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Clinical Summary

Impaled FB around the eye has a special apprehension because of the potential for loss of sight. The FB should be stabilized to prevent further damage. Nausea, retching, pain, coughing, and other symptoms should be aggressively controlled to prevent movement of the FB. Empiric broad-spectrum antibiotics should be administered. Tetanus immunization status should be addressed.

Plain x-rays are an acceptable starting point and screening tool, but typically, advanced imaging such as CT is indicated to thoroughly evaluate the depth of penetration, fragmentation of FB, degree of associated injuries, and proximity to sensitive structures. The possibility of intracranial involvement must always be considered. If organic materials are involved, CT may not fully evaluate the FB, so alternate imaging such as MRI and/or ultrasound should be used. It is essential to collect as much information as possible regarding the location of the object and surrounding anatomy to determine the most appropriate surgical approach.

Management and Disposition

Head-to-toe trauma evaluation and resuscitation are completed in the emergency department. A multidisciplinary team may be required for management of impaled facial FB: anesthesiology for preoperative airway management to minimize movement of the FB, ophthalmology for eye injuries, and maxillofacial or otorhinolaryngology surgery for associated head and neck injuries. If there is intracranial involvement, neurosurgery will typically take first priority.

FIGURE 4.46

Impaled Stick. A stick is impaled 7 cm into the medial aspect of the eye. Globe penetration was ruled out in the operating room. (Photo contributor: Elena Geraymovych, MD.)

Pearls

  1. Detailed ophthalmic and neurologic examinations are required upon presentation and serially to guide treatment decisions and to document deficits.

  2. The face is highly vascular. The FB may be tamponading damaged blood vessels; movement or dislodgement can lead to torrential bleeding.

FIGURE 4.47

Impaled Spring. (A) A spring impaled into the periocular structures is seen. The orbit was not injured despite the appearance of the injury. (B) Three-dimensional reconstruction showing spring in relation to the orbit. (Photo contributor: Dallas E. Peak, MD.)

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