# Serious Rectal Bleeding Question



## ZombieEMT (Jan 25, 2011)

I have a serious question about rectal bleeding, so please do not make jokes or think I am trying to joke. I just wanted to know what is the best way for EMS to treat rectal bleeding, and the best set of actions to take. For example, what position on the stretcher, best dressings, pressure, and exam? Maybe also appropriate questions to be asked. I have heard several calls go out for rectal bleeding and thankfully have not had one on my own, but I do want to be prepared. It is something that was not discussed during my training.


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## Veneficus (Jan 25, 2011)

HaleEMT said:


> I have a serious question about rectal bleeding, so please do not make jokes or think I am trying to joke. I just wanted to know what is the best way for EMS to treat rectal bleeding, and the best set of actions to take. For example, what position on the stretcher, best dressings, pressure, and exam? Maybe also appropriate questions to be asked. I have heard several calls go out for rectal bleeding and thankfully have not had one on my own, but I do want to be prepared. It is something that was not discussed during my training.



Don't worry about it. It doesn't do any good to stop the blood flow at the anus unless it is a ruptured hemorrhoid, which is really perianal anyway.

There is nothing EMS can do for any of the causes of rectal bleeding, whether it is immune mediated, cancer related, infective, etc. You cannot even assess for trauma in the field. 

But you may want to find a surgical mask to wear because it really stinks.


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## NomadicMedic (Jan 25, 2011)

Veneficus said:


> But you may want to find a surgical mask to wear because it really stinks.



...with a dab of Vic's VapoRub. :sad:

Rectal Bleeding can come in several flavors. If it's "bright red blood when wiping" you can almost always assume it's a hemorrhoid. For some reason, I've been getting a LOT of these lately.

If it's a BOWL FULL of frank blood, it's a GI bleed, and you'll want to treat for shock and get ALS en route.

Appropriate questions? Has this ever happened before? Are you vomiting blood? Are you being treated for any abdominal/stomach/intestinal conditions?

Get a good SAMPLE and you'll be set.


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## medicdan (Jan 25, 2011)

Normal positioning (POC as appropriate), although you may want to consider thowing an extra chuck or towel on the stretcher (perhaps in addition to the blanket/wrap). Depending on LOC of patient or sending facility, try to gather information about the duration of bleeding, color, PMH (cancer? Hemmoroids? Infective? C Diff?, etc). On a BLS level, be sure to monitor vital signs, especially evaluating for hypovolemia, sepsis, or increase in pain during transport.


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## Handsome Robb (Jan 25, 2011)

emt.dan said:


> you may want to consider thowing an extra chuck or towel on the stretcher (perhaps in addition to the blanket/wrap).



This.


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## Veneficus (Jan 25, 2011)

I know everyone should take as good of history as possible, always, but I really think in this case, especially with the basic scope of practice, a surgical mask and an extra pad on the cot are about as much as is useful. 

There are so many differentials of GI bleed, I am not going to bother to type them. Most of the Dx is based on some kind of scope with some lab work. 

The most likely Dx are age and sex dependant. 

There are even pharmacological causes as well as distant surgeries with extraordinarily rare complications years later. 

Even if you do guess what the cause is, there is absolutely nothing to be done for it on an ambulance. 

Sure you could start some fluids, which may help, do nothing, or harm. 

You might even try a systemic pressor, which no study has shown any significant difference, though in theory it should work. 

If you are really feeling like you can call it portal hypertension you could even try some nitro. But I will bet dollars to doughnuts that is not in the protocol and no physician in their right mind would ok that over the phone.

Moreover, not to be mean, but I have taught basic class and seen all the textbooks, there is not even enough listed to know what history would be significant.

It is a rare case when I don't think EMS could make an impact, but this is one of them. Unless you have a lab and 90cm of blackscope, you basically got nothing. 

As an example, you could have a 60 year old male, with hemorrhoids, portal hypertension, taking aspirin and warfarin, with a recent infection of e-coli 0157:h7 grown on culture and suseptable to clindamycin which the patient was given, and you still cannot rule out colon cancer. (without blood work, a scope, and histopathology report.)


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## reaper (Jan 25, 2011)

So Tampex is out of the question? :O


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## dixie_flatline (Jan 25, 2011)

reaper said:


> So Tampex is out of the question? :O



Several years ago I had a pilonidal abscess develop and become severely inflamed; ended up needing to be lanced at the ER.  I had to wear a kotex or whatever pad home.  That was... not fun.  Not rectal bleeding obviously but I just thought I'd share   If I recall correctly though, due to the puss it also smelled pretty awful.  Hope you lot never run into one of those (on a call or on yourself)


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## medic417 (Jan 26, 2011)

Veneficus said:


> . You cannot even assess for trauma in the field.
> 
> But you may want to find a surgical mask to wear because it really stinks.



I hope I am misunderstanding you.  If a patient claims unusual bleeding whether rectally or vaginally you should visually check the area.  Is that a complete assessment?  No but you are still assessing the area.  You can always place at least the OB pad from the OB kit to help absorb some of the blood if there is actually a constant flow.  If it is external tissue you can still use an abd pad and pressure to help control the external bleeding.  

Yes rectal bleeding is the kryptonite of many a Paramedic as it stinks so bad.


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## MasterIntubator (Jan 26, 2011)

Most all of them are really cut and dry to handle.  Small leaks ---> chux, IV and transport.  Once in a blue moon, you will get the diamond in the rough... and walk thru the doors with the pt on the bathroom floor... you can smell the blood and feces in the air ( almost parvo like ), and the floor and walls are covered in blood.... we are talking like waterballoon amounts of blood.  The pt is pale and diaphoretic, semi-responsive and no one else is around to give any history, name, etc.  
You do a rapid exam, notice where it is coming from... and scoop them up on the stretcher... head down, feet up.  IV, O2 and MAST ( yup, the one call where they may have done a little good ) ----> granted, this was the early 90s.  Would I use them today?  Probably not, but it would make me wonder if they may help a bit. 
Other than a blood Y of fluids going and keeping the systolic about 70-80... there is not much else one can do in the field. 

Its just a poopy situation.


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## Veneficus (Jan 26, 2011)

medic417 said:


> I hope I am misunderstanding you..



I think you are



medic417 said:


> If a patient claims unusual bleeding whether rectally or vaginally you should visually check the area..



I agree with this fully.



medic417 said:


> Is that a complete assessment?  No but you are still assessing the area.  You can always place at least the OB pad from the OB kit to help absorb some of the blood if there is actually a constant flow..



and absorbant pad not only keeps the mess down, it makes the patient feel better. I also recall that being in the EMS standard of care.

I think we are on the same page still.



medic417 said:


> If it is external tissue you can still use an abd pad and pressure to help control the external bleeding..



I think this is where the misunderstanding is.

If the bleeding is from an external site, it is not rectal/anal bleeding. It is perianal bleeding, which shold be treated no different from any other surface wound encountered by EMS providers. What I am talking about is not that. 

I am speaking about blood originating internally and presenting from the orifice. 

The same would hold true about your bringing up a vaginal bleed or a urethral bleed. 

It is not in the capability of EMS to go rooting around looking for a cause. 

I am not suggesting that the providers should not perform a normal assessment, only that the level of information that assessment will yield is almost nothing. 

Even if something is found, it cannot be treated by EMS.


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## Veneficus (Jan 26, 2011)

MasterIntubator said:


> You do a rapid exam, notice where it is coming from... and scoop them up on the stretcher... head down, feet up.  IV, O2 and MAST ( yup, the one call where they may have done a little good ) ----> granted, this was the early 90s.  Would I use them today?  Probably not, but it would make me wonder if they may help a bit.



You might be interested to know there was a study competing with the MAST study that Dr. Mattox did that "debunked" MAST. As I recall the study found that MAST was actually very useful and increasing the peritoneal compartment pressure and pneumatically tamponading the bleeding from the Abd. Aorta. So I would think your MAST application may have stumbled upon perhaps one of its only uses.  



MasterIntubator said:


> Other than a blood Y of fluids going and keeping the systolic about 70-80... there is not much else one can do in the field.


 
I know this is the idea behind what EMS is calling permissive hypotension, but I would just ask you to consider the end game of a ruptured vessle from something like portal hypertension. If you have a ruptured esophageal varicy, Aortic/esophageal fistula, or a AAA, as the primary etiology, adding fluid is only going to make the situation worse.

Much worse if it actually is a AAA. You would most likely be better off doing nothing. 

If I could point out?

In emergent surgical repair of a ruptured AAA, fluid resuscitation is not started until the surgeons are at the patient side and anesthesia is about to be induced. Then it is begun with blood. (a minimum of 8 units FFP and PRBCs)

If even anesthesia witholds fluids in the resucitation of these patients, I would seriously doubt the wisdom of following a prehospital protocol based on SBP.  

Under the best circumstances, a ruptured AAA has a mortality rate of 80% When you add in the stats on prehospital rupture, it approaches 95%. When you go one more and count the post op complication mortality, it is basically 99%.

Toss in some inappropriate fluid therapy, and EMS might as well transport to the grave yard.


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## MasterIntubator (Jan 26, 2011)

Veneficus said:


> You might be interested to know there was a study competing with the MAST study that Dr. Mattox did that "debunked" MAST. As I recall the study found that MAST was actually very useful and increasing the peritoneal compartment pressure and pneumatically tamponading the bleeding from the Abd. Aorta. So I would think your MAST application may have stumbled upon perhaps one of its only uses.
> 
> I agree, my thought precisely.
> 
> ...



In the field, you need somewhere to start.  If the BP is unobtainable, give some fluid... it has been the standard of care for generations.  We stopped "flooding" in the early 90s based on the reasons you speak of.


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## Veneficus (Jan 27, 2011)

MasterIntubator said:


> In the field, you need somewhere to start.  If the BP is unobtainable, give some fluid... it has been the standard of care for generations.




That doesn't make it the right thing to do.


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## MediMike (Jan 27, 2011)

Veneficus said:


> In emergent surgical repair of a ruptured AAA, fluid resuscitation is not started until the surgeons are at the patient side and anesthesia is about to be induced. Then it is begun with blood. (a minimum of 8 units FFP and PRBCs)
> 
> If even anesthesia witholds fluids in the resucitation of these patients, I would seriously doubt the wisdom of following a prehospital protocol based on SBP.
> 
> ...



Could you define inappropriate fluid therapy for me here Vene?  You've got a pt. with a sys down in the 50's are you still holding that its inappropriate for me to toss a 20cc/kg bolus his way? (88y/o Seated syncope, altered, rigid abdomen/cramping lower abd px, cold skin etc.)


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## Veneficus (Jan 27, 2011)

MediMike said:


> Could you define inappropriate fluid therapy for me here Vene?  You've got a pt. with a sys down in the 50's are you still holding that its inappropriate for me to toss a 20cc/kg bolus his way? (88y/o Seated syncope, altered, rigid abdomen/cramping lower abd px, cold skin etc.)



It is patient specific. But, generally if adding fluid makes the patient numbers look nicer but worsens the condition, it is inappropriate. 

If you seriously suspect a AAA, adding pressure adds to blood loss. It can make a small hole a complete rupture. (paramedic assisted death)

You see it in other conditions, not only with bleeding, like cardiogenic shock of various etiology. 

Likewise the reverse is true. A patient in cardiogenic shock from septal anterior motion actually benefits from fluid bolus.

Citing yor example, would you rather deliver an unconscious patient to the ER with a systolic of 50, 40, 30 over garbage or doing chest compressions with a BP of 0/0 and an intrisic heart rate of 0 and in irreversible shock?

If the patient is in progressive shock, the crystaloid does nothing for them anyway. They need oxygen offloading capacity to help. In 2011 that means a blood product.

Would the patient be better off in a basic squad that could do nothing or an advanced squad that was making their situation worse? 

Can you always come up with the exact differential in the field? Hell no. Anyone who thinks they can is either a fool or a liar.

But you have to make a decision. Right or wrong, it is your call and you live with the consequences. Choosing to follow a formula irrespective of patient condition is a choice. It is a choice providers make every day. But that choice may sometimes mean that you took away what little chance the patient had. It means that you may have made things worse than no medical help. It means that you are not treating patients who do not fall into the most causes or presentations. 

You have to decide for yourself if you are ok with that.

Sometimes discretion is the better part of valor.


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## Sam Adams (Jan 27, 2011)

I cringed when I saw this thread. However, it's turned out to be interesting reading.

Still, I can't believe NO ONE has pointed this out!



n7lxi said:


> Get a good SAMPLE and you'll be set.



some of the abbreviations in EMS are funny in the right places.


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## 8jimi8 (Jan 27, 2011)

n7lxi said:


> ...with a dab of Vic's VapoRub. :sad:
> 
> Rectal Bleeding can come in several flavors. If it's "bright red blood when wiping" you can almost always assume it's a hemorrhoid. For some reason, I've been getting a LOT of these lately.
> 
> ...


Does the vaporub not relieve congestion... Opening airways....That's what you are trying for?


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## Veneficus (Jan 27, 2011)

8jimi8 said:


> Does the vaporub not relieve congestion... Opening airways....That's what you are trying for?



I think the goal is to constantly saturate and stimulate olfactory receptors so they cannot respond to other stimuli.


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## medicRob (Jan 27, 2011)

8jimi8 said:


> Does the vaporub not relieve congestion... Opening airways....That's what you are trying for?



Actually, coroners have done this for quite some time to overwhelm their sense of olfaction and mask the horrible smell of decomposing flesh.


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## dixie_flatline (Jan 27, 2011)

medicRob said:


> Actually, coroners have done this for quite some time to overwhelm their sense of olfaction and mask the horrible smell of decomposing flesh.



I think even Sherlock Holmes used camphor when around carcasses.


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## MasterIntubator (Jan 28, 2011)

Veneficus said:


> That doesn't make it the right thing to do.



For now ... it is the thing to do. There is no way any of us will predict what will happen in the field when it comes to these internal situations


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## Veneficus (Jan 28, 2011)

MasterIntubator said:


> For now ... it is the thing to do. There is no way any of us will predict what will happen in the field when it comes to these internal situations



I think that is the difference between technicians and medical professionals and why EMS will never hope to be one.

There are physical exam and history findings that can give data that will support reasonable decision making.

Like I said, not in every case for sure, but to make no effort, or to always defer to a protocol when the medical professionals responsible for attempting to help the patient are educated and specifically told not to perform an intervention for a particular pathology, it does not win much respect nor earn recognition as a capable provider.


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## MasterIntubator (Jan 28, 2011)

I agree with you.  New folks are confused enough coming out of school without all the stuff the teachings leave out of real world.  Experience brings on the knowledge that you possess, and for many medics, it takes their entire career to grasp that idea and break free from cookie cutter books and think along the assessment based treatments.  ( I yearn for that day its actually taught correctly )...  but look what they did to the EMT-B program.....  Cut out info and eased up on the testing from the EMT-A program.


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## johnmedic (Feb 1, 2011)

Sam Adams said:


> I cringed when I saw this thread. However, it's turned out to be interesting reading.
> 
> "Get a good SAMPLE and you'll be set."
> 
> Still, I can't believe NO ONE has pointed this out!



Haha! Good catch, I completely missed it..


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## bradford (Mar 2, 2011)

MasterIntubator said:


> Most all of them are really cut and dry to handle.  Small leaks ---> chux, IV and transport.  Once in a blue moon, you will get the diamond in the rough... and walk thru the doors with the pt on the bathroom floor... you can smell the blood and feces in the air ( almost parvo like ), and the floor and walls are covered in blood.... we are talking like waterballoon amounts of blood.  The pt is pale and diaphoretic, semi-responsive and no one else is around to give any history, name, etc.
> You do a rapid exam, notice where it is coming from... and scoop them up on the stretcher... head down, feet up.  IV, O2 and MAST ( yup, the one call where they may have done a little good ) ----> granted, this was the early 90s.  Would I use them today?  Probably not, but it would make me wonder if they may help a bit.
> Other than a blood Y of fluids going and keeping the systolic about 70-80... there is not much else one can do in the field.
> 
> Its just a poopy situation.



Wow. You just brought back a memory there. My first lower GI bleed call. Pt was unresponsive until I made contact and she grabbed me with her bloody/poopy hand right on my bare arm. It looked like a poop/blood grenade went off inside the bathroom. Uggh, I can still remember the smell...


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## MasterIntubator (Mar 2, 2011)

Don't you just hate that???  Freshly laundered uniform and those mud butt grubs come right at you.


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