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The Procedural Pause

Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, CEN, are teaming up to create a new EMN blog, The Procedural Pause.

The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.

Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

Thursday, December 1, 2016

How do you go about choosing your suture thread? Absorbable sutures may include polyglycolic acid, chromic catgut, or glycerol-impregnated catgut. Non-absorbable sutures are typically made of silk, Prolene, or nylon. Suture materials may be synthetic or natural, and they can be mono- or multifilament. Sutures may also be braided, unbraided, or coated. Sizes of suture materials also vary greatly. A 3.0-sized thread is a lot bigger than a 6.0-sized thread, for example.

Keep these key principles in mind: The time it takes for the thread to be absorbed is dependent on the tissue type and thickness, the size and type of the thread, the condition of the patient, and the absorption half-life of the product. Many online guides can help you learn more. Some sutures will be absorbed in five to seven days; some may take more than 200 days to disappear completely.

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Vicryl Rapide vs. Vicryl

Vicryl Rapide and Vicryl are absorbable sutures and are potential choices for repairing nail bed lacerations. Vicryl Rapide is a new and improved form of Vicryl, and may be more commonly used. Vicryl Rapide absorbs more quickly than other absorbable sutures, including Vicryl. Vicryl Rapide typically is completely absorbed after 42 days.

The most important thing to know is that after five days, Vicryl Rapide becomes 50 percent weaker than it was when you first put it in. No traction is left at all by day 14. Take this into consideration when you are assessing the wound. This is enough time for a pediatric finger laceration to heal if it is appropriately splinted and followed up.​

Polyglycolic acid derivatives such as Vicryl Rapide and Vicryl are far superior to non-absorbable sutures for wound healing, but problems still occur with their use, often because they are placed inappropriately or in areas with high tension.


Sample of Ethicon's 5.0 Vicryl Rapide polyglactin 910 undyed, braided, synthetic absorbable suture material.

A randomized prospective study in the Journal of Hand Surgery investigated Vicryl and Vicryl Rapide in 60 pediatric hand surgery cases. Thirty of the patients received Vicryl and the other 30 received Vicryl Rapide. The results showed that five "problems" occurred in the Vicryl treatment group and none in the Vicryl Rapide group (P=0.03).

All of the problems were related to the delayed absorption of the Vicryl suture material. The author concluded that Vicryl Rapide sutures are "more suitable than Vicryl ones in pediatric hand surgery." (2005;30[1]:90). Vicryl Rapide also has an antibiotic coating called triclosan. Studies are limited, but the coating has shown lower the rates of infection.

The major difference between Vicryl and Vicryl Rapide is in the composition and handling. Typical Vicryl is made up of a polyglycolic acid called polyglactin 370. Providers reported this coating made tying their knots more difficult, but it did decrease tension through the tissue and did less damage to the wound. The advantage of Vicryl Rapide is that it is a type of polyglcolic acid called polyglactin 910, which is not only easy to use but also easier to tie and secure. Its tension is better, and the absorption rates are relatively the same.

We will discuss suture materials in depth in future blogs, and talk about the differences between nylon and Prolene and when to use deep sutures for various parts of the body. The pediatric population requires strict guidelines and tension relief because of the difference in their skin composition, healing times, and body mechanics.

Tetanus Status: Pay Attention to These Kids!

When does a child first receive a tetanus shot? The American Academy of Pediatrics suggests the DTaP (diphtheria, tetanus, and pertussis) at ages 2, 4, and 6 months and again at 15 to 18 months. A DTaP booster is recommended for children ages 4 through 6 years old. Don't forget to administer appropriate boosters if your patient requires one. If parents are wary of receiving vaccines in the ED, they have 24 to 72 hours to discuss it with their pediatrician and have it still be effective.

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Recommended guidelines from the CDC on Td vaccine.

Next month: Antibiotics for open finger fractures (such as tuft fractures), using Dermabond vs. suturing for nail bed lacerations, and referrals and additional treatments for hand injury patients.

Watch Ms. Roberts repair a nail bed laceration in this video.​



Tuesday, November 1, 2016

Our pediatric patient population is special, small humans with distinctive needs, medication doses, and unexpected challenges. The more you use the simple approach to pediatric emergency department procedures, the more you will experience faster, smoother, and better results.

You don't have to get fancy unless of course you have a Child Life Program in your department. The materials are simple and the skill is straightforward. Adding a sense of humor, learning the words to "Frozen," and laughing with your pediatric patient (whenever possible) will also help ease the tension.


A 4-year-old with pediatric nail bed laceration and partial nail bed avulsion.

