Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, PNP, are teaming up to create a new EMN blog, The Procedural Pause.
The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.
The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.
Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.
Monday, October 3, 2016
Solutions for Difficult Problems:Eye Irrigation — Morgan Lens No More! Part 2
We promised you short, sweet, and simple solutions, and we plan to deliver. Many of the tools we want you to use may have merely been forgotten. The steps to complete these simple solutions will require just a few minutes of brushing up on the basics while watching our how-to videos and reading our step-by-step blog posts.
One of the lengthiest procedures in the emergency department can be eye irrigation. Some patients may need 5-15 liters of normal saline flush, which can take hours. Alkaline products need ample flushing and constant reevaluation with pH checks to avoid ocular burns. Patients can get frustrated and often times will ask you to stop the procedure. Keeping up with an eye irrigation patient can be difficult for providers as well, and create a long stay.
This patient suffered from alkaline burns to both eyes. He is being treated with normal saline irrigation using a nasal cannula. Photo by Martha Roberts.
Many providers have traditionally used the Morgan Lens in the ED to assist in ocular irrigation. The process is time-consuming and sometimes painful, and it can cause corneal abrasions. Patients, especially children, have difficulty tolerating the lens. Insertion can be agonizing if proper anesthesia is not obtained. Depending on the patient, the lens may need to be replaced several times if there are multiple liters of irrigation. Many urgent care facilities and some EDs may not stock the Morgan Lens and need an alternative approach to treatment. Finally, the Morgan Lens can be harmful to the patient if the normal saline infusion bags run dry. Many times providers will be unable to monitor the lens/bolus. This can be frightening for the patient and can cause ocular trauma.
One of the best ways to irrigate the eye involves using IV saline via a nasal cannula and connector piece from a Salem Sump kit. This procedure is far less invasive than using the Morgan Lens and is less traumatic for the patient. Patients feel less claustrophobic and are able to move freely. It is an effective and forgotten form of treatment to consider the next time you need to irrigate a patient's eye.
The Approach
- Careful but speedy examination of eye
- Initial ocular anesthesia (i.e., tetracaine)
- Oral pain or anxiety control
- Set up an irrigation system using nasal cannula and normal saline
- Repeat boluses of normal saline and pH status checks
- Consult with poison control and ophthalmology as needed
The Procedure
- Begin manual flushes of the eye as soon as possible after carefully (but quickly) examining the patient's eye. Do this while the irrigation system is being set up. The sooner the caustic agent is washed from the eye, the better.
- Check the pH of the eye for a baseline. Your goal is to get as close to 7.0 as possible.
Sample of pH strip used for ocular pH testing.
- Discuss with ophthalmology and poison control. If the patient has brought in the bottle of the chemical he was exposed to, report each ingredient to the specialists.
- Equipment: Obtain several normal saline bags, a nasal cannula, tetracaine (or other ocular anesthesia), towels and absorbent padding, and an NG or Salem Sump kit.
- Each Salem Sump kit contains a small, white plastic connector piece. This piece is key to attaching the NS IV line to the nasal cannula.
Salem Sump connector piece.
- You may use tape to reinforce the connection, but the connection alone is quite secure once placed.
- Set up a piggyback line to the IV connection so more than one bolus can run at a time and you can alternate without stopping.
- Consider giving the patient oral pain control (if the caustic agent is painful) or antianxiety medication such as Valium to relax him during this lengthy procedure.
- Administered ocular anesthesia into both eyes. This pain relief will help the patient tolerate the initial NS bolus. Additional numbing drops can be administered between boluses.
- Have the patient remove all top layers of clothing. This procedure will get them wet. Then position the patient at a 30-degree angle on the stretcher.
- Lay the nasal cannula over the bridge of his nose so that the prongs are directed to the inner canthus. If both eyes are affected, separating the two prongs will allow saline delivery into both.
- If only one eye is affected, both prongs can be directed to a single eye.
- Allow the NS to flow from the bag into the IV line and over the patient's face, across his eyes. This flow is quite powerful and will copiously irrigate the eyes. The patient does not need to keep his eyes open.
- Continue this as needed and until the pH is at an acceptable level.
- Follow up with ophthalmology as recommended.
Watch a video demonstrating this technique.The ports typically used for oxygen deliver the normal saline to both eyes, left. If one eye is affected, you can shift both prongs to that eye. Give ocular anesthesia before the first bolus. A patient may keep his eyes closed because the saline will bathe the inner canthus and inner eye. The saline is delivered at a fast rate, allowing for generous irrigation. The Salem Sump connector piece, right, connected to the NS bolus bag. Photos by Martha Roberts.
Cautions and Pearls
- Patients get wet when you do this procedure. This also means they get cold. Consider frequent hospital gown changes, appropriate drainage techniques (such as using drainage headboards, towels, Chux, etc.). You should also give your patient some blankets. Use warmed NS if available.
- Report all ingredients to poison control for assistance.
- Remember to check the pH. It's important to wait 10 minutes between each NS bolus to check the pH level because it can continue to rise.
- This is a long procedure at times and can cause anxiety. Absolutely use a numbing agent if the patient can tolerate it and frequently check on the patient. Reassurance can play a major role, but when it can't, anxiolytics can be of assistance.
- Complete a full eye exam if possible, but do not delay irrigation tactics.
- Discuss home medications with ophthalmology such as erythromycin or other antibiotics before discharge.
- Tell patients to avoid wearing contact lenses for at least two weeks.
Toxicology Tip of the Week
Alkaline cleaning products can cause burns to the skin or face. Straightforward chemical burns from these products, however, generally only affect the eye. The solution is not absorbed systemically nor does it enter the nasal pharynx.
Alkaline is Everywhere
Patients often present with known complaints of chemical burns to the eye, but some patients may not know they have an alkaline burn. A single case report of a chemical keratitis involved alkaline gas from a deployed passenger airbag. The authors noted that inflation of an airbag converts sodium azide to nitrogen gas. The bags are vented so that nitrogen and residual byproducts of combustion, such as alkaline gas, which could cause injury. (Ann Emerg Med 1992;21[11]:1400.)
Posted by James R. Roberts, MD & Martha Roberts, ACNP, PNP at 3:36 PM
Tags: Eye irrigation, Morgan Lens, ocular burns, IV saline, nasal cannula, Salem Sump kit
