing glasses or goggles?

Does the patient complain of pain or decreased vision?

What object struck the patient?

How was the patient struck?

How long ago did the injury occur?

Does the patient have lingering vision impairment, diplopia, or severe pain?

When was the last time that the patient got vaccinated against tetanus?

Key Points

1.

A good history taking is the first step of successful treatment.

2.

If the patient’s only healthy eye is injured, the treatment should be cautious. Consultation with senior doctors is necessary.

3.

The patient’s general condition, systemic disease, and medication use need to be recorded particularly.

4.

A well-written medical record is not only convenient to read and communicate but also an important part of legal instruments.

1.3.2 Ocular Examinations

It is important to make a routine procedure to assess the patient’s conditions comprehensively. Both eyes need to be checked thoroughly. For multiple injury patients, vital signs should be checked first. When the patient’s signs are steady, ocular examinations could follow up. When a patient has chemical burn, the first thing to do is irrigating. If the patient’s symptoms suggest infective conjunctivitis, mydriasis is not recommended at the time.

1.3.2.1 Visual Acuity

Measuring visual acuity is the first and foremost test for ophthalmic emergency patients. Severely injured or immobilized patients could use near vision test to record. If the patient cannot see the largest Snellen letter, alternative tests (counting finger acuity, hand movement acuity, and light perception acuity) should be performed to assess the patient’s eyesight. For presbyopia and aphakia patients, their corrected visual acuity should be recorded.

Key Points

1.

The patient’s both eyes need to be checked.

2.

For patients with severe visual loss, visual acuity test is crucial for the assessment of their vision prognosis.

3.

Visual acuity test is an important part of legal instruments for cases that may involve in legal disputes.

4.

Topical anesthetics can greatly help the test of patients who have difficulty in opening eyes.

5.

Even though the patient’s eyesight is normal, there still may be underlying sickness within the eye.

1.3.2.2 External Examination

Many ocular traumas and emergencies can be diagnosed by inspection of the facial and periorbital area. Symptoms and signs like exophthalmos, enophthalmos, skin ecchymosis, periorbital emphysema, ptosis, and numbness of the infraorbital should be noticed.

Under direct penlight illumination, doctors should inspect the eyelid, lacrimal apparatus, and eye muscles. After inspection, details such as the injured place, range, severity, and complications need to be carefully recorded and drawn.

Key Points

1.

Any laceration should estimate the depth of the wound and describe the adjacent tissue’s situation especially lacrimal apparatus’s condition.

2.

Palpate the rim of the orbital bone to see whether it is irregular to identify fractures.

3.

Enophthalmos indicates rupture of the globe or orbital fractures, while exophthalmos suggests orbital hemorrhage.

4.

Numbness of certain facial area indicates the fracture sites.

5.

Subcutaneous emphysema in the eyelid and ocular adnexa indicates medial wall or floor fracture in the orbit.

1.3.2.3 Pupillary Examination

Pupillary examination offers objective evaluation of the condition of the visual pathway. The pupils should appear symmetric, and each one should be examined for size, shape (circular or irregular), and reactivity to both light and accommodation. Pupillary abnormalities may be due to neurologic disease, acute intraocular inflammation, and ocular trauma.

Key Points

1.

The size of the pupil is an important indication of cranial nerve involvement.

2.

The shape of the pupil offers information about iris damage, detached vitreous body, and intraocular foreign body.

3.

In traumatic cases, relative afferent pupil defect (RAPD) is usually a sign of a unilateral optic nerve lesion or of bilateral but asymmetric optic nerve lesions.

1.3.2.4 Visual Fields

When treating ocular emergencies, confrontation visual field test can be used to detect gross visual pathway disturbances. This test measures the patient’s ability to use peripheral vision to identify large targets. More definitive visual field testing employs instruments called perimeters.

1.3.2.5 Ocular Motility

The objective of ocular motility testing is to evaluate the alignment of the eyes and their movements, both individually and in tandem. If the patient’s situation involves orbital injury or cranial nerve injury, it is important to test the patient’s ocular motility.

Key Points

1.

The decrease in ocular motility indicates rupture of the globe or orbital fractures.

2.

The paralytic or restricted eyeball movement can be identified by forced duction test. If it is open wound, the test should be delayed.