Children, just like adults, don't like when you lie to them. It's important you give them just enough details to be able to complete your procedure. Be careful not to divulge too much scary information because it will just make treatment more difficult. Be aware of age-appropriate milestones and emotional development. Use suitable language to describe things to your patient, and involve the parent the entire time. Consider having mom or dad hold the gauze or a Band-Aid. Any complex or scary conversations should be held outside the room away from children's ears. Remember, don't use medications if they are not indicated and you can get through a procedure without them. Some kids are actually braver than you think. But do not hesitate to use light sedation if it will be safer for the patient, less stressful for the parent, and easier for you.


Each age group should reach specific personality and emotional milestones, according to the American Academy of Pediatrics. All children are different, and this guideline may assist with decision-making.

The Pause

How old is your patient? What milestones has this child reached? Does the child seem responsive to treatment? Are there any emotional development delays? Discuss the procedure with the parent and determine the best plan. Discuss pros and cons of light sedation. Ask the parents how the child may handle shots and gore. Some children, even 4-year-olds, are actually quite brave and are willing to do the procedure without hassle. It may be helpful to review Erikson's States of Psychosocial Development before proceeding: http://bit.ly/PsychosocialChart. Use your best judgment and then proceed with a set plan. Apply LMX 4% cream or EMLA cream to the base of the finger to make the digital block injection of anesthesia less painful.

The Approach

  • Identification of injury and the extent of the injury (Fracture? Multiple lacerations? Nail condition?).
  • Perform radiograph if indicated.
  • Determine plan (Sedation? Forms of anesthesia such as lidocaine?).
  • Inject a digital nerve block into the affected finger.
  • Clean and explore the wound.
  • Suture and repair the nail bed laceration(s).
  • Apply Dermabond or other adhesive glue to nail to secure it in place.
  • Repair any other lacerations.
  • Add dressing and splinting as indicated.
  • Determine if tetanus update is needed and discuss immunizations.
  • Give antibiotics if indicated.
  • Develop a follow-up plan

The Procedure

  • Assess the child's milestones and emotional development. Assess the wound and then discuss the plan with the parents. Include the child in the conversation only if appropriate.
  • Some parents prefer the use of a papoose or child procedure board that limits movement while you work. It is the right of the parent to refuse pain or anxiolytic medications for her child. You may want to at least offer ibuprofen or acetaminophen if the parents refuse sedation.
  • Apply topical LMX 4 % cream or EMLA cream to base of the finger. Cover it with Tegaderm or gauze to help with absorption.
AgentDuration Max Dose
LidocaineMedium (30-60 min)Without epinephrine: 4.5 mg/kg, not to exceed 300 mg
Lidocaine + EpinephrineLong (120-360 min)With epinephrine: 7 mg/kg, not to exceed 500 mg
BupivicaneLong (120-240 min)Without epinephrine: 2.5 mg/kg, not to exceed 175 mg total dose
Bupivicane + EpinephrineLong (180-420 min)With epinephrine: Not to exceed 225 mg total dose

  • Review your department's protocol and safety measures if you have chosen light sedation (i.e., anxiolytic +/- anesthesia, pain control) for your patient. I use intranasal Versed per our hospital protocol. All safety measures must be in place; it is your responsibility to review these guidelines.
  • All intranasal Versed doses are weight-based in kilograms. Determine the appropriate dose and administration per your protocol and current drug guidelines.
  • Set up the digital block once the child is calm, appropriately medicated, and ready for the procedure.
  • Allow at least 15-20 minutes for the anesthesia to take full effect after application.
  • Clean the wound with soap and water.
  • Complete the digital block using 1% buffered lidocaine. Massage the anesthesia into the base of the finger along the nerves.
  • Assess the wound and determine the degree of the laceration.
  • Repair the nail bed laceration with dissolvable sutures only. We suggest a 5.0 Vicryl Rapide. (More on suture types below).
  • You may decide to use a finger tourniquet to control the bleeding. A clean, dry field will allow you to place sutures more effectively. If a finger tourniquet is unavailable, you can use a rubber band over a piece of gauze around the base of the affected finger.
  • Replace the nail in the original position as best as possible. Use Dermabond or other skin adhesive to secure the nail in place directly over your applied nail bed sutures. The use of nondissolvable sutures through the nail and into the skin is a practice that is no longer needed. (See video.)
  • The nail not only is the best and most effective barrier over the injury but also allows the new nail to grow out straight. It is important to maintain the opening of the cuticle for at least one week to avoid scarring and a deformed nail. You can pack open the cuticle with a piece of gauze if the nail is not available. Other providers have used cut-out pieces of the suture packaging. The packaging is cut in the shape of the missing nail and inserted into the cuticle. This topic has not been researched thoroughly but may be of use in your practice. Providers may also use a folded piece of Steri-Strip as a fake nail to keep the cuticle open. Just make sure it is folded flat, and no sticky portions are open.
  • Speaking of Steri-Strips, use these to secure the nail if you think the adhesive needs added protection.
  • Dress the wound with a nonadherent dressing. Show parents how to care for the wound. It should be redressed twice a day.
  • Follow up with hand specialist in three to seven days.
  • Discuss tetanus, immunizations, and antibiotics with parents if there is an open fracture.

