Hemorrhoids and Anal Fissures

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Hemorrhoids

·      Symptomatic hemorrhoids result from dilatory distortion of vasculature and changes in connective tissue.

·      Can present with bleeding, pruritus, fullness, discharge, burning, and pain

·      Up to half of hemorrhoids visualized on anoscopy are not associated with symptoms

·      5% of the US suffer from symptomatic hemorrhoids.

·      Risk factors include constipation, straining, frequent diarrhea, elderly, IBD.

·      Internal Hemorrhoids

o   Proximal to dentate line, covered in columnar epithelium, which DOES NOT have pain fibers.

o   PAINLESS bleeding

o   Best visualized through anoscope

o   Goligher Classification

·      Management

o   Conservative treatment

§  Stool softeners (psyllium), topical analgesics

§  Sitz baths

§  Outpatient surgical referral

§  Prolapsed hemorrhoid in patient with minimal symptoms can be manually reduced

o   Emergent surgical consult

§  Continued or severe bleeding

§  Incarcerated or strangulated (grade IV)

§  Intractable pain

  • External Hemorrhoids

    • Distal to dentate line, PAINFUL

    • Pain with defecation, bleeding

    • Color change, swelling, and or palpable clot suggest a thrombosed external hemorrhoid – tender on defecation, sitting, walking, or intercourse

    • Thrombosed external hemorrhoid.

  • Management

 

Anal Fissure

·      Linear tear or ulceration of the anoderm that are visible on inspection

·      May be due to passage of hard stool or frequent diarrhea.

·      Most common cause of painful rectal bleeding

·      Bright red rectal bleeding with SIGNIFICANT PAIN on defecation but can last several hours after

·      Pain is thought to be due to hypertonic anal sphincter spam and resultant ischemia

·      Waxing and waning course

·      Primary (<8weeks) vs chronic (>8 weeks)

·      90% are midline posteriorly due to half the blood supply compared to other quadrants of anal canal

·      Non-healing fissures or ones not located midline may suggest other etiology such as Crohn’s or malignancy

·      Complications include anorectal abscess

·      Management

o   Warm sitz baths 15 mins TID-QID after each bowel movement

§  Provides symptomatic relief by improving anal blood flow and relieving anal spasm

o   Topical medications

§  Lidocaine

§  Vasodilators such as nitroglycerin or nifedipine

§  Hydrocortisone

o   Botulinum toxin can be used for treatment of chronic anal fissures, unfortunately it can also result in some form of temporary incontinence

o   High-fiber diet

o   Meticulous anal hygiene

o   Surgical referral if healing does not occur in reasonable amount of time – Lateral internal sphincterotomy which is curative in 95% of patients, but 15% are left with some form of minor incontinence.

References:

https://accessemergencymedicine.mhmedical.com/content.aspx?sectionid=45343707&bookid=683#57707005

Chapter 67. Anal Fissure Management | Emergency Medicine Procedures, 2e | AccessEmergency Medicine | McGraw Hill Medical

https://emottawablog.com/2019/10/the-bottom-line-hemorrhoids-and-anal-fissures-in-the-ed/

The Bottom Line: Hemorrhoids and Anal Fissures in the ED - EMOttawa Blog

https://www.mayoclinic.org/diseases-conditions/anal-fissure/symptoms-causes/syc-20351424


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Ropivacaine vs Bupivacaine

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Pain Pathophysiology Basics

·      Noxious stimuli cause opening of cation channels on the membrane of neurons, allows sodium and other positive ions into cell.

·      Extra positive ions going into the cell depolarize the cell causing nearby voltage gated sodium channels to open, triggering a  chain reaction down length of the axon

·      Local anesthetics inhibit conduction of action potentials in free nerve endings, can’t travel up the neuron, so patient won’t perceive the pain.

·      Greater effect on nerves that are small and myelinated (usually are the nerves that transmit pain signals), whereas at larger doses can lose temperature, touch, pressure, and finally motor function.

 

Ropivacaine Dosing (UpToDate)

Adult

Dose varies with procedure, onset and depth of anesthesia desired, vascularity of tissues, duration of anesthesia, and condition of patient. 

