Severe GI Bleed

[Nick15]

Had this call a few months ago and wanted to get input on what you medics would have done...sorry if any of the info seems off or anything like that, some of the details of the call I don't quite remember.
We were called to one of our convalescent facilities in our area for a sick person. Get on scene to find an elderly person in their bed who had a severe GI Bleed and had bled over half his bed and it was even all over the floor. Fire had told us that the patient was throwing up blood as well. His vitals were normal however, his skin signs were pale and diaphoretic. Fire cancelled the squad on scene and had us go bls to the patients facility he was normally seen at rather than the closest. Both my partner and I thought that this for sure would be a follow up to the hospital because of how much blood loss the person had.
After the call, my partner and I were a little uneasy about how the call went. I would have thought at least that the medics could have started an IV since the patient was dehydrated.
My partner and I are both relatively new, so were we crazy to think that there could have been more done for the patient? Like to hear you guys input on this call.

 

[VentMonkey]

Sadly? Welcome to SoCal EMS, Nick. I have seen them BLS a symptomatic CHB. You're right they should have followed up, but the truth is more often than not they're lazy, and/ or inept to a real critically ill patient; bad habits, Nick, bad habits.

A standard ALS work up is in order, depending on the severity a fluid challenge as well. The patient could be anemic and some EM docs may be a little perturbed with a bag wide open upon arrival. A 500-1,000 cc FB won't kill them and may perk the up until they're at the hospital. A glucose check wouldn't hurt either and a half an amp of D50, or even a D10 gtt IVPB (my county's option) if hypoglycemic.

Once in the ED chances are if it's a LGIB they'll get a stool sample, type and cross, and blood. Sounds like you should consider paramedic school.

 

[Gurby]

"Vitals were normal" I seriously doubt that given your description of the situation. He was probably in compensated shock - did his vitals look something like 116/70 with HR of 110? At first glance you might be inclined to think "eh that's pretty much WNL", and not pay much attention to the fact that he's a wee bit too fast and a wee bit on the low side.... Easy to write that off as stress or whatever, but don't be fooled.

What would I, as a medic, do? Pretty much the same thing you guys did: I would have taken him to the hospital. We aren't going to fix this problem in the field.

I try to be as fast as possible on scene and start transport, start the IV en route and run in a small amount of fluid based on his weight. Checking his sugar as above and a D10 drip if he's low... But otherwise I go lights and sirens to the nearest level 3+ trauma center if it's within a reasonable distance. If it's a long transport to a trauma center a small community hospital can still at least give the guy some blood before transferring him out to see a surgeon.

I think the patient should have gone with ALS, but then I think any legitimately sick patient should probably go ALS. But realistically, it probably doesn't make a difference and nothing we would do for him is likely to have much of an impact.

 

[Nick15]

I think my partner took them and they honestly were something around the 110/70 and pulse a little elevated. I know the patient kept going in and out during the time we transported, and my partner kept telling the person "hey stay awake." He even put the patient in the shock position too before we got to the hospital. Honestly I would have been semi-ok with fire starting an IV and leaving it open and having us go bls, just bc of the obvious dehydration that the patient had.


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[Gurby]

I think my partner took them and they honestly were something around the 110/70 and pulse a little elevated. I know the patient kept going in and out during the time we transported, and my partner kept telling the person "hey stay awake." He even put the patient in the shock position too before we got to the hospital. Honestly I would have been semi-ok with fire starting an IV and leaving it open and having us go bls, just bc of the obvious dehydration that the patient had.

Just based on your description of a cool/pale/diaphoretic patient who is vomiting blood and with significant rectal bleeding.... Starting an IV and running it open would be bad. The patient isn't "dehydrated", he is bleeding to death from somewhere in his GI tract. If you pump him full of saline you just dilute the ability of the blood to clot and make him bleed out faster.

See the "trauma triad of death": https://en.wikipedia.org/wiki/Trauma_triad_of_death

One thing you could have done that you may not have done, would be to cover him up with every blanket you have on the truck. We always keep our linen cabinet over-stocked because I know we'll be using 1000 blankets any time we have a major trauma.

