# Vomiting Blood During Full Arrest



## BryanR (Feb 27, 2017)

So last night I had this full arrest.  During transport, a ton of bright red blood came out of his mouth.  It wasn't vomit.  Anyone know what this could be?  The medic that was transporting with us had no clue.


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## GMCmedic (Feb 27, 2017)

Blood is sometimes a byproduct of CPR but It wouldnt be a ton. Ruptured Varices comes to mind, that would likely make the back of the Ambulance look like a murder scene. 

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## BryanR (Feb 27, 2017)

GMCmedic said:


> Blood is sometimes a byproduct of CPR but It wouldnt be a ton. Ruptured Varices comes to mind, that would likely make the back of the Ambulance look like a murder scene.
> 
> Sent from my SAMSUNG-SM-G920A using Tapatalk



It was pretty bad.  The gurney, backboard, and ground were all covered in it.


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## EpiEMS (Feb 27, 2017)

You could request a follow-up from the hospital, if you wanted to.
It could be interesting if it isn't something sort of expected (like esophageal varices, etc.).


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## VentMonkey (Feb 27, 2017)

GMCmedic said:


> Blood is sometimes a byproduct of CPR but It wouldnt be a ton. *Ruptured Varices comes to mind*, that would likely make the back of the Ambulance look like a murder scene.


This^^^, perhaps a Mallory-Weiss tear from the trauma induced by the CPR performed? Idk, either way how new was your medic that they had "no clue"?


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## BryanR (Feb 27, 2017)

VentMonkey said:


> This^^^, perhaps a Mallory-Weiss tear from the trauma induced by the CPR performed? Idk, either way how new was your medic that they had "no clue"?



He seemed pretty experienced.  It was a county fire guy, and he seemed to know what he was doing.  But he said he had no clue what that was.


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## EpiEMS (Feb 27, 2017)

BryanR said:


> It was a county fire guy








*Snicker snicker*

In all seriousness, though, esophageal varices, Boerhaave sydrome, etc. are covered in the EMT curriculum...


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## VFlutter (Feb 27, 2017)

Ebola


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## E tank (Feb 27, 2017)

Bleed came before arrest?


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## medichopeful (Feb 27, 2017)

Chase said:


> Ebola



Great, now that you even mentioned that we have to sterilize this page.  Nice.


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## BryanR (Feb 27, 2017)

E tank said:


> Bleed came before arrest?



Nothing before the collapse, according the family.  Fine one minute, dead the next.  It happened after about 10-15 minutes of compressions.


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## BryanR (Feb 27, 2017)

Chase said:


> Ebola


That's what I was thinking.


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## E tank (Feb 27, 2017)

BryanR said:


> Nothing before the collapse, according the family.  Fine one minute, dead the next.  It happened after about 10-15 minutes of compressions.



Nothing you could see.


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## Underoath87 (Feb 27, 2017)

Why do people call it a "full arrest" rather than "cardiac arrest"?  Is there such a thing as a partial arrest (respiratory maybe)?


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## Jim37F (Feb 27, 2017)

Underoath87 said:


> Why do people call it a "full arrest" rather than "cardiac arrest"?  Is there such a thing as a partial arrest (respiratory maybe)?


:shrugs: That's what everyone around here calls them. Might as well question why some people call them Traffic Collisions vs Traffic Accidents vs Motor Vehicle Collisions or Rigs vs Bus vs Truck (even in a Type II vanbulance)


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## CALEMT (Feb 27, 2017)

Jim37F said:


> Rigs vs Bus vs Truck



It's an ambulance, you're just wrong if you call it something else...

For the OP, like everyone else has suggested a ruptured varices comes to mind.


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## FK911 (Feb 27, 2017)

Was he intubated?


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## FK911 (Feb 27, 2017)

Because if he was intubated. It sound like the medic, and just because he is FD... same clown different costume.....if he was tubed then  it sound like there could have been some trauma caused by the intubation 
If u remember a show called AIRWOLF? 
The main Actor was riding his motorcycle in Malibu and crashed. 
He was intubated by LAFD medics who severed his vocal chords and left him unable to speak. 
I would follow up with receiving facility.