1.3.2.6 Anterior Segment Examination

If the patient’s condition is stable and convenient, slit lamp is the best option to inspect the patient’s anterior segment. The direct ophthalmoscope is alternative. The examination should be organized in order:

eyelashes → eyelid → conjunctiva → sclera → cornea → anterior chamber → iris/pupil → lens.

1.3.2.7 Posterior Segment Examination

Since ocular emergency patient’s conditions could be complicated, the patient’s posterior segment should be thoroughly checked as soon as possible. If the process is delayed, situations like corneal decompensation, vitreous hemorrhage, endophthalmitis, and hyphema may further affect the examination.

Key Points

1.

Before mydriasis, the patient’s iris and pupil should be inspected.

2.

If the patient’s head or iris is injured, mydriatic should be forbidden.

3.

The patient’s usage of mydriatic needs to be recorded carefully, especially when the patient’s head is injured.

1.3.2.8 Intraocular Pressure

The change of intraocular pressure (IOP) is a reminder of certain disease. The decrease of IOP is a sign of situations like retinal detachment, traumatic iridocyclitis, cyclodialysis, and perforating globe injury. Increased IOP are usually linked with disorders like glaucoma, hyphema, and uveitis.

Key Points

1.

Decreased IOP is an important clue to search for hidden wounds in perforating globe injury.

2.

The increase of IOP cannot rule out the possibility of eyeball rupture.

3.

In case of acute angle-closure glaucoma, patient’s IOP could increase drastically, which calls for immediate medical intervention.

1.4 Treatment of Ocular Emergencies

The outcome of ocular emergencies depends on timely management, which makes prompt and appropriate treatment essential in the primary care setting. Chemical burns, penetrating globe injuries, central retinal artery occlusion, acute angle-closure glaucoma, and retinal detachment are the most common and urgent cases for ocular emergency. In these circumstances, patients need to be transferred immediately to the emergency department or an ophthalmologist. In Table 1.2 [1], the initial treatment of these situations is summarized.

Table 1.2

Initial treatment of ocular emergencies

IOP intraocular pressure, IV intravenously

aBrand only available in the oral formulation

1.4.1 Penetrating Globe Injuries

(a)

Leave the foreign object in situ since removal may lead to further herniation of the eye content. Do not touch or manipulate the injured eye.

(b)

Auxiliary medicine like antiemetics, topical anesthetics, and antibiotics can be given to suppress vomiting, aid comfort, and reduce the risk of infection. Tetanus status should be confirmed and a booster dose given if required [2].

(c)

Advise the patient to avoid movement that may deepen the wound before seeing a specialist. Eating or drinking should be forbidden since surgery is often required in this situation.

(d)

Eye shields, instead of pressure patch, can be placed over the injured eye to offer protection. The bottom of a disposable cup can be used as substitute.

1.4.2 Retinal Detachment

(a)

Patient history is crucial in making the diagnosis. Symptoms of flashes and floaters, especially progressive onset of symptoms, are often recorded.

(b)

Patients may also describe a cloud or web over their vision as the detachment progresses. A recent history of ocular trauma or surgery is commonly related to the sickness [2].

(c)

Instant referral to an ophthalmologist is required if a retinal detachment is diagnosed.

(d)

The best treatment for retinal detachment is surgery, including pneumatic retinopexy, scleral buckle, pars plana vitrectomy, or a combination of these methods.

1.4.3 Central Retinal Artery Occlusion

(a)

Transfer the patient with symptoms and signs of central retinal artery occlusion (CRAO) immediately to an ophthalmologist since irreversible damage occurs in 100 min after occlusion [1].

(b)

Initial treatment of CRAO includes the acute presentation of inhalation (95% O2 and 5% CO2), laying the patient flat on his or her back, administering oral nitrates, or ocular-digital massage.

(c)

Timely treatment is the first priority, and there is no clear evidence to recommend one treatment over another for acute CRAO.

1.4.4 Acute Angle-Closure Glaucoma

(a)

Lowering the intraocular pressure is the centerpiece of all the clinical treatment.

(b)

Before seeing an ophthalmologist, the following procedures are highly recommended: give the patient eye drops (0.5% timolol maleate, 1% apraclonidine, or 2% pilocarpine) for three times at 5-min intervals; take a 500-mg tablet of acetazolamide; measure the patient’s intraocular pressure every hour [1].

(c)

Laser or surgical iridectomy is the definitive treatment for primary acute angle-closure glaucoma.

