What is the appropriate assessment and management plan for a patient with a left periorbital hematoma and bleeding after a fall?

Assessment and Management of Left Periorbital Hematoma with Bleeding After Fall

Apply direct pressure immediately to control active bleeding, assess for vision-threatening orbital compartment syndrome by checking visual acuity and pupillary response, and obtain urgent ophthalmology consultation if any visual disturbance is present. 1, 2

Immediate Bleeding Control

• Apply firm local compression directly to the bleeding site for a minimum of 10-30 minutes to achieve hemostasis 1, 3
• Avoid excessive pressure that could increase intraocular pressure or worsen orbital compartment syndrome 3
• Apply ice to the affected area for at least 10 minutes to reduce swelling and bleeding 3

Critical Initial Assessment

Vision-Threatening Signs (Orbital Compartment Syndrome)

Assess immediately for these findings that indicate urgent surgical decompression is needed:

• Visual acuity testing - any decrease from baseline is concerning 1, 2
• Pupillary response - check for relative afferent pupillary defect or sluggish constriction 1, 4
• Proptosis (eye bulging forward) - indicates significant orbital pressure 5, 2
• Painful or restricted extraocular movements - suggests mass effect on the globe 5, 2
• Increased intraocular pressure - the optic nerve tolerates elevated pressure for only 60-100 minutes before irreversible damage occurs 4, 2

Mechanism and Associated Injuries

• Document the height of fall (>6 meters is high-risk for major trauma) and mechanism 1
• Assess for altered consciousness (GCS <8), which may indicate traumatic brain injury requiring different blood pressure targets 1
• Examine for orbital fractures by palpating the orbital rim and checking for step-offs 4
• Assess the globe itself for penetrating injury, hyphema, or rupture 6, 2

Hemodynamic Assessment

• Check vital signs and calculate shock index (heart rate/systolic BP; >1.0 suggests significant blood loss) 1
• Measure serum lactate or base deficit to estimate bleeding severity - these are superior to single hematocrit measurements 1, 7
• Establish IV access if signs of hypovolemia are present 7, 8

Imaging Decision

For hemodynamically stable patients without immediate vision-threatening signs:

• Obtain CT scan of the orbits and face to identify orbital fractures, measure hematoma size and location (subperiosteal vs retrobulbar), and rule out globe rupture 1, 5, 4
• CT should not delay treatment if orbital compartment syndrome is clinically evident 2

For patients with vision-threatening signs:

• Proceed directly to urgent ophthalmology consultation for possible lateral canthotomy/cantholysis without waiting for imaging 2

Definitive Management Based on Findings

If Orbital Compartment Syndrome Present (Vision Loss, Proptosis, Pupil Abnormality)

• Immediate lateral canthotomy and cantholysis by ophthalmology or trained emergency physician within 60-100 minutes of symptom onset 4, 2
• This is a true ophthalmic emergency requiring surgical decompression to prevent permanent blindness 2

If Simple Periorbital Hematoma Without Vision Threat

• Conservative management with ice, elevation, and observation 5, 6
• Arrange ophthalmology follow-up within 24-48 hours for repeat examination 1, 5
• The hematoma will typically resolve over weeks to months without intervention 9

If Large Subperiosteal Hematoma with Sinusitis

• Start IV antibiotics immediately if imaging shows concurrent sinusitis 5
• Consider surgical drainage if the hematoma causes significant mass effect or fails to improve 5, 9

Coagulation Considerations

• Check PT/INR, aPTT, platelet count if the patient is on anticoagulants or has unexplained bleeding 1, 4
• Reverse anticoagulation if clinically significant bleeding is present and vision-threatening 7

Common Pitfalls to Avoid

• Do not assume vision is intact without formal testing - patients may not volunteer visual complaints 2
• Do not delay ophthalmology consultation if any visual symptoms are present - the 60-100 minute window for optic nerve salvage is narrow 4, 2
• Do not rely on a single hematocrit measurement to assess bleeding severity 1
• Do not apply excessive pressure that could increase intraorbital pressure 3

Disposition

• Admit patients with orbital compartment syndrome requiring surgical decompression 4, 2
• Discharge patients with simple periorbital hematoma after confirming normal vision, normal pupillary response, and arranging ophthalmology follow-up 5
• Provide strict return precautions for new vision changes, increasing pain, or worsening proptosis 5, 2