# What can you tell me about active variceal hemorrhage



## bigbaldguy (Jun 24, 2011)

I'm interested in hearing any stories you might have about calls that involved bleeding varices. Specifically I am interested in varices caused by cirrhosis of the liver due to chronic alcoholism and what the outcomes were (mortality). Beyond fluid replacement is there anything that can be done prehospital?


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## wandering_idiot (Jun 24, 2011)

I've had to put a pt. on a Dopamine drip due to esophageal varice rupture.  He wound up taking 2 bags of NS initially and 6 bags of blood in the ER in addition to the Dopamine... I think he lived another week in ICU, IIRC.


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## bigbaldguy (Jun 24, 2011)

wandering_idiot said:


> I've had to put a pt. on a Dopamine drip due to esophageal varice rupture.  He wound up taking 2 bags of NS initially and 6 bags of blood in the ER in addition to the Dopamine... I think he lived another week in ICU, IIRC.



That pretty much jives with what I've been reading. I recently had a neighbor who died of this and I'm wondering if we had found him sooner if he would have had a chance but almost everything I've read says that once they have had a massive rupture its pretty much over.


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## firetender (Jun 24, 2011)

It's not something that emergency intervention can gain much traction on. It's an indication the patient has crossed the tipping point.


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## usalsfyre (Jun 24, 2011)

Serious varacies rupture+out of hospital environment=death.

It's really that simple. There's always the exceptions, but your looking at extreme mortality.


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## medicsb (Jun 24, 2011)

The only one I've had prehospital was a man who called 911 and said something about bleeding and "chainsaw", resulting EMS having to stage initially.  When PD arrived a few minutes later, he was in cardiac arrest.  We (ALS) had a 13ish minute response time.  When we got there, the place looked like a slaughter took place.  The police and BLS were doing CPR and rolling the patient to let the blood flow from his mouth while they suctioned.  They'd roll him back and within a minute his mouth would be filled with blood.  We got an order for pronouncement immediately.  It was clear that he had gone to the bathroom and spewed blood all over and then collapsed in his living room.  What confirmed it as varices was the hep c diagnosis mentioned in hospital discharge papers tacked to his wall.  We later put together that he said something like "it's like I've been cut with a chainsaw" to dispatch.  One of the more foul calls I've had.


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## Smash (Jun 24, 2011)

usalsfyre said:


> Serious varacies rupture+out of hospital environment=death.
> 
> It's really that simple. There's always the exceptions, but your looking at extreme mortality.



+1

Also, fluids (crystalloids that is) and inotropes/pressors are bugger all use, this is an uncontrolled hemorrhage.  You wouldn't pour fluids and inotropes/pressors into a stabbing or shooting victim, nor is it a good idea in these patients.


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## bigbaldguy (Jun 24, 2011)

Thanks all. My neighbors and I have been feeling kinda guilty that none of us noticed anything wrong sooner and checked on him. It makes us all feel better that even if we had been right there it prob wouldn't have played out any better. He had been DOS for 12 to 24 hours by the time I found him.

I have to say I never realized how much blood loss a person can have from a non trauma related issue. It just blew me away. His place was handled as a crime scene because of the sheer scale of the blood loss. No one could wrap their heads around how it could be so messy with no wounds. I was thinking he died of asphyxiation or aspiration of blood but from what I've researched and what you all have told me I realize now he just bled out as if he had severed an artery. Its good to know it was fairly quick way to go. He was a good guy.


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## mycrofft (Jun 25, 2011)

*We had three during my tenure.*

Every one died. One made it to the hospital.


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## boingo (Jun 25, 2011)

Vasopressin is an option for those systems that carry it, pouring saline into these patients just hastens death.


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## CAOX3 (Jun 25, 2011)

I have never seen one live.

And I  agree pouring saline into these patients is probably going to seal the deal.


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## usalsfyre (Jun 25, 2011)

boingo said:


> Vasopressin is an option for those systems that carry it, pouring saline into these patients just hastens death.



Usually you see vasopressin started after initial hemorrhage control, in the non-surgical sense this would probably be a Blakemore. Which at most community EDs is probably gathering dust in a cabinet somewhere. I'm not sure how effective things like vasopressin and sandostatin are when no control of hemorrhage has been achieved.


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## NomadicMedic (Jun 25, 2011)

CAOX3 said:


> I have never seen one live.
> 
> And I agree pouring saline into these patients is probably going to seal the deal.



Then I'm curious... if you've got a patient with active variceal bleeding, are you NOT going to start two large bore IVs and start "pouring in saline"? The standard of care for resuscitation for these cases is initial volume replacement with a crystalloid, then blood, a Blakemore and then some pharmacological interventions like Vasopressin and octreotide before definitive repair. 

