The dangers of FOAM at St.Emlyn’s

#FOAM and #FOAMed have certainly captured the zeitgeist of emergency medicine but is foam always a good thing? It’s a question that we should ask and it seems that there are some answers in the literature.

pixelperfectdigital.com

pixelperfectdigital.com

I do tend to keep an eye out for papers related to Ophthalmology (family reasons) and recently came across this paper from Cornea on the dangers of FOAM related injuries to the eye.

The paper and abstract are accessible here

So this paper caught my attention for two reasons. Firstly, the identification and management of ocular injuries is an interest of mine, and in particular I have concerns about the identification of chemical injury to the eye from sources that might not be apparent to clinicians when patients first present. A good example would be around the potential damage from detergents in capsule, powder or tablet form. This is a concern that has been raised in the UK back in 2010, but we still see injuries today.

Anyway, in this paper from Israel the authors looked back at two centres to look at the incidence and severity of eye injuries attributed to FOAM, they found that a large number of patients (96 patients and 135 eyes) suffered injuries as a result of party foam/silly string. If you don’t know what I’m talking about then please have a look at these fine examples of British talent indulging in a bit of ‘stringing’ this year….!

(Ed- your attempts to be cool by getting One Direction into a blog post are pathetic)

You can see how the nature of the device could lead to conjunctival and corneal contact with subsequent chemical and abrasive injury. The nature of the chemical injury is unclear in the paper as silly string is basically a propelled plastic foam. Since 2007/08 the propellent has changed in many countries away from ozone damaging agents so the chemical nature may no longer be an issue. There is the suggestion that there is an alkaline component in the paper (attributed to some low pH scores on assessment), but it is not proven.

In itself this is interesting enough as silly string is widely available. In addition the authors attribute the reduction of eye injuries between 2007 and 2008 to a media campaign highlighting the dangers of this substance and that got me wondering about how good we are as emergency physicians about liasing with our colleagues in public health, and indeed with using the media to reduce the incidence and severity of injury and illness. In the UK departments are involved in the reporting of knife and gun crime, child protection, domestic violence, alcohol use and (as a hospital trust) HIV, but is there more out there that we should be getting involved in?

The only example I can think of recently in the UK is also in the ocular sphere (geddit?). Back in 2006 the EMJ published an article on the incidence of eye injuries around Halloween as a result of egg throwing. As a paper it was not that scientific or challenging, but it was very topical and caught the attention  of the media and the public, reaching as far as China in media coverage!

So what does this tell us? Firstly that when we are assessing patients for ocular injury we need to know the nature of any substances that might have entered the eye. Be very careful if there is any possibility of an alkaline agent getting onto the ocular surface, if in doubt check the pH of the eye and/or the substance. You can look up the characteristics of many substances online including their pH. Patients with alkaline injury require immediate washout and discussion with the on-call Ophthalmology team. There is a nice aide-memoire here from Columbia.

From the ED perspective the treatment of suspected chemical injury is

  • analgesia
  • copious washout
  • removal of any foreign material
  • referral
  • mydriatics (probably – the evidence is weak)

I would highlight the importance of getting some local anaesthetic drops into the eye asap as that really facilitates the washout and removal of foreign bodies.

Washout is fairly basic to be honest, but you can watch a video here (quite long) for a very in depth and quite slow explanation. You may also come across the Morgan Lens which I’m not convinced about as yet, but would love to hear more from people who have used it. Nice demo and some top tips on this vidoe…….but how the hell did he get the guy to lie there and do this to him? Fairly sure my med students/docs would decline this in my practice.

‘Matt’s a real trooper as no tetracaine’!!!!

They don’t even let him speak! How bad has he been to deserve this I ask?

So, with your next eye injury just be really careful that you know what caused it, and remember to duck when the silly string flies this Christmas.

Whilst silly string may cause injuries, we have no reported of Flubber related injuries……yet!

vb

Simon Carley