What can you tell me about active variceal hemorrhage

[bigbaldguy]

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?

 

[wandering_idiot]

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.

 

[bigbaldguy]

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.

 

[firetender]

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

 

[usalsfyre]

Serious varacies rupture+out of hospital environment=death.

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

 

[medicsb]

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.

 

[Smash]

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.

 

[bigbaldguy]

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.

 

[mycrofft]

We had three during my tenure.

Every one died. One made it to the hospital.

 

[boingo]

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

 

[CAOX3]

I have never seen one live.

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

 

[usalsfyre]

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.

 

[NomadicMedic]

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.

 

[mycrofft]

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.

 

[CAOX3]

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.

 

[NomadicMedic]

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.

 

[CAOX3]

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.

 

[Smash]

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.

 

[Akulahawk]

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.

 

[NomadicMedic]

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.