I've only seen one of these cases, it was a bloody mess and the patient expired on arrival at the ED, but I still started fluid replacement to attempt to keep some volume present in his circulatory system. The fact is, he was going die, no matter what I did, but I don't believe my treatment was in any way inappropriate.


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## mycrofft (Jun 25, 2011)

*Oesoph varicele is like a grenade in your shirt pocket.*

Without control of major bleeds, pharmacologically elevating systemic BP would just pump it out the bleeders more. NS dilutes blood. Anatomically, when you go in and try to compress such a bleed (which you probably can't even see in the first place) with any measure, the adjacent tissues often prove to be unsound/friable and the bleeding area increases, or multiplies. Add to this the fact that many of these people have had bleeding going on for a while of some degree and dietary/lifestyle issues unconducive to a good CBC/Chem Panel, and clotting anywhere on board rapidly becomes an issue if somehow their active oesop bleed is slowed.

One doc talked about autotransfusing, but the returned blood was not very good the first time, and if you keep it up, some of those corpuscles flowing by are looking familiar.


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## CAOX3 (Jun 25, 2011)

n7lxi said:


> Then I'm curious... if you've got a patient with active variceal bleeding, are you NOT going to start two large bore IVs and start "pouring in saline"? The standard of care for resuscitation for these cases is initial volume replacement with a crystalloid, then blood, a Blakemore and then some pharmacological interventions like Vasopressin and octreotide before definitive repair.
> 
> I've only seen one of these cases, it was a bloody mess and the patient expired on arrival at the ED, but I still started fluid replacement to attempt to keep some volume present in his circulatory system. The fact is, he was going die, no matter what I did, but I don't believe my treatment was in any way inappropriate.



The science says no, we should be titrating to a pressure and allowing hypotension and vasoconstriction to work for us. Blowing off partial clots and increasing the container by pouring fluid into these individuals isnt in their best interest.


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## NomadicMedic (Jun 26, 2011)

I understand your point, but when all you've got in the tool box is fluid to try and keep a PT viable, do you do it or not? I don't have standing orders for Vasopressin in the field. All I had was an ET tube and fluids. It was a losing battle, akin to transporting a trauma code. 

But, ethically, what to do? If fluid is indicated by protocol and standard of care, the argument that "it's not doing the patient any good" is simply academic and likely to get you, at best, QIed, at worst, sued for negligence.


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## CAOX3 (Jun 26, 2011)

n7lxi said:


> I understand your point, but when all you've got in the tool box is fluid to try and keep a PT viable, do you do it or not? I don't have standing orders for Vasopressin in the field. All I had was an ET tube and fluids. It was a losing battle, akin to transporting a trauma code.
> 
> But, ethically, what to do? If fluid is indicated by protocol and standard of care, the argument that "it's not doing the patient any good" is simply academic and likely to get you, at best, QIed, at worst, sued for negligence.



Agreed, I wasnt attempting to change your practice just alert you to the science.  It is occuring in other services, perhaps if you addressed it with your medical director it may grease the wheels.  Frankly what do we have to lose, these people normally dont survive why not take a different approach.

Maybe if we deliver them with a pulse even if its at the core, we may have a chance to change the outcome. As with many things in EMS practice doesnt always equate to a positive outcome.


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## Smash (Jun 26, 2011)

n7lxi said:


> I understand your point, but when all you've got in the tool box is fluid to try and keep a PT viable, do you do it or not? I don't have standing orders for Vasopressin in the field. All I had was an ET tube and fluids. It was a losing battle, akin to transporting a trauma code.
> 
> But, ethically, what to do? If fluid is indicated by protocol and standard of care, the argument that "it's not doing the patient any good" is simply academic and likely to get you, at best, QIed, at worst, sued for negligence.



I understand your conundrum with attempting some temporising measures to keep a patient alive.  However I would be quite surprised if any surgeon thought that large volume crystalloid resuscitation in an uncontrolled hemorrhage would be the standard of care.  I would call for orders for vasopressin if possible and when the worst happened try some very small aliquots of fluid to maintain a carotid pulse and hope for the best.  The best won't happen, but still...

I don't think that argument against cyclic crystalloid resuscitation in active bleeding is purely an academic thing any more either.

Ethically, if I knew that I was doing harm, I would have more problem following protocol than not.


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## Akulahawk (Jun 26, 2011)

n7lxi said:


> I understand your point, but when all you've got in the tool box is fluid to try and keep a PT viable, do you do it or not? I don't have standing orders for Vasopressin in the field. All I had was an ET tube and fluids. It was a losing battle, akin to transporting a trauma code.
> 
> But, ethically, what to do? If fluid is indicated by protocol and standard of care, the argument that "it's not doing the patient any good" is simply academic and likely to get you, at best, QIed, at worst, sued for negligence.