Watch Ms. Roberts repair a nail bed laceration in this video.​


Next month, we will discuss antibiotics for open finger fractures (such as tuft fractures) and the use of Dermabond vs. suturing for nail bed lacerations. Then we will touch upon referrals and additional treatments for hand injury patients.


Monday, October 3, 2016

We promised you short, sweet, and simple solutions, and we plan to deliver. Many of the tools we want you to use may have merely been forgotten. The steps to complete these simple solutions will require just a few minutes of brushing up on the basics while watching our how-to videos and reading our step-by-step blog posts.

One of the lengthiest procedures in the emergency department can be eye irrigation. Some patients may need 5-15 liters of normal saline flush, which can take hours. Alkaline products need ample flushing and constant reevaluation with pH checks to avoid ocular burns. Patients can get frustrated and often times will ask you to stop the procedure. Keeping up with an eye irrigation patient can be difficult for providers as well, and create a long stay.

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This patient suffered from alkaline burns to both eyes. He is being treated with normal saline irrigation using a nasal cannula. Photo by Martha Roberts.

Many providers have traditionally used the Morgan Lens in the ED to assist in ocular irrigation. The process is time-consuming and sometimes painful, and it can cause corneal abrasions. Patients, especially children, have difficulty tolerating the lens. Insertion can be agonizing if proper anesthesia is not obtained. Depending on the patient, the lens may need to be replaced several times if there are multiple liters of irrigation. Many urgent care facilities and some EDs may not stock the Morgan Lens and need an alternative approach to treatment. Finally, the Morgan Lens can be harmful to the patient if the normal saline infusion bags run dry. Many times providers will be unable to monitor the lens/bolus. This can be frightening for the patient and can cause ocular trauma.

One of the best ways to irrigate the eye involves using IV saline via a nasal cannula and connector piece from a Salem Sump kit. This procedure is far less invasive than using the Morgan Lens and is less traumatic for the patient. Patients feel less claustrophobic and are able to move freely. It is an effective and forgotten form of treatment to consider the next time you need to irrigate a patient's eye.

The Approach

  • Careful but speedy examination of eye
  • Initial ocular anesthesia (i.e., tetracaine)
  • Oral pain or anxiety control
  • Set up an irrigation system using nasal cannula and normal saline
  • Repeat boluses of normal saline and pH status checks
  • Consult with poison control and ophthalmology as needed

The Procedure

  • Begin manual flushes of the eye as soon as possible after carefully (but quickly) examining the patient's eye. Do this while the irrigation system is being set up. The sooner the caustic agent is washed from the eye, the better.
  • Check the pH of the eye for a baseline. Your goal is to get as close to 7.0 as possible.

 

strips.jpg
Sample of pH strip used for ocular pH testing.

  • Discuss with ophthalmology and poison control. If the patient has brought in the bottle of the chemical he was exposed to, report each ingredient to the specialists.
  • Equipment: Obtain several normal saline bags, a nasal cannula, tetracaine (or other ocular anesthesia), towels and absorbent padding, and an NG or Salem Sump kit.
  • Each Salem Sump kit contains a small, white plastic connector piece. This piece is key to attaching the NS IV line to the nasal cannula.

connector.jpg
Salem Sump connector piece.

  • You may use tape to reinforce the connection, but the connection alone is quite secure once placed.
  • Set up a piggyback line to the IV connection so more than one bolus can run at a time and you can alternate without stopping.
  • Consider giving the patient oral pain control (if the caustic agent is painful) or antianxiety medication such as Valium to relax him during this lengthy procedure.
  • Administered ocular anesthesia into both eyes. This pain relief will help the patient tolerate the initial NS bolus. Additional numbing drops can be administered between boluses.
  • Have the patient remove all top layers of clothing. This procedure will get them wet. Then position the patient at a 30-degree angle on the stretcher.
  • Lay the nasal cannula over the bridge of his nose so that the prongs are directed to the inner canthus. If both eyes are affected, separating the two prongs will allow saline delivery into both.
  • If only one eye is affected, both prongs can be directed to a single eye.
  • Allow the NS to flow from the bag into the IV line and over the patient's face, across his eyes. This flow is quite powerful and will copiously irrigate the eyes. The patient does not need to keep his eyes open.
  • Continue this as needed and until the pH is at an acceptable level.
  • Follow up with ophthalmology as recommended.


