Barry Smith; 52 yo 4/26/1958
Authors: Elliot Rodriguez, MD, FACEP/Brian Kloss, MD, JD
Reviewer: Sharon Griswold, MD, MPH
Case Title: “Can’t See the Forest Because of the Tree”
Target Audience: Resident (EM1-3)
Primary Learning Objectives: key learning objectives of the scenario
1. Perform an appropriately thorough and efficient trauma evaluation.
2. Identify the signs & symptoms of ocular compartment syndrome due to retrobulbar
hematoma.
3. Recognize the need for emergent lateral canthotomy.
4. Describe the steps for performing a lateral canthotomy.
Secondary Learning Objectives: detailed technical goals, behavioral goals, didactic points
1. Consult Ophthalmology.
2. Recognize the cause of bradycardia is the oculo-cardiac reflex & does not require
treatment as patient is not unstable.
Critical actions checklist
1. Perform primary survey & appropriate secondary trauma survey to identify injuries
2. Immobilize cervical spine.
3. Perform visual acuity and IOP.
4. Diagnose orbital compartment syndrome.
5. Consult ophthalmology immediately upon recognition of acute traumatic visual loss.
6. Identify need for emergent lateral canthotomy and describe procedure.
Environment (if using as a simulation case)
1.
Room Set Up – trauma bay
a. Manikin Set Up – Full body mannequin, needs clay & makeup to simulate left
periorbital swelling and bruising, needs eye with dilated pupil, no IV lines in
place, 1% lidocaine w/epinephrine
b. Props – EKG (attached), CT images (attached), laceration tray
2.
Distractors - none
Actors (optional)
1.
Roles – nurse, ophthalmology consultant (will be limited to telephone
conversation)
2.
Who may play them – nurse can be played by anyone, consultant should be
played by confederate with foreknowledge of scenario.
3.
Action Role – nurse is helpful, consultant is unhelpful (unavailable to come in
emergently due to currently in outpt surgery center with elective OR case – “ I can be
there in 2-3 hours”).
1
Barry Smith; 52 yo 4/26/1958
For Examiner Only
Authors: Elliot Rodriguez, MD, FACEP/Brian Kloss, MD, JD
Reviewer:
Case Title: “Can’t See the Forest Because of the Tree”
CASE SUMMARY
CORE CONTENT AREA
2009 Model of the Clinical Practice of EM
18.1 Trauma; Ophthalmologic; Retrobulbar Hemorrhage
Appendix 1. Procedures; Head & Neck; Lateral Canthotomy
SYNOPSIS OF HISTORY/ Scenario Background
52 yo male was cutting trees down on his property 60 minutes prior to presentation. He
was struck in the left side of the face with a tree branch while using chainsaw. He presents via
private vehicle with friend. He complains of severe left side face & eye pain, poor vision
from left eye, nausea, dizziness. He denies LOC or neck pain. He was not injured by
the chainsaw and has no other injuries. He has a retrobulbar hematoma with orbital
compartment syndrome that requires emergent lateral canthotomy.
Chief Complaint – “I got hit in the face with a tree branch”
Triage note – While cutting down trees got hit with branch to left side of face 60 minutes
ago. He c/o pain & blurry vision.
Past medical history - HTN
Medications and allergies – atenolol 50mg daily
Family and social history – married, 2 adult children, drinks alcohol socially, smokes ½
ppd. No significant family history.
SYNOPSIS OF PHYSICAL
Initial scenario conditions: Vital signs, initial physical examination, any pertinent patient
physiology
Initial triage VS – BP 130/80, HR 42, RR 20, T 36.8 C (oral)
Abnormal PE findings limited to left side of face which reveals proptosis of left eye with
associated left periorbital swelling & ecchymosis, VA OS has light perception only,
+RAPD, IOP=80.
Patient is bradycardic due to oculo-cardiac reflex from his ocular compartment
syndrome but his blood pressure remains stable.
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Barry Smith; 52 yo 4/26/1958
For Examiner Only
CRITICAL ACTIONS
SCENARIO BRANCH POINTS/ PLAY OF CASE GUIDELINES
1. Critical Action
Perform primary survey & appropriate secondary trauma survey to identify injuries
Cueing Guideline: Consider having patient complain of additional areas of pain (eg, neck,
extremity) to prompt candidate to search for other potential injuries.
