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Case of the Month
July 2007
10-year-old male - vomiting blood
Dispatch
"Aid 82, 10-year-old male, vomiting blood”
En route your crew discusses the following considerations:
While en route the dispatcher advises that the patient has vomited several times in the past hour, but only a small amount of blood.
Scene Size-up
Your crew arrives at the patient’s home and is met by an adult male in the front yard. He leads you in to the home where you find the patient, a ten-year-old boy, lying on the sofa with a grimace on his face. The scene is safe. As the air temperature is extremely warm today, all the windows in the home are open to increase airflow and cooling. It is about 1930 hours.
Initial Assessment
As you approach the patient you see that he is mildly pale. He holds a plastic bag in one hand and his belly with the other. His knees are drawn up and he is lying on his side right side. Looking in the bag you see mostly mucus, with some bile, and a tinge of blood.
The patient has a heart rate of 110/min, which is strong, and a respiratory rate of 24/min. He has a blood pressure of 94/P. He moans occasionally and is aware of your presence.
Initial Treatment
Initial appearance of the child leads you to believe he is NOT SICK (no immediate life threats) but certainly not feeling well. Your team member starts oxygen at 4 liters per minute via cannula.
Event and Recent History
Because of age and gastrointestinal discomfort, the patient proves to be an unreliable historian. Through the mother you learn the patient was feeling well until two hours ago when he began to complain of abdominal discomfort. About an hour ago he began to throw up—he has vomited several times since. He had emptied his stomach with the first 20 minutes of vomiting, however the vomiting continued. The family became concerned when they started to see blood in the vomit. The father states the blood now in the plastic bag is about half of what they have seen to this point. The father states the patient’s older sister, 14 years old, started complaining of abdominal cramping about fifteen minutes ago, but has not vomited.
Further Evaluation and Treatment
Upon performing an abdominal exam you find a generalized tenderness, but no masses. The decision is made to transport the patient BLS to the local pediatric emergency department. During transport you discover that the patient attended a family reunion that day with a potluck meal.
The mother noted that the patient and his sister had both eaten sizeable portions of Uncle Helbock’s potato salad. It was a hot day (90 degrees plus) and the food was sitting out for several hours. You surmise that the GI discomfort that your patient and his sister are suffering might be caused by food poisoning.
You initiate transport of the patient. Consideration for a POV transport is discussed, but given the patient’s bleeding and the father’s concern, BLS transport is chosen. The transport is unremarkable with the exception of a couple episodes of vomiting.
Food Poisoning
The term food poisoning covers a wide number of conditions that result in gastrointestinal symptoms after the ingestion of improperly prepared, improperly stored or contaminated food. With over 200 different diseases that can be transmitted through food, it is no wonder that in over 80% of all cases the exact cause is never identified. The onset of symptoms usually comes on rapidly, within 48 hours of ingestion and can include nausea, diarrhea, vomiting, and/or abdominal cramping. Depending on the contaminate and severity of the case, a patient may suffer low grade fever, bloody stool, dehydration, and nervous system damage. Death is rare but possible.
The EMS approach to a possible food poisoning is largely supportive. Many different maladies can cause GI symptoms similar to those listed in this scenario. Your treatment depends on history and symptoms observed, with the anticipation that the patient’s illness may become worse.
The small amount of blood in this patient’s vomit is the result of a Mallory-Weiss tear. These tears can occur with forceful repeated vomiting or coughing. Severity of these tears can range from minor to life threatening, depending on the amount of blood loss. Most cases of M-W tear are very minor and require no intervention.
View more information on foodborne diseases
National Institute of Allergies and Infectious Diseases (external link)
View more on the pathophysiology of SBS
National Digestive Diseases Information Clearinghouse (external link)
View more information on Mallory-Weiss tear
eMedicine (external link)
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