 

Major nerve block:

35 to 50 mL dose of 0.5% solution

 

Infiltration/minor nerve block:

1 to 100 mL dose of 0.2% solution

1 to 40 mL dose of 0.5% solution

 

Max dose of 3 mg/kg

 

Infants ≥6 months, Children, and Adolescents: Single Injection Peripheral nerve blocks/local anesthesia - Maximum dose of 3 mg/kg/dose based on lean body mass; dosing based on extrapolation from adult experience; additional data necessary to more clearly define the pediatric upper dose limit. Note: For infants <6 months of age, dose reductions (eg, by 30%) have been suggested by experts 

Commonly accepted doses:

Head and neck blocks: 0.05 mL/kg.

Maxillary nerve: 0.15 mL/kg

Upper extremity blocks:

Brachial plexus: 0.2 to 0.3 mL/kg.

Digital nerve: ≤0.2% (2 mg/mL) solution: 0.05 mL/kg.

Truncal blocks:

Transversus abdominis plane: 0.2 to 0.5 mL/kg.

Ilioinguinal nerve: 0.075 mL/kg.

Rectus sheath: 0.1 to 0.2 mL/kg.

Lower extremity blocks:

Femoral nerve: 0.2% to 0.5% (2 to 5 mg/mL) solution: 0.2 to 0.4 mL/k

Sciatic nerve: 0.2 to 0.3 mL/kg.

 

Bupivacaine Dosing (UpToDate)

Adult

Local anesthesia: Infiltration: 0.25% infiltrated locally; maximum: 175 mg.

Peripheral nerve block: 5 mL of 0.25% or 0.5%; maximum:  mg/day

 

Pediatrics

Dose should not exceed 2 mg/kg plain solution, or 3 mg/kg with epinephrine

For infants <6 months, maximum doses should be reduced by 30%

Commonly suggested doses:

Head and neck: 0.05 mL/kg.

Upper extremity:

Brachial plexus: 0.2 to 0.3 mL/kg.

Digital nerve: 0.05 mL/kg.

Truncal blocks:

Transversus abdominis plane: 0.2 to 0.5 mL/kg (Jöhr 2015).

Rectus sheath: 0.1 mL/kg.

Ilioinguinal: 0.075 mL/kg.

Lower extremity blocks:

Femoral nerve: 0.2 to 0.3 mL/kg.

Sciatic nerve: 0.2 to 0.3 mL/kg.

 

Adolescents: 0.25% or 0.5% solution with or without epinephrine: 5 mL; maximum daily dose: 400 mg/day (manufacturer's labeling).

 

Ropivacaine vs Bupivacaine

·      A strict correlation exists between the lipid solubility of the local anesthetic and its potency and toxicity.

·      Ropivacaine is less lipophilic than bupivacaine and is less likely to penetrate large, myelinated motor fibers, resulting in a relatively reduced motor blockade.

·      The reduced lipophilicity is also associated with decreased potential for central nervous system toxicity and cardiotoxicity

·      CNS symptoms (restlessness, anxiety, tinnitus, dizziness, blurred vision, tremors, depression, or drowsiness) may be early warning signs of CNS toxicity, and generally occur before cardiac symptoms.

·      Bupivacaine is the most cardiotoxic of all the local anesthetics agents due to its strong affinity for the cardiac calcium channel and intravascular injection of bupivacaine may result in cardiovascular collapse prior to the onset of CNS toxicity.

·      Cardiac function involving contractility, conduction time, and QRS prolongation found to be significantly less with ropivacaine than with bupivacaine.

·      According to minimum local anesthetic concentration (MLAC) studies, which are based on effective analgesia in 50% of patients) ropivacaine has similar potency to bupivacaine at higher doses (eg, doses required for peripheral nerve blocks for surgical anesthesia), ropivacaine is less potent than bupivacaine and levobupivacaine at lower doses

·      Peripheral nerve block: The long-acting sensory and motor block provided by ropivacaine is 0.5% or 0.75% for axillary, interscalene and subclavian perivascular brachial plexus block for hand or arm surgery compared favorably with bupivacaine 0.5% with a similar quality of regional anesthesia.

·      In lower limb surgeries where sciatic or combined femoral and sciatic block was given for knee, ankle, or foot procedures, ropivacaine 0.75% (25 ml) had a significantly faster onset of sensory and motor block than 25 ml bupivacaine 0.5%. Although ropivacaine had a significantly shorter duration of sensory block, the duration of motor block remained similar with both agents

 

Conclusion

·      Ropivacaine is a well-tolerated regional anesthetic.

·      The efficacy of ropivacaine is like that of bupivacaine and for peripheral nerve blocks.

·      Clinically adequate doses of ropivacaine has a reduced potential for CNS toxicity and cardiotoxicity, which makes this medication a great tool for regional anesthesia.

 

References

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3106379/

https://www.uptodate.com/contents/ropivacaine-drug-information?source=auto_suggest&selectedTitle=1~1---1~4---ropiv&search=ropivacaine#F219203

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4347153/#:~:text=Ropivacaine%20is%20a%20long%2Dacting,a%20relatively%20reduced%20motor%20blockade

https://europepmc.org/article/med/2679230

 

 

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Penetrating Neck Trauma and Laryngotracheal Injuries

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Penetrating Neck Trauma

ABCs

  • Assume a difficult airway in a patient with neck trauma.

· When bag-mask ventilation proves difficult due to airway distortion or physical characteristics, perform an awake, orotracheal intubation using a sedative without a paralytic

· Pneumothorax and hemothorax are present in up to 20% of patients with penetrating neck trauma. Listen for breath sides and signs of tension physiology

· Exsanguination is the proximate cause of death in most penetrating neck injury victims, apply direct pressure to wounds, but be careful not to simultaneously occlude both carotid arteries and or obstruct the airway.

Zones of the Neck

· Classically, zone II injuries undergo surgical exploration; zone I and III wounds undergo further evaluation

· The trajectory of the penetrating object can be difficult to determine clinically, and nearly half traverse multiple zones

· Zone II is injured most

· The platysma is a thin muscle that stretches from the facial muscles to the thorax, demarcating superficial from deep wounds.

· Wounds that do not penetrate the platysma are largely not life threatening.

Diagnosis and Treatment

· Any wound deep to the platysma raises concern for damage to the vital structures of the neck

· Instruct awake and cooperative patients to cough (to check for hemoptysis), to swallow saliva (to assess for dysphagia from esophageal injury), and to speak (to evaluate for laryngeal fracture)

· Assess the patient for “hard” and “soft” signs of injury

· Nine out of 10 patients with hard signs will have an injury requiring repair and should be rapidly transferred to the operating room or angiography suite.

· Remember “HARD BRUIT”

· Treatment: depends on the vessel involved and accessibility of the lesion.

· Options vary from observation to surgical repair to angiographic embolization or stenting.


Laryngotracheal Injury

· Rare, seen in about 1 in 30,000 ED visits

· Protection by the jaw, spine, and sternum

· In patients with head and neck trauma, it is the second most common cause of death after intracranial hemorrhage

· Usually seen in the setting of polytrauma and their presenting features often do not correlate with the extent of injury

· Most injuries are due to blunt trauma rather than penetrating trauma

· When the extended neck accelerates forward, striking a steering wheel or dashboard, the laryngeal structures are compressed posteriorly against the spine

· Injuries: endolaryngeal hematomas or lacerations managed conservatively with symptomatic treatment and observation, to complete tracheal transection requiring open laryngotracheal reconstruction

· Symptoms: dysphonia, dyspnea, dysphagia, stridor, neck pain, or hemoptysis

· Physical Exam: tracheal tenderness, subcutaneous emphysema, cyanosis, or persistent air leak after chest tube placement

· Management:

o The immediate first step in managing laryngotracheal injuries is always to establish a secure airway

o A fiberoptic bronchoscope will aid in visualization and minimize further airway trauma during intubation

o Injury distal to the carina should be managed with fiberoptic bronchoscopy with endotracheal tube placement in the mainstem bronchus opposite the side of injury.

o Once the airway is secured, a complete secondary survey should be performed to identify other traumatic injuries

o A chest X-ray should be obtained to identify pneumothorax, pneumomediastinum, tracheal deviation, or subcutaneous emphysema. A computed tomography of the neck will identify laryngeal fractures or dislocations.

· The cricoid cartilage is a complete ring, and fractures occur in two locations, most commonly anterior and posterior.

o Cricoid cartilage injuries are often concomitant with thyroid cartilage fractures

o The recurrent laryngeal nerve is commonly injured in cricoid cartilage fractures

o Endolaryngeal stents may be used to repair injuries with significant mucosal damage or those that disrupt the anterior laryngeal commissure.

· Treatment: Patients with grade I and II injuries can be managed medically; grade III, IV, and V injuries typically require operative intervention.

References

Tintinallis Emergency Medicine A Comprehensive Study Guide

Hippo EM

Rosh Review

https://rebelem.com/penetrating-neck-injuries/

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