fireflymedic Posted December 12, 2008 Share Posted December 12, 2008 You get dispatched for a transfer of a 65 year old man who initially presented to the local podunk ER with a near syncopal episode upon standing. ER states when he came in, he stated he had blood in his stool and was nauseated. They dropped an NG tube which returned coffee ground like material. Pt also stated he had dark, tarry stools and has been tired and weak and also short of breath for last several days. ER states they administered ice water via NG tube and eventually return became clear. Pt states history of smoking for 30 years. Initial BP is 100/70, pulse is 110, but when you sit him up in the ambulance, it drops to 90/70 and pulse increases to 115. Pt also states he has epigastric pain. Pt states he regularly takes Tums, no other meds. No significant medical history except chronic bronchitis. Okay, what's going wrong with this guy, what will you do for him? You can cure or kill him, based on your treatment. More to follow - we aren't done yet ! Link to comment Share on other sites More sharing options...
mobey Posted December 12, 2008 Share Posted December 12, 2008 he is obvioustly in need of some volume replacement, I would give him a bit (250ml) NaCl and reasess. I would need a Cxr, and hit the gastro dept for a peek see, but my DD at this time is: Upper GI bleed, Seeping esophogeal varcies (spelling?). Any chronic alcohol use? The blood in the stool.... Coulor? Quantity? AE sounds? Temp? OPQRST on the Epigastric pain? Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted December 12, 2008 Share Posted December 12, 2008 I'm with you mobey, GI bleed The ER obviously did an H&H - what were his hematocrit and Hemoglobin? I'll be getting the blood ready sir. But why in the word was EMS called to a patient in the ER? Is this for a transfer? Link to comment Share on other sites More sharing options...
fireflymedic Posted December 12, 2008 Author Share Posted December 12, 2008 "You get dispatched for a transfer of a 65 year old man" - just for you ruff was in initial report, but hey all good H and H - Hemoglobin - 10.1, Hematocrit - 30 Didn't want to throw those in there due to most not knowing normal values but there you guys go no chronic alcohol use, dark tarry stools, no bright blood in stool, pt states pain is relieved with antacids and acid inhibitors given in ER with positive results - you are going to a facility with GI capabilites which is an hour away by ground. ER is just a freestanding clinic with family practice doc staffing ER. Blood is not available at this facility and air med is not a possibilty due to weather. Ground CCT is an option though. What else would you like to do or know? Link to comment Share on other sites More sharing options...
AnthonyM83 Posted December 12, 2008 Share Posted December 12, 2008 Mallory-Weiss Tear? Link to comment Share on other sites More sharing options...
tniuqs Posted December 12, 2008 Share Posted December 12, 2008 Ok first whats LOC ? TEMP again? Got any O2 on him, SAO2 ? Monitor shows ?, Any Pain control rx as in opiates morphine will slow the gut down. BGL? Lytes ? FLAT Plate of belly would be a good idea too. ABGs if possible ... any serious metabolic acidosis could indicate dead gut ... all bad. Pop two lines in fer sure. Big thing is he is an "anemic hypoxemic" no matter what the pulse ox is telling you ... this can lead to cardiac issues/ angina but he really needs blood and GI consult asap, dx of guts is not easy for ER docs, let alone medics. If we knew ABG (sats) and Hbg we could calculate O2 Volume % .. just for fun. The difference in BP is classic postural hypotenson and indicating he's a down a "few pints" in addition to Hemglobin of 10 ... Crit of .30 which is kinda odd ? has he had lots of fluid already ? I would give him a little more fluids if he's still hypotensive but going slow is good, my first choice would be Ringers prehospital and keep the target BP 100 if you can, don't want to fluid overload and complicate issues, or hemdilute. With Black tarry stools lower GI bleed is more likely and usually slower in onset from my limited experiance possibly this is not a super acute patient coffee ground's more indicative of bleeding ulcer, I sure hope they were gentle inserting the N/G ! but he really needs a GI consult. If this was a Mallory Weiss tear/ esophageal tear they are usually bright red and vomiting +++ in the cases I have observed and a really crappy way to croak. If this facility did have the capabilities then Type and Cross match would a dang good idea, pull couple of units of O pos . (yea, I know you don't have that in the senario but what the heck for competeness) when I see these numbers blood replacement is the best thing for blood loss and is the best choice hands down... that said any "volume expanders" Hepastarch, Pentaspan hiding in the supply room, grab a liter .. te he. Just wondering ...can you give pentaloc in your guidelines if given a direct order from sending MD ? cheers Link to comment Share on other sites More sharing options...
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