16-year-old with lacerations to the eye

Issue: April 2010

A 16-year-old male was playing baseball, when he ran into a chain-link fence with his face, severely injuring his left eye. He was brought to the ER for evaluation and was found to have severe lacerations about the left eye and was admitted to the trauma service.

His past medical history is unremarkable. He has been healthy all his life and his immunizations are up to date.

James H. Brien, DO

Pediatric Infectious Disease, Scott and White's Children's Health Center and Associate Professor of Pediatrics,
Texas A&M University, College of Medicine, Temple, Texas.
e-mail:jhbrien@aol.com

Examination revealed an athletic male with normal vital signs and the injury noted above, as shown in figures 1 and 2. His ear exam was normal. There was no cerebrospinal fluid leak from the injured site according to the ophthalmologists, or any other site. The rest of his examination was normal. A computed tomography scan of his head and sinuses revealed severe soft tissue injury with orbital fracture and pneumocephalus (figures 3 & 4 — note intracranial air bubbles). You are consulted to recommend antibiotic prophylaxis. In the meantime, ceftriaxone (100 mg/kg/day) and vancomycin (60 mg/kg/day ÷ Q6 Hours) were started.


The patient had severely injured his left eye by running into a chain-link fence. Photos courtesy of James H. Brien.

$Figure 3: A CT scan of his head and sinuses revealed severe soft tissue injury with orbital fracture and pneumocephalus.$	$Figure 4: A CT scan of his head and sinuses revealed severe soft tissue injury with orbital fracture and pneumocephalus.$
A CT scan of his head and sinuses revealed severe soft tissue injury with orbital fracture and pneumocephalus.

What Would You Recommend?

Ceftriaxone + vancomycin as ordered
Metronidazole
Ceftriaxone + vancomycin + metronidazole
No prophylaxis

Case Discussion

My answer was D., no prophylaxis. However, it is understandable that some experts might recommend prophylaxis in a similar case, mainly because there is such a paucity of evidence-based data in this area. Nonetheless, when 109 patients were studied using scientific methods in non-penetrating head injuries with pneumocephalus, there was no difference between the antimicrobial prophylaxis (Ceftriaxone) group and the no-treatment group (Eftekhar et al, Journal of Neurosurgery, November 2004). In fact, the number of cases of bacterial meningitis in that study was the same in both groups. Of note, the treatment group had a death due to Gram-negative meningitis resistant to ceftriaxone. Having said that, if there is a CSF leak or an intracranial air volume of more than 10 ml, there is an increased risk of bacterial meningitis, and prophylaxis then possibly is indicated. But remember, you may just be selecting out a resistant organism.

If prophylaxis is going to be used, it probably should cover Streptococcus pneumoniae, and Staphylococcus aureus and coliforms, especially if it is associated with a penetrating injury. A combination of ceftriaxone plus vancomycin might be the best choice in that setting. However, there really are no standard guidelines. Therefore, my next choice would be to just leave him on that combination as ordered (A). The next question is “How long to use prophylaxis?” In the study sited above, the duration was five days; again, rather arbitrary.


The patient had surgical repair and was discharged after 48 hours.

The patient presented had surgical repair, as shown in figures 5 and 6. The injuries included (1) a full-thickness laceration of the left lateral canthus with avulsion of the left lateral canthus tendon, (2) a stellate laceration across the nasal bridge, (3) a small hyphema of the left eye, (4) laceration of the left brow and (5) orbital wall fractures. He was discharged 48 hours after admission on no antibiotics, and with the exception of some transient visual loss in the eye, he recovered without further complications.

Columnist comments

Trauma, such as the case above, accidental as it may be, is often self-inflicted and preventable. However, the trauma inflicted upon parts of Haiti, both physical and psychological, came as a result of a natural disaster last Jan. 12, resulting in the deaths of almost one-quarter of a million people. And while several high-profile celebrities and political figures have stepped up (with cameras rolling) with their time and money, and that’s very good, there are many altruistic physicians, nurses, and many other paraprofessionals quietly donating their time, money and talents long before the disaster hit, and continue to help today. Such is the case with a Texas pediatrician, Jeannine Hatt, MD, (figure 7), with TexomaCare Pediatrics and the Texoma Medical Center in the Sherman-Denison area of north Texas, who has a long history of donating her time (and money) engaged in international medical care.

Jeannine Hatt

Her first trip into Haiti was with a team to Grace Children’s Hospital in Port-au-Prince in 2000 for the purpose of exploring opportunities to help broaden and expand their range of services. She is a member of the Section on International Child Health of the American Academy of Pediatrics and also serves on the International Child Care USA (a religion-based child health development organization) board of directors as chair of the Medical Resources Committee. She and her group of volunteers, some of whom are represented in figure 8, have made many trips back since; the most recent being after the earthquake (figure 9).

Jeannine Hatt, MD, FAAP, with TexomaCare Pediatrics and the Texoma Medical Center, and a group of volunteers that have been working in Haiti in the aftermath of the earthquake.


Volunteers working with Dr. Hatt on her most recent trip to Haiti.	A Haitian patient suffering from malnutrition.


A Haitian patient recovering from TB meningitis.	A Haitian child suffering with Pott disease.


A Haitian patient with TB, HIV and malnutrition.	Haitian children fed through Dr. Hatt’s volunteer program.	Dr. Hatt’s team has long been involved in continuing education of local providers, including PALS.

These unsung heroes, and many others similar to them, have been helping the people of Haiti for years, treating children with severe malnutrition (figure 10), serious infections such as TB meningitis (figure 11), Pott disease (figure 12), Pulmonary TB, HIV AND malnutrition (figure 13), and simply feeding children (figure 14). In addition to patient care, Dr. Hatt’s team has long been involved in continuing education of local providers, including PALS (figure 15) and other life-saving services, so that they can better take care of their own, which is the primary goal. Since the earthquake, they have been engaged in helping rebuild Grace Children’s Hospital and restoring their services. While I’m not a practitioner of any specific religion, I have great respect for all forms of faith, and I stand in awe of these people.