Rosen & Barkin's 5-Minute Emergency Medicine Consult (331 page)

Anal Fissure

CODES

• 455.0 Internal hemorrhoids without mention of complication
  
• 455.3 External hemorrhoids without mention of complication
  
• 455.6 Unspecified hemorrhoids without mention of complication
  

BASICS

• Accumulation of blood in the intrapleural space after blunt/penetrating chest trauma or other nontraumatic etiology. Bleeding is usually a result of disruption of the tissues/vessels of the chest wall, pleura, or intrathoracic structures:
  
  • Results in decreased vital capacity, hypoxia, and respiratory compromise.
    
  • Loss of large intravascular volume results in hemodynamic instability and hemorrhagic shock.
    
  • Massive hemothorax can cause increased intrathoracic pressure, resulting in compromised venous return and decreased cardiac output.
    
• Rarely a solitary finding in blunt trauma:
  
  • Commonly associated with pneumothorax (25% of cases), extrathoracic injuries (73% of cases), and pulmonary contusion.
    
• Large hemothoraces cause the release of substances that can act as anticoagulants and contribute to continued intrathoracic bleeding.
  
• If left untreated, can lead to empyema and fibrothorax (lung trapping due to adhesions).
  

• Traumatic injuries (including iatrogenic) to major blood vessels:
  
  • Common vessels, including intercostal artery, internal mammary artery, pulmonary artery, pulmonary vein, aorta, vena cava, and heart are associated with hemorrhage into the thoracic cavity.
    
• Traumatic lung parenchymal injuries:
  
  • Often stops spontaneously as a result of low pulmonary pressures and high concentrations of thromboplastin in the lung.
    
  • Often associated with pneumothorax.
    
• Nontraumatic or spontaneous hemothoraces:
  
  • Very rare.
    
  • Consider coagulation disorder, malignancy, primary vascular event (such as aortic dissection, ruptured aneurysm), PE with infarction, infection (TB), bullous emphysema, pulmonary AV malformation, lobar sequestration.
    
• Torn pleural adhesions as a complication of spontaneous pneumothorax or tube thoracostomy
  

DIAGNOSIS

• Small amount of blood in thorax (<400 mL): Little or no change in patient’s appearance, vital signs, or physical findings
  
• Large amount of blood (>1,000 mL): Restlessness, anxiety, pallor, pleuritic chest pain, hemoptysis, dyspnea, or air hunger:
  
  • Signs of shock with loss of blood volume ≥30% (1,500–2,000 mL).
    
  • Tachycardia, tachypnea, hypotension.
    
• With insidious onset (i.e., malignancy): Dyspnea is the most common presenting sign since blood loss is usually not acute enough to produce a visible hemodynamic response.
  

• Acute blunt or penetrating trauma to chest.
  
• Recent rib fracture or flail chest.
  
• Delayed hemothorax can occur hours to days later without initial evidence of intrathoracic pathology on CXR; may be related to rupture of chest wall hematoma or disruption of intercostal vessels by rib fracture edges during movement.
  
• Malignancy or metastatic disease.
  
• Recent surgical procedure: Thoracentesis, thoracostomy, etc.
  

• Vitals signs: Depending on severity and time course, hypoxia, tachypnea, tachycardia, and hypotension maybe seen.
  
• Neck: JVD if increased intrathoracic pressure, tracheal deviation
  
• Chest inspection: Asymmetric expansion, gross deformity, paradoxical wall movement, abrasion, hematoma, and contusion
  
• Chest wall palpation: Tenderness or crepitus over ribs, clavicles, scapulae, or the sternum; SC emphysema, dullness to percussion
  
• Auscultation: Decreased or absent breath sounds over ipsilateral side (best appreciated in the upright patient)
  

CXR is the ideal diagnostic tool:

• In the hemodynamically stable patient, upright posteroanterior (PA) projection at full inspiration is optimal:
  
  • Fluid collections >200–300 mL can usually be seen on upright or decubitus CXR.
    
  • In a normal unscarred pleural space, fluid will be noted as a meniscus/fluid level blunting the costophrenic angle.
    
• In the supine anteroposterior (AP) radiograph (i.e., portable), up to 1,000 mL of blood may not be readily apparent:
  
  • Only a slight hazy infiltrate over the involved hemithorax maybe seen.
    
• Look for associated injuries (pneumothorax, rib fractures, pulmonary contusion, widened mediastinum, etc.) when reading chest radiography.
  

• Hematocrit may be helpful if it shows a drop or changes on serial evaluations.
  
• Type and cross-match.
  
• Pulse oximetry, ABG
  
• Pleural fluid removed should reveal a hematocrit >50% of the blood hematocrit.
  

• US diagnostic imaging is a valuable tool in the evaluation of intrapleural fluid collection:
  
  • An extended FAST scan can diagnose hemothorax with a higher sensitivity than a portable CXR in trained hands.
    
• CT is useful in detecting small amounts of intrapleural fluid not visible on the chest radiograph.
  

• Hemopneumothorax
  
• Pneumothorax
  
• Pulmonary contusion
  
• Pleural effusion
  
• Empyema/pneumonia
  

TREATMENT

• Assess vital signs and pulse oximetry; administer oxygen and obtain IV access.
  
• Fluid resuscitation as needed for hypotension
  
• Cautions:
  
  • Difficult to differentiate hemothoraces from pneumothoraces clinically:
    
    • All may present with dyspnea, pleuritic chest pain, decreased breath sounds, and hemodynamic instability.
      
    • Certain clues aid in making the diagnosis, such as SC emphysema for pneumothorax and dullness to percussion for hemothorax.
      
  • Perform needle thoracostomy for potential tension pneumothorax if the patient is hemodynamically unstable.
    

• Manage airway, breathing, circulation:
  
  • Control airway as needed; endotracheal intubation for patients with impending respiratory failure
    
  • Supplemental oxygen
    
  • 2 large-bore IV access sites and fluid bolus to restore circulating blood volume
    
  • Needle thoracostomy should be performed in patients with hemodynamic instability unless chest tube kit is immediately available.
    
• Patient should be positioned to sit upright unless contraindicated.
  

• Obtain upright CXR as quickly as possible, but if patient unstable do not wait to administer definitive therapy.
  
• Hemothorax is treated by evacuating accumulated blood in the intrapleural space.
  
• Tube thoracostomy evacuates blood; allows for re-expansion of the lung, as well as constant monitoring of blood loss.
  
• Tube thoracostomy:
  
  • Use a large-bore chest tube (36–40Fr).
    
  • Insert in the 4th–5th intercostal space at the mid-axillary line aiming posteriorly and superiorly.
    
  • Tube is then connected to underwater-seal drainage and suction (20–30 mL H
    ₂
    O).
    
  • Correct placement and adequate drainage is confirmed via CXR.
    
• Autotransfusion should be used if available to replace blood loss.
  
• Indications for OR thoracotomy:
  
  • Initial tube drainage >20 mL/kg of blood (or 1,000 mL of blood for adults from the pleural cavity).
    
  • Persistent bleeding at a rate >7 mL/kg/hr (or 200 mL/hr for 4 hr).
    
  • Increasing hemothorax seen on chest radiography.
    
  • Patient remains hypotensive despite adequate blood replacement and other sites of blood loss have been ruled out.
    
  • Patient decompensates after initial response to resuscitation.
    
• Indications for ED thoracotomy:
  
  • Penetrating trauma:
    
    • Traumatic arrest in the ED or within 10 min of ED arrival.
      
    • Severe shock with clinical signs of cardiac tamponade
      
  • Blunt trauma: Traumatic arrest in the ED at a trauma center or with surgeon available within 10 min
    

• Local anesthetics for cutaneous anesthesia prior to tube thoracostomy in awake, conscious patients
  
• Procedural sedation (midazolam) and analgesia (fentanyl) may be used for stable, awake patients prior to tube thoracostomy:
  
  • Fentanyl: Adult/peds: 2–5 μg/kg per dose
    
  • Midazolam: Adult/peds: 0.02–0.04 mg/kg per dose
    
  • Other sedative agents may be considered.
    

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