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## E tank (Feb 27, 2017)

FK911 said:


> Because if he was intubated. It sound like the medic, and just because he is FD... same clown different costume.....if he was tubed then  it sound like there could have been some trauma caused by the intubation
> .



Torrential bleeding caused by DL and intubation would have to be in the circumstance of a completely unavoidable anomaly somewhere in the airway. Leaving aside the miniscule odds that what is described was because of a traumatic intubation, even with tumor or airway disruption,  the bleeding doesn't look like the OP's patient.


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## TomB (Feb 28, 2017)

BryanR said:


> He seemed pretty experienced.  It was a county fire guy, and he seemed to know what he was doing.  But he said he had no clue what that was.



Good for him. There is a lot of narrative fallacy in medicine. "He was purple from the nipple line up so he must have had a massive PE." I respect people who say they don't know unless they actually know.


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## VFlutter (Feb 28, 2017)

TomB said:


> Good for him. There is a lot of narrative fallacy in medicine. "He was purple from the nipple line up so he must have had a massive PE." I respect people who say they don't know unless they actually know.



Agreed, however when new provider asks a question it would be more beneficial to throw out some common differentials instead of just saying "no clue".


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## BryanR (Feb 28, 2017)

He wasn't even intubated!  All we did was put in an OPA, bag him, and do compressions.  At least the medic admitted that he had no clue.  Most of them couldn't do that, what with their giant ego XD


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## Ridryder911 (Feb 28, 2017)

Bleeding diathesis could had been caused by many factors. Anything like described such as varicies  (ruptured hemorrhoids in the esophagus) do doubt that many of you have ever seen a Sengstaken Blakemoore tube in use). Could have been cirrhosis of liver, good ole GI bleed, ASA OD.. and so forth


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## VFlutter (Feb 28, 2017)

Ridryder911 said:


> Bleeding diathesis could had been caused by many factors. Anything like described such as varicies  (ruptured hemorrhoids in the esophagus) do doubt that many of you have ever seen a Sengstaken Blakemoore tube in use). Could have been cirrhosis of liver, good ole GI bleed, ASA OD.. and so forth



I love Blakemoore tubes. "Why do you have a football helmet in the supply room?"


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## EpiEMS (Feb 28, 2017)

Chase said:


> I love Blakemoore tubes. "Why do you have a football helmet in the supply room?"


Does not look comfy. Hopefully this kinda patient gets some anxiolytic agent?


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## VFlutter (Feb 28, 2017)

EpiEMS said:


> Does not look comfy. Hopefully this kinda patient gets some anxiolytic agent?



They are all intubated and heavily sedated.


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## Handsome Robb (Feb 28, 2017)

Chase said:


> They are all intubated and heavily sedated.



Why do y'all put a helmet on them anyways? 


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## medicsb (Feb 28, 2017)

Mallord-Weise tears and Boorhaves don't typically bleed much.  But, if the person was coagulopathic, that could change.  Varices can bleed horrifically.  I've also seen MASSIVE hemoptysis due to malignancy.  It's possible that he could have had an upper GI bleed.

Anyhow, for what it is worth, I have placed a blakemoore tube (with GI on the phone to help with verbal instructions).  The reason for the football helmet is that traction is required for the gastric balloon to work if there is proximal gastric/distal esophageal bleeding.  The helmet is just one way to ensure traction, but it has the advantage of providing a point of traction that is attached to the patient, especially if they need to be rolled or moved.   One down side to the helmet is it make is easier to dislodge the ETT when taking it on or off.


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## medichopeful (Feb 28, 2017)

Handsome Robb said:


> Why do y'all put a helmet on them anyways?
> 
> 
> Sent from my iPhone using Tapatalk




It provides an anchor for the tube.


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## EpiEMS (Mar 1, 2017)

medichopeful said:


> It *makes them look silly*.


FTFY 

So you've got an ETT in first then this tube? How does that work out?


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## medichopeful (Mar 1, 2017)

EpiEMS said:


> FTFY
> 
> So you've got an ETT in first then this tube? How does that work out?



Dang autocorrect always changing what I meant to type! 

