What medication is recommended for a 4-year-old girl with swelling over her eye due to trauma?

Management of Periorbital Swelling from Trauma in a 4-Year-Old

For a 4-year-old girl with periorbital swelling due to trauma, oral acetaminophen or ibuprofen should be administered for pain control and swelling reduction, with urgent ophthalmologic evaluation to rule out serious ocular injury or orbital fracture.

Immediate Assessment Priorities

Before initiating any medication, the following must be evaluated urgently 1, 2:

• Visual acuity testing - any vision loss indicates severe injury requiring immediate ophthalmology consultation 2
• Pupillary examination - asymmetry or poor reactivity suggests serious trauma 2
• Globe integrity - look for active bleeding from the eye (hard sign of penetrating injury), hyphema, or subconjunctival hemorrhage 2, 3
• Extraocular movements - restriction, especially on upward gaze, may indicate orbital floor fracture with muscle entrapment 3
• Eyelid function - assess for lagophthalmos or inability to close the eye 1
• Palpation over frontal bone - tenderness suggests possible fracture requiring CT imaging 1

Medication Management

For Pain and Swelling Control

Acetaminophen is the preferred first-line agent for post-traumatic periorbital swelling in children 4, 5:

• Acetaminophen reduces post-traumatic swelling by approximately 30% and provides effective pain relief 5
• Dosing: Standard pediatric weight-based dosing (10-15 mg/kg every 4-6 hours, maximum 75 mg/kg/day) 4

Ibuprofen is an acceptable alternative 6, 5:

• Provides pain relief, though evidence suggests it may be less effective than acetaminophen for acute post-traumatic swelling 5
• Dosing: Standard pediatric weight-based dosing (5-10 mg/kg every 6-8 hours) 6

Avoid aspirin - it has been shown to fail to reduce or even increase post-traumatic swelling 5

Important Caveat About Corticosteroids

While systemic glucocorticoids reduce post-traumatic swelling by approximately 50% (more effectively than NSAIDs), they should only be considered after ophthalmologic evaluation rules out globe injury 5. Corticosteroids can mask infection and complicate management of open globe injuries.

When to Obtain Urgent Ophthalmology Consultation

Immediate ophthalmology referral is required if 1, 2:

• Any visual changes or eye pain present 1
• Active bleeding from the eye 2
• Suspected open globe injury 2
• Bradycardia, nausea, vomiting, or loss of consciousness (suggests oculocardiac reflex from muscle entrapment) 3

When to Obtain CT Imaging

CT orbit without contrast with thin cuts and multiplanar reconstructions is indicated when 1, 2:

• Tenderness over the frontal bone suggesting orbital fracture 1
• Clinical suspicion of orbital wall fracture or intraocular foreign body 2
• Diplopia with restricted extraocular movements 3

CT has 94.9% sensitivity for intraorbital foreign bodies and is the study of choice for orbital trauma 2.

Critical Pitfalls to Avoid

• Never apply pressure to the eye - if open globe injury is suspected, protect with a rigid eye shield without any pressure to prevent extrusion of intraocular contents 2
• Do not patch the eye if there is any possibility of corneal abrasion in the setting of trauma, as this increases risk of bacterial keratitis 7
• Do not delay ophthalmology consultation for imaging if open globe injury is clinically obvious 2
• Do not assume simple soft tissue swelling - 5.5% of patients with facial fractures have complete vision loss in one eye, and 24% of orbital floor fractures present with severe eye injury 2

Follow-Up Considerations

Even if initial evaluation is reassuring, close monitoring is essential 1:

• Periorbital swelling from trauma can evolve over 24-48 hours 1
• Delayed complications such as orbital compartment syndrome or infection can develop 1
• Parents should be instructed to return immediately for worsening pain, vision changes, or development of fever 1