closeup patient.jpgconnector 2.jpg
Watch a video demonstrating this technique
. The ports typically used for oxygen deliver the normal saline to both eyes, left. If one eye is affected, you can shift both prongs to that eye. Give ocular anesthesia before the first bolus. A patient may keep his eyes closed because the saline will bathe the inner canthus and inner eye. The saline is delivered at a fast rate, allowing for generous irrigation. The Salem Sump connector piece, right, connected to the NS bolus bag. Photos by Martha Roberts.

Cautions and Pearls

  • Patients get wet when you do this procedure. This also means they get cold. Consider frequent hospital gown changes, appropriate drainage techniques (such as using drainage headboards, towels, Chux, etc.). You should also give your patient some blankets. Use warmed NS if available.
  • Report all ingredients to poison control for assistance.
  • Remember to check the pH. It's important to wait 10 minutes between each NS bolus to check the pH level because it can continue to rise.
  • This is a long procedure at times and can cause anxiety. Absolutely use a numbing agent if the patient can tolerate it and frequently check on the patient. Reassurance can play a major role, but when it can't, anxiolytics can be of assistance.
  • Complete a full eye exam if possible, but do not delay irrigation tactics.
  • Discuss home medications with ophthalmology such as erythromycin or other antibiotics before discharge.
  • Tell patients to avoid wearing contact lenses for at least two weeks.

Toxicology Tip of the Week
Alkaline cleaning products can cause burns to the skin or face. Straightforward chemical burns from these products, however, generally only affect the eye. The solution is not absorbed systemically nor does it enter the nasal pharynx.

​Alkaline is Everywhere
Patients often present with known complaints of chemical burns to the eye, but some patients may not know they have an alkaline burn. A single case report of a chemical keratitis involved alkaline gas from a deployed passenger airbag. The authors noted that inflation of an airbag converts sodium azide to nitrogen gas. The bags are vented so that nitrogen and residual byproducts of combustion, such as alkaline gas, which could cause injury. (Ann Emerg Med 1992;21[11]:1400.)


Thursday, September 1, 2016

Sometimes the best solution is the simple one, and this series of handy tricks will help you master the most difficult problems. The majority of the procedures require old-school techniques with a new flare. Many of these might have been forgotten, but just a few minutes of brushing up on the basics while watching our how-to videos and reading our step-by-step blog will get you ready.

How many times have you removed objects from someone's ear? If it's too many to count and you have been successful, then you don't have to reinvent the wheel. But if you are looking for a different way to remove objects such as earbuds, insects, tips of glasses, wads of cotton, or other bizarre findings, then topical cocaine can help you painlessly remove foreign objects from the ear.

It is almost impossible for any patient to hold still while a clinician removes a deeply imbedded foreign body from the ear canal. It's just too sensitive of an area. Some foreign bodies can be removed with irrigation, and those easily seen and grasped can be removed with a gentle hand. IM/IV conscious sedation may be tried, but it is often not totally effective. A number of ways to anesthetize the canal have been suggested, but they are not readily effective. Topical cocaine is about the only way to anesthetize the canal enough, without distortion of anatomy, to gain successful topical anesthesia.

Importantly, don't persist if the foreign body cannot be removed. Persnickety foreign bodies are best removed by a specialist, and there is no shame in referring such cases. Creating a bloody mess in the canal makes it more difficult for patient and specialist.

The Approach

  • Identify the foreign body in the ear of the adult patient.
  • Use 4% or 10% cocaine hydrochloride solution.
  • Administration of solution into affected ear, then wait!
  • Painless removal of the foreign body

Procedural Tool Selection

  • The following tools may be of use to you. It's time to get acquainted with them if you are not familiar with the way they work.
  • 4% cocaine hydrochloride. A 10% solution may also be used.
  • Microscopic otoscope with removable lens
  • Nasal speculum
  • Headlamp or other appropriate lighting
  • Nasal speculum
  • Bayonet or alligator forceps
  • 20 g angiocatheter or 18 g needle, depending on patient
  • Emesis basin, Chux, and pads
  • Soft-tipped suction catheter or suction equipment
  • Magnet (for metallic foreign bodies)
  • Mineral oil or other bug-zapping solution
  • Acetone
  • Ethyl chloride
  • Intranasal midazolam (Versed) (See your hospital protocol for dosing guides.)

