# First time CPR - Blood squirting



## jparent (Oct 2, 2011)

Long time lurker first time CPR so I thought I would share.

About an hour ago a cardiac arrest call went out right down the street from me.  I arrived first with the police and we went into the house and started CPR.  We delivered a shock inserted an OPA, at about this time the medics, duty crew and a few members arrived.  The medics immediately hooked the pt up to the EKG and intubated her.  A few minutes later I saw blood coming from her mouth and could hear the blood in the tube when I was doing chest compressions.  This is where it all gets interesting.  

We delivered another shock and a bunch of blood squirted from her mouth.  One of the medics re-evaulated lung sounds which where 'clear'.  CPR was continued and the intubation tube was constantly needing to be suctioned.  The next time we shocked the pt blood squirted out 2-3 feet into the air from the tube.  We ended up getting a pulse after a few more shocks and few more squirts of blood.  

I've only been an EMT for 6 months and this is my first time doing chest compressions.  It was just a little freaky seeing all of the blood and especially the squirting from the tube during the shocks.

So expect the unexpected! And know where your face masks are.


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## the_negro_puppy (Oct 2, 2011)

jparent said:


> Long time lurker first time CPR so I thought I would share.
> 
> About an hour ago a cardiac arrest call went out right down the street from me.  I arrived first with the police and we went into the house and started CPR.  We delivered a shock inserted an OPA, at about this time the medics, duty crew and a few members arrived.  The medics immediately hooked the pt up to the EKG and intubated her.  A few minutes later I saw blood coming from her mouth and could hear the blood in the tube when I was doing chest compressions.  This is where it all gets interesting.
> 
> ...




Strange. Is it  possible the bleeding was caused through oral/airway trauma by the laryngoscopy and ETT tube? or did this patient have something like oesophageal varices?


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## adamjh3 (Oct 2, 2011)

Weird... I wonder if the tube placement was rough on the way in.


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## CAOX3 (Oct 2, 2011)

the_negro_puppy said:


> Strange. Is it  possible the bleeding was caused through oral/airway trauma by the laryngoscopy and ETT tube? or did this patient have something like oesophageal varices?



I agree.

Varicies, or Gi bleed.

What color was the blood bright red, coffe grounds?

What was the history?


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## silver (Oct 2, 2011)

Are you sure it was blood and not bloody secretions?

Codes get real messy around the airway.


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## Aidey (Oct 2, 2011)

2-3 feet in the air? Why was the BVM being removed for every shock?


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## jparent (Oct 2, 2011)

The blood was bright red coming out and filled up 1/2 of the portable suction container.  The blood only squirted in the air twice, the tube was being suctioned just prior to the shock on both occasions. The other few times it was just kind of leaking everywhere.

Hx - non smoker 50yo, unknown medical history besides that.  The pt was sitting at the kitchen table prior to the arrest.


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## CAOX3 (Oct 2, 2011)

jparent said:


> The blood was bright red coming out and filled up 1/2 of the portable suction container.  The blood only squirted in the air twice, the tube was being suctioned just prior to the shock on both occasions. The other few times it was just kind of leaking everywhere.
> 
> Hx - non smoker 50yo, unknown medical history besides that.  The pt was sitting at the kitchen table prior to the arrest.



Ruptured varices.


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## jparent (Oct 3, 2011)

Would broken ribs cause the same type of bleeding?  First time doing chest compressions so I have nothing to compare the feeling of the Pt's rib cage to but a few times during compressions the chest didn't rebound instantly, I paused for a second for the chest to rise and continued like normal.


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## usafmedic45 (Oct 3, 2011)

CAOX3 said:


> Ruptured varices.



There would have likely been a lot more blood than what was described.  The last varices case I worked looked like a scene from Kill Bill.


