Acute Visual Loss in the ED

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  1. History including specific eye involvement, sudden vs. chronic loss, pain, redness and discharge, trauma, other symptoms, and medication use are vital.
  2. Physicians should be comfortable completing an appropriate history and physical examination including general inspection, visual acuity, pupils, EOMs, visual fields, fluorescein, lids, IOP, slit lamp, and US.
  3. Emergent consultation is required for acute angle closure glaucoma, retinal detachment, CRAO, open globe, endophthalmitis, chemical burn, infectious keratitis, and giant cell arteritis.
  4. Urgent referral is needed for uveitis, vitreous hemorrhage, acute maculopathy, CRVO, and optic neuritis.
  5. Keep in mind other etiologies of vision loss including ischemia, stroke, toxin, infection, and functional.

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TIA

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Cornerstones of treatment for TIA revolve around reducing the risk of future events with blood pressure control, lipid control, and antiplatelet agents. Blood pressure should be maintained at 140/90 with a thiazide diuretic and/or an ACE inhibitor. Statins should be given to keep LDL of under 100mg/dL or 70mg/dL in high risk patients. Niacin or gemfibrozil are recommended to maintain HDL above 40mg/dL. Antiplatelet agents include aspirin with or without dipyridamole, or clopidogrel alone.

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Central Retinal Artery Occlusion

  • Presentation: Painless vision loss
  • Early ophthalmology consultation (true eye emergency)
  • Should be treated as a stroke
  • Traditionally poor prognosis overall
  • Promising HBO experience thus far. Consider early consultation with an emergent hyperbaric treatment center if available

Stroke…as simple as STR

You spend 3 hours in traffic everyday…this is how long a patient with an acute stroke has to get to an appropriate facility that could save them from a lifetime of disability.

Someone you know or you will probably have a stroke in your lifetime, early diagnosis and immediate referral could make all the difference.

Sometimes symptoms of a stroke are difficult to identify. Unfortunately, the lack of awareness spells disaster.
The stroke victim may suffer severe brain damage when people nearby fail to recognize the symptoms of a stroke.

A bystander can recognize a stroke by asking three simple questions :

S * Ask the individual to SMILE ..

T * = TALK. Ask the person to SPEAK A SIMPLE SENTENCE (Coherently) (eg ‘It is sunny out today’).
R * Ask him or her to RAISE BOTH ARMS .

If he or she has trouble with ANY ONE of these tasks, CALL AN AMBULANCE and get the patient to a STROKE APPROPRIATE FACILITY.

NOTE : Another ‘sign’ of a stroke is

  1. Ask the person to ‘stick’ out their tongue.
  2. If the tongue is ‘crooked’, if it goes to one side or the other that is also an indication of a stroke.

Remember these ‘3’ steps, STR . Read, Learn and Teach someone!

Serious reasons why your patient fainted…

If your patient presents with…

  1. Symptoms of arm ischemia or paresthesias with syncope – Subclavian steal syndrome
  2. Chest pain that is acute, radiates, tearing/sharp, involves symptoms above and below diaphragm with syncope – Aortic dissection
  3. Tachypnea, pleuritic chest pain, shortness of breath with syncope – PE
  4. Neurologic deficit with syncope – TIA/stroke
  5. Headache that is sudden in onset, maximal at onset, worst of life with syncope – Subarachnoid hemorrhage
  6. Minor trauma with head or neck pain and syncope – Carotid/vertebral artery dissection
  7. Abdominal/flank pain in older patient with syncope – Ruptured AAA