The Pause
Who is the wrong candidate for this procedure? You may have guessed it, but the pediatric population is excluded from this procedure. The use of cocaine in children is "limited by possible toxicity. (Emerg Med Clin North Am 1989;7[1]:117.) IM ketamine (4-5 mg/kg IM) is the best way to sedate a child to remove a stubborn foreign body of the ear canal.

The Procedure: Short and Sweet

  • Complete a full head, ears, eyes, nose, and throat (HEENT) exam.
  • Identify the foreign body at large. Use a microscopic technique. Good visualization is key. One study found that ear canal lacerations occurred in 48 percent of patients where removal was attempted without the use of a microscope, compared with only four percent where a microscope was used. (Laryngoscope 1993;103[4 Pt 1]:367.)
  • Prepare your workspace. Gather your equipment. Obtain 4% cocaine hydrochloride.
  • Position patient supine with the affected ear up. Fill the entire canal with cocaine. Allow cocaine to sit in place a full 20 minutes before attempting foreign body removal.
  • Remove the cocaine solution by aspiration or allow it to drain.
  • Use a nasal speculum to open the ear canal or direct vision to grasp the object, being careful to avoid the tympanic membrane. The alligator forceps are often the best instrument to grasp the object. Gently insert alligator or bayonet forceps to remove the foreign body. Be careful to avoid excessively touching the canal's surface; that's the most sensitive area.
  • Re-examine the canal to ensure that the object has been completely removed.
  • Follow-up is not routinely indicated unless hearing or other ear complaints persist.

Cautions

  • Note that local anesthesia can be invasive and typically is used for complicated foreign body removal. An uncomplicated foreign body should be removed without additional measures because the external ear canal is sensitive and has incredibly delicate anatomy.
  • Did you check both ears? We hope so, because where there is one….
  • Complete a full HEENT (head, ears, eyes, nose and throat) exam.
  • Procedural sedation is required for foreign body removal of any kind in children. IM ketamine is probably the best way to sedate a child.
  • Is it a bug? Live insects in the ear should be stopped dead. You must first immobilize them before removal. The use of mineral oil, microscope oil, and viscous lidocaine have all been used to put them down. (Laryngoscope 2001;111[1]:15.)
  • Can't quite get it? Complications may occur, and we suggest contacting ENT (especially during business hours for immediate referral) if all else fails. If you continue to poke around in the ear, it may result in infection, perforation, pain, or other unintentional injury. (Laryngoscope 2003;113[11]:1912.)

Contraindications

  • You must consult ENT to have the foreign body removed by microscope and speculum if you are concerned about a tympanic membrane perforation.
  • Approach with caution if a button battery, hearing aid battery, or other electrical device is present. These, too, should be referred to ENT for removal. These electronic bodies are time-sensitive and potential liquefaction necrosis may lead to subsequent tympanic membrane perforation and further complications. In fact, irrigation should never be attempted in such cases because it accelerates the necrotic process. (Ear Foreign Body Removal Procedures. Medscape. Feb. 16, 2016; http://bit.ly/2aCnUQS.)

Tip of the Month

This month's tip comes directly from our patient, Dr. James Roberts. Although he is not our patient or model very often, celebrities are just like us! When cruising back through the Virginia area, Jim got a piece of this microphone ear bud stuck in his ear. Although Martha Roberts, NP, offered to remove it, he decided to head to the local ED where the helpful Dr. J. J. Sverha was ready to try a seasoned trick of the trade.

Jim was suffering from severe pain from his earbud accident after trying to pick and prod at it himself. After hours of unsuccessful attempts, he turned away his deaf ear, and let Dr. Sverha remove it carefully with this very procedure. Jim suggests using the least invasive techniques to remove objects from the ear. When positioning the patient, always have him lie on the unaffected side and drip the cocaine slowly into the ear. Special thanks to Dr. Sverha for his careful handling and success with Jim! The use of cocaine solution provided remarkable anesthesia.

​Insider Tips Worth Trading

  • Acetone has been used successfully to remove chewing gum, Styrofoam, and superglue from the ear canal. (J Laryngol Otol 1995;109[12]:1219.)
  • Ethyl chloride has been used to remove Styrofoam beads from the ear canal. (J Accid Emerg Med 2000;17[2]:91.)

​Watch Dr. Sverha anesthetize Dr. Roberts' ear with cocaine and then remove his foreign body.​

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Monday, August 1, 2016

We are going to get up close and personal this month to talk about hemorrhoids. You should be familiar with these painful offenders because half to two-thirds of people between 45 and 65 will suffer from their cruelty. (Am Surg 2009;75[8]:635.) Patients may seek emergency department care if they experience bleeding or severe pain from hemorrhoids.