1.4.5 Chemical Burns

(a)

Instant and sufficient irrigation is the most important treatment for chemical burns.

(b)

Lactated Ringer’s solution, normal saline, or water can be used as irrigation solutions. The injured eye should be irrigated with at least 2 L of fluid.

(c)

The pH of the ocular surface should be strictly monitored, and a wet cotton swab can be used to sweep the upper and lower fornices to remove any retained crystallized chemical particles.

(d)

For mild burns, treatment with antibiotic eye drops and artificial tears is sufficient for corneal and conjunctival epithelial healing. In severe cases, topical steroid, ascorbate, and citrate drops should be added to reduce inflammation and promote epithelialization [3].

References

1.

Pokhrel PK, Loftus SA. Ocular emergencies. Am Fam Physician. 2007;76:830–6.

2.

Hodge C, Lawless M. Ocular emergencies. Aust Fam Physician. 2008;37:506–9.PubMed

3.

Gelston CD. Common eye emergencies. Am Fam Physician. 2013;88:515–9.PubMed

© Springer Nature Singapore Pte Ltd. 2018

Hua Yan (ed.)Ocular EmergencyOcular Traumahttps://doi.org/10.1007/978-981-10-6802-7_2

2. Emergency Room (ER)

Haoyu Chen¹   and Danny Siu-Chun Ng²

(1)

Shantou International Eye Center, Shantou University and the Chinese University of Hong Kong, Shantou, China

(2)

The Chinese University of Hong Kong, Hong Kong, China

Haoyu Chen

Email: [e-mail]

Abstract

The design of the emergency rooms needs to be comprehensively considered. Some general principles, such as accessibility, signage, and good relationship with other departments, should be considered. There are also some special instruments, drugs, and common supplies needed in the ocular emergency rooms. In an eye hospital, the emergency room should have some essential setting for examination and management of systemic emergency. Patients coming to the emergency room are mixed with different levels of severity and crisis. They should be managed differently according to their specific situations. First aid is needed for the following conditions: chemical injury, open globe injury, and acute painless vision loss. Hospital-acquired infection is a major challenge in high turnover emergency rooms. The following strategies should be used for infection control: hand hygiene, separate infection source from the rest of departments, healthcare personnel protection, and environment controls.

Keywords

Emergency roomsSettingTriageFirst aidInfection control

Emergency room is essential in any healthcare system. It provides immediate management for patients suffering from serious, acute ocular illness. The design of the emergency rooms needs to be comprehensive. There are many things which should be considered. First, the design must follow some general requirements, including the location, accessibility, privacy, infection control, and so on. Second, there are some special design, instruments, drugs, and supplies for the ocular emergency room. Third, in eye hospital, there may be some patients with life-threatening systemic emergency and need immediate management. Therefore, the emergency room in eye hospital must have some instruments and drugs for diagnosis and management of systemic emergency.

2.1 General Consideration Is Designing Emergency Rooms

Emergency rooms have some specific purposes which should be considered in its design.

1.

The patients are usually in acute condition and need immediate care.

2.

The patients and companions are usually stressed and anxious.

3.

The patients have different severities and levels of emergency.

4.

The triage and discharge pathways of patients may vary.

Therefore, there are some general considerations:

1.

Accessibility. The emergency room should locate near the front door. And the front door can be assessed by ambulance or other vehicle transporting the emergency patients. So the patients in acute condition can arrive at the emergency room in the shortest time.

2.

Signage. Clear signage of emergency room should begin outside the hospital to guild the patients/drivers to the emergency room. Inside the department, signage about the patient pathway, services, and facilities should be clear. Braille for visually impaired patients should be used [3].

3.

Good relationship with other departments. The patients may need further investigation and/or admission. Therefore, the emergency rooms should have access to these modalities, including radiology, ultrasound, CT scanning, clinical chemistry lab, inpatient wards, operating theatre, pharmacy, etc. Signage, clear unencumbered route, and information technology communication are necessary in connecting the relationship.

4.

Other general requirements: clean and well-maintained environment; noise control, with stereo system playing calming and non-repetitive music; appropriate room temperature; adequate space for waiting patients and companions; information kiosks; and health education magazines or television.

2.2 Instruments, Drugs, and Common Supplies in the Ocular Emergency Rooms

Ocular emergency rooms should include at least an examination room and a treatment room. The room should have enough lighting but also have curtain to keep the room in dark when the light turned off. If there is enough space, the examination room can be separated into two independent rooms, the consultation room and examination room. The consultation room is for consultation and examination by physicians. While the examination rooms have the examination instruments performed by nurse or technicians.

