Case of the Month
March 2008

56-year-old male — vomiting blood

Dispatch

Your BLS unit is dispatched with an ALS unit to a 56-year-old male who is vomiting blood.

While en route the dispatcher notifies you that the patient is vomiting large amounts of bright red blood and is light headed.

En route your crew discusses the following considerations:

• Additional BSI
• Reasons for vomiting blood
• Additional resources

Scene Size-up
As you roll up to an apartment building you are met by a frantic woman. She states her husband is in their apartment on the second floor and has thrown up several cups of blood. Your team members quickly don gowns and masks in addition to your normal eye protection and gloves.

She leads you up the stairs to the apartment and brings you inside. Inside you see a large amount of blood on the floor by the side of the sofa and a trail of bright red blood leading into the hallway. She takes you into the bathroom where the blood trail ends and the patient is sitting on the floor next to the toilet bowl. He is leaning against the bowl and has a large amount of bright red blood on his chin, shirt, and trousers.

Initial Assessment
You approach the patient and check his radial pulse. You note that he has a rapid, weak pulse and his skin is cool and clammy. He appears very weak--as soon as you release his wrist his hand falls freely to the floor. He coughs once, splattering you with a fine mist of blood. (Good thing you have your protective eyewear on). You note that his respirations are rapid, about 32. You decide the patient is SICK.

Initial Treatment
You quickly update the ALS unit that you have a very SICK patient and you will be preparing for rapid transport. You request an additional unit to assist with carrying the patient out to the transport vehicle. Your partner gets vital signs and begins oxygen therapy using a mask at 15 liters per minute. Your partner then quickly returns to the rig to get a patient transfer tarp.

Vital Signs

• Respirations                          32
• Pulse                                   140
• Mental status                       Conscious but weak and lethargic
• Pulse oximetry                      95% on NRM
• Blood sugar                          Not taken
• Blood pressure                      86/Palp

Further Evaluation and Treatment
Since there is no report of trauma and no visible signs of trauma you decide to carry the patient out on a transfer tarp. As soon as the next unit arrives you begin to move the patient out to your ambulance. As the ALS unit has not yet arrived it is decided to start transport to the nearest surgical hospital and rendezvous with the ALS unit. About halfway to the hospital the ALS unit meets up with your team and the ALS crew boards your unit with their kits so that they can initiate ALS care while continuing to transport in your BLS unit.

The ALS team starts two IVs and intubates the patient to protect his airway from aspiration. The ALS crew gives a small amount of fluid as he is still conscious. His vital signs are reassessed and he is found to have a blood pressure of 88/P with a heart rate of 136. He arrives at the hospital in stabilized condition and without further vomiting.

Vomiting Blood from Esophageal Varices
Bloody emesis can come from many different sources and can be anywhere from trivial to fatal. In the case presented above the patient was suffering from ruptured esophageal varices. Varices usually occur when scar tissue develops in the portal vein of the liver, which might be seen in cirrhosis and chronic hepatitis, thus restricting blood flow and causing a back up into vessels around the stomach, esophagus and occasionally the rectum. This back up creates engorged veins that are referred to as varices which can become very large and very delicate. Often these vessels will leak, resulting in the signs and symptoms of a GI bleed (tarry stool, “coffee ground” emesis, poor vital signs ).

If a varices ruptures it can lead to perfuse, life threatening bleeding with rapid death. Since there is no way of controlling this type of bleeding in the field, the patient must be rapidly transported to a hospital with early notification of the emergency department staff. Treatment in the ED often involves placing a specialized balloon that extends down the esophagus and into the top of the stomach. Once the balloon is in place it is inflated, placing pressure on the any varices to slow or stop the bleeding.

Esophageal varices
Mayo Clinic (external website)

Bleeding esophageal varices
Medline Plus (external website)

Esophageal varices
eMedicine (external website)