Here's a thinker.

NTXFF

Forum Crew Member
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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.
 

PotatoMedic

Has no idea what I'm doing.
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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?
 

EMT2015

Forum Captain
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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
 

Carlos Danger

Forum Deputy Chief
Premium Member
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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.
 
Last edited:

ERDoc

Forum Asst. Chief
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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?
 

Brandon O

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

teedubbyaw

Forum Deputy Chief
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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?
 
OP
NTXFF

NTXFF

Forum Crew Member
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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.
 
OP
NTXFF

NTXFF

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

teedubbyaw

Forum Deputy Chief
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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.
 

ERDoc

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

PotatoMedic

Has no idea what I'm doing.
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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.
 
OP
NTXFF

NTXFF

Forum Crew Member
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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.
 
OP
NTXFF

NTXFF

Forum Crew Member
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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.
 

EMTinCT

Forum Crew Member
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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.
 

Clare

Forum Asst. Chief
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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.
 

Summit

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

RedAirplane

Forum Asst. Chief
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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)

:)
 

shelvpower

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

Regards
S
 

DesertMedic66

Forum Troll
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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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