2.2.1 The Examination Room Should Have the Following Instruments

1.

Visual chart. The room should have enough space for visual examination, which depends on the type of visual chart used. The visual chart can be Snellen, ETDRS, or any other charts commonly used in local practice. Near visual chart should also be supplied to differentiate myopia and other diseases.

2.

Tonometry. Usually noncontact tonometry is used. However, some patient may have uneven ocular surface or extremely high or low intraocular pressure. Noncontact tonometry can be inaccurate in these conditions. Tono-Pen or ICare tonometry can be used in these cases and should also be available.

3.

Refraction instruments. Auto refractometer or kerato-refractometer can objectively read the refraction of the eye in a short time. Trial frames and trial lens sets can help to measure the best corrected visual acuity. Lensmeter can read the power of the lens wearied by the patients.

4.

Flashlight. Although flashlight is simple, but it is very useful and should not be forgotten in the inventory. It can be used to assess whether the patient has light perception and light projection. Using flashlight and a pair of red/green lens, simple color vision can be tested. Furthermore, it can be used to exam whether the patient has strabismus and how is the eye movement. Last but not least, it can exam direct/indirect pupil reflex and relative afferent pupil defect.

5.

Slit lamp microscopy. Although any brand of slit lamp microscopy can be used in the consultation room, it is recommended using the ones with digital camera to record the lesions on anterior segment. We also suggest that a portable slit lamp microscopy be supplied, because some patients may not be able to sit in front of an instrument. Portable slit lamp microscopy is especially useful for these patients.

6.

Direct or indirect ophthalmoscopy. It is recommended the models come with battery and can be easily used without limitation to the examined desk. Direct ophthalmoscopy has advantage of high resolution but only for a small field. While indirect ophthalmoscopy has the advantage of wide-field and stereo view. Direct ophthalmoscopy is useful for macular disease, while indirect one is better for peripheral retinal diseases.

7.

Contact and noncontract slit lamp lens. The contact slit lamp lens includes goniolens and Goldmann three-mirror lens. They are used to examine the anterior chamber angle and retina. The noncontact slit lamp lens includes models with different power, which have different magnifications and fields of view. They are used for macula/optic disc or peripheral retina examination, under different sizes of the pupil.

2.2.2 The Following Drugs or Consumables Should Be Supplied in the Examination/Consultation Rooms

2.2.3 Setting for Ocular Treatment Room

1.

The ocular treatment should locate near to the consultation room. Some patients may need immediate eye washing and can be transported from the consultation room to treatment room in the shortest time.

2.

There should have adequate lighting. Shadowless lamp should also be supplied to illuminate the field of treatment/operation. Electric power outlet should be provided.

3.

Therapeutic bed and therapeutic chair.

4.

Surgical microscopy: it would be better to have a surgical microscopy so some emergent surgical management can be performed. It doesn’t need to be an advanced model, but a simple surgical microscopy is enough (Fig. 2.1).

5.

Surgical table and chairs.

6.

Surgical tools: the autoclaved surgical tools can be packed and ready for used.

7.

Syringe and needles: with different sizes and gauges.

8.

Changing and packing.

9.

Disinfection reagents: 75% alcohol, 2% H2O2, povidone iodine. The room should have a UV light and disinfection at least 30 min, twice a day.

10.

Washing set and washing solution: 9% NaCl for regular washing, 2% boric acid for alkali burn, 2% NaHCO2 for acid burn.

11.

Garbages for biohazard waste and non-biohazard waste. They should be separated and have clear signs.

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Fig. 2.1

Surgical microscopy and surgical table

2.2.4 Setting for Management Systemic Emergency in Eye Hospital

It must be kept in mind that some patients may develop or have pre-existing systemic disorders. For example, a patient receiving intravenous injection of fluorescein may develop allergic reaction, even shock. Some systemic disease may need emergency management. In general hospital, these conditions can be managed by other subspecialties. However, the emergency room in eye hospital should have some essential setting for examination and management of systemic emergency.

The essential instruments include:

1.

Multifunction monitor. The device has multiple functions, including blood pressure measurement, electrocardiogram monitor, and pulse oximeter monitor.

2.

