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Pediatric Emergencies

The first thing in the newborn nursery that you see is the red reflex. The important thing is making sure you do not see that white reflex. I think it’s very difficult at times because you get the yellow sheen, the brown sheen and you have to move around sometimes to get it. But this is what we are looking for. The white reflex. And when it comes to the white reflex, or leukocoria, you want to make sure the child does not have cataracts. And when you look at cataracts, for the complete cataract, it is like you are looking at a white piece of paper in a child’s eye. Once you see it you know you’ve never missed it.

Another thing, and I think you all realize this, the nasal lacrimal duct stenosis. What’s happening is this membrane down here, called the Hasner membrane, is blocked up. And what happens is you get tearing of this eye. It’s important because this is the number one cause of tearing in newborns, is nasal lacrimal duct stenosis. But it’s important to differentiate between this and congenital glaucoma, which I’m going to talk about in a little bit. Because with congenital glaucoma you also have a child with a very teary eye and that is something you don’t want to miss.

So again, that’s when this part is blocked, but what happens when these two, superior and inferior canaliculi up here are blocked? Then what you get is something called a dacryocystocele which you may see in the newborn period. It looks like a bruise. In the nursery .. the last family I had said, "Oh, we thought that was a bruise and somebody had hit the child, but nobody had said anything." But it looks like a bruise.

Now the other cause of tearing, congenital glaucoma, it is very important that you do not miss. Of course with this child, I don’t think anybody could miss it. It’s a very cloudy eye. They present with tearing, photophobia - which is very difficult to appreciate because you go in and they all close their eyes and start crying, at times - the cloudy cornea and the corneal enlargement are key here. So really getting a good look in the eye.

Sturge-Weber has a high incidence of congenital glaucoma and it’s the kids who have the V-1, the ophthalmic, and the V-2 maxillary division where you have that birth mark or port wine stain over V-1 and V-2, they are at highest risk for glaucoma. They all get the ophthalmology consult. Of course the kids with Sturge-Weber also get the neural consult.

Strabismus. Strabismus of course is transient strabismus, normal until four months of age. All of a sudden, deviation after that, you really need to go see the ophthalmologist. Why? Well because there’s a critical period for the infant’s eyes and when there is significant strabismus, when the child is getting two parts of information into the brain, the brain is pretty smart and says, "Uh, this is confusing, I’m just going to use this side."

Visual deprivation amblyopia. A couple of things. If you were to miss … let’s say a child had bilateral cataracts that got missed, just to tell you what you would see. What you would see later on at two months of age is a wandering nystagmus. If you really missed completely, complete cataracts in a child’s eye. Why? Because they aren’t getting any input. You can imagine. It’s wandering and you are going to see nystagmus. So that’s what you would see. With visual deprivation of varying degrees this child has a little ptosis. Not you can imagine this child might correct himself by having his head tilted back and walking around like this. So he can’t lift his eyelid, or some kids will just go around holding up their eyelid.

Now let’s go to eye emergencies, and this is probably the one thing that pediatricians can really intervene and do a lot of good. It’s when eye injuries, chemical exposures to the eye. So what happens? You know all of this. Alkaline versus acid burns. Alkaline being more severe because it can cross, it can saponify the fatty acids and really get inside rather quickly, versus the acids. The chemical burns, when you get the call - I realize you know what to do - you tell the parents, "No, don’t come to the ER right away." They are going to be at home and they are going to be flushing that eye out. Most parents will tend to turn on the water, the tap, full blast. You know hot water.

What happens with eye injuries, chemical burns, you initially have them wash out the eye at home and then what happens is they come in. What happens when they come into the ER is you do quick visual exam - how many fingers? If they are still symptomatic and they are squinting, then you don’t do anything. You just go straight again and you lavage. You take that normal saline, Ringer’s lactate, liter, take the IV tubing.

Pretty much the next this that you’re going to do is fluorescein looking for eye injuries. Take a fluorescein strip, wet it, put it in the eye and take a good look for those eye injuries. What we are worried about with chemical burns are all of the … what happens subsequently. You are going to see all of these things; glaucoma, cataracts, retinal detachment, perforation. These are the things that we want to prevent with chemical eye injuries.

Okay, trauma. When it comes to trauma the important thing is the history, looking at exactly what happened. The mechanism of the injury. A lot of times something flew into the eye, projectile. What was it? If you are in a factory and someone is hammering something, that’s very significant for something penetrating into the eye. Very very concerning. With trauma, again you don’t want to do a lot if you think the globe is ruptured.

We’ll talk about the ruptured globe. Fortunately I don’t have a picture of a ruptured globe. I don’t think you want to see a picture of a ruptured globe. Very very concerning. They don’t go anywhere. They go straight to the ophthalmologist. It’s very very urgent. You do not want to put pressure on the eye. Some people may get this confused because they think, "We’ve got to patch every eye that we send to the ophthalmologist."

How about hyphema? Again, another emergency. Bleeding into the anterior chamber. Sometimes the bleeding is not obvious. Sometimes you might just see haziness before the blood settles down with gravity.

Foreign body. This actually is a Desmarres clamp, which again in the emergency room can help you with when you are going an eye lavage. For foreign bodies - everyone has had something in their eye. It’s actually quite painful. Some of them can actually be quite painful, you are tearing, you really just can’t open your eye. It’s just sort of spasm-ing shut. So for kids, they are actually going to squint, there can be tearing. What’s important to do when you have a foreign, look closely. You can use this or the Q-tip. The double eversion; it’s always easy to do the first eversion.

Corneal abrasion can also occur besides corneal laceration. The abrasion, as you can see here with the light, you can see all these abrasions. When you take a light and have a look. You can take the Wood’s light, the cobalt blue, you can do the fluorescein strip and look into it.

How about eye injuries, like fractures? So if someone is in a fight, orbital floor fracture is a very common one. With orbital floor fracture you can imagine this part is fractured. Remember that little nerve that comes out here? You can get ipsilateral numbness of the cheek and upper lip from that orbital nerve coming out right here. Nosebleeds, eyelid bruising. You can have limitation of the upward gaze. You can also have some limitation of the lower gaze.

A couple of other things to mention. On the Boards, what happens when your lens of the eye … your lens of your eye is dislocated, what would you see? You would see the tremulous eye. So that you go look at something and the eye is just bouncing around. And that’s called iridodonesis.

Okay, finally just one thing. Retinal blastoma. We’ll just look at this slide. Retinal blastoma. We saw that slide earlier of leukocoria, very important, retinal blastoma to diagnose in children. The number one cause of intraocular tumor in kids. So number one cause of tumor in the eye.

Now we are going to go to conjunctivitis really quick. When we look at conjunctivitis in kids eyes, looking at the age of the child. There’s different infections for the newborn versus the older kids. How long has it been going on? Two days versus three weeks? For three weeks you are going to be worrying about other things.