2. Critical Action
Immobilize cervical spine initially. As patient did not come into ED via EMS, candidate must
recognize mechanism of injury could involve cervical spine.
Cueing Guideline: Have patient complain of neck pain. Alternatively have patient comment
on how severe his pain is to prompt candidate to consider facial trauma as distracting injury.
3. Critical Action
Identify presence of ocular compartment syndrome, including assessment of visual acuity &
measurement of intraocular pressure.
Cueing Guideline: Have nurse question candidate as to why patient’s vision is being
affected by this injury.
4. Critical Action
Consult ophthalmology immediately upon recognition of acute traumatic visual loss.
Cueing Guideline: Have nurse comment that CT will be delayed if consult not requested
prior to imaging ordered.
5. Critical Action
Identify need for emergent lateral canthotomy and describe procedure. At completion of
procedure patient’s pain improves, VA OS improves to finger count & heart rate increases to
70 bpm.
Cueing Guideline: Have nurse & patient question whether it is safe to wait the 2-3 hours
before the ophthalmology consultant arrives.
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Barry Smith; 52 yo 4/26/1958
SCORING GUIDELINES
1. Perform primary survey & appropriate secondary trauma survey to identify injuries
2. Immobilize cervical spine.
3. Perform visual acuity and IOP.
4. Diagnose orbital compartment syndrome.
5. Consult ophthalmology.
6. Identify need for emergent lateral canthotomy and describe procedure.
4
Barry Smith; 52 yo 4/26/1958
For Examiner Only
Onset of Symptoms:
HISTORY
One hour prior to presentation.
Background Info:
52 year old male with left eye & face pain
Chief Complaint:
“I got hit in the face with a tree branch.”
Past Medical Hx:
Hypertension
Past Surgical Hx:
None
Medications:
Atenolol 50 mg daily
Allergies:
None
Habits:
Smoking: ½ pack/day
ETOH: social;
Drugs: None
Family Medical Hx:
None
Social Hx:
Marital Status: Married
Children: 2 adult children (healthy)
Education: High school
Employment: Security guard
ROS:
List pertinent positives and negatives:
Positives:
Headache – left sided
Eye pain – left sided
Acute visual loss OS – light perception only
Nausea without vomiting
Dizziness
Negatives:
Loss of consciousness
Neck/back pain
Numbness or weakness
Chest pain
Dyspnea
Syncope
Abdominal pain
Extremity pain
5
Barry Smith; 52 yo 4/26/1958
For Examiner Only
PHYSICAL EXAM
Patient Name: Barry Smith
Age & Sex: 52 yo, male
General Appearance: Well-developed, well-nourished male in moderate distress, obvious left
sided facial trauma
Vital Signs: BP 130/80, HR 42, RR 20, T 36.8 C (oral)
Head: Left sided periorbital ecchymosis, swelling, abrasion
Eyes: Proptotic left eye with fixed dilated pupil (+ Relative Afferrent Pupillary Defect (RAPD));
lateral subconjunctival hemorrhage; cornea, clear; anterior chamber clear; visual acuity OS –
light perception only, OD – normal; IOP = 80
Ears: normal
Mouth: normal
Neck: no midline cervical tenderness, no masses
Skin: no rashes
Chest: normal
Lungs: normal
Heart: normal
Back: normal
Abdomen: normal
Extremities: non tender
Rectal: deferred
Pelvic: non tender
Neurological: 5/5 motor in all extremities with intact sensation, speech clear
Mental Status: alert, no confusion, follows commands
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Barry Smith; 52 yo 4/26/1958
For Examiner Only
STIMULUS INVENTORY
#1