Hemorrhoids are highly vascular structures that are round or oval in shape. They arise from the rectal and anal canal, and sometimes appear around the anus itself. It is important to note that hemorrhoids do not have arteries and veins but special blood vessels called sinusoids, connective tissue, and smooth muscle. (Beck, DE, et al. The ASCRS Textbook of Colon and Rectal Surgery, Second Edition. New York, NY: Springer New York, 2015, p. 175.) Hemorrhoids at times can exist within the anal canal and be completely painless because sensory innervation to the rectum is primarily visceral. (Roberts JR, Hedges JR, et al. Clinical Procedures in Emergency Medicine. Elsevier, Philadelphia, PA, 2015, p. 880.)

Hemorrhoids protrude around the anus and swell, causing significant pain, when they become inflamed or irritated. The straining from constipation and poor diet choices may be the main cause of hemorrhoids, although lack of exercise, aging, pregnancy, and hereditary may also contribute to their formation. Very rarely are hemorrhoids cancerous. Fissures or tears in the skin around the rectum may occasionally accompany hemorrhoids.

Not all external hemorrhoids contain clots; some are just swollen and irritated and not amenable to incision. Some hemorrhoids are swollen, soft, and compressible, and may be tender. If the hemorrhoid is not tense or a clot is not palpated, topical corticosteroids and sitz baths are the best intervention.

Thrombosed external hemorrhoids are readily drained in the ED. Surgical intervention for internal hemorrhoids is not an outpatient procedure and usually is a last resort. Hemorrhoid surgery can be a difficult procedure for many to endure, and patients who suffer from long-term hemorrhoid complaints may benefit from a visit to a colorectal surgeon. A colonoscopy or sigmoidoscopy may assist in ruling out more complicated or serious diagnoses.

​Anatomy Review
Hemorrhoids are veins in the rectum. They are normal vascular structures in the anal canal, arising from a channel of arteriovenous connective tissues that drain into the superior and inferior hemorrhoidal veins. They are located in the submucosal layer in the lower rectum and may be external, internal, or mixed based on their location relative to the dentate line. External hemorrhoids are located distal to the dentate line; internal ones are located proximal. Hemorrhoidal bleeding is characterized by the painless passage of bright red blood from the rectum with a bowel movement. Painful defecation is not associated with hemorrhoids unless they are thrombosed. Acute onset of perianal pain with perianal swelling suggests the presence of a thrombosed hemorrhoid.

​Presentation
Hemorrhoids can produce bleeding with a bowel movement, itching, pain, feces leakage, difficulty cleaning after a bowel movement, or tissue bulging around the anus. Patients may be able to see or feel hemorrhoids, or they may be hidden from view inside the rectum. Hemorrhoids are classified as internal or external; internal ones are best treated by medication and a surgeon, but acutely thrombosed external hemorrhoids are fair game for drainage in the ED or clinic. Neither type of hemorrhoid is painful unless complications develop.

Both internal and external hemorrhoids can develop clots in the vessels. A thrombosed hemorrhoid is extremely tender to palpation, and a thrombus may be palpable within the tense hemorrhoid. Internal hemorrhoids can also contain a clot, but more likely prolapse outside the rectum, causing significant pain and increased bleeding. Prolapsed internal hemorrhoids appear as dark pink, glistening, and tender masses at the anal margin. Thrombosed internal hemorrhoids can cause pain but to a lesser degree than external hemorrhoids. An exception is when internal hemorrhoids become prolapsed and strangulated, and develop gangrenous changes from the associated lack of blood supply.

External hemorrhoids are not typically graded, but internal hemorrhoids are according to the degree to which they prolapse from the anal canal. Grade I hemorrhoids are visualized on anoscopy and may bulge into the lumen but do not prolapse below the dentate line. Grade II hemorrhoids prolapse out of the anal canal with defecation or with straining but reduce spontaneously. Grade III hemorrhoids prolapse out of the anal canal with defecation or straining, and require manual reduction. Grade IV hemorrhoids are irreducible and may strangulate, and urgent surgery is required for grade IV internal hemorrhoids, though rubber band ligation is the most widely used procedure for other grades. Rubber bands or rings are placed around the base of an internal hemorrhoid. As the blood supply is restricted, the hemorrhoid shrinks and degenerates over several days. Banding is successful in approximately 70 to 80 percent of patients. (Roberts & Hedges, 2015.)

