Case of the Month
December 2007

73-year-old male – rectal bleeding

Dispatch
Your BLS unit is dispatched to a local assisted-living facility for a 73-year-old male with rectaling bleeding.

While en route the dispatcher notifies you that the patient is in his room on the first floor and feels somewhat lightheaded.

En route your crew discusses the following considerations:

• Reasons for rectal bleeding
• Intrinsic complications of geriatric patients
• Potential for a SICK patien

Scene Size-up
You arrive on scene and are met at the front door by a staff member. She leads you the patient’s room where you find him sitting on the toilet. He is leaning forward and appears pale. There are a few large drops of bright red blood leading up to the toilet.

Initial Assessment
You approach the patient and check his radial pulse. It is weak and about 130/min. His skin feels cool and he looks tired. His breathing appears to be fine.  You decide he is SICK and request an ALS unit and additional personnel to assist with rapid transport.

Initial Treatment
You and a crew member pick the patient up and move him out to the living room.  You notice the toilet bowl is full of bright-red blood and some blood clots. It is difficult to determine how much blood the patient has lost. Before lying him flat his lung sounds are assessed and you find them clear on both sides. Once flat you elevate his legs and further assess vital signs. You start oxygen at 10 L/min via NRM.

Vital Signs

• Respirations                          24
• Pulse                                   136
• Mental status                       Fully alert
• Blood pressure                      84/palp
• Pulse oximetry                      98% on mask

Further Evaluation and Treatment
Your partner further examines the patient while you instruct the incoming units to bring up a stretcher. As you place him on the stretcher your partner notes that her exam was unremarkable; there was no tenderness in the abdomen and it did not appear distended. The patient reveals that he has had some blood in his stool over the past 24 hours, but nothing as severe as today. He also states he did not become lightheaded until about 45 minutes ago. He admits to no abdominal pain in the recent past. He has a history of mild hypertension, diet controlled diabetes, and hypothyroidism. 

As ALS transports the patient, his vital signs improve somewhat. With an intravenous line established his blood pressure rises to 92/P and his heart rate decreases to 124. He continues to be pale and cool. He is released to the emergency room without incident.

Diverticular Bleeding
Rectal bleeding can come from several sources, but one of the most common is a ruptured diverticulum. A diverticulum is a small sac that can form in the lining of the intestinal tract. These sacs most commonly develop in the lower intestine and, by the age of 50, most people will have them. 

Most of those who have this condition will never know it and it never becomes a problem; however, if one of the sacs becomes infected or ruptures, then the results can be catastrophic. The bleeding can range from dark red to bright red and the flow can be light or heavy. This condition can be a surgical emergency.

There is no way to stop the bleeding of a diverticulum in the field. The best treatment for a severe case is as follows:

• Determine SICK or NOT SICK
• Confirm ALS is en route
• Treat for shock
• Administer high flow oxygen
• Rapid transport

Diverticular Bleeding
WebMD (external link)

Rectal Bleeding
MedicineNet (external link)

Diverticular disease
UpToDate Website (external link)