Debatable Call?

[mycrofft]

PS to my post above: Veneficus found me the Northwest Passage from the liver into the stomach. You back up through the gall bladder, down the duct into the colon....well, like the NW Passage you need an icebreaker and a compass won't help you.

 

[FLdoc2011]

Let me clarify. Currently, in the US, there is no dialysis for liver failure that is approved beyond clinical trials.

Was just going to add this. Funny but was just speaking with one of our nephrologist today about this. Nothing in the US yet but some uses overseas, I think he mentioned mostly in those awaiting liver transplants.

 

[FLdoc2011]

You can sit by me.

I would also add anemia and hepatorenal syndrome to his list of possible problems.

I agree, looking at his BP and a report of vomiting blood. Which may likely have been wretching with some bloody streaks if there was no evidence is highly suspicious of a varice.

From the amount of providers who saw him and decided nothing was wrong, sounds like there may have been some social bias in there as well.

Agreed.

Certainly at top of my differential. I've seen variceal bleeders crash very quickly. I'm even nervous when they're admitted to a regular floor as we've had them crash and then are scrambling to get blood/fluid and good access.

Regardless, I wasn't there and didn't see him and sometimes bad things just happen and people go south who otherwise looked ok, but certainly him already tachy and dropping BP would've sent up red flags.

 

[TatuICU]

If he is in liver failure for whatever reason or has a cirrhotic liver, another aspect to this is that generally if he ruptures a varix or has any significant source of bleeding, there's a good chance his clotting time is going to suck. Guess where TPO is made and what's responsible for Factors 1, 2, 5, 7, etc. Usually moderate thrombocytopenia is tolerated pretty well by these folks, but if there's a significant source of bleeding they're generally at a higher risk for serious problems.

Not critiquing your call, I assume everyone comes here for others opinions and to get new perspectives. That's just another facet to look at. If he goes, there's a fairly good chance he's going to GO.

 

[kindofafireguy]

Interesting. Pretty sure I just ran a patient with ruptured esophageal varices. She had pretty substantial hematemesis, a bp of 84/52, and was tachy at 120. Plus she said she felt like she had heartburn.

And judging by the empty 40 oz's around the bed, she was no stranger to liquor.

But I just first respond. I do know the medic crew ran her in hot, though

But I digress.

My opinion on calling BS on something you didn't see is that you should probably just take it at face value. In all honesty, you have less to lose from believing it and considering it than you do from ignoring it.

Just my opinion though. Based on your assessment, it doesn't sound unreasonable that it would have occurred.