This current discussion concerns diagnosis and treatment of thrombosed external hemorrhoids only. These are covered by modified squamous epithelium (anoderm), which contains numerous somatic pain receptors, making external hemorrhoids extremely painful with thrombosis. Thrombosed external hemorrhoids are acutely tender and have a purplish hue, and occasionally a partially extruded clot can be seen. Patients present with acute onset of perianal pain and a palpable perianal "lump" from thrombosis. Thromboses of external hemorrhoids may be associated with excruciating pain as the overlying perianal skin is highly innervated and becomes distended and inflamed. Importantly, not all swollen external hemorrhoids contain an organized extractable clot, and incision of a swollen hemorrhoid is of no value unless a clot is present. A clotted hemorrhoid is generally very firm and discolored from the underlying clot.

hem 1.jpg
Typical appearance of external hemorrhoids. Note the partially extruded clot from one thrombosed hemorrhoid. The other hemorrhoids are swollen, but are soft and do not contain a clot. Incision of non-thrombosed hemorrhoids should be avoided. They are treated with frequent sitz baths and topical corticosteroid ointments. (Photo by Martha Roberts.)


The ED is a place people will visit for this ailment, and you need to be ready. Hemorrhoids aren't just for grandmas and grownups but also occur in children and athletes. In fact, George Brett, one of baseball's Hall-of-Fame inductees, had to stop playing in the 1980 World Series because of hemorrhoid pain. Glenn Beck, a well known talk show host, took his treatment of hemorrhoids to the next level in 2008 by having surgery and speaking out about his case. He stated that the pain medications (opioids) only made his hemorrhoids worse and affected his mental state. (http://cnn.it/29iIAvV.) Stories like this give rise to concerns of pain control complications and addiction. ED interventions can help patients be well and learn about nonopioid treatments.

Now that you know a little bit more about hemorrhoids and their mercilessness, we are going to highlight some ways you can treat painful, thrombosed external hemorrhoids. Remember, internal hemorrhoids are not treated by minor surgery in the ED. We are also going to remind you that your craft requires compassion and that treatment should be carefully completed.

The Procedure

  • Identification of thrombosed external hemorrhoids and differentiation from prolapsed internal hemorrhoids
  • Sedation/pain control techniques, usually parenteral opioids
  • Cleaning of area and application of topical LET or EMLA cream
  • Taping technique and setup
  • Injection of anesthesia used during the procedure
  • Removal of thrombosis and drainage with incision
  • Follow-up care and treatments

hem 3.jpg
Multiple external hemorrhoids. Not all visible hemorrhoids contain a thrombosis. A clot produces a firm palpable mass. If a clot is not palpated, do not incise. Note partially extruded clot in one hemorrhoid. (Photo by Martha Roberts.)


The Pause
How do we identify thrombosed external hemorrhoids and when do we need to intervene? A thrombosed hemorrhoid will be protruding from the anal canal around the anus. The hemorrhoid itself will appear dark blue or purple, and appear quite swollen. The hemorrhoid appears this color because of the collection of blood clots inside the hemorrhoid itself. This can cause significant pain, and incision and drainage may help with relief. Thrombosed external hemorrhoids that are not drained most likely will spontaneously rupture in one to three weeks and leave a skin tag behind. Sitz baths two to three times a day are often curative if a patient declines drainage in the ED.

