RESUMO
Ocular trauma is one of the most common and vision-threatening ophthalmic presentations with a wide spectrum of complications, such as bleeding, infection, vision loss, and enucleation. A 64-year-old-male presented to the emergency department (ED) with a self-inflicted orbital penetrating injury with a hair comb. Computed tomography showed the comb traversed the medial orbit inferior to the medial rectus but did not damage the optic nerve; there were no globe or orbital wall fractures. His ocular exam was significant for a right eye afferent pupillary defect and decreased visual acuity 20/800, consistent with optic neuropathy. Primary concerns were stabilizing and removing the foreign body without causing further damage in the setting of an uncooperative patient. The comb was removed with the aid of local and systemic analgesia using gentle traction and normal saline irrigation. The patient was admitted for systemic and topical antibiotics and showed improvement in visual acuity and resolution of his optic neuropathy. This case illustrates the importance of rapid ED assessment and management of complex penetrating ocular trauma. Examination should specifically look for signs of globe rupture and optic nerve injury. Expedited foreign body removal should be managed together with an ophthalmologist with procedural sedation and broad-spectrum antibiotics to avoid further visual and infectious complications.
RESUMO
BACKGROUND: Inert gas rebreathing (IGR) techniques provide rapid, reliable estimates of cardiac output in adults with structurally normal hearts. Data on IGR reliability in pediatric and congenital heart disease populations are lacking. Our objective was to validate pulmonary blood flow (Qp) measurement by IGR compared with clinical reference tests, cardiovascular magnetic resonance (CMR), and indirect Fick. METHODS: Pulmonary blood flow was measured by IGR and CMR or indirect Fick in 80 patients grouped by presence and type of shunt lesion. Inert gas rebreathing precision was assessed using Bland-Altman analysis, repeatability coefficient, intraclass correlation, and coefficient of error. Agreement with the reference tests was assessed with Bland-Altman plots. For comparison, agreement between the 2 reference tests, CMR and indirect Fick, was assessed in 34 contemporary patients. RESULTS: Subjects were aged 7-78 years and had a wide range of cardiac diagnoses. Inert gas rebreathing Qp showed good repeatability (95% limits of agreement for 2 trials = ±22%, repeatability coefficient = 1.2 L/min, intraclass correlation = 0.92, and coefficient of error = 5%). In the absence of left-to-right shunting (n = 67), IGR Qp estimates agreed with CMR and indirect Fick Qp estimates, and the reference tests agreed with each other, with mean bias ≤10% (≤0.5 L/min) and 95% limits of agreement ±33%-38%. Conversely, IGR was unreliable in patients with left-to-right shunt (n = 14), with large bias (-58%, -4.0 L/min) and wide limits of agreement (±76%). CONCLUSIONS: Inert gas rebreathing reliably estimates Qp in children and adults with congenital heart disease in the absence of left-to-right shunting, with agreement comparable to that seen between CMR and indirect Fick estimates.