Emergency Admitting Form
#2
CBC - included
#3
BMP - included
#4
Cardiac Enzymes - included
#5
CXR report included
#6
CT head report
#7
CT Cervical spine report
#8
CT maxillofacial images
#9
EKG – image attached
#10
Debriefing materials – article attached
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Barry Smith; 52 yo 4/26/1958
For Examiner Only
LAB DATA & IMAGING RESULTS
Stimulus #2
Complete Blood Count (CBC)
WBC
17,000/mm3
Hgb
15 g/dL
Hct
45 %
Platelets
350,000/mm3
Differential
Segs
65%
Bands
0%
Lymphs
20%
Monos
10%
Eos
5%
Stimulus #3
Basic Metabolic Profile (BMP)
Na+
140 mEq/L
K+
4.5 mEq/L
CO2
30 mEq/L
Cl
100 mEq/L
Glucose
150 mg/dL
BUN
15 mg/dL
Creatinine
1.1 mg/dL
Stimulus #4
Cardiac Enzymes
Troponin
0.0 ng/ml
Diagnostic Imaging
Stimulus #5
CXR:
Negative
Stimulus #6
Head CT:
Negative
Stimulus #7
Cervical spine CT:
Negative
Stimulus # 8
Maxillofacial CT:
Orbital floor & medial wall fractures with retrobulbar hemorrhage &
proptosis (images attached)
Stimulus #9
EKG: sinus bradycardia (image attached)
8
Barry Smith; 52 yo 4/26/1958
Learner Stimulus #1
ABEM General Hospital
Emergency Admitting Form
Name:
Barry Smith
Age:
52 years
Sex:
Male
Method of Transportation:
Private car
Person giving information:
Patient
Presenting complaint:
Hit with branch to left face
Background: Patient was struck in the left side of the face with a tree branch while using
chainsaw. Neighbor brought patient into ED via car. Patient complains of left side face & eye
pain with poor vision.
Triage or Initial Vital Signs
BP:
130/80
P:
42
R:
20
T:
36.8 C (oral)
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Barry Smith; 52 yo 4/26/1958
Learner Stimulus #2
Complete Blood Count (CBC)
WBC
17,000/mm3
Hgb
15 g/dL
Hct
45 %
Platelets
350,000/mm3
Differential
Segs
65%
Bands
0%
Lymphs
20%
Monos
10%
Eos
5%
10
Barry Smith; 52 yo 4/26/1958
Learner Stimulus #3
Basic Metabolic Profile (BMP)
Na+
140 mEq/L
+
K
4.5 mEq/L
CO2
30 mEq/L
Cl100 mEq/L
Glucose
150 mg/dL
BUN
15 mg/dL
Creatinine
1.1 mg/dL
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Barry Smith; 52 yo 4/26/1958
Learner Stimulus #6
Cardiac Enzymes
Troponin 0.0
12
Barry Smith; 52 yo 4/26/1958
Learner Stimulus #8
Chest Xray Report
Normal CXR
13
Barry Smith; 52 yo 4/26/1958
Learner Stimulus #9
Head CT Report
No acute intracranial abnormalities.
14
Barry Smith; 52 yo 4/26/1958
Learner Stimulus #10
Cervical spine CT Report
No acute fracture or subluxation.
15
Barry Smith; 52 yo 4/26/1958
Learner Stimulus #11
Maxillofacial CT images (2 images)
16
Barry Smith; 52 yo 4/26/1958
Stimulus #12
EKG
17
Barry Smith; 52 yo 4/26/1958
Feedback/ Assessment Form
“Can’t See the Forest Because of the Tree”
Candidate ________________________
Examiner _________________________
Critical Actions:
 Critical Action #1 Perform primary survey & appropriate secondary trauma survey to
identify injuries
 Critical Action #2 Immobilize cervical spine.
 Critical Action #3 Perform visual acuity and IOP.
 Critical Action #4 Diagnose orbital compartment syndrome.
 Critical Action #5 Consult ophthalmology immediately upon recognition of acute traumatic
visual loss.
 Critical Action #6 Identify need for emergent lateral canthotomy and describe procedure.
Dangerous Actions: (Performance of one dangerous action results in failure of the case)
 Dangerous Action #1 Treating bradycardia with atropine despite normal blood pressure.
 Dangerous Action #2 Waiting for ophthalmologist to come in and perform procedure.