The Approach

  • Provide an area of privacy for comfort. Professionalism, kindness, and caring are key to successful treatment.
  • Positioning this patient is variable. There are several ways to position the patient including prone, left lateral decubitus, or Sims knee-shoulder position. Our position of choice will be prone. Patients with breathing complications, obesity, claustrophobia, or anxiety may not be good candidates for this procedure.
  • A digital rectal exam should be completed with guaiac testing if indicated. Anoscope may not be needed for severely thrombosed hemorrhoids and too painful to complete.
  • A CBC and 500 mL bolus may be ordered if the patient reports copious bleeding.
  • Obtain IV access and administer sedation/pain control. IV opioids are best, providing some relaxation/sedation as well as analgesia. IV fentanyl, hydromorphone, and morphine are suitable options. Use appropriate dosing. Be sure to monitor the patient's airway during the procedure with end-tidal CO2 and oxygen saturation. Do not forget to document appropriately.
  • Clean the area well with soap and water and Betadine.
  • Apply LET, a combination of lidocaine (2%), epinephrine (0.1%), and tetracaine (0.5%), and wait 20 minutes. EMLA cream is also suitable, but can take up to one hour to work.
  • Ask the nurse, technician, or another provider to assist with initial investigating and setup.
  • Use 2-inch tape to tape the buttock apart. This will allow for free use of both hands and full exposure.
  • Locate the thrombosed hemorrhoid and prepare for analgesic injection.
  • Obtain a 25-gauge needle and 10 mL syringe for medication injection.
  • Obtain a suture kit and 11-blade scalpel for incision and drainage.
  • Use a single injection of buffered long-acting bupivicane (NOT LIDOCAINE) with epinephrine. Buffer the injection with sodium bicarbonate.
  • Infiltrate the thrombosed hemorrhoid just under the skin and over the dome of the hemorrhoid. Avoid deep injection, and inject slowly.
  • If full pain control is not achieved, you may advance the needle slightly and inject more analgesia.
  • Make an elliptical incision around the clot and direct it radially from the anal orifice. An elliptical incision should be made as opposed to a simple cut because premature closing of the incision may prevent clots from dissolving.
  • Squeeze the hemorrhoid with your fingertips to express clots.
  • Forceps may be used to remove residual clots.
  • Do not pack the hemorrhoids. Apply pressure to the site to control bleeding. Use a folded gauze to pad over the operative site and tape the buttock closed to hold it in place. Gelfoam may be used to help control bleeding.
  • Home care: Have the patient soak in a few inches of water in warm tub bid for the next two to three days. NSAIDs are first-line treatment for pain and inflammation. Wash (shower is best) the anal area after every bowel movement with soap and water. Post-operative opioids are relatively safe in small amounts with stool softener and increased fluids. Fiber regimen should be added after healing.
  • Antibiotics are not indicated.
  • Warn patients of residual skin tags and that scant bleeding is OK.
  • Plan colorectal follow-up care.

 

Contraindications and Cautions

  • Thrombosed external hemorrhoids are most effectively drained less than 48 hours after onset. Prolapsed/thrombosed internal hemorrhoids are not amenable to ED surgical drainage.
  • Consider surgical consult for prolapsed internal hemorrhoids, multiple external hemorrhoids, or severe bleeding.
  • You should not complete this procedure on patients who are obese, who have breathing disorders or airway compromise, bleeding disorders, seriously systemic illness, rectal abscess, or who are hemodynamically unstable.
  • Patients using aspirin, Plavix, warfarin, or other anticoagulants should be approached with caution and possibly referred to a colorectal surgeon, although it is not an absolute contraindication.
  • A post-thrombectomy flexible sigmoidoscopy or colonoscopy based on the presence of associated symptoms and risk factors for colorectal cancer should be considered in patients over 40.
  • Have the patient increase his fluid intake. Steroid creams should not be applied until the incision has healed, and then should be applied twice a day for no more than seven days.

Supportive Treatments and Prophylaxis
Topical analgesics can be used postoperatively. Topical corticosteroids and astringents can control itching and irritation. Avoiding constipation and straining with stool bulking agents and softeners are the best ways to prevent recurrence.

Drugs Used for Hemorrhoids

  • Benzocaine 5-20% rectal ointment or other topical analgesic
  • Astringents such as witch hazel (Tucks, Preparation H pads) zinc oxide (Desitin)
  • Bulk-forming laxatives (oral): methylcellulose (Citrucel), polycarbophil (FiberCon), psyllium (Metamucil), wheat dextrin (Benefiber)
  • Corticosteriods (topical): hydrocortisone rectal creams 1 to 2.5% (Anusol-HC, Preparation H, Proctosol-HC); hydrocortisone rectal suppository 25 to 30 mg (Anusol-HC)
  • Stool softeners: ducosate sodium (Colace)

Tip of the Week: Antispasmodic Agents
Several types of agents can be useful for reducing anal sphincter spasm. A small series suggested that topical 0.5% nitroglycerin ointment may provide temporary analgesia by reducing internal anal sphincter spasm. (Dis Colon Rectum 1995;38[5]:453.)


Watch a video of hemorrhoid treatment in the ED​.

hem 2.jpg 

About the Author

James R. Roberts, MD & Martha Roberts, ACNP, CEN

James R. Roberts, MD, is the director of the division of toxicology at Mercy Catholic Medical Center, and a professor of emergency medicine at the Drexel University College of Medicine, both in Philadelphia. He is also the chairman of the editorial board of Emergency Medicine News, and has written InFocus for more than 25 years.

Martha Roberts, ACNP, CEN, is an acute care nurse practitioner for Johns Hopkins Medicine at the Sibley Memorial Hospital in Washington, DC, an adjunct faculty associate and clinical instructor of nursing at the Malek School of Health Professions, Marymount University in Arlington, VA, and is Dr. Roberts’ daughter.

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