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## jparent (Oct 3, 2011)

usafmedic45 - there was A LOT of blood, I watched a video on youtube of ruptured varices and would say the amount of blood in the suction/on the floor could have been consistent with ruptured varices.  Maybe I didn't describe just how much blood came from her mouth, about 2-3 were used to wipe off the pt/floor.  It's just a guessing game at this point, thanks for everyones reply!


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## bigbaldguy (Oct 3, 2011)

Wouldn't a properly placed tube seal off the portion of the GI track that generally bleeds from varicies? It does sound like my experience with varicies though.

OP please check back in if you find out anything further. After my one and only varicies experience I'm interested to know what you find out.


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## Handsome Robb (Oct 3, 2011)

DIC maybe?


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## usafmedic45 (Oct 3, 2011)

NVRob said:


> DIC maybe?



Not from someone with no apparently medical history....that's a zebra.  Could have been bleeding from a rough intubation or trauma to the mouth or face from the agonal fall.

More than likely the OP is being dramatic in describing relatively minor bleeding.  When in doubt, assume someone is lying or exaggerating.


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## Handsome Robb (Oct 3, 2011)

Sorry I missed the no previous hx part. My buddy had a case like this, but his pt had a hx of chronic ETOH abuse.


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## jparent (Oct 3, 2011)

usafmedic45 said:


> Not from someone with no apparently medical history....that's a zebra.  Could have been bleeding from a rough intubation or trauma to the mouth or face from the agonal fall.
> 
> More than likely the OP is being dramatic in describing relatively minor bleeding.  When in doubt, assume someone is lying or exaggerating.




It's always safe to say someone is exaggerating on lying online, i think I'm describing it fairly though.  The medic said he's never see that much blood coming out like that before. And I don't know the size of the portable suction container but it filled up half way. Also on the big squirt from the ntt tube it hit the medic that was kneeling by the pt's waist, he had a good amount of blood on his arm/chest from 2-3 feet away.


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## jparent (Oct 3, 2011)

bigbaldguy said:


> Wouldn't a properly placed tube seal off the portion of the GI track that generally bleeds from varicies? It does sound like my experience with varicies though.
> 
> OP please check back in if you find out anything further. After my one and only varicies experience I'm interested to know what you find out.



 If I hear anything I'll update this thread, thanks for everyone's replies.


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## usafmedic45 (Oct 3, 2011)

> It's always safe to say someone is exaggerating on lying online, i think I'm describing it fairly though



That's the rule I live by in person as well.  It's basically Occam's razor (the simplest answer is the one most likely to be correct). 



> The medic said he's never see that much blood coming out like that before. And I don't know the size of the portable suction container but it filled up half way. Also on the big squirt from the ntt tube it hit the medic that was kneeling by the pt's waist, he had a good amount of blood on his arm/chest from 2-3 feet away.



Well, find out if they did an autopsy and get the medical director to request a copy of the report.  That's the best way to find out. 



> Wouldn't a properly placed tube seal off the portion of the GI track that generally bleeds from varicies? It does sound like my experience with varicies though.



Not unless the tube in question was of the Sengstaken-Blakemore variety.


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## jparent (Oct 3, 2011)

usafmedic45 said:


> Well, find out if they did an autopsy and get the medical director to request a copy of the report.  That's the best way to find out



It was a CPR save, only way I'll find out is if she tells one of our members I guess.


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## Handsome Robb (Oct 3, 2011)

From the sounds of it, you may have gotten ROSC, survival to discharge is another matter.

Even then your medical director can request the records for QI/QA purposes.


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## usafmedic45 (Oct 3, 2011)

jparent said:


> It was a CPR save, only way I'll find out is if she tells one of our members I guess.



Just because they made it to the hospital with a pulse does not mean it's a save.  Two words: Terri Schiavo.  So let me rephrase my earlier comment, "Once they do an autopsy...."


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## epipusher (Oct 3, 2011)

Wow, I don't blame you for lurking after reading a couple of these replies.


