“teardrop sign,” which represents herniated orbital fat and muscle in the roof
of the maxillary sinus. There may also be an air-fluid level in the maxillary
sinus as a result of bleeding into it. Patients usually do well and recover com-
pletely in mild to moderate fractures.
(a) Zygomatic arch fractures usually present with periauricular
depression and point tenderness and may be complicated by trismus sec-
ondary to impingement of the coronoid process of the mandible on the
arch during mouth opening. (c)A retrobulbar hematoma occurs secondary
to blunt orbital trauma and typically causes exophthalmos. Patients usually
present with periorbital edema, ecchymosis, a decrease in visual acuity, and
an afferent papillary defect in the involved eye. (d)Open globe injuries
typically result from penetrating trauma to the eye. Patients may present
with leakage of aqueous humor, a teardrop-shaped pupil, or prolapse of
choroid through the wound. (e)Patients with mandible fractures present
with pain and decreased range of motion of the jaw, malocclusion or pain
with teeth clenching, and inability to fully open the mouth.
154.The answer is e.(Scaletta and Schaider, pp 204-212. Tintinalli,
p 1617.)An important concern with anterior abdominal GSWis to deter-
mine whether the missile traversed the peritoneal cavity. Patients with trans-
abdominal GSWs nearly all have intra-abdominal injuries requiring surgery.
Most of the time, this can be determined by approximating the trajectory.
Therefore, a hole in both the anterior and posterior abdomen highly suggests
a transabdominal trajectory. If there are a single or odd number of holes, a
plain film may help estimate the trajectory. In cases of tangential or multiple
GSWs, it may be impossible to determine trajectory with any certainty. In a
patient with evidence of peritoneal penetration, a missile tract that clearly
enters the abdominal cavity, or has a positive diagnostic study (eg, DPL,
FAST, CT) in a tangential wound, he or she should undergo exploratory
laparotomy. The standard algorithm for penetrating abdominal traumarec-
ommends that any patient with unstablevital signs be taken directly to the
OR to undergo an exploratory laparotomy. If their vital signs are stable,
they should undergo further diagnostic studies, such as a FAST examination,
DPL, or CT scan.
(a)In general, penetrating abdominal wounds should not be probed.
This may worsen the injury and disrupt hemostasis, resulting in uncontrolled
hemorrhage. Instead, gently separate the skin edges to see if the base of the
wound can be visualized. (b, c, and d)In the setting of penetrating abdomi-
nal trauma, further diagnostic tests should only occur if the patient has stable
168 Emergency Medicine