Would you push fluids or not?

[spenac]

We all know that we need to treat the patient. Presentation, history, etc. are critical. I was trying to get a handle on what appeared to be a blanket statement by the medical director. The information I related to you was what was provided at the run review. I had a lot of questions after it and the type of discussion this has generated on this site was what I was looking for at the review. Thank you all for contributing. As a scared, inexperienced newbie thrown to the wolves, I have to stop trying to come up with a few simple "rules" about patient care and continue to try and learn and keep thinking. Thanks again.

Each patient is different, treat that patient. Based on the initial info you gave I still say they did right maintaining BP above 90 systolic. Now were other s/s present that would change that, hard to say not actually having been there.

You will be a fine medic, just get your confidence level up. People can sense if you are insecure and that makes your job harder. No matter how scared act like you know what you are doing and that you are in control.

[defib_wizard]

For the most part I agree with what was done except the fluid amount. I have a good team of docs that are pretty aggressive for med control. ( med dir. is a former medic ) If the bleeding is internal we can max out at 2000cc isotonic crystalloid. The feeling is the same that anything more will contribute to platelet washout. The target BP is 100 systolic as most people can maintain at this bp and there is less of a chance of you (overfilling the pt) causing an excessive pressure that will cause whatever is bleeding to worsen.

That being said If it is external trauma with the bleeding being controlled then wide open to support perfusion is appropriate.

Case in point I had a 47 yof that cut her wrists with about 1.5 liters of blood loss + etoh. U/a she had a weak carotid pulse and gcs of 3

she received almost 4000cc of ns during transport and woke up before I could intubate her. She received 4 units of rbcs at ed then was flown to higher care fore surgery. We had the bleeding stopped with pressure bandages as we ran the fluids in. I also patched to clarify that the bleeding was stopped and was given orders to continue the fluid wide open. BP at ed was approx 90-100 systolic if I remember correctly.

[crotchitymedic1986]

Kaisu, its ok to be a scared newbie, no matter how good your school was there is no way to prepare you for every situation you will face in the field. If you continue to study, learn from yours and other's calls, you will be fine. And when you feel the pucker factor remember these simple rules:

1. ABC always works, if you take care of that regardless of symptoms you and the patient will be fine.

2. Patients do not get brain damage because Paramedics fail to intubate them, they get brain damage because paramedics do not venitlate them. One day you will be an intubating god, but if you are still unable at this point due to lack of confidence -- just make sure you ventilate them well.

3. When you dont have a clue whats going on, transport them -- its never wrong to transport.

4. Trust your gut.

And when you get a chance, try to get an ER job (paid or volunteer), you will learn more in a month there than you will in 2 years in the field. Being able to see a patient from start to end, signs and symptoms, how the doctor's made treatment decisions, and what the outcome was will help you immensley in the field.

[p3medic]

Salt water doesn't carry oxygen, it isn't a substitute for blood, has no clotting factors, and is very likely cold. This patient needed blood/blood products, and perhaps a little crystaloid for good measure. 2 liters of room temp saline is not going to improve this patients outcome. Cold, acidotic, and coagulopathic is one sure way to end up dead. Now, same patient, atensive, altered mental status, yeah, some wide open saline would be ok, at that point you need to do something, but short of that, pouring in saline seems like a bad idea. As for his hemoglobin, you don't have that luxury in the field, so the fact that his GI bleed has been progressing for some time is purely one based on HPI.

Giving volume to a patient with bleeding that you cannot control is a whole lot different than a patient with bleeding you can control. Example, hypotensive patient with GSW to the abd = permissive hypotension, hypotensive pt with GSW to femoral artery, controlled with TQ, volume expansion to a reasonable MAP. Both will need blood/blood products, however one is in need of a rapid trip to the OR for surgical control of hemmorhage, the other can recieve blood products/saline, be normothermic and normotensive prior to the OR. At least thats how I see it.

[Fox800]

Giving volume to a patient with bleeding that you cannot control is a whole lot different than a patient with bleeding you can control. Example, hypotensive patient with GSW to the abd = permissive hypotension, hypotensive pt with GSW to femoral artery, controlled with TQ, volume expansion to a reasonable MAP. Both will need blood/blood products, however one is in need of a rapid trip to the OR for surgical control of hemmorhage, the other can recieve blood products/saline, be normothermic and normotensive prior to the OR. At least thats how I see it.