For further reading, see also "permissive hypotension": https://en.wikipedia.org/wiki/Permissive_hypotension

 

[E tank]

The elderly don't have the sympathetic reserve to bump their HR in the face of hypovolemia like younger folks do, so a "normal" HR isn't surprising. Anemia doesn't help either. Guessing the patient was more or less supine with blood pressure measurement? A postural set of blood pressures would have shed light on the situation that the liter or more on the bed and floor didn't.

Setting aside all of that, GI bleeds, especially like you describe, don't happen for nothing. For example, patient on blood thinners for chronic A-Fib? That kind of volume loss takes on an order of magnitude greater significance.

An elderly patient like that needs a MAP of 65. Someone passing out from blood loss needs volume.

 

[VentMonkey]

So what do you guys think about the UGIB/ LGIB who is an otherwise healthy adult (20ish?) with positive orthostatic changes, and obvious signs of volume depletion? Clearly, a blood pressure of 70, and/ or MAP (<) 60 mmHg isn't conducive to their end organ perfusion. No blood product on our units, but what fine line are we drawing to walk with these patients, guys? Thanks.

I understand the concept with blood dilution. This is an excellent takeaway point @Gurby mentions, Nick. Trauma patients are not the only ones prone to this cascade of most unfortunate physiological events. Some supplemental O2 is certainly warranted, IMO/ IME.

 

[Gurby]

The elderly don't have the sympathetic reserve to bump their HR in the face of hypovolemia like younger folks do, so a "normal" HR isn't surprising.

They also tend to be on beta blockers and other meds that will limit their ability to compensate.

 

[NysEms2117]

**I AM NOT A PARAMEDIC** However, from what i can gather with GI issues(having one), is that most bleeds occur after a pre-existing condition(chrons, UC, perforation ect). These folks tend to be on anti- Tumor necrosis factor medicine, Humira is an example(which is an immune system suppressant if im not mistaken). If that changes your plan idk, just throwing in that 2 cents incase it would change something.

 

[Nick15]

Just based on your description of a cool/pale/diaphoretic patient who is vomiting blood and with significant rectal bleeding.... Starting an IV and running it open would be bad. The patient isn't "dehydrated", he is bleeding to death from somewhere in his GI tract. If you pump him full of saline you just dilute the ability of the blood to clot and make him bleed out faster.

See the "trauma triad of death": https://en.wikipedia.org/wiki/Trauma_triad_of_death

One thing you could have done that you may not have done, would be to cover him up with every blanket you have on the truck. We always keep our linen cabinet over-stocked because I know we'll be using 1000 blankets any time we have a major trauma.

For further reading, see also "permissive hypotension": https://en.wikipedia.org/wiki/Permissive_hypotension

I did not even think of that @Gurby. Thank you for the advice and information.


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[SpecialK]

It is very easy for clinical personnel to over-estimate how much blood a person has actually bled, a bit like how it's very easy to over-estimate burn size because we generally also take into account superficial burns.

Unless it's really obvious (for example a lacerated artery) then I am a bit rubbish at having a good estimate because (and I have seen this done), you can spread out 50 ml or 100 ml of blood on a towel or sheet and it looks like a lot because the surface area it can spread over can be quite large, particularly if the garment is thin. Somebody vomiting blood may only vomit say, a couple hundred ml of blood but over a large area and then it looks like a lot.

Certainly you take into account what you can see but this must also fit with the "overall picture" of how the patient looks and what their vital signs are, noting blood pressure is not a good indicator of the degree of hypovolaemia because people can compensate quite well (normally).

Yes there is some merit in giving IV fluid, but I wouldn't spend a long time trying to achieve this if IV access is difficult and the hospital is close by. If I could quickly gain IV access then sure, no reason not to give a litre of fluid as a bolus. If the patient is very unwell and you can get blood to you before reaching hospital, as many places in the world now can, then call for blood I say.