Here's a link and some videos on placement:

https://emcrit.org/procedures/blakemore-tube-placement/

I won't be able to explain it very well, but basically, you insert it in a similar way as an OGT (the tubes shouldn't interfere with each other).  The ETT tube (clearly) blocks off the trachea, and the Blakemore goes into the esophagus and down into the stomach, and provides tamponade to bleeding esophageal varices to halt the bleeding.  Hopefully that helps a little bit?


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## EpiEMS (Mar 1, 2017)

@medichopeful, very helpful! Thanks! (I love EMCrit, it is often my go-to reference for procedures that I know nothing about!)


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## E tank (Mar 1, 2017)

EpiEMS said:


> @medichopeful, very helpful! Thanks! (I love EMCrit, it is often my go-to reference for procedures that I know nothing about!)



I last saw one of these used not so late in the 20th century. Flexible endoscopy has more or less replaced them. 

Anyone still seeing these with any regularity? Like in the past year?


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## VFlutter (Mar 1, 2017)

E tank said:


> I last saw one of these used not so late in the 20th century. Flexible endoscopy has more or less replaced them.
> 
> Anyone still seeing these with any regularity? Like in the past year?



I have seen it once. By the time it takes you to set up and actually place the thing GI is at the bedside to scope. I am assuming it would be more common in rural ERs without GI available on call.


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## EpiEMS (Mar 1, 2017)

@E tank
Relevant:





Also relevant, are ED physicians performing this procedure, or are they calling GI or surgery?


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## VFlutter (Mar 1, 2017)

EpiEMS said:


> @E tank
> Relevant:
> Also relevant, are ED physicians performing this procedure, or are they calling GI or surgery?



This is usually done by the ED physician as a temporizing measure until GI can get there. Definitive treatment is endoscopy. Almost like placing a tourniquet.


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## NomadicMedic (Mar 1, 2017)

EpiEMS said:


> @E tank
> Relevant:
> 
> 
> ...




Saw one in my little rural ED a year or so ago. PT was flown to da big city. Where he subsequently expired.


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## E tank (Mar 1, 2017)

NomadicMedic said:


> Saw one in my little rural ED a year or so ago. PT was flown to da big city. Where he subsequently expired.



Ya...those football helmets usually meant to break out the tape measure...


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## medicsb (Mar 1, 2017)

Chase said:


> This is usually done by the ED physician as a temporizing measure until GI can get there. Definitive treatment is endoscopy. Almost like placing a tourniquet.



It is also done by intensivists and GI.  And really, it can be placed by anyone.  Also, endoscopy can only do so much.  In the patient that I placed a Blakemore, he had been scoped multiple times and had a blakemore placed at least once previously.  GI did not immediately re-scope him.  Really, what the definitive treatment is for these patients is reducing portal pressure, which is often accomplished by going to IR for TIPS (Transjugular intrahepatic portosystemic shunt), and down the line they will need a transplant if they are a candidate for such.  
.


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## harold1981 (Mar 8, 2017)

TomB said:


> Good for him. There is a lot of narrative fallacy in medicine. "He was purple from the nipple line up so he must have had a massive PE." I respect people who say they don't know unless they actually know.



Indeed. What´s wrong with guys that see it as a sign of incompetency. No matter how experienced, you won´t always know, unless you are pretending to.


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## VentMonkey (Mar 8, 2017)

BryanR said:


> *He wasn't even intubated!  All we did was put in an OPA*, bag him, and do compressions.  At least the medic admitted that he had no clue.  Most of them couldn't do that, what with their giant ego XD





harold1981 said:


> Indeed. What´s wrong with guys that see it as a sign of incompetency. No matter how experienced, you won´t always know, unless you are pretending to.


The OP's from the greater LA County area, I believe. His bolded statement here implies they're operating the same way they were when I left with a "I-could-care-less" attitude because they got a late call, or are tired, or just plain don't care; probably all of the above.

There's absolutely nothing wrong with admitting you don't know, if anything it shows what you do, and ensures you're open to learning more, typically, but the way the majority (not all) of these fire medics at least in this county function goes a bit further than just saying I "don't know". 

So I say no, chances are they don't know, _and_ won't care to ever learn any better; that's a problem. They're probably pissed they're not on the engine that day anyhow. That's how it was when I was there, that's how it still appears from the encounters we have with them at their hospitals.