Agreed. You're not goint to be able to compress/stop this patient's hemorrhage. Permissive hypotension per protocol (here our goal is to maintain a SBP 70mmHG for non-compressible bleeding). Of course establish the two lines, apply high-flow O2, keep the pt. warm, etc. Flooding this pt. with saline will increase the SBP but also potentially make the bleed worse and/or blow out clots.

[Arizonaffcep]

Agreed. You're not goint to be able to compress/stop this patient's hemorrhage. Permissive hypotension per protocol (here our goal is to maintain a SBP 70mmHG for non-compressible bleeding). Of course establish the two lines, apply high-flow O2, keep the pt. warm, etc. Flooding this pt. with saline will increase the SBP but also potentially make the bleed worse and/or blow out clots.

It would seem to me though, that the bleed in question, while maybe not BAD itself, it has just been going a while, as is evidenced by the dark tarry stools, vs frank blood (and the low hemoglobin). It just seems to me that this has been going on for maybe at least a day or two. Besides, we know the Pt died, but HOW did he die? Was he taken to surgery and died as a result of a complication? I just DON'T think permissive hypotension is appropriate here. 'Zilla or ERDoc, you guys wanna weigh in on this? Any opinions/pointers?

[Fox800]

The man had had black tarry stools and hemoemesis. He was feeling "pretty weak". BP was 98/60ish, HR of 95 (or so - he may have been slightly tachy at some point). 2 large bore IVs established and about 200 ml infused by the time they got to the hospital.

It'd be interesting to see some other indicators of perfusion, though that'd be hard to get sine the thread starter wasn't on this particular call. I wonder what the pt.'s normal BP is, as well as an end-tidal CO2 measurement, skin color/condition, etc. This patient's bleed isn't something that you're going to fix in the field (Captain Obvious, I know). Seems to me that if he's mentating well, with warm/dry skin, a HR under 100, and a halfway decent BP (98/60 in the face of considerable hemorrhage), then I'm inclined to provide high quality BLS, have my IV's in place as a precaution, and mosey on over to the ER.

[Arizonaffcep]

It'd be interesting to see some other indicators of perfusion, though that'd be hard to get sine the thread starter wasn't on this particular call. I wonder what the pt.'s normal BP is, as well as an end-tidal CO2 measurement, skin color/condition, etc. This patient's bleed isn't something that you're going to fix in the field (Captain Obvious, I know). Seems to me that if he's mentating well, with warm/dry skin, a HR under 100, and a halfway decent BP (98/60 in the face of considerable hemorrhage), then I'm inclined to provide high quality BLS, have my IV's in place as a precaution, and mosey on over to the ER.

I would guess that this pt is probably on HTN meds, and probably beta blockers at that. He's a truck driver (not ment to be profiling) but how many truck drivers do you know that eat well, get good exercise and don't have HTN?

[Fox800]

I would guess that this pt is probably on HTN meds, and probably beta blockers at that. He's a truck driver (not ment to be profiling) but how many truck drivers do you know that eat well, get good exercise and don't have HTN?

This is true, they aren't usually shining examples of fitness and nutrition. I could see the beta blockers explaining a HR < 100 in the face of hemorrhage. I'm also curious as to how long the patient's been bleeding. Did he notice tarry stool the night before and now this, or BAM! did it start 30 minutes ago? (Forgive me for the Emeril refernce)

[Arizonaffcep]

This is true, they aren't usually shining examples of fitness and nutrition. I could see the beta blockers explaining a HR < 100 in the face of hemorrhage. I'm also curious as to how long the patient's been bleeding. Did he notice tarry stool the night before and now this, or BAM! did it start 30 minutes ago? (Forgive me for the Emeril refernce)

Here's the thing though...even if the tarry stool started 30 seconds ago, its been sitting in his gut for a while digesting. Hence the dark tarry stool vs. frank blood. Even with hematoemesis, coffee ground emesis is indicative of a chronic GI bleed as well...other wise the blood would be undigested and unchanged. This means it's a small, steady bleed.