# Here's a thinker.



## NTXFF (Aug 9, 2015)

You're dispatched to a hemorrhage.  You check in route and dispatched tells you that you're responding to a 25 year old female conscious and breathing.  Pt is complaining of blood coming from her mouth.  In addition dispatch informs you she had three teeth extracted 6 hours ago.  You're met at the door by her father who takes you to the master bath where you find a 25 year old female white as a ghost and unresponsive.  Go! 

Hint - Don't try and go the easy road here because it wasn't the answer.


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## PotatoMedic (Aug 9, 2015)

Left lateral to get pt horizontal and drain blood.

Examin mouth to see where the bleeding is from.  Have pt bite on gauze to put pressure of bleeding if it is from the gums.  (Breath through nose).  Vitals iv fluids transport to facility with a dentist!  Did I win?


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## EMT2015 (Aug 9, 2015)

ABCs
Left lateral position
Oxygen by a nasal cannula @ 6L or even BVM @ max flow (picked this so that you can remove it to drain the blood from the mouth)
Suction
Rapid assessment
bleeding control
ALS intercept if you're BLS
Load and go


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## Carlos Danger (Aug 9, 2015)

Position on side & one person starts IV or IO while the other assesses and attempts to determine if bleeding is from extraction sites or is GI in origin.

If bleeding from teeth: ketamine --> LMA while on side, direct pressure on sockets. Suction as needed.

If suspected GI --> ketamine --> sux --> roll to back --> tube --> back on side when tube is secured. NGT.

Drive to closest ED or call for a helicopter. She needs blood and drugs and procedures that I probably don't have with me on the ambulance.


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## ERDoc (Aug 9, 2015)

Left side and suction
We need to look in the mouth and see where the bleeding is coming from.  Don't just attribute it to the teeth.  Which teeth were removed and how were they removed?  There are some pretty important things that can be found close to certain teeth.  Any evidence of seizure activity?


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## Brandon O (Aug 9, 2015)

Worth asking about history of any known coagulopathies or platelet abnormalities..


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## teedubbyaw (Aug 9, 2015)

Completely unresponsive/GCS 3? She's getting a tube to protect what's left of her airway. If I can control bleeding with pressure, I'll have a firefighter ride with me to do that. 

Hmm, ever use hemostatic gauze in be mouth?


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## NTXFF (Aug 9, 2015)

Yes completely unresponsive, rides out any painful stimuli you can throw at her.  Gauze is still in mouth and no blood is present.  There is blood splattered on the mirror in a pattern that suggests vomiting of blood.  Airway is patent breathing 14 times a minute.  Initial BP 154/98 move her to the ambulance 84/52.  Only medical history is sepsis last year.  No allergies and she's prescribed an antibiotic and Hydrocodone 5's both taken over an hour ago.


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## NTXFF (Aug 9, 2015)

Oh and you have a Level 2 12 min away or a community hospital 5 min.


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## teedubbyaw (Aug 9, 2015)

Those pressures don't add up. 

Get rolling and give a fluid bolus. Something else may be going on. When was she last seen normal? Community hospital should be able to handle it just fine.


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## ERDoc (Aug 9, 2015)

It looks like she is vomiting blood, but the gauze is still in her mouth and there is no blood?


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## PotatoMedic (Aug 9, 2015)

Missed the unresponsive part.  She's buying a tube with me and going to the level 2.  Pressures don't make sense but that won't change a rapid transport to the hospital.  Iv or io with fluids.  I would try to get the dentists number so the er can call them to ask about complications.


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## NTXFF (Aug 9, 2015)

Yes.  She was throwing it up and her father changed out the packing and cleaned up everything but the mirror.  We gave 1000cc fluid bolus and got her pressure back up.  Began getting her to come around before we left for the hospital enough to get info.  Pt then went unresponsive again with adequate breathing.  Transported her to the level 2 where everything regulated out upon arrival but only responded to painful stimuli.  We did not tube her because she was maintaining her airway and her sats were great, if we wouldn't of gotten her to come around before we left the RSI stuff was out.  She was admitted to ICU with what was ruled as an adverse effect to propofal and her antibiotic.  She's still not intubated and is now alert to verbal stimuli in the ICU.


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## NTXFF (Aug 9, 2015)

Her pressure keep fluctuating in the ICU as well she'll go from hypertensive to hypo in the blink of an eye according to the staff.  They haven't figured out why it's happening so they're calling in the specialists.


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## EMTinCT (Aug 9, 2015)

Do we know her blood type? If not then see if anyone nearby by an O- and get them to start a STAT transfusion. The ER can wait.


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## Clare (Aug 10, 2015)

Strange, but righto, not unmanageable. 

If there is obvious haemorrhage - firm, direct pressure.  

Airway - suction, position on side, if no bleeding or haematemesis then whatever adjunct works. 

Call for RSI Officer if quicker than hospital.

IV access and one litre of 0.9% NaCl as a bolus.

Hospital.


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## Summit (Aug 10, 2015)

Now that we are in the unit... what were her admit labs?