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## Jon (Oct 3, 2011)

jparent said:


> Long time lurker first time CPR so I thought I would share.
> 
> About an hour ago a cardiac arrest call went out right down the street  from me.  I arrived first with the police and we went into the house and  started CPR.  We delivered a shock inserted an OPA, at about this time  the medics, duty crew and a few members arrived.  The medics immediately  hooked the pt up to the EKG and intubated her.  A few minutes later I  saw blood coming from her mouth and could hear the blood in the tube  when I was doing chest compressions.  This is where it all gets  interesting.
> 
> ...



I have no idea. If it's in the airway, I can only come up with blood from trauma (airway management including intubation and/or post-arrest fall). If the tube was in the esophagus, I'd think varacies.



usafmedic45 said:


> There would have likely been a lot more blood than what was described.  The last varices case I worked looked like a scene from Kill Bill.



Amen. Only ever had one. I've NEVER seen THAT much blood. 


NVRob said:


> From the sounds of it, you may have gotten ROSC, survival to discharge is another matter.
> 
> Even then your medical director can request the records for QI/QA purposes.


Calling it a CPR save because they got to the hospital with a pulse isn't a good measure of cardiac arrest survival. If you give a rock enough Epi, you'll get a pulse... that doesn't mean the rock is alive (Stolen from my first paramedic instructor, credit to CB). To truly be a "save" they need to survive to discharge, preferably neurologically intact.

Not sure which squad you're with. If you have an active medical director, I'd seek him (or her) out and ask about this call. Have them look into it as a learning tool. If you don't, talk with your squad folks and consider reaching out to the QA/QI/Education staff of the MICU project. They will likely be able to get some answers for you.


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## imadriver (Oct 3, 2011)

I've only seen one thing like this. Lots of blood in the tube, and it came up with every compression. What we figured out is when the Medic intubated, we was a little excited and caused it from a rough intubation.


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## usafmedic45 (Oct 3, 2011)

There are things that can cause massive apparent pulmonary hemorrhage.  A pulmonary AVM comes to mind but it's so uncommon as to be highly unlikely in this case.  Likewise with an aortoesophageal or a vascular fistula involving the trachea.


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## RocketMedic (Oct 4, 2011)

And the 'clear' lung sounds complicate a lot of those differentials. Rales/bloody secretions would make a lot more sense, but if they weren't there, who knows?


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## mycrofft (Oct 4, 2011)

*Blood is like snakes, and oesophagae are not trachea.*

1. When someone tells me how long a snake is, or when I estimate it, I divide by two and add one third of the remainder. Blood loss is tricky to tell on scene, especially if it is potentially mixed with saliva or other pulmonary secretions, or rainwater, sweat etc.

2. Never heard of or saw a tracheal varix, and a lung bleed in an apneic unconscious pt would not ordinarily be magically defying gravity and physics to be "shooting out". Eosophgeal varix: blood all over all the time, not just on shocks.

My vote is oropharyngeal bleeding due to primary and/or airway access trauma (it happens, relax) and/or buccal or lingual injury, mixed with saliva and secretions and expelled in a _*cough*_, maybe powered by thoracic muscle spasm secondary to defibrillation. It pooled, then was blown outwards.

Things get confusing sometimes, and even if someone sees it wrong, they need to stick by their observation ("I saw XYZ") but concede that it could have been due to something they don't know about (don't guess and claim at mechanisms you can't assess).


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## jparent (Oct 18, 2011)

Just wanted to update in case anyone cared, the pt went back home a week ago.  She spoke with one of our members and is a little distraught about the whole incident.  Apparently we (probably me) broke a rib and it punctured a lung.  I don't know 100% but its what I heard down the grape vine.


thanks


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## ArcticKat (Oct 18, 2011)

Well, congratulations are in order.  Too bad she's pissed about a broken rib (dislocation of which is a common side effect)  Hopefully if she decides to sue the judge will take into consideration what the end result would have been had you not done CPR.  Too bad the medic didn't catch the pneumothorax when he checked lung sounds.


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## jparent (Oct 18, 2011)

jparent said:


> Would broken ribs cause the same type of bleeding?  First time doing chest compressions so I have nothing to compare the feeling of the Pt's rib cage to but a few times during compressions the chest didn't rebound instantly, I paused for a second for the chest to rise and continued like normal.




I posted this on the first page but nobody responded.  I didn't feel anything 'pop' but it definitely started to feel different after a while, guess it kind of makes sense now


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## mycrofft (Oct 18, 2011)

*Looking back:*

We delivered another shock and a bunch of blood squirted from her mouth. One of the medics re-evaulated lung sounds which where 'clear'. CPR was continued and the intubation tube was constantly needing to be suctioned. The next time we shocked the pt blood squirted out 2-3 feet into the air from the tube. We ended up getting a pulse after a few more shocks and few more squirts of blood.
Maybe the medic didn't hear any rhonchii due to congestion...naw, I really don't belive this. Sorry.h34r:


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## firetender (Oct 18, 2011)

I've handled traumatic chest injuries, likely rib involvement, where blood did spurt way out of the ET tube.  So, we're not talking minor trauma from CPR, but something that the person doing the compressions would almost have to have known if he caused it. During CPR a rib doesn't just happen to snap and get thrust into a lung in other than the old and debilitated. Improper hand placement accompanied by a deep compression is the likely culprit. 



> Apparently we (probably me) broke a rib and it punctured a lung...
> I didn't feel anything 'pop' but it definitely started to feel different after a while, guess it kind of makes sense now


 
The OP suspects it was he who did it, but, since it was his first experience, I can see how he wouldn't be sure. He DOES, however now know the difference. Stuff like this DOES happen and there could be many, many underlying contributing factors here (like unreported recent rib trauma), so it's all about the lesson. 

Bottom line, she lived. Complications go hand in hand with pulling people out of the drain.


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## mycrofft (Oct 18, 2011)

*Per my PM with the OP*

Maybe what I perceive as "squirting" is not what other people do. Good OP, sparked some good discussions.


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## Fish (Oct 18, 2011)

Aidey said:


> 2-3 feet in the air? Why was the BVM being removed for every shock?



Thats what I am sayin, keep that bad boy on so it stops bloody squirts.


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## coopera (May 21, 2012)

*Same thing happened to a friend*

Sadly we lost our grandfather yesterday.

He was sitting on the lounge, completely normal, then his head fell back and he lost consciousness. My partner got him onto the floor, whilst another person called the ambulance. My partner started CPR then blood started to come from the patients mouth. As CPR continued it seemed to get worse. 

I'm not a medical expert by any means, but my partner is feeling pretty down about the whole experience - thinking something was done wrong incorrectly. The Ambulance Paramedics confirmed that the CPR was administered properly yet they too questioned the bleeding. I discussed this with a doctor at the hospital and he told me that breakage of ribs was not likely to be the cause.

After doing some research I found this thread and I was wondering if anyone actually knows possible causes. The patient had a history of heart problems that were controlled by medication. His heart rate was slow and weak - that's all the info I actually know.


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## Melmd (May 21, 2012)

coopera said:


> The patient had a history of heart problems that were controlled by medication. His heart rate was slow and weak - that's all the info I actually know.



If he's on aspirin or other blood thinners, maybe you can start from there.


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## coopera (May 21, 2012)

Melmd said:


> If he's on aspirin or other blood thinners, maybe you can start from there.



*I believe he was on some kind of blood thinners, but I just wanted to know if bleeding like this during CPR is fairly common?

Thanks for your fast reply btw*


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## Melmd (May 21, 2012)

coopera said:


> *I believe he was on some kind of blood thinners, but I just wanted to know if bleeding like this during CPR is fairly common?
> 
> Thanks for your fast reply btw*



I doubt doing CPR caused it, maybe the patient has an esophageal/gastric bleeding that was exacerbated by the blood thinners.


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