GI Bleed =12 lead?

[EMS49393]

I don't know another way to answer your question without presenting a case study to validate my response.

Patient is a 25 year old female, with a chief complaint of "I just have the flu." Patient presents alert and oriented. Skin is pale, nearly white, including nail beds and lips. She appears to feel poorly and admits to being very tired for the past three days. Vital signs BP 90/50, which is normal for patient, HR 130's at rest, RR 24. Unable to obtain a pulse ox reading. Lung sounds clear and equal bilaterally. Patient is nauseated, however no vomiting, no diarrhea. Rest of physical assessment is unremarkable. Patient was strongly urged by paramedic to be evaluated at the ER. I guess it was a gut feeling based on experience and patient appearance. Patient is goes to the ER as a walkin. Apparently she stated to the triage nurse "I don't feel well" and looked bad enough that the triage nurse nearly set her pants on fire scrambling to find a gurney and a physician. The patient had a Hct of 12 and a Hgb of 3.2. She was also in heart failure secondary to lack of oxygen rich blood. The body can only compensate for so long. The ER performed a 12-lead and it showed ischemia and T-wave changes in every lead. The EGD showed several ulcers and mallory weiss tears in the esophagus, along with a lot of blood in the stomach. I have no idea why there was no vomiting since the stomach isn't a real fan of blood.

Do you need to perform a 12-lead? Probably not, especially if you are a stones throw from the ER. If you have to trek the distance, for whatever reason, a 12-lead may serve to trend any changes in coronary oxygenation and perfusion from start of patient contact until the ECG is repeated in the ER. I know every physician I work with will order an ECG on a patient with that presentation and those labs.

The heart not only needs blood, it needs oxygen-rich blood, and a decrease in hemoglobin that results from a GI Bleed can send a patient into heart failure. It's not a necessity, but I'm a trending type of paramedic.

I know that case study backwards and forwards because I was the patient. The most recent ECG I've had performed still shows ST changes indicative of prior ischemia. I only respond because I keep seeing the age of the patient being brought up as a determining factor in whether or not to perform a 12-lead. After my experience, it cements the fact that heart failure secondary to GI bleed knows no age. You do what you feel is right. Perhaps I'm just a little overly cautious.

[chbare]

Exactly, any time you have a situation where hypoxia develops (hypovolemia, decreased hgb, etc) , cardiac stress is a given. I have seen young health people sustain significant myocardial insult as a result of stress conditions. Cocaine abuse, amphetamine abuse, and heat related injuries are among the top of the list. i see no problem with obtaining a XII lead provided time and situation permits.

Take care,

chbare.

[defib_wizard]

We have to remember that not only will a hypoperfusion state cause myocardial ischemia. the pancreas is very good at releasing an enzyme called myocardial depressant factor. So in retrospect a 12 lead would not be a bad thing. I just don't think I would delay transport for it. I would document why it wasn't done; eta to ed etc. I don't think a " ding " is necessary, but a hey think about this. Type talk would be more beneficial. I feel it is better to turn a situation like this into an positive educational experience. Rather than a negative butt chewing.

[bigj1130]

What are your thoughts on performing 12-lead ECG's on patients with GI bleeds? I'm not talking about "everyone gets a 12-lead just to be safe", I am looking for actual risks/concerns that would warrant a 12-lead vs. just 3-lead monitoring. A fellow coworked was dinged for not doing one and I'm left scratching my head. Assume no obvious cardiorespiratory sympyoms/history.

Yes without a doubt... regardless of age risk factors family history etc. It takes 30 seconds to a minute to obtain a 12 lead. Personally I also think a b/p of 90/50 with a rate of 130 is a damn good reason to take a look at the heart regardless of age. Hyperemesis causes electrolyte imbalances. What more reason due you need? We also are aware that a tachycardiac heart has increased O2 demand and that O2 demand is not going to be met for very long with those vitals.

Treat him/her as an ACS patient, no but still look at the heart.

[CBEMT]

90 year-old non-verbal demented male, skilled nursing facility, called for hypotension. Staff report rectal bleeding for several days, they want him to go to the family's community hospital of choice (daughter is onscene, even at 3am). Their last BP was in the 80's.

As per habit, my Basic partner took vitals while I set up the monitor and questioned the staff. He comes up with something like 70/30, and about that time I notice something hinky in leads II/II/AVf. Decided to run the 12-lead, comes back with significant elevations in II/III/AVf/V5/V6 with reciprocal changes.

"Sorry, he can't go to _______ Hospital. He might have the GI bleed but it's not the biggest problem right now."

Cath lab facility 1.25 miles up the road is diverting, so it's off for the 2-mile trip to the trauma center (community hospital is about 5 miles away). Zero IV access due to overall vein condition and arm flexion, patient is a G-tube feed so ASA is out.

Come to find out he'd had an MI 12 weeks prior that nobody deemed important enough to tell me about. When we left they were discussing medical treatment as opposed to catheterization due to his age and overall condition, which the daughter seemed comfortable with.

[zippyRN]

hypoxic and tachycardic = gets a 12 lead ,

assume nothing seeing more and more MIs due to traditional causes in patients in their 30s and MIs / coronary artery spasm in younger people on the the ol' colomobian marching powder...

[celticcare]

Whilst sitting at work at 0130 hrs, I am reading this and thinking yes it is a tough one to toss up, whether do a 12 lead or not. Couple things do spring to mind -

Has the service just received 12 lead capability and has to justify having 12 lead monitors to the bosses or are the bosses being anal about wanting to show off new toys?

With more and more refered pain and patients placing their bodies under strain due to secondary sources such as drugs, stress, alcohol etc, perhaps routine 12 lead is going to be the plan of attack for patients. Remember roughly 80 % of women dont show or exhibit signs of chest pain during MI or other cardiac events so I always ear on the side of caution with gastro and back complaints.

I do see routine 12 leads being done in the near future almost as common as 3 leads. Kinda watch this space eh.

[badmedicine]

Hard to give a hard straight answer with the info given. Because you say GI bleed nothing else. But reading between the lines you find Tachycardia, Hypotension, and potential Hypovolemia. = decompensating shock = 12 lead. But I will say since it was not my call and I did not do the exam and HX on this Pt. 3 lead may have been appropriate. But with the info given fall on the side of treatment. Since you didn't say other wise I will assume this pt. survived the transport and no harm done due to 3 lead -vs- 12 lead. which would make this a great moment of influence, to train the medic on why a 12 lead was warranted. Instead of a ding it should be a negative turned into a positive.

[iMac]

From my own view, if I have the time to set it up and I have already gotten by baseline vitals and Hx and I've done a rapid assessment of what I have on hand then I would but again to try to see if I can find anything else to report to the hospital. It can make a HUGE difference if you do find out that your patient is in a block or other rhythm that is questionable.

The age of the patient in question (along with the Hx,vitals) will give me a brief idea as to whether or not the ABD pain might potentially be referred from a cardiac episode. Would help rule out the pain is NOT cardiac in nature but I wouldn't waste time on it on scene.

[spenac]

I see no problem spending an additional minute on scene to get a twelve lead. If bleed is bad enough ischemia may already show up in 12 lead. Perhaps the original complaint was not cardiac in nature but it could be progressing to a point that it will be.

As to cost. Really not that much, instead of the 3 or 4 for your 3 lead you use 10 electrodes so even if a dollar a piece wow it added 6 or 7 dollars to the cost of care. Not that much in the long run and especially if you catch something and keep patient from crashing. A complete exam is the best exam.