Blood pressure meter. Although blood pressure can be measured with the monitor, an independent automatic or manual blood pressure is also needed to measure the blood pressure at the other limbs if needed. Furthermore, there may be more than one patient who needs measurement of blood pressure.

3.

Electrocardiogram. Electrocardiogram can be shown on the monitor; however, it usually only demonstrates one or two channels. A standard 12-channel electrocardiogram is essential to identify heart diseases.

4.

Defibrillator. Defibrillator is an important therapy for patients with life-threatening cardiac dysrhythmias, specially ventricular fibrillation and ventricular tachycardia. It can convert these dysrhythmias to normal electrocardiogram. It can be combined with the multifunction monitor or be an independent instrument.

5.

Oxygen tank and mask. Oxygen supply is not only essential for patients with respiratory distress but also an important therapy for patients with central or branch retinal artery occlusion. Although central supply is a safer method for oxygen delivery, oxygen tank is needed for patients with immediate need and cannot be transported to the oxygen outlet.

6.

Electric suction apparatus. The opening of airway is critical. Some patients may have airway obstruction by foreign body, sputum, etc. Electric suction apparatus help to clean the airway and keep it open.

7.

Ventilator. It is a machine designed to help breathing for a patient who is in respiratory failure, due to central nerve system disorders or others. Ventilator is essential to provide sufficient oxygen for the need of the body in these patients.

In emergency, some drugs are needed to be administered to patient within a short time without delay from delivery from the pharmacy. Following are some examples of drugs which should be stored in the emergency rooms.

In addition, some common supplies should also be stored in the ER, including syringes, cotton swabs, adhesive tapes, blood collection needle and tubes, infusion tubes, three-way stopcocks, pads, connecting tubes, heparin plugs, 18 G needles, trocars, tourniquet, povidone, tapes, medical bottle opener, scissors, thermometer, bottle opener, flashlight, tracheostomy set, vein incision kit, tongue forceps, mouth gag, tongue blade, sterile towels, urinary catheterization set, gloves, oxygen tubes, oxygen masks, bandage, electrode slice, tracheal cannula, breathing pipe, suction tubes, blood sugar tester, stethoscope, power strip, etc.

Due to the large variety of drugs and supplies required to be stored in ER, it is important to store them with good organization. An emergency cart with several layers, trays, and drawers will help to organize the storage. The wheel underneath will help to move it to any patient in crisis (Fig. 2.2).

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Fig. 2.2

An emergency cart with several layers, trays, and drawers help to organize the storage of drugs and supplies needed for management of crisis

2.3 Triage

The patients coming to emergency room are mixed with different levels of severity and crisis. They should be managed differently according to their specific situations [1]. The nurses at the reception desk should immediately assess the patients upon arrival. Patients can be tagged with different colors, which represent different levels of emergency. The triage area or reception desk should be located at the entrance of emergency rooms. Following are examples of codes or tags used for different patients.

1.

Red tags: The patients are critical and need immediate treatment. They must be seen by doctor immediately. They can be directly sent to the treatment room. Inform doctor and other nurses. Registration can be made after or at the meantime of immediate management.

(a)

Chemical injury

(b)

Patients with systemic criticism

2.

Yellow tags: For the patients who need acute but not immediate management. Registration can be made after or at the meantime of immediate management.

(a)

Central retinal artery occlusion and branch retinal artery occlusion

(b)

Acute angle closure or other acute glaucoma

(c)

Open globe injury

(d)

Endophthalmitis and orbital cellulitis

3.

Green tags: For the patients who are not seriously sick and don’t need acute management within 1 h.

(a)

Acute red eye

(b)

Closed globed injury

(c)

Uveitis and scleritis

(d)

Orbital injury

(e)

Retinal detachment

(f)

Optic neuropathy

(g)

Retinal vein occlusion

(h)

Vitreous hemorrhage

(i)

Conjunctivitis

(j)

Keratitis

(k)

Ocular surface injury

(l)

Subconjunctival hemorrhage

2.4 First Aid in the Ocular Emergency Rooms

2.4.1 Chemical Injury

When chemical injury is suspected, immediate management should be started. PH paper should be used to test the PH value of conjunctiva. Then the eye should be irrigated with at least 500 ml solution. PH test will be repeated. More solution irrigation if the PH value is still not normal.

Topical anesthesia can be used to relieve any irritating sensation. A speculum should be