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## RedAirplane (Aug 10, 2015)

Is she part vampire? Those patients tend to be chronically hemodynamically unstable, and may also explain the need for dental work in the first place. (Elongated fangs)


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## shelvpower (Aug 10, 2015)

Clare said:


> Strange, but righto, not unmanageable.
> 
> If there is obvious haemorrhage - firm, direct pressure.
> 
> ...


Reason for NaCl and not Ringers Lactate? 
Sorry for asking but I'm still studying. 

Regards
S


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## DesertMedic66 (Aug 10, 2015)

shelvpower said:


> Reason for NaCl and not Ringers Lactate?
> Sorry for asking but I'm still studying.
> 
> Regards
> S


NaCl is favorited in some areas. Out here the only fluids we carry in the ambulance is NaCl. Inside our EDs NaCl is what pretty much every patient gets. I've never even seen LRs hanging on a patient here.


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## Tigger (Aug 10, 2015)

shelvpower said:


> Reason for NaCl and not Ringers Lactate?
> Sorry for asking but I'm still studying.
> 
> Regards
> S


Probably because ambulances carrying LR seem to be few and far between I'd guess.


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## shelvpower (Aug 10, 2015)

Here in South Africa RL is used for most patients. 200ml NaCL is used in patients that require drugs but not a vast amount of fluids.


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## exodus (Aug 11, 2015)

EMTinCT said:


> Do we know her blood type? If not then see if anyone nearby by an O- and get them to start a STAT transfusion. The ER can wait.


You're matching and carrying blood products on a BLS ambulance. okay.


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## Summit (Aug 11, 2015)

I'm certain that was in jest


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## EMTinCT (Aug 11, 2015)

exodus said:


> You're matching and carrying blood products on a BLS ambulance. okay.



Oh totally we do. We're also just certified as Medical First Responders, not EMTs. We also do C-Sections in the ambulance.


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## Jim37F (Aug 11, 2015)

EMTinCT said:


> Oh totally we do. We're also just certified as Medical First Responders, not EMTs. We also do C-Sections in the ambulance.


pssh. Call us when you're scope catches up to the latest brain surgeries ;P


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## EMTinCT (Aug 12, 2015)

Jim37F said:


> pssh. Call us when you're scope catches up to the latest brain surgeries ;P



Our medical director (who is the local mortician and is highly educated with an Associates Degree in Mortuary Studies) just isn't that progressive. We asked him if we could do neurosurgery by taking the 30 minute ConEd course but he said "no". Can you believe that?


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## DesertMedic66 (Aug 12, 2015)

EMTinCT said:


> Our medical director (who is the local mortician and is highly educated with an Associates Degree in Mortuary Studies) just isn't that progressive. We asked him if we could do neurosurgery by taking the 30 minute ConEd course but he said "no". Can you believe that?


So if you kill patients that means a boost for him?


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## Summit (Aug 12, 2015)

DesertMedic66 said:


> So if you kill patients that means a boost for him?


That explains why most of their protocols include "100mEQ KCl fast IVP"


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## EMTinCT (Aug 12, 2015)

Summit said:


> That explains why most of their protocols include "100mEQ KCl fast IVP"


This is a very appropriate treatment to boost his mortuary business.


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## zzyzx (Aug 17, 2015)

Sounds like a behavioral issue. Was she tachy when you guys got there? She would have to be profoundly hypotensive to be completely unresponsive. You are not going to bleed out because you had a few wisdom teeth pulled! Also consider that many people vagal when they see their own blood. That could account for fluctuating blood pressures.
The hospital considered an odd reaction to her conscious sedation meds? I suppose that's possible, but it just seems really unlikely that she would have effects for that long. Perhaps the hospital also thought it was a behavioral issue but had to admit her to an ICU bed because of her "unresponsive" episodes.


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## NTXFF (Sep 1, 2015)

zzyzx said:


> Sounds like a behavioral issue. Was she tachy when you guys got there? She would have to be profoundly hypotensive to be completely unresponsive. You are not going to bleed out because you had a few wisdom teeth pulled! Also consider that many people vagal when they see their own blood. That could account for fluctuating blood pressures.
> The hospital considered an odd reaction to her conscious sedation meds? I suppose that's possible, but it just seems really unlikely that she would have effects for that long. Perhaps the hospital also thought it was a behavioral issue but had to admit her to an ICU bed because of her "unresponsive" episodes.


It wasn't behavioral.  She had an adverse reaction to the antibiotic and propofal.  She's still in the hospital but has been downgraded to a PCU bed.  It was one of those ones where not much made sense.  I also wasn't lead on this particular call, just taken as a third rider as I was riding the engine.  I enjoyed the responses on here though.  Some made me laugh and some made we wonder what we could of done differently!  Thanks for everyone's responses.  As far as tachy she was bouncing between brady and tachy to the point where we had I wanna say 10 different strips by the time we got to the hospital.  Her body and vitals were all over the place.  She stayed in ICU on a ventilator for 6 days after not being intubated for 3.


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