Severe Vomiting (Adult and Pediatric)

David Eng · April 12, 2022 · EMS

Belly problems? Have we got a protocol for you!
Not a ton to this week’s protocol – patients in severe abdominal pain will be kept NPO at all EMS provider levels, and paramedics can give a dose of ondansetron by Standing Order as needed – with a reminder to check an EKG, both for QT prolongation and for possible cardiac etiologies of the abdominal pain. Remember that there is a separate pain management protocol available for patients requiring prehospital analgesia.
That’s it for this week, hope you were all able to…stomach it?
www.nycremsco.org and the protocol binder for more

Dave

EMS Protocol of the Week - Heat Emergencies (Adult and Pediatric)

David Eng · April 5, 2022 · EMS

Believe it or not, the weather is actually nice in Brooklyn sometimes. We hopefully seem to finally be finding ourselves leaving behind all the lousy cold, wet, depressing weather, which means we’ve got approximately 1-2 weeks before we find ourselves in lousy hot, sticky, depressing weather! Which makes now the best time to start reviewing the prehospital approach to heat emergencies, which in NYC generally amounts to exposure control (remove outser clothing) and fluid resuscitation (for ALS). Unfortunately, there isn’t enough room in an ambulance for a full ice bath, but that leaves something for you to do when the patient arrives to the ED! Just remember not to drop the temperature too quickly and to avoid shivering.

Stay cool out there, gang! Or warm, depending on how the weather is today when this email goes out.

www.nycremsco.org and the protocol binder for more!

Dave

Hemorrhoids and Anal Fissures

Christopher Stoll · April 1, 2022 · Hemorroids, Anal Fissure

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
- Not-thrombosed, usually self-limited and will resolve
- Thrombosed
  - Conservative treatment (sitz baths and bulk laxatives) IF:
    - Thrombosis >72hrs
    - Swelling starting to shrink
    - Pain is tolerable
  - Conservative treatment can include topical 0.3% nifedipine and 1.5% viscous lidocaine
  - Perianal block for pain relief
  - Consider excision IF:
    - Patient is not immunocompromised, child, pregnant, portal hypertension, or coagulopathic
    - Thrombosis <72 hours (acute)
    - Extremely Painful
    - https://www.merckmanuals.com/professional/gastrointestinal-disorders/anorectal-disorders/hemorrhoids?query=external%20hemorrhoid (Instructional video)
    - Hemorrhoids - Gastrointestinal Disorders - Merck Manuals Professional Edition
      www.merckmanuals.com
      Hemorrhoids - Etiology, pathophysiology, symptoms, signs, diagnosis & prognosis from the Merck Manuals - Medical Professional Version.
- Provide colorectal surgery follow up in 24-48 hours.

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