Would you push fluids or not?

[spenac]

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.

And a small steady bleed becomes a gusher if you push to much fluids. It is important to treat eac patient based on what you see happening. If the doctor disagrees, listens to his points, but then still make the best decision based on what you see on your next patient. In fact had this patient had a liter or 2 pushed and had died he would have said they should have just titrated fluids to maintain 90 systolic. So either way I think in this case doctor would say it was handled wrong. And conversly had the patient lived he might have said good call guys on not giving to fluid.

[crotchitymedic1986]

I would be interested in seeing the ER's chart. What were the initial v/s the ER got, how long was it before he coded. The details we have been given were from an EMS review, where a rosier picture may have been painted by medics who knew the patient died and were covering their butts. The H&H stated is hard to believe with the B/P listed (not impossible). If the patient died within 10-15 minutes of ER arrival, I am thinking the medics may have not recognized the severity of the situation. Obvioulsy, I wasnt there, so i cant second guess them, but my guess is this was an altered, pale, critical patient who got a "pediatric bolus".

[Fox800]

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.

Understood, however the considering the onset of symtpoms and the amount of blood lost is important. Losing 1.5L in 2 hours vs. 18 hours...

[Arizonaffcep]

And a small steady bleed becomes a gusher if you push to much fluids. It is important to treat eac patient based on what you see happening. If the doctor disagrees, listens to his points, but then still make the best decision based on what you see on your next patient. In fact had this patient had a liter or 2 pushed and had died he would have said they should have just titrated fluids to maintain 90 systolic. So either way I think in this case doctor would say it was handled wrong. And conversely had the patient lived he might have said good call guys on not giving to fluid.

And what if this GI bleed was not a surgical bleed? What then? Withhold fluids? We all agree that he needs a transfusion...one unit of blood will have more effect on his B/P than NS or LR! So what then, no blood either? He needs fluid. Preferably blood. But we don't carry blood, so that rules that out. Next best thing...

So, in the tradition of the City, here's a study on fluid resuscitation. Please, keep in mind I am not trying to disprove permissive hypotension, just show that this is NOT a case for it. http://cat.inist.fr/?aModele=afficheN&cpsidt=13745104

To quote from it, "Conclusion: Fluid resuscitation with either large-volume LR solution or small-volume HSD, during uncontrolled hemorrhage from intra-abdominal vascular injury, produced hemodynamic and metabolic benefits, without additional blood loss, whereas no fluid resuscitation was associated with sustained low cardiac output and hypotension."

Here's another: http://pdm.medicine.wisc.edu/Volume14/riddez.htm

"Conclusion: Short-term crystalloid fluid therapy in uncontrolled aortic hemorrhage transiently improved the hemodynamic status and the oxygen consumption following the initial bleeding. Furthermore, the infusion did not cause re-bleeding of more than 100 ml, which occurred in previously conducted experiments when the infusion was continued for more than 20 minutes."

Here's from the Merk Manual: http://www.merck.com/mmpe/sec02/ch010/ch010a.html This also goes on to say that 80% of GI bleeds stop spontaneously.

"Fluid resuscitation: IV fluids are initiated as for any patient with hypovolemia or hemorrhagic shock (see Shock and Fluid Resuscitation: Intravenous Fluid Resuscitation): healthy adults are given normal saline IV in 500- to 1000-mL aliquots until signs of hypovolemia remit—up to a maximum of 2 L (for children, 20 mL/kg, that may be repeated once). Patients requiring further resuscitation should receive transfusion with packed RBCs. Transfusions continue until intravascular volume is restored and then are given as needed to replace ongoing blood loss. Transfusions in older patients or those with coronary artery disease may be stopped when Hct is stable at 30 unless the patient is symptomatic. Younger patients or those with chronic bleeding are usually not transfused unless Hct is < 23 or they have symptoms such as dyspnea or coronary ischemia."

Heres the guidelines from the American Journal of Gastroenterology: http://www.acg.gi.org/physicians/guideline...inginAdults.pdf

[p3medic]

The research using swine suggest that crytalloid infusion didn't significantly worsen pre-existing bleeding, and transiently increased perfussion. All animals were uthanized at the end of the study, none were resusitated, so the degree of acidosis, coagulopathy and hypothermia were not addressed or studied.

In humans, our goal is to restore hemodynamic stability, normothermia and prevent worsening of the patients condition. Patients treated with large volumes of crystalloid have been shown to do worse; increased degree of acidosis, hypothemia, coagulopathy, SIRS, MOF, etc...

I'm not saying giving a small bolus of crystalloid is wrong, however replacing blood with salt water doesn't work. Without the benefit of lab work that the hospital has access to, the hypovolemia is most likely secondary to an acute hemmorhagic process, and as long as he awake and appopriate, pouring large volumes of salt water in him would be unwise.

[Fox800]

Arizonaffcep, thank you for posting those links. It's refreshing to have someone back up their arguments with that much material!

Although the ACG Guidelines do specify fluid resuscitation, they don't mention a specific bolus amount, cutoff point, or target BP other than "euvolemia" and stabilized vital signs. So, am I infusing 20 mL/kg, trying to reach an SBP of 100mmHg? Smaller boluses (250-500mL) and attempt to maintain the pt.'s BP where it's at in the 90's? Infusing that fluid will increase perfusion and raise BP, but certainly won't help a clot form.

"The goal of resuscitation is the restoration of euvolemia

and resultant stability in vital signs. Resuscitative measures

include initial fluid administration via large bore intravenous

catheters. The amount of transfusion of red blood cells

and blood products must be individualized. There are potential

adverse effects of blood transfusion; the goal of

transfusion should be to minimize the risk of complications

due to red blood cell loss and/or correction of coagulopathy,

and not to transfuse to an arbitrary level of hemoglobin/

hematocrit."

[Arizonaffcep]

The research using swine suggest that crytalloid infusion didn't significantly worsen pre-existing bleeding, and transiently increased perfussion. All animals were uthanized at the end of the study, none were resusitated, so the degree of acidosis, coagulopathy and hypothermia were not addressed or studied.

In humans, our goal is to restore hemodynamic stability, normothermia and prevent worsening of the patients condition. Patients treated with large volumes of crystalloid have been shown to do worse; increased degree of acidosis, hypothemia, coagulopathy, SIRS, MOF, etc...

I'm not saying giving a small bolus of crystalloid is wrong, however replacing blood with salt water doesn't work. Without the benefit of lab work that the hospital has access to, the hypovolemia is most likely secondary to an acute hemmorhagic process, and as long as he awake and appopriate, pouring large volumes of salt water in him would be unwise.

At that point, why would you? He's not in shock....In THIS scenario, permissive hypotension is not called for. So, here's another question for you...as you stated (please see the underlined sentence above), if you don't have an IV warmer, it sounds like you wouldn't treat sock with fluid replