12-phase flow (12)

1. 1FRAME
   Frame acute ocular trauma as a TIME-CRITICAL triage problem with three findings that override normal sequencing: (1) chemical/alkali splash → irrigate FIRST before anything; (2) open/ruptured globe → STOP, rigid shield, no pressure/pad, NPO, OR; (3) orbital compartment / retrobulbar haemorrhage → immediate bedside lateral canthotomy + cantholysis BEFORE imaging. This engine OWNS the trauma triage + routing; definitive globe/orbit/canalicular surgery is recognised then routed OUT by engine_id (AAO PPP Ocular Trauma; Wills Eye Manual). It is the reciprocal routing target of ophtho.corneal-abrasion.core.v1 and ophtho.acute-red-eye.core.v1.
   advance: trauma scope confirmed; the three sequence-overriding emergencies primed; definitive-surgery concerns flagged for route-out
2. 2ENTRY
   Recognise the trauma presentation and capture mechanism + chemical status up front. A chemical/alkali splash short-circuits the flow to immediate irrigation. Mechanism (high-velocity metal grinding/hammering vs blunt vs sharp/penetrating vs chemical) is the dominant pre-test-prior and imaging-path driver (Kuhn BETT; Durrani Clin Ophthalmol 2021 PMID 34040343).
   inputs: mechanism_of_injury, chemical_exposure_and_agent_ph
   advance: entry trigger present; mechanism recorded; chemical exposure excluded OR irrigation already initiated
3. 3CONTEXT
   Build the trauma prior + special-population modifiers without manipulating a suspected open globe: documented acuity per eye (Ocular Trauma Score input), sickle-cell trait/disease (hyphema catastrophe; avoid CAI/hyperosmotics), anticoagulation (rebleed/retrobulbar severity), monocular status, age (paediatric white-eyed blowout / NAI). These reframe priors and thresholds (Gharaibeh Cochrane 2013 PMID 24302299; Coelho Ophthalmologica 2022 PMID 35196665).
   inputs: visual_acuity_each_eye, sickle_cell_trait_or_disease, anticoagulation_or_antiplatelet, monocular_or_only_eye
   actions: workup.acute_red_eye
   advance: acuity + sickle + anticoagulation + monocular + age modifiers captured; trauma prior assigned
4. 4RED_FLAGS
   The three sequence-overriding emergencies, each recognised then acted on / routed: (1) OPEN/RUPTURED GLOBE — Seidel+, peaked pupil, uveal prolapse, full-thickness laceration, shallow chamber, ↓IOP, low acuity → STOP exam, rigid shield (NO pad/pressure), NPO, antiemetic, IV antibiotics, tetanus, urgent OR; (2) ORBITAL COMPARTMENT / RETROBULBAR HAEMORRHAGE — proptosis + tight orbit + ↑IOP + RAPD + pain → IMMEDIATE lateral canthotomy + inferior cantholysis at the bedside BEFORE imaging; (3) (already-running) chemical-burn irrigation continues to neutral stable pH. Sickle hyphema with refractory IOP also fires here. These are time-critical (vision lost in minutes-hours) (AAO PPP Ocular Trauma; Wills Eye Manual).
   inputs: open_globe_signs, intraocular_pressure, proptosis_rapd_tight_orbit
   actions: workup.acute_vision_loss, calc.news2
   advance: open-globe shielded+NPO+routed if positive; orbital compartment decompressed by canthotomy if positive; chemical irrigation to neutral pH; sickle-IOP escalated
5. 5INITIAL_WORKUP
   After the open globe is shielded (or excluded) and the orbit decompressed (or excluded): structured non-pressure assessment — pen-torch acuity/pupil/RAPD, lids/adnexa for canalicular involvement (medial-canthal laceration), Seidel test if globe not already obviously open, hyphema grading, fundus only if globe intact (commotio/RD). Post-chemical-burn: pH recheck after irrigation, fluorescein epithelial defect, limbal-ischaemia (Roper-Hall/Dua) grading. CBC/coag/CMP only when sickle status, anticoagulation, polytrauma, or pre-OR (Gharaibeh Cochrane 2013 PMID 24302299; Soleimani Clin Ophthalmol 2020 PMID 32982161).
   inputs: hyphema_grade_and_pupil
   actions: panel.cbc, panel.coag, panel.cmp
   advance: open globe / hyphema grade / canalicular involvement / chemical-burn grade characterised without globe manipulation; pre-OR labs sent if indicated
6. 6BRANCHING_WORKUP
   Imaging + sub-pathway decision tree (canthotomy already done if it was needed — orbital compartment is clinical, not imaging-gated): high-velocity metal / occult rupture / IOFB-suspected → thin-slice orbital CT, NEVER MRI if metallic; blunt + restricted vertical gaze + nausea/bradycardia in a child → white-eyed trapdoor blowout with entrapment + oculocardiac reflex → 24-48 h surgical urgency; medial-canthal lid laceration → canalicular-system probing; post-traumatic vision loss with quiet eye + RAPD and no compressive lesion → traumatic optic neuropathy; child unable to cooperate / inconsistent history → exam under sedation + NAI safeguarding (Durrani Clin Ophthalmol 2021 PMID 34040343; Bera J Maxillofac Oral Surg 2021 PMID 35400913; Levin Ophthalmology 1999 PMID 10406604).
   inputs: extraocular_motility_and_entrapment, orbital_ct_thin_slice, pediatric_uncooperative_or_nai
   actions: workup.acute_vision_loss, workup.cellulitis_necfasc
   advance: IOFB/rupture imaged (CT not MRI), entrapment/canalicular/TON sub-pathway assigned, NAI screened
7. 7DIFFERENTIAL
   Terminal trauma differential with explicit pivots — OPEN GLOBE / RUPTURE / PENETRATION (Seidel+ + peaked pupil + uveal prolapse + ↓IOP + low acuity pivot) vs CHEMICAL BURN (splash history + pH abnormal + limbal blanching/ischaemia pivot — alkali worse than acid) vs ORBITAL COMPARTMENT / RETROBULBAR HAEMORRHAGE (proptosis + tight orbit + ↑IOP + RAPD pivot) vs TRAUMATIC HYPHEMA (layered AC blood + rebleed/sickle pivot) vs ORBITAL-WALL BLOWOUT — esp. paediatric white-eyed trapdoor (restricted vertical gaze + nausea/bradycardia + minimal external signs pivot) vs INTRAOCULAR/ORBITAL FOREIGN BODY (high-velocity metal + occult entry + CT-dense pivot) vs TRAUMATIC OPTIC NEUROPATHY (vision loss + RAPD + quiet eye + no compressive lesion pivot) vs COMMOTIO RETINAE (blunt + grey retinal whitening + intact globe pivot) vs LID/CANALICULAR LACERATION (medial-canthal wound + lacrimal involvement pivot). Distinguish from simple corneal abrasion, non-traumatic red eye, microbial keratitis. Co-existence flagged (e.g., hyphema + occult rupture; abrasion overlying open globe).
   advance: single best trauma diagnosis selected; co-existing occult globe rupture never excluded by a benign-looking surface finding; look-alike (abrasion / red eye / keratitis) pivoted
8. 8RISK_STRATIFICATION
   Apply the Ocular Trauma Score (presenting acuity, rupture, endophthalmitis, perforation, RD, RAPD) for visual-prognosis counselling and surgical planning; OTS correlates with final VA across large series (Coelho Ophthalmologica 2022 PMID 35196665; Dave/Kuhn 2023 PMID 36804845). Roper-Hall/Dua grade for chemical-burn prognosis (limbal-ischaemia clock hours / LSCD risk — Iyer BJO 2017 PMID 28407620). NEWS2 only with associated systemic/major trauma. Stratify endophthalmitis risk: time-to-repair, IOFB, zone-1, dirty wound, ruptured lens (Durrani Clin Ophthalmol 2021 PMID 34040343).
   inputs: visual_acuity_each_eye, open_globe_signs
   actions: calc.news2, calc.qsofa
   advance: OTS / chemical-burn grade / endophthalmitis-risk tier assigned; prognosis counselled
9. 9TREATMENT
   Injury-stratified initial management (definitive surgery routed OUT): OPEN GLOBE → rigid shield (NO pad/pressure/manipulation), NPO, antiemetic (prevent Valsalva uveal/vitreous expulsion), IV broad-spectrum antibiotics (vancomycin + ceftazidime — endophthalmitis prophylaxis), tetanus, analgesia, urgent OR (Abouammoh Acta Ophthalmol 2017 PMID 28771946; Durrani Clin Ophthalmol 2021 PMID 34040343). CHEMICAL BURN → continued copious irrigation to neutral stable pH, then topical (no pharmacologic step precedes irrigation) (Soleimani Clin Ophthalmol 2020 PMID 32982161). HYPHEMA → topical cycloplegic ± topical/oral steroid, IOP control (timolol; acetazolamide CONTRAINDICATED in sickle), antifibrinolytic (aminocaproic acid) to reduce rebleed, head elevation, shield, activity restriction, sickle-aware (Gharaibeh Cochrane 2013 PMID 24302299). ORBITAL COMPARTMENT → lateral canthotomy + cantholysis is the treatment (non-pharm, already done). TON → individualised (no proven steroid/decompression benefit — Levin Ophthalmology 1999 PMID 10406604). Drug-safety gating in pregnancy/sickle/anticoagulation.
   inputs: tetanus_immunisation_status, pregnancy, sickle_cell_trait_or_disease
   advance: injury-stratified initial bundle delivered (shield+NPO+IV abx+antiemetic+tetanus / irrigation / hyphema bundle / canthotomy); definitive surgery routed by engine_id
10. 10DISPOSITION
    Open globe / IOFB / orbital compartment post-canthotomy / sight-threatening chemical burn / white-eyed blowout with entrapment → emergent ophthalmology + OR, admit, route by engine_id (endophthalmitis risk → ophtho.endophthalmitis.core.v1; traumatic RD/commotio → ophtho.retinal-detachment.core.v1; TON adjacency → ophtho.optic-neuritis.core.v1). Traumatic hyphema → admit vs close outpatient by grade/sickle/rebleed-risk/compliance. Simple lid laceration not involving lid margin/canaliculus, minor commotio with intact globe → repair/observe with next-day ophthalmology. Document the eye-specific safety net and route-out engine_id with carryover (AAO PPP Ocular Trauma; Wills Eye Manual).
    inputs: open_globe_signs, hyphema_grade_and_pupil
    advance: disposition + route-out engine_id documented; admission vs outpatient by grade/risk; OR arranged for surgical lesions
11. 11MONITORING
    Open globe pre-/post-op: watch for endophthalmitis (pain out of proportion, hypopyon, worsening vision — Durrani Clin Ophthalmol 2021 PMID 34040343 → route ophtho.endophthalmitis.core.v1) and sympathetic ophthalmia counselling. Hyphema: daily IOP + rebleed watch (peak rebleed days 2-5, worse with sickle/anticoagulation), clearance time (longer on aminocaproic acid — Gharaibeh Cochrane 2013 PMID 24302299). Chemical burn: serial pH, epithelial healing, IOP, limbal perfusion (Soleimani Clin Ophthalmol 2020 PMID 32982161). Blowout entrapment: do not let the white-eyed trapdoor sit — re-image / re-refer if persistent oculocardiac reflex/restriction (Bera J Maxillofac Oral Surg 2021 PMID 35400913).
    inputs: intraocular_pressure, hyphema_grade_and_pupil
    actions: panel.cbc
    advance: endophthalmitis / rebleed / IOP / chemical-healing surveillance active; deterioration re-triggers RED_FLAGS or routes by engine_id
12. 12FOLLOWUP
    Post-trauma long tail + prevention: sympathetic-ophthalmia awareness and fellow-eye monitoring after open globe; traumatic-glaucoma / angle-recession surveillance after hyphema; late retinal-detachment / epiretinal-membrane risk after commotio (→ ophtho.retinal-detachment.core.v1); chemical-burn limbal-stem-cell-deficiency rehabilitation pathway (Iyer BJO 2017 PMID 28407620; Mittal BJO 2015 PMID 26701687); occupational + sport eye-protection counselling (the dominant preventable mechanism); NAI safeguarding follow-through in children; reciprocal handback to ophtho.corneal-abrasion.core.v1 / ophtho.acute-red-eye.core.v1 if trauma excluded and a simple surface diagnosis remains.
    inputs: monocular_or_only_eye, pediatric_uncooperative_or_nai
    advance: sympathetic-ophthalmia / traumatic-glaucoma / LSCD / eye-protection / NAI follow-up documented; reciprocal handback made if applicable