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## EpiEMS (Mar 8, 2017)

@VentMonkey I would imagine it'd be hard to get good ETT placement with lots of emesis. Under those circumstances, wouldn't BVM + BLS airway adjuncts be OK "for now"?


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## VentMonkey (Mar 8, 2017)

EpiEMS said:


> @VentMonkey I would imagine it'd be hard to get good ETT placement with lots of emesis. Under those circumstances, wouldn't BVM + BLS airway adjuncts be OK "for now"?


Possibly, sure. I'm not going to arm-chair QB the call, at least not without more insight from the OP.

I think this is a perfect candidate for a King, a 30-45 degree angle, and continuous suction once the King is placed, and adequate SPO2 is confirmed.


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## EpiEMS (Mar 8, 2017)

VentMonkey said:


> Possibly, sure. I'm not going to arm-chair QB the call, at least not without more insight from the OP.
> 
> I think this is a perfect candidate for a King, a 30-45 degree angle, and continuous suction once the King is placed, and adequate SPO2 is confirmed.



Yeah, I didn't think of an SGA - makes sense to me.


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## photog (Mar 11, 2017)

BryanR said:


> So last night I had this full arrest.  During transport...



Why would you transport if no ROSC was achieved on scene? Was he hypothermic or did he go into cardiac arrest during transport?

One possibility for bleeding from trachea during resuscitation is that the distal airways and vessels collapse and a good quality CPR generates quite a strong thoraic vacuum which sucks variable amount of blood into the alveoli. We try to avoid that by keeping the alveoli open with a PEEP of around 5 cmH2O.


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## DesertMedic66 (Mar 11, 2017)

photog said:


> Why would you transport if no ROSC was achieved on scene? Was he hypothermic or did he go into cardiac arrest during transport?
> 
> One possibility for bleeding from trachea during resuscitation is that the distal airways and vessels collapse and a good quality CPR generates quite a strong thoraic vacuum which sucks variable amount of blood into the alveoli. We try to avoid that by keeping the alveoli open with a PEEP of around 5 cmH2O.


Seems like the vast majority of places are still transporting full arrests that do not get ROSC on scene. Sadly we are still required to transport all full arrests who have been in any rhythm that is not asystole or PEA <20


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## EpiEMS (Mar 11, 2017)

Protocol, man, that's why. It is a sad state of the world. Also it is hard to explain, in some cases - so that is a reason of debatable validity. 


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## VentMonkey (Mar 11, 2017)

Our protocols recently "updated" to include a 30 minute scene time for all arrests without ROSC in spite of the rhythm (asystole, PEA, VF/ VT without a pulse) after 30 minutes.

Honestly speaking? Not much different than what I have been taught over a decade plus of ACLS. It did seem like a lot of newer medics around here were doing a load and go approach recently, perhaps being egged on by fire (had a captain try that once with me, and my intern...that was funny). 

Long story short, our current county medical director made it official. Again, my personal opinion is som people really need to be told what to do to-a-tee. With the exception of certain circumstances I plan on going about what I've been doing for pretty much every arrest I have had thus far.


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## GMCmedic (Mar 11, 2017)

Weve been given the go ahead to  terminate efforts without medical direction at our discretion. 

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## NomadicMedic (Mar 11, 2017)

We're updating our protocols to specifically address the "work them on scene" issue. 

Also, Ketamine and Fentanyl. At last.


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## VentMonkey (Mar 11, 2017)

GMCmedic said:


> Weve been given the go ahead to  terminate efforts without medical direction at our discretion.


That too has been in our protocols since I've been here, I think even before. That said, aside from an obvious death, If I work it I'm typically pawning that off on "Doc Hazard", and "Nurse Crupp" for my documentation.


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## GMCmedic (Mar 11, 2017)

VentMonkey said:


> That too has been in our protocols since I've been here, I think even before. That said, aside from an obvious death, If I work it I'm typically pawning that off on "Doc Hazard", and "Nurse Crupp" for my documentation.


Really the only time I dont call is trauma codes. There are a few docs that will still have us work them only to call them within a couple minutes. 


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