# ALS question to pt w/vomit/stool dark red blood



## thatJeffguy (Nov 29, 2009)

Arrived on scene, pt was 70yo w/f, laying on her left side, semi-fetal, after having fallen off the bed.  I'll give the Readers Digest version here;  dark red vomit, dark red stool, two syncope episodes, bp 84/p, pulse VERY weak and 55bpm on scene (done with pulse oximeter, probably incorrect) , SpO2 98%.  Due to low b/p, the crew chief called for ALS intercept.  ALS met us at a local PD. Pt remained awake and conscious throughout transport. 

Upon arrival, the medic asked her if she'd eaten any "grains or nuts" the day of or prior to her bleeding beginning.  I made a note and asked him after the pt was checked in.  He explained what he was inquiring about but, in my haste and lack of sleep in the past 30 hours, it's gotten a bit fuzzy.  Something about specific elements of those foods lodging in deformaties in the intestines and then causing tearing?  Any information would be very helpful!  Thanks in advance!


----------



## thatJeffguy (Nov 29, 2009)

Google-fu attempt;

Was the medic referring to "diverticulosis" and/or "diverticulitis"?


----------



## Lifeguards For Life (Nov 29, 2009)

thatJeffguy said:


> Arrived on scene, pt was 70yo w/f, laying on her left side, semi-fetal, after having fallen off the bed.  I'll give the Readers Digest version here;  dark red vomit, dark red stool, two syncope episodes, bp 84/p, pulse VERY weak and 55bpm on scene (done with pulse oximeter, probably incorrect) , SpO2 98%.  Due to low b/p, the crew chief called for ALS intercept.  ALS met us at a local PD. Pt remained awake and conscious throughout transport.
> 
> Upon arrival, the medic asked her if she'd eaten any "grains or nuts" the day of or prior to her bleeding beginning.  I made a note and asked him after the pt was checked in.  He explained what he was inquiring about but, in my haste and lack of sleep in the past 30 hours, it's gotten a bit fuzzy.  Something about specific elements of those foods lodging in deformaties in the intestines and then causing tearing?  Any information would be very helpful!  Thanks in advance!



although it is unproven, there is a theory that diets low in fiber can cause diverticular disease. diverticulosis and diverticulitis both became apparent in the early 1900's when processed foods began to make up a larger portion of consumers diets, decreasing fiber intake. Occurrences are also most common in more developed countrys, and are less likely to be found in countries such as asia or africa, where high fiber diets are the norm.

a lot of people have small pouches that bulge out through weak spots in the large intestines.each pouch is called a diverticulum, multiple pouches are called diverticula. the condition of having these pouches is called diverticulosis. this condition becomes more common as we age. diverticulosis becomes diverticulitis, when the diverticula become inflamed.

Fiber is found in grains and nuts. fiber is the part of the grains and nuts that our body can not digest. this type of fiber known as insoluble fiber takes on a soft jelly like texture and passes almost unchanged through the intestines.
This is good, it helps to soften the stools and prevent constipation. this is good, because straining to pass stools increases presure in the colon, potentially causing the colon lining to bulge out through weak spots in the colon wall(diverticula). 

We do not know exactly what causes diverticula to become inflamedm though it is most commonly though to be a bacterial infection, or when stool becomes "caught" in the diverticula. foods high in fiber are actually reccomended to patients with diverticular disease for the above mentioned reason. Actually, that is usually the only treatment needed, unless it is an advanced case.

However from the small amount of information given, it is very unlikely your patient had diverticulosis or diverticulitis do you know why?


----------



## Lifeguards For Life (Nov 29, 2009)

i'm gonna go ahead and say this is not diverticular disease.

is this the same patient you mentioned in a recently started thread about odd 911 call refusals?

and your chiefs biggest reaons for concern was a low blood pressure?

If you tought the pulse reading from the oximeter was incorrect, why did you not take a manual reading?


----------



## Shishkabob (Nov 29, 2009)

55pulse with a bp of 84/p is a little on the odd side...


Was an EKG done?  I'm going to guess there is a block going on.



But for the blood being lost in the stool / vomit, and a pulse that low, something else is going on.  Is the pt on beta blockers?


----------



## boingo (Nov 30, 2009)

Enhanced vagal tone due to nausea or abd pain is certainly a possibility.  I had a case a month or two ago, elderly woman, 1 L + bright red blood from rectum, syncope, pale, cool and hypotensive with sinus brady in the 50's.


----------



## redcrossemt (Nov 30, 2009)

Lifeguards For Life said:


> a lot of people have small pouches that bulge out through weak spots in the large intestines.each pouch is called a diverticulum, multiple pouches are called diverticula. the condition of having these pouches is called diverticulosis. this condition becomes more common as we age. diverticulosis becomes diverticulitis, when the diverticula become inflamed.



Does diverticulitis often result in bleeding?

Seems like this patient has some sort of gastrointestinal bleeding complicated by hypovolemia, a vasovagal response, a heart block, and/or beta-blocker (or other rate-controlling) meds.


----------



## thatJeffguy (Nov 30, 2009)

Lifeguards For Life said:


> However from the small amount of information given, it is very unlikely your patient had diverticulosis or diverticulitis do you know why?


I have no idea why? Do tell 



Lifeguards For Life said:


> i'm gonna go ahead and say this is not diverticular disease.
> 
> is this the same patient you mentioned in a recently started thread about odd 911 call refusals?
> 
> and your chiefs biggest reaons for concern was a low blood pressure?


Yes.  The low blood pressure and pulse were the reason ALS was notified.



> If you tought the pulse reading from the oximeter was incorrect, why did you not take a manual reading?



I'm not allowed to do that, I'm just a ride along.  ;-)  I'll grab stuff for the tech's, write stuff down, ask questions.  I agree though, especially since the b/p was taken on scene by palpation.  If you've got your fingers on the spot, might as well take 15 seconds to get a pulse.



Linuss said:


> 55pulse with a bp of 84/p is a little on the odd side...
> 
> 
> Was an EKG done?  I'm going to guess there is a block going on.


Yes.  The medic did say that something was wrong.  What do you think it was?  I don't recall exactly what he  said.



> But for the blood being lost in the stool / vomit, and a pulse that low, something else is going on.  Is the pt on beta blockers?



No, just a cholesterol drug.


----------



## zmedic (Nov 30, 2009)

Diverticulosis is a disease of the colon (large intestine). Unlikely to cause vomiting. Typically presents as painless, bright rectal bleeding.  

Dark rectal blood suggests an upper GI bleed, since the dark blood has likely been partially digested on its transit through the GI system. 

Was the patient a drinker? I'd be worried about esoph rupture, varicies, peptic ulcer etc.


----------



## Lifeguards For Life (Nov 30, 2009)

redcrossemt said:


> Does diverticulitis often result in bleeding?
> 
> Seems like this patient has some sort of gastrointestinal bleeding complicated by hypovolemia, a vasovagal response, a heart block, and/or beta-blocker (or other rate-controlling) meds.



can. If a patient was exhibiting GI bleeding, Diverticulitis would not rank overly high on the differential diagnosis. Diverticular bleeding is a diagnosis of exclusion. Diverticular bleeding is diagnosed only after all other possible causes have been exhausted.


----------



## Lifeguards For Life (Nov 30, 2009)

thatJeffguy said:


> I have no idea why? Do tell
> 
> 
> .



Diverticular disease most often(not always, but most often) occurs in the lower 1/3 of the sigmoid colon. Bleeding this low in the digestive tract, if apparent in the stools will be bright red in color. blood turns black in the gut lumen because reduced hemoglobin is dark and because bacteria alter the porphyrin pigments. Most of this conversion occurs in the right colon where the colonic bacteria are most active. Thus if blood in the stool looks entirely fresh, its source is the distal one-third of the colon; if it is completely black, its source is likely to be above the cecum; if it is mixed black and red, the source is somewhere in between.
Given that we expect diverticulitis to occur in the distal sigmoid colon we would expect to see bright red blood if any.

You described your patient as lying in the fetal position on their LEFT side.
what is located in the LLQ that would be irritated in any form of diverticular disease?


----------



## So. IL Medic (Dec 5, 2009)

thatJeffguy said:


> , pulse VERY weak and 55bpm on scene (done with pulse oximeter, probably incorrect) ,



Since other posts already hashed out the diverticulitis issue I wanted to smack this one:

Never ever ever ever ever ever ever ever ever ever ever ever never never depend on the pulse ox for a correct pulse rate.

Never ever

Always palpate the pulse. Always.

Reasons why: Call #1 - respond to nursing home for a resident with a pulse of 32. I walked in, saw pt sitting in wheelchair, fully alert, pink and happy. Knelt down to take pulse while asking the nurse what she got for a pulse. "Well the pulse ox said 32" Yes, but what did you get. "I told you the pulse ox said 32" Sooooo you didn't take a pulse? "I told you the..." Yeah. Palpated pulse of 85, strong and regular,

Call #2 - ALS intercept of BLS unit with elderly male, pulse over 200 and 'jumping all over the place'. Intercepted unit, I jumped in back with my gear to see an elderly male wondering what all the fuss was about. I asked EMT what pulse he got...and repeat the above silliness about a pulse ox. Palpated pulse normal, ecg normal. 

Call #3 - the bad side - ALS intercept to BLS unit with 56 year old female with decreasing level of consciousness, becoming ashen. EMTs told they picked her up for a general sickness call, got a bypass to the patients hospital of choice which was an additional 20 min transport time as she was CAOx3, BP 104/60, P 70's and 80's Glucose 180mg/dl. At intercept, pt was unresponsive, shallow resps, an irregular pulse too fast and weak to palpate for a count. Slapped the monitor on and 'oh ****' that's v-tach! 

Pulse oximeters are good at guesstimating O2 sat and that's it. So endeth the rant.


----------



## Lifeguards For Life (Dec 5, 2009)

So. IL Medic said:


> Since other posts already hashed out the diverticulitis issue I wanted to smack this one:
> 
> Never ever ever ever ever ever ever ever ever ever ever ever never never depend on the pulse ox for a correct pulse rate.
> 
> ...



agreed. +1
"too much monitor not enough patient"


----------



## Melbourne MICA (Dec 15, 2009)

*PR Haemorrhage*

Agree about the use of electronic devices especially the pulse Ox for Hr's being a bad idea. Seems to be an awful lot of emphasis in the thread and from the ALS Paramedic at the scene about fishing up for a "diagnosis" and not much about the urgent need to treat and transport. Without in-hospital testing and the huge amount of knowledge and training MD's receive on the "acute abdomen" I would suggest that diagnosis is best left for them.

If I may venture a small criticism, if you are spending time asking about nuts you are not spending time gathering the salient details that will impact your immediate treatment such as the estimated blood volume loss, time frame of the event, prior history etc. Details like most recent meal, alcohol consumption etc are still important information but can be gathered much further down the track.

Bleeding from the bowel when severe is a time critical emergency. The HR may reflect beta blocker use so a good question to ask is about exiting cardiac disease, with early EKG monitoring vital, all the more so as many cardiac meds which are usually attached to meds for the precipitating causes of IHD like HT, diabetes, obesity etc have SE's that will impact on perfusion state. eg if the pt is taking an antihypertensive, a beta blocker, an antiplatelet or other coag drug like warfarin (Hx of Afib)/clopridogrel etc it's not hard to see this is pretty relevant information in the shocked pt with an actual blood volume depletion.

One of my old lecturers use to refer to the acute abdomen as "tiger country" given there are an almost endless list of possible causes for pain, bleeding, urine/faecal issues etc. Looking for a diagnosis in this one seems like an academic exercise at best with no guarantee of getting it right.

As an overseas operator I would certainly be interested to hear if your US Rx and assessment protocols differ from ours in such cases.

MM


----------



## J. Burdett (Feb 7, 2010)

A diverticuli rupture would result in pertonitis as well as septicemia. That would explain the hypotension, N/V, and could account for the bleeding depending on the location. Still..... I concur it doesn't really add up with the intial assessment and should be way down on the list unless pt states hx of diverticulitis. Most pt's w/ diverticulitis will present w/ RLQ/LLQ abd pain due to most diverticuli forming in asc. or sigmoid.


----------



## JPINFV (Feb 7, 2010)

Since we're jumping on the pulse ox issue, the reason why a pulse ox supplies a pulse rate is not for documentation purposes, but as an accuracy check. If the patient's pulse is 100 and the pulse ox is reading 68, then the SpO2 reading is bad and shouldn't be used. By using the pulse ox to obtain a pulse rate you are eliminating an important accuracy check in pulse ox's that lack a waveform display (like most portable pulse ox's).


----------



## JPINFV (Feb 7, 2010)

Melbourne MICA said:


> One of my old lecturers use to refer to the acute abdomen as "tiger country" given there are an almost endless list of possible causes for pain, bleeding, urine/faecal issues etc. Looking for a diagnosis in this one seems like an academic exercise at best with no guarantee of getting it right.



While it might be an academic exercise at best, I don't see why it shouldn't be done provided that patient care isn't suffering. I would agree that transport and treatment shouldn't be delayed because the HPI wasn't significant enough to provide a good DDx, however, I'd also argue that throwing a few questions in to try to clarify HPI isn't necessarily a bad thing. For all we know, he was asking about nuts while in the process of doing something more immediately pertinent.


----------



## socalmdx (Feb 8, 2010)

1st suggestion!  Dont over think it!  

Then give o2, Start IV give a bolus for BP and Transport...thats all that matters!  Monitor ALL Vitals and who cares or knows what is causing her bleeding.  We are PARAMEDICS remember we DONT DIAGNOSE.  Our job is to recognize Sx/Sx. and treat accordingly.


----------



## JPINFV (Feb 8, 2010)

Actually, you do diagnose. If you didn't, you'd use the same treatment for every patient who was short of breath, had chest pain (oh, your chest hurt because you just got shot in the chest? Here's some nitro), or was hypotensive. You don't because, in the end, you come to a conclusion about the etiology of what's going on and use that to treat your patient.


----------



## Lifeguards For Life (Feb 8, 2010)

socalmdx said:


> 1st suggestion!  Dont over think it!
> 
> Then give o2, Start IV give a bolus for BP and Transport...thats all that matters!  Monitor ALL Vitals and who cares or knows what is causing her bleeding.  We are PARAMEDICS remember we DONT DIAGNOSE.  Our job is to recognize Sx/Sx. and treat accordingly.



1st suggestion! Diagnose your patients!

While many cases, this case included will not be diagnosed in the pre hospital environment, it is ridiculous to say paramedics and EMT's do not diagnose. For if you do not diagnose your patients with _something_ before performing a treatment or intervention, then you are just randomly treating patients, which would be a very bad thing. If you were experiencing an emergency, would you want a paramedic to give you Diltiazem without a diagnosis of Atrial fibrillation? Do your cardiovert or pace your patients because they have abdominal pain? Or have you diagnosed a problem, that you believe will best be treated by pacing?


----------



## socalmdx (Feb 8, 2010)

NO Doctors Diagnose...

is there anything in our drug boxes that will tell us why this women is bleeding?  NO

We simply ask questions, fact find, look in our toolbox (a.k.a. Drug Box and Brain) and pull out what we THINK will fix the current problem!  Then we will pass on any and all findings we have to a doctor so he can decide what the DIAGNOSIS is!

and we can play the what if game alllllll day!!! But you and I both know ULTIMATELY DOCTORS Diagnose!  If you want to diagnose go to MED school and earn your degree and then YES you may DIAGNOSE!


----------



## Lifeguards For Life (Feb 8, 2010)

socalmdx said:


> NO Doctors Diagnose...
> 
> is there anything in our drug boxes that will tell us why this women is bleeding?  NO
> 
> ...



This argument has been made several times among varying members, and invariably always produces the same outcome. If you are so adamant that you do not diagnose, you may consider turning in your paramedic patch, resigning back to the old EMT patch, as paramedics have little business treating patients with minimally invasive procedures and pharmacological agents if they do not know why they are performing these interventions.

Why do you do perform a pleural decompression? Because you have "looked in your toolbox (a.k.a. Drug Box and Brain) and pull out what we THINK will fix the current problem!  Then we will pass on any and all findings we have to a doctor so he can decide what the DIAGNOSIS is!"

You have made a diagnosis and initiated the proper treatment to correct the underlying cause.

I did recognize that this particular scenario is a purely academic pursuit, with no way to form an accurate and confirmed diagnosis in the field. however many illnesses, conditions and injuries can, and are diagnosed successfully, in the pre hospital environment every day.


----------



## JPINFV (Feb 8, 2010)

So anaphylaxic shock, cardiogenic shock, and septic shock all get the same treatment from you? After all, all types of shock are equal, right? 

Do you give Lasix to all patients with dyspnea, or only after "deciding" (read diagnosing) the patient with pulmonary edema secondary to heart failure and ruling out pneumonia.


----------



## MrBrown (Feb 8, 2010)

Melbourne MICA said:


> One of my old lecturers use to refer to the acute abdomen as "tiger country" given there are an almost endless list of possible causes for pain, bleeding, urine/faecal issues etc. Looking for a diagnosis in this one seems like an academic exercise at best with no guarantee of getting it right.



Have you been hit in the head with Frank Archer's 4x2 with "brilliance" written on it too? Wow he's just friggin awesome!

I think that's what most of the job of an ambo is, unless it is horrendously obvious eg a cardiac arrest or a broken arm then there is little room for being a true diagnostician in the acute medical sense because the tools are not present that we need to make a confirmed diagnosis

Agreed that you should not be relying on electronic gizmo's for heart rate and I will go one further and sat even BP; I dislike using the NIBP on the Lifepack as much as possible!



> dark red vomit, dark red stool, two syncope episodes, bp 84/p, pulse VERY weak and 55bpm on scene (done with pulse oximeter, probably incorrect) , SpO2 98%. Due to low b/p, the crew chief called for ALS intercept.



Your patient sounds pretty crook.



			
				Melbourne MICA said:
			
		

> As an overseas operator I would certainly be interested to hear if your US Rx and assessment protocols differ from ours in such cases.



Can't speak to the US but ours would be lots of transport very quickly and maybe 500ml of fluid.


----------



## mycrofft (Feb 9, 2010)

*Five is four. Diagnose Schmiagnose, of course we do.*

BRB out both ends at once?
The diverticulosis thing is a red herring. An acute case of diverticul_*itis*_ presents as belly pain, it is the equivalent of a leaking appendix.
Bright red bleeding out both ends argues for two etiologies with one trigger. Examples could be: oral injury, esophageal varices (my pt survived by the way), posterior nasal bleed; the rectal arena could be rectal trauma, very lower GI trauma, including small penetrating injury to the bowel such as .22 cal. or stabbing. Meds could make for worse bleeding, such as coumadin, NSAIDs, as would some herbals and of course alcohol.
Vomitting? I want to see food in it or see the vomit ocurr. Most time it's spit up, not vomited. If it is vomited, mre likely esoph or bad stomch bleed (again, look for small penetraing wounds or blunt force trauma if scene suggests).
Oh, yeah....also cancer.
Or did someone beat up Granny?

NEVER heard of or saw a diverticulum cause a frank bleed.


----------



## zmedic (Feb 9, 2010)

There's a big difference between saying "this is traumatic chest pain" or "this is chest pain from a likely cardiac source"

A real diagnosis would be to tell me exactly what is wrong with the heart. Is it an effusion, myocarditis, MI, valvular abnormality etc. They are treated differently at the hospital. Yes I'd agree that you shouldn't be blindly following algorythms, but at the same time it's good to keep some perspective on how much you can determine in the field. And it usually isn't worth the extra ten minutes on scene to really satisfy yourself that you've done a detailed history and physical to try to get the answer.


----------



## mycrofft (Feb 9, 2010)

*zmedic roger that*

Nice to know later, though, for reference sake. We used to NEVER get the outcomes or definitve dx except through back channels.


----------



## JPINFV (Feb 9, 2010)

zmedic said:


> A real diagnosis would be to tell me exactly what is wrong with the heart.



Not necessarily. A lot of times physicians in the hospital will only be able to narrow down a list of differential diagnoses until more test results come back. It's like saying EM physicians shouldn't diagnosis patients being admitted because the admitting diagnosis will often be different from the discharge diagnosis. I agree, and have stated, that transport shouldn't be delayed because a medic is wavering in his assessment (assessment, as in diagnosis. The A in SOAP) of what is going on. However there's a thought process difference between "I'm treating X protocol" and "I'm treating a patient with either A, B, or C who has the following acute problems (hypotension, etc)." 

Yes, not every piece of the puzzle can be found in the field, however not every piece of the puzzle is going to be found in the ER.


----------



## mycrofft (Feb 9, 2010)

*Why not take the diagnosis versus assessment thing to a separate thread?*

The OP was looking for a scenario response.


----------