The problem is that pouring in fluids will only serve to make the patient's blood about like kool-aid and about as useful to the patient... There is good evidence that in trauma, keeping the patient dry, maintaining a SBP somewhere near 90 (MAP of 60) improves outcomes. In major bleeds, I would imagine that the same physiological processes are in play, so while you do use the fluids, be judicious in doing so to maintain a some pressure while not allowing pressure to rise to the point where you pop clots. In my mind, it also stands to reason that if you keep the fluids down, you're also going to be limiting venous return... thus slowing the rate of hemorrhage. 

Am I off-base? Maybe. Follow your protocols... but be able to defend stepping outside that if need be. You might even have to call a Base Physician to get orders to accomplish the change in treatment protocol for that patient.


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## NomadicMedic (Jun 26, 2011)

Right. We're right back to where we started. First I'm not a big fan of phrases like "pouring in saline, I used it only to illustrated the point that, as field providers, we are way behind the 8 ball. I'm a careful, judicious user of permissive hypotension to maintain an acceptable pressure. But with massive bleeding, how much fluid do you have to put in to maintain 90 systolic? When are you moving from careful titration to running the lines wide open?

I'm only asking because I'm a new medic and really want to learn. It seems like a rock and a hard place. If you aggressively resuscitate with fluid, you blow out clots and kill him. If you don't, he loses all his volume and you kill him.


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## Smash (Jun 26, 2011)

I would argue that if you pour in fluid and pop clots, you will help kill the patient, whereas if you hold off they will unfortunately die from their disease process. Maybe a subtle distinction, but an important one I think.


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## 8jimi8 (Jun 26, 2011)

During one of my clinical rotations at the ER (for an EMS cert).  We had a woman come in with active variceal bleeding.  Hep C+ and hypotensive.  We gave Oneg in the level 1 transfuser initially 4 units.  Intubated, got a subclavian triple and then My clinical partner (another student) transported with me to the ICU (as well as an ER doc and a few other nurses, RT etc.)

When we got there, I was at the HOB while a GI specialist dropped the scope and began clipping bands and sclerosing the bleeds.  We were monitoring pressures such as 60/20.  She lived at least 1 day, i know that because i returned the next day for my 2nd 12.

Altogether we gave her 8 units of blood and 2 liters of fluid.  I remember bicarb getting pushed after an ABG, but i dont quite remember what our sedation/paralytic package was.  Nor do i remember our hemodynamic medications.  

I was just looking last night at Vasopressin off label uses.  it is VERY high dosages of vasopressin.  As a vasopressor the max i've used in a code was 1 unit/min.  The usual maintenance dose is 0.04 units/min (2.4 cc/hr on a 60gtt)  I seem to remeber seeing doses as high as 4 or 6 units / minute to stop bowel bleeding.  I didn't know it could be used for UGIB.  Can you imagine what the pt's blood pressure would be doing?!!


Anecdotally,
 i reported that the patient was a likely right mainstem (due to silent left sided breath sounds).

My student friend and I were mistaken for ER doctors.  and the ICU nurses went white, when they realized that there wasn't a doc with them.  

Uh... sorry... we're "paramedic" students (my partner lied).  We were just earning our basics then.  

That was a long time ago, I was a 3rd semester nursing student and had just finished my week long EMT-B skills boot camp.


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## usalsfyre (Jun 26, 2011)

8jimi8 said:


> During one of my clinical rotations at the ER (for an EMS cert).  We had a woman come in with active variceal bleeding.  Hep C+ and hypotensive.  We gave Oneg in the level 1 transfuser initially 4 units.  Intubated, got a subclavian triple and then My clinical partner (another student) transported with me to the ICU (as well as an ER doc and a few other nurses, RT etc.)
> 
> When we got there, I was at the HOB while a GI specialist dropped the scope and began clipping bands and sclerosing the bleeds.  We were monitoring pressures such as 60/20.  She lived at least 1 day, i know that because i returned the next day for my 2nd 12.


Pretty well the level of care that's required to save these people.



8jimi8 said:


> Altogether we gave her 8 units of blood and 2 liters of fluid.  I remember bicarb getting pushed after an ABG, but i dont quite remember what our sedation/paralytic package was.


Probably succs and an apology :unsure:.


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## mycrofft (Jun 27, 2011)

*Reminiscent of dissecting aortic aneurysm.*

"There I was, helpless...".


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## NomadicMedic (Jun 28, 2011)

I have an ER doc I was talking to last night who is interested in doing a podcast with me about this subject. If I can nail down a time with him between packing for the new job, I'll do it!


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## johnmedic (Jul 2, 2011)

What I've been taught recently & what I've read shows that _the _standard of care is crystalloids/colloids & catecholamine pressors. Yes, that includes uncontrolled hemorrhages. My mental math, however, does come to the conclusion that with how fast NS extravasates the attempted BP maintenance would be so fleeting that it's not worth it due to the blood you're essentially pushing out. So I'm gonna lean: Yes on pressors, no on just running NS wide open.

Obviously, there are valid arguments on the futility of either.

2005 article:
http://www.vitris.at/pdf/lit/stadlbauer-editorial-hem-shock-anesth-analg-2005.pdf


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## usalsfyre (Jul 2, 2011)

johnmedic, 

That's a pretty ambiguous article that references a couple of animal studies and two case reports of patients who got vasopressin AFTER anatomical control of hemorrhage. Pretty shaky. There's definitely a place for catecholamine pressors in hemorrhagic shock BUT a)I'd put it AFTER surgical control of hemorrhage and b)Even IF the place for pressors is pre-surgery, I'm not sure the average medic has the physiologic know-how to pull it off.


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## johnmedic (Jul 2, 2011)

Thanks usalfyre, so you're not for pressors pre-hemorrhage control, are you for running crystalloids? Or just expedite until you're at the ED? Yeah, the article isn't entirely relevant but I felt like the first couple paragraphs did a good job of summarizing what I've been taught about the subject of uncontrolled hemorrhage not exclusive to esophageal varices. Also posted because the article states the accepted standard of care, granted it's not specific to EMS.


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## usalsfyre (Jul 2, 2011)

Ehhhh...I'm not sure. I'm DEFINTELY not for crystaloids/colloids and pressors, standard of care or not. This is diluting down blood and squeezing it out faster...

With blood products it gets a little murkier. Keep in mine when you read anesthesia literature and the say "fluid" they mean "packed red cells, platelets and FFP" when it comes to trauma. Catecholamine depletion is a very real issue in these patients, so they may indeed need pressors if their hypotension is refractory to adequate fluid resuscitation. But we can't really tell that because we're not giving blood.


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## 8jimi8 (Jul 2, 2011)

don't forget that normal saline will end up negatively affecting the patient's pH.  LR is the fluid of choice in this situation, as the strong ion difference is balanced against the dilutional effect of fluid administration.


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## Smash (Jul 2, 2011)

I'm definitely not for crystalloids/pressors either, but bear in mind that with vaasopressin the idea is that we are reducing portal pressure to limit further bleeding.  I remain dubious as to it's value, but that is the rationale.  It is certainly different from using noradrenaline or phenylepherine or something like that.

"Standard of Care" is a pernicious little phrase often used as a excuse for poor decision making.  I like it not.


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## bigbaldguy (Jul 2, 2011)

n7lxi said:


> I have an ER doc I was talking to last night who is interested in doing a podcast with me about this subject. If I can nail down a time with him between packing for the new job, I'll do it!



Let me know if you do this I would like to hear it.


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## usalsfyre (Jul 2, 2011)

Smash said:


> I'm definitely not for crystalloids/pressors either, but bear in mind that with vaasopressin the idea is that we are reducing portal pressure to limit further bleeding.  I remain dubious as to it's value, but that is the rationale.  It is certainly different from using noradrenaline or phenylepherine or something like that.



But "vasopressin" wasn't what was mentioned. "Pressors" were what was mentioned. I agree there "may" (and it's a big may) be some utility to vasopressin, I doubt the decision making ability of the routine field medic to NOT hang a bag if dopa and go to town...


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## Smash (Jul 2, 2011)

usalsfyre said:


> But "vasopressin" wasn't what was mentioned. "Pressors" were what was mentioned. I agree there "may" (and it's a big may) be some utility to vasopressin, I doubt the decision making ability of the routine field medic to NOT hang a bag if dopa and go to town...



Vasopressin was bandied around on pages 1-3 for a bit after the second poster mentioned hanging a dopamine infusion (which just doesn't make sense)  Most people consider vasopressin to be a pure pressor, which is why I brought it up.  And I agree, the decision making is not likely to be up to scratch for the most part, which is why I dislike the defaulting to "I was told it is standard of care" argument.

I think pressors in general for hemorrhagic shock should be contraindicated in the field.  Different story in an OR with blood and products and potential problems like adrenal insufficiency or Waterhouse-Friedrichson syndrome, but we aren't really in a position to deal with those things.


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