Overall Score:
 Pass
 Fail
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Barry Smith; 52 yo 4/26/1958
For Examiner
Date:
Examiner:
Examinee(s):
Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)
The learner should be scored (based on level of training) for each item above with one
of the following:
NI = Needs Improvement
ME = Meets Expectations
AE = Above Expectations
NA= Not Assessed
Critical Actions
Perform primary survey & appropriate
secondary survey to identify injuries
Immobilize cervical spine
Perform visual acuity and IOP
Diagnose orbital compartment
syndrome
Consult ophthalmology
Identify need for emergent lateral
canthotomy and describe procedure##
NI
ME
AE
NA
Category
PC, MK
PC, MK
PC, MK
PC, MK, PBL
PC, ICS, SBP
PC, MK, PBL,
SBP
## EM1 & 2 can request review of procedure using text or electronic reference, however
EM3 must describe the procedure accurately without a reference.
N/A= not assessed.
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Barry Smith; 52 yo 4/26/1958
Category: One or more of the ACGME Core Competencies as defined in the SDOT
PC=
Patient Care
Compassionate, appropriate, and effective for the treatment of health problems and the promotion
of health
MK= Medical Knowledge
Residents are expected to formulate an appropriate differential diagnosis with special attention to
life-threatening conditions, demonstrate the ability to utilize available medical resources effectively,
and apply this knowledge to clinical decision making
PBL= Practice Based Learning & Improvement
Involves investigation and evaluation of their own patient care, appraisal and assimilation of
scientific evidence, and improvements in patient care
ICS= Interpersonal Communication Skills
Results in effective information exchange and teaming with patients, their families, and other health
professionals
P=
Professionalism
Manifested through a commitment to carrying out professional responsibilities, adherence to ethical
principles, and sensitivity to a diverse patient population
SBP= Systems Based Practice
Manifested by actions that demonstrate an awareness of and responsiveness to the larger context
and system of health care and the ability to effectively call on system resources to provide care that
is of optimal value
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Barry Smith; 52 yo 4/26/1958
Keywords for future searching functions
Orbital Compartment Syndrome
Retrobulbar Hematoma
Lateral Canthotomy
References
Innes G, Howes D. Lateral canthotomy and cantholysis: A simple, vision saving procedure.
Canadian Journal of Emergency Medicine (2002); 4(1), p 49-52
(Need permission if published) Thomas J. Walsh, M.D. Relative Afferent Pupillary Defect.
Reference taken from http://www.cybersight.org/bins/volume_page.asp?cid=1-13-161-987.
Retrieved February 2, 2011
Hoffman JR, Wolfson AB, Todd K, Mower WR.Selective cervical spine radiography in blunt
trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS).
Ann Emerg Med. 1998 Oct;32(4):461-9.
Has this work been previously published?
No
Simulation Flowchart - patient physiologic status does not change during the scenario except
at completion of canthotomy procedure – pain improves, VA OS improves to finger count, heart
rate improves to 70 bpm.
Simulation Equipment Checklist
ENVIRONMENT
This scenario requires (checked boxes):
X
X
X
X
X
Simulator
Type:
Standardized Patient
Non-Invasive BP Cuff
2 lead EKG
Pulse Oximeter
Arterial Line
CVP
PA Catheter
Temperature Probe
Capnograph
Resp Rate Monitor
SP for family member
Additional nurse SP
Other SP
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ETT
LMA
Laryngoscope
Fiberoptic scope
Gum Bougie
Crash Cart
Central line set up
Chest tube set up
Ultrasound Machine
Barry Smith; 52 yo 4/26/1958
Debriefing Stimuli:
The following article attached in a separate pdf is an excellent review of lateral
canthotomy procedure.
Innes G, Howes D. Lateral canthotomy and cantholysis: A simple, vision saving
procedure. Canadian Journal of Emergency Medicine (2002); 4(1), p 49-52
Relative Afferent Pupillary Defect
Room Light
OD 20/20
OS 20/20
Bright Light OD = Both pupils constrict
Move light rapidly to OS,
both eyes stay constricted
Normal pupillary response to rapid shift of bright light from one eye to the other indicates equal optic nerve
function.
Room Light
OD 20/20
OS 20/200
Bright light OD = Both pupils constrict
Move light rapidly to OS,
both eyes dilate equally
Positive RAPD left eye confirms optic nerve disease is cause of decreased visual acuity.
Thomas J. Walsh, M.D.
(Permission requested) Thomas J. Walsh, M.D. Relative Afferent Pupillary Defect. Reference
taken from http://www.cybersight.org/bins/volume_page.asp?cid=1-13-161-987. Retrieved
February 2, 2011.
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