Ocular presentations

Any person, aged 16 years and over, presenting with ocular injury or eye-related symptoms. Excludes patients who present with acute vision loss.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort Supine if penetrating injury

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and effort Auscultate chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation as clinically indicated Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93% Patients at risk of hypercapnia, maintain SpO2 at 88–92%

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern
IVC and/or pathology	Insert IV cannula, if trained and clinically indicated If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Disability

Assessment	Intervention
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment, as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature
Skin inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited	Commence fluid balance chart, as required
NBM	Consider clear fluids or NBM based on red flags and clinical severity

Glucose

Assessment	Intervention
BGL	Measure BGL, if clinically indicated If less than 4 mmol/L, consider hypoglycaemia protocol

Focused assessment

Complete ocular focused assessment.

Consider neurological focused assessment, if history of blunt trauma or head injury.

Precautions and notes

• Visual acuity (VA) is required to be assessed in all patients with ocular injuries or related symptoms.  It is an important parameter and is of medico-legal importance. A VA may be done after initiating treatment.
• Always compare both eyes.
• Treatment is directed at preventing further injury or vision loss. A visual acuity of 6/6 does not exclude a serious eye injury.
• Metallic foreign bodies:
  • If suspected, do not irrigate the eyes.
  • If not correctly removed,  may lead to the formation of rust ring, corneal scarring, infection and retinal damage.
• Advise patient not to blow nose as this increases the risk of ocular damage.

Interventions and diagnostics

Specific treatment

All patients

• Check visual acuity, including Snellen chart, finger count, light perception assessment and pupillary response.
• Test both eyes separately.
• Swinging torch test for Relative Afferent Pupillary Defects (RAPD).
• Where available, document findings using NSW Health Eye Emergencies Form (SMR 040.200) or eye examination chart.

Acute red eye

• Provide symptomatic relief.

Blunt injury

• Apply an eye shield where possible.
• Do not apply an eye pad or pressure to the eye.
• For black eye, provide supportive care, including rest, ice and analgesia.
• Check for bruising behind the ears, clear fluid leakage from ears or nose. If present escalate as per local CERS protocol.
• Check for presence of hyphema (blood fluid level in anterior chamber visible in the iris). Hyphema needs urgent ophthalmology referral or phone consult.
• If blowout fracture is suspected, instruct patient not to blow their nose.

Chemical exposures

Corneal foreign bodies

Flash burns (UV keratitis)

Ocular burn

Penetrating injury

• Do not touch the eye. Do not remove foreign body.
• Stabilise foreign body.
• Apply an eye shield where possible.
• Do not apply an eye pad or pressure to the eye.
• Do not instil drops or ointment until ophthalmology consultation.
• Elevate the head of the bed to 45° and limit activity.
• All patients with penetrating trauma require urgent referral to a facility with ophthalmology services and expedited ophthalmology review.
• Assess for other injuries.
• Assess patient’s tetanus immunisation status and give tetanus booster if clinically indicated, as per the tetanus section.

Suspected retinal detachment, vitreous injury or hyphema

• Urgent ophthalmic assessment required.
• A protective eye shield can be placed over the affected eye to avoid further injury.
• Record if patient reports flashes, floaters or visual field defects.
• Patient to be confined to bed rest if suspected retinal detachment.

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Analgesia

If pain score 1–6 (mild–moderate), give:

• paracetamol 1000 mg orally once only
• and/or ibuprofen 400 mg orally once only.

If severe pain present, give analgesia and escalate as per local CERS protocol.

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Nausea and/or vomiting

If nausea and/or vomiting is present, give:

• metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
• or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
• or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only

Choice of antiemetic should be determined by cause of symptoms.

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Tetanus

If patient has a ‘tetanus-prone’ wound, consider giving a tetanus booster vaccine.

• Diphtheria and tetanus (ADT booster) vaccine should be given as per the Australian Immunisation Handbook Guide for tetanus prophylaxis in wound management.
• If ADT booster is not available then diphtheria/tetanus/pertussis (Boostrix) vaccine can be used.
• If no documented history of a primary vaccination course (3 doses) with a tetanus toxoid-containing vaccine: refer to medical or nurse practitioner or nurse immuniser.
• If pregnant or breastfeeding: dTpa vaccine (diphtheria-tetanus-acellular pertussis) is recommended. Refer to medical or nurse practitioner or nurse immuniser.

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Radiology

Not usually indicated. If there is concern for urgent radiology, escalate care as per local CERS protocol.

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Pathology

Not usually indicated. If there is concern for urgent pathology, escalate care as per local CERS protocol.

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au