PEDIATRIC PAINS
Steven M. Selbst, MD, Professor of Pediatrics, and Vice-Chair for Education, Department of Pediatrics, Jefferson Medical
College, Thomas Jefferson University, Philadelphia, and Alfred I. duPont Hospital for Children, Wilmington, Delaware
| EYE EMERGENCIES: WHEN DO YOU NEED AN OPHTHALMOLOGIST?
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| Incidence: 70,000 children per year present with eye injuries needing emergency care; most are sports injuries; boys injured
more often than girls; Bungee cords big cause of eye injuries; paintball injuries increasing; 40% of injuries
caused by BB guns leave permanent damage; ≈33% of fireworks injuries involve eyes; eye injuries can be caused by
airbags
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| Approach: follow airway, breathing, and circulation (ABCs), not appearance of severity of injury; examine both eyes;
assess vision; consider globe injury; do not use steroids; arrange follow-up
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| History: children and parents may not give complete history due to feelings of guilt about how injury occurred; ask
about preexisting disorders or eye injuries, corrective lenses, medications that might affect vision, when child last
ate, and mechanism of injury
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| Physical examination: be patient and gentle; assess visual acuity; start on outside of eye and work in, ie, periorbital tissue,
lids, eye surface, intraocular structures; if dilation necessary, perform last (likely will lose child’s cooperation);
pull eyelid up or wrap around cotton swab while patient looks down (also may use lid retractor or folded paper
clip); do not touch globe (place thumbs on supraorbital and infraorbital areas)
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| Foreign body in eye: cloud of dust sprayed into patient’s face while playing baseball; patient presents with eye pain;
children old enough to talk will say they have foreign body sensation; often have tearing and red eye; perform careful
inspection by inverting upper eyelid and asking patient to look down; usually can pick out foreign body with
cotton swab or irrigation; giving topical anesthetic helpful (do not send patient home with topical anesthetic); consider
dilating eye (seems to help with pain) to look for corneal abrasion; call ophthalmologist if cannot remove foreign
body or if intraocular foreign body suspected
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| Corneal abrasion: can occur from direct trauma, patient rubbing eye while foreign body in it, UV light burn, or overuse
of contact lenses; signs and symptoms include pain, tearing, photophobia, redness; perform fluorescein stain
(moisten strip with saline, place at corner of eye); use blue light or Wood’s lamp; use topical anesthetic during initial
management; antibiotic ointment indicated at time of discharge (ointment works better than drops); consider
cycloplegic agent and systemic analgesic; do not need to patch eye; patient should follow up with ophthalmologist
in 24 to 36 hr if still symptomatic; patients with large abrasions or patients who wear contact lenses should be seen
by ophthalmologist within 12 to 24 hr
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| Tissue glue: eyelids stuck together; eye seldom injured; do not need ophthalmologist; apply mineral oil or petroleum
jelly on glued site for 30 to 60 min; may take hours to work if glue has set; do not force eyelids open
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| Cleaning substance splashed in face: child complains of eye pain and vision loss; alkali worst offender, acid second; in
most cases, cleaning substance just soap and causes irritation or abrasion but otherwise innocuous; however, assume
alkali when parents call from home; instruct parents to irrigate patient’s eye as soon as possible before coming
to hospital; need ophthalmologist immediately if alkali or acid involved; severity of injury depends on pH of
solution, ie, “the more alkaline, the worse the injury”; acids coagulate surface protein, whereas alkali penetrates;
crucial factors are how much and how long eye in contact with substance; irrigate before checking vision; administer
topical anesthetic multiple times while irrigating; irrigate under eyelids; irrigate at least 20 min or 2 L of fluid,
whichever comes last, up to 1 hr if chemical injury severe; pH of eye should be neutral; do not forget to check other
eye, which also may need to be irrigated; apply topical antibiotic
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| Hyphema: 5-yr-old boy hit in eye with action figure; consider hyphema with blunt trauma to eye; need ophthalmologist;
slit lamp helpful; larger hyphemas seen with naked eye; patients present with eye pain and some somnolence
(natural reaction to being hit in eye); look for associated injuries, eg, globe laceration; treat with bed rest; can
watch television but no reading or coloring (rapid eye movement can be irritating); unless very large, hyphema
heals on its own in 3 to 5 days; chance of permanent damage, glaucoma, and staining of eye if eye rebleeds; keep
head of bed elevated; use cycloplegic agent for pain
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 | Management: if child will sit in bed at home, has small bleed (less than one third of iris), and parents will bring
child back for follow-up, patient can go home; if not, admit; patients with sickle cell disease have worse prognosis;
poor prognosis if entire anterior chamber filled with blood; obtain immediate ophthalmology consult in
emergency department (ED) for patients with large hyphemas; give acetaminophen instead of ibuprofen (could
lead to bleeding) for pain; most resolve in few days; 20% rebleed (can lead to permanent damage; try to prevent)
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| Blowout fracture: 15-yr-old boy punched in face, complaining of eye pain and diplopia; suspect orbital blowout fracture
and detached retina; x-rays unsatisfactory; computed tomography (CT) best method for detecting orbital fracture; patients
with blowout fractures have pain, swelling, ecchymosis, nose bleed, and may have air in periorbital area; check
extraocular muscles (patient who cannot look up has blowout fracture); fracture not clinically significant if extraocular
movement intact (ophthalmologist can see patient in office next day; must wait for swelling to decrease); check eye for
other injuries, eg, to globe); consider prophylactic oral antibiotics
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| Eyelid laceration: boy attacked by pit bull; any patient with injury in medial third of eye lid has tear duct involvement;
consider damage to nasolacrimal duct system; worry about infection; update tetanus prophylaxis, and consider rabies
prophylaxis if indicated; call ophthalmologist immediately if injury involves medial third of eye lid; difficult
to sew and assess; check for other injuries, eg, globe laceration
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| Globe laceration: 7-yr-old boy gets poked in eye by low-lying branch; need ophthalmologist immediately; true eye
emergency; protect eye with physical barrier (do not put pressure on eye); corneal wounds heal rapidly; if pupil not
perfectly round (eg, teardrop shape), suspect laceration; consider sedation (do not want patient crying; may cause
intraocular contents to spill out); bed rest indicated with head elevated to reduce eye pressure; give antibiotics if
long delay before ophthalmologist sees patient
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| Purulent eye drainage in 6-day-old: consider gonorrhea (GC), chlamydia, herpes; newborns can get chemical conjunctivitis
on day 1, GC conjunctivitis few days later, chlamydia usually at end of first week; herpes usually within first 2
wk; GC usually has very thick discharge, chlamydia generally more watery than GC, herpes more watery than
chlamydia; GC conjunctivitis patients present with purulent discharge; consider sepsis work-up (corneal ulceration
develops if left untreated); treat conjunctivitis as GC until proven otherwise; obtain culture and Gram’s stain for
chlamydia, GC, and herpes; admit and treat with IV antibiotics and topical ointment; call ophthalmologist to see
patient immediately or within next few hours
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| Cellulitis: 5-yr-old boy febrile with red, swollen, painful eye; try to distinguish between preseptal cellulitis (only eye lid
involved) and orbital cellulitis (abscess behind globe involving eye itself); preseptal cellulitis usually due to minor
trauma followed by secondary infection with Staphylococcus (also could be due to blood-borne infection, ie, bacteremia);
orbital cellulitis usually due to sinusitis; proptosis, chemosis, pain on eye movement, decreased eye movement,
or decreased vision indicate orbital process involved
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| Management: need ophthalmologist if cannot open patient’s eye to check for movement; check vision; if patient febrile,
obtain complete blood count (CBC) and blood culture; obtain CT (definitive); children with preseptal cellulitis
can be treated as outpatients; if they look well, send them home on oral cephalexin (Keflex) or amoxicillin
and potassium clavulanate (Augmentin); if patient being admitted, worry about methicillin-resistant Staphylococcus
aureus (MRSA) and give IV clindamycin; obtain ophthalmology consult within 24 hr if orbital process involved;
do not need ophthalmologist with periorbital (preseptal) process unless child very sick
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| Differential diagnosis of bruises
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| Henoch-Schönlein purpura (HSP): multiple bruises limited to lower extremities and buttocks; child also has joint
pain, belly pain, abnormal urine, and hypertension; young children can have bruises on face and extensor surface
of arms; sparing of abdomen and back support diagnosis of HSP
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| Coining and cupping injuries: bruising caused by heated coins or cup; form of therapy used in Asian cultures to reduce
fever (not reported as child abuse)
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| Self-inflicted: injuries seen only in areas where child can reach
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| Mongolian spots: not tender and resolve over several months
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| Impetigo: sometimes confused with cigarette burns; cigarette burns deeper; impetigo has multiple lesions of different
sizes that crust and slough off easily
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| Toddler’s fracture: may look like spiral fracture; minor event in most cases; no physical findings or swelling other
than limp
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| Osteopenia or osteogenesis imperfecta: bones fracture easily; these patients have chronic neurologic developmental
diseases and decreased bone calcium; children often bound to wheelchairs or bedridden; these patients likely to be
abused because they are difficult to care for at home
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| Shaken baby syndrome: child <1 yr of age; history of sudden deterioration; “there is no disease known to man that
can go from perfectly well to needing cardiac resuscitation in less than an hour other than head trauma”;
mother’s boyfriend common perpetrator; present with seizures, coma, respiratory arrest, often have full fontanelle
(may be misdiagnosed as meningitis); rarely have bruises; lumbar puncture yields xanthochromic bloody fluid that
does not clear; often have rib fractures from being squeezed while being shaken; retinal hemorrhages pathognomonic
for child abuse, with few exceptions; treat with resuscitation first (studies have shown that retinal hemorrhages
do not occur as result of resuscitation)
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| Münchausen by proxy: difficult diagnosis to make because family goes to many EDs; happy baby presented with diaper
full of blood; all studies negative; blood found to belong to mother; mother almost always perpetrator, typically
medically astute and overly involved; father often absent; child does worse while parents present; high
morbidity
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| Sexual abuse: defined as any exposure inappropriate for child’s age or psychosocial development; girls most often
victims; abuser usually family member or trusted friend (violence not common); stress usually present in family
(eg, alcoholism, drug abuse); may see behavior problems in child; rarely see venereal disease; child with herpes
almost always has been sexually abused; trauma rare in sexual abuse; physical examination normal in most cases
(does not mean no abuse); do not write on record, “no evidence of sexual abuse”; history convicts abuser in 90%
of cases; write, “normal examination, no trauma”; average emergency physician cannot tell normal size of vaginal
opening (document “normal genitalia”); presence of sexually transmitted disease (STD) equals sexual abuse
until proven otherwise (eg, GC, syphilis, HIV, or Chlamydia); diseases suspicious of abuse include herpes or venereal
warts (bacterial vaginosis inconclusive)
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| Management: sensitive interview; quiet room; document child’s words if willing to tell (most children do not tell
physician, but have told someone); gather team with social workers so child only has to tell story once; perform
gentle physical examination; perform on mother’s lap if mother supportive and child willing (be sensitive to
clues indicating mother involved in abuse); obtain cultures from oropharynx, anus, and genitalia only if significant
suspicion of abuse; evidence not usually collected; however, if acute assault occurred within 24 hr of presentation,
child’s clothing most important evidence to send to police; file report, arrange for counseling, transfer
patient to expert; if referring patient to another hospital, clearly document who will report case
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Educational Objectives
| The goal of this program is to educate the listener about pediatric eye emergencies and child abuse. After hearing and
assimilating this program, the clinician will be better able to:
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| 1. Illustrate the basic approach to a child with an eye injury.
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| 2. Describe the management of a child whose eyes are glued shut with tissue adhesive.
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| 3. Discuss the management of a hyphema.
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| 4. List several disease states that can be misdiagnosed as child abuse.
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| 5. Give the definition of sexual abuse and describe its management.
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Discussed on This Program
Acetaminophen (N -acetyl-P -aminophenol; APAP) [several trade names]
Amoxicillin and potassium clavulanate (co-amoxiclav) [Augmentin]
Cephalexin [Biocef, Keflex]
Clindamycin (several trade names)
Erythromycin (several trade names)
Ibuprofen (several trade names)
Programs of Related Interest
Feinberg D: Pediatric depression/adolescent substance abuse. Audio-Digest Psychiatry 34:20(Oct 21), 2005; Satkowiak
L: High risk pediatrics. Audio-Digest Emergency Medicine 21:19(Oct 7), 2004; Sharieff G, King C: Pediatric update. Audio-Digest
Emergency Medicine 21:09(May 7), 2004; Hoffman RS: Pediatric poisonings: deadly in a dose. Audio-Digest
Emergency Medicine 22:14(Jul 21), 2005; Satkowiak L, Plumley DA: Abdominal emergencies. Audio-Digest Emergency
Medicine 22:04(Feb 21), 2005.
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Suggested Reading
Aldave AJ et al: Bungee cord-associated ocular trauma. Ophthalmology 108:788, 2001; American Academy of Pediatrics:
Committee on Injury and Poison Prevention: Fireworks-related injuries to children. Pediatrics 108:190, 2001;
Beringer-Brown C et al: Child restraint misuse: a case example and strategies for injury prevention. Accid Emerg Nurs
13:82, 2005; Conn JM et al: Injuries from paintball game related activities in the United States, 1997-2001. Inj Prev
10:139, 2004; Filipe JA et al: Sports-related ocular injuries. A three-year follow-up study. Ophthalmology 104:313,
1997; Hamid RK et al: Pediatric eye emergencies. Anesthesiol Clin North America 19:257, 2001; Jan S et al: Ocular
emergencies. J Coll Physicians Surg Pak 14:333, 2004; Juang PS et al: Ocular examination techniques for the emergency
department. J Emerg Med 15:793, 1997; Lee WB et al: Airbags and bilateral eye injury: five case reports and a
review of the literature. J Emerg Med 20:129, 2001; Listman DA: Paintball injuries in children: more than meets the
eye. Pediatrics 113:e15, 2004; McGwin G Jr et al: Incidence of emergency department-treated eye injury in the United
States. Arch Ophthalmol 123:662, 2005; McLean CJ: Ocular superglue injury. J Accid Emerg Med 14:40, 1997; Saidinejad
M et al: Ocular irrigant alternatives in pediatric emergency medicine. Pediatr Emerg Care 21:23, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the speaker reported no conflict.
Dr. Selbst’s lecture on eye emergencies was recorded March 30, 2005, in Lake Buena Vista, Florida, at Pediatric Emergency
Medicine 2005, sponsored by The Nemours Children’s Clinic; Dr. Selbst’s lecture on child abuse was recorded
February 17, 2005, in San Diego, at the 11th Annual Scientific Assembly, of the American Academy of Emergency Medicine
(AAEM). The Audio-Digest Foundation thanks the speaker and the sponsors for their cooperation in the production
of this program.
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