Visual Diagnoses in the ED

1. 23/02/17
Visual Stimuli In Emergency
Medicine
CME Teaching

2. A 50 year old man is BIBA following an MVA - the driver
of a car travelling 80km/hr that was hit head on by a car
travelling roughly the same speed

6. Basilar skull fracture
✤ Bleeding from the fracture site into the surrounding
structures
✤ Clinical manifestations of basilar skull fracture may
take hours to fully develop
✤ Needs urgent CT to evaluate and identify any
underlying brain injuries

8. Seatbelt sign
✤ Increased risk of underlying visceral injuries
✤ Low threshold for CT

10. Septal haematoma
✤ Risk of avascular necrosis or secondary
infection/abscess formation
✤ Can cause permanent deformity if left untreated
✤ Needs ENT input for urgent aspiration/drainage

12. Hyphaema
✤ Collection of red blood cells within the anterior
chamber
✤ Usually managed conservatively with close
ophthalmology follow up
✤ Can be complicated by obstruction of the trabecular
meshwork leading to raised intraoccular pressure

13. A 26 year old man presents to ED with a 2 day history of
a red, painful eye with blurred vision

15. Hypopyon
✤ Visible accumulation of white cells in the anterior
chamber
✤ Indicates severe anterior uveitis
✤ Needs urgent ophthalmology referral
✤ Can be sight threatening

16. A 38 year old lady presents to hospital with a one day
history of pain and irritation in her right eye

18. Dendritic ulcer
✤ Herpes simplex keratitis
✤ Treated with topical anti-virals and needs urgent
ophthalmology referral
✤ Can be sight threatening

19. A 78 year old lady with a background of hypertension
and type 2 diabetes presents with painless visual loss in
her right eye

21. Central retinal vein occlusion
✤ Predisposing factors include age, HTN and Diabetes
✤ Visual acuity varies depending on the severity of the
bleed
✤ Needs urgent ophthalmology referral

22. A 63 year old man presents with sudden loss of vision in
his left eye

24. Central retinal artery occlusion
✤ Visual acuity always reduced <6/60
✤ Need to rule out Giant Cell Arteritis
✤ Needs urgent ophthalmology referral

25. A 32 year old lady presents with severe headaches and
blurred vision

27. Papilloedema
✤ Assess with full neurological and ophthalmological
examinations
✤ Needs urgent neurological imaging
✤ Neurology/opthalmology input depending on cause

28. A 56 year old man presents with loss of vision in one
after complaining of flashes and floaters over the last
couple of days

30. Retinal detachment
✤ Direct fundoscopy can’t always rule out a detachment
✤ Ultrasound is a useful tool for diagnosis
✤ Needs urgent ophthalmology referral

31. A 68 year old man in brought into ED following a
collapse at home. He is GCS 6/15

33. Unequal pupils
✤ Injury or compression of the third cranial nerve and
upper brainstem
✤ Suggests severe inter cranial pathology
✤ Needs urgent CT head to assess

34. A 45 year old smoker presents to ED complaining that
her left eye is ‘droopy’

36. Horner’s Syndrome
✤ Ptosis, miosis and anhidrosis
✤ Interruption of the sympathetic nerve supply to the eye
✤ Painful Horner’s - need to consider dissection

37. A 70 year old man presents to hospital with a painful
rash and redness in his right eye

39. Hutchinson’s sign
✤ Supplied by the nasocilliary branch of the trigeminal
nerve
✤ Highly predictive of eye involvement
✤ Needs urgent ophthalmology referral - can be sight
threatening

40. A 72 year old man with a background of lung cancer
presents to hospital complaining of increasing shortness
of breath

43. SVC obstruction
✤ Pemberton’s sign
✤ Most common cause is lung cancer
✤ Treated with chemotherapy/radiotherapy or stenting

44. A 54 year old man presenting to hospital with abdominal
pain and distention

46. Distended abdominal veins
✤ IVC obstruction vs caput medusa
✤ Caput medusa signifies severe portal hypertension

48. Spider Naevi
✤ Dilation of arterioles caused by increased oestrogen
levels
✤ Multiple spider naevi is a common sign in liver disease
✤ Also common in pregnancy

49. A 46 year old alcoholic man presents to hospital with
severe abdominal pain and vomiting

52. Retroperitoneal bleed
✤ Trauma, ectopic pregnancy rupture or pancreatitis
✤ Signifies necrotizing pancreatitis
✤ Associated with very high mortality

53. A 78 year old lady with a history of COPD presents to
hospital with respiratory distress

55. Peripheral cyanosis
✤ Caused by excessive deoxyhaemoglobin in the blood
✤ Inadequate or obstructed circulation
✤ Anaemic patients may be hypoxic without cyanosis

56. A 42 year old IVDU presents to hospital feeling generally
unwell with high fevers

59. Infective endocarditis
✤ Vascular and immunologic phenomena
✤ Most commonly caused by Staph aureus
✤ Modified Dukes criteria for diagnosis

61. A 72 year old man presents to ED with SOB which has
been getting worse over the last few months

63. Clubbing
✤ Many associated diseases
✤ Schamroth’s test used to identify subtle clubbing
✤ Needs further investigation if not known to have a
causative disease

64. A 38 year old man presents to hospital with a painful
rash on his chest

66. HSV
✤ Cause by the varicella zoster virus
✤ Never crosses the midline
✤ Infective until lesions have crusted
✤ Often complicated by post-herpetic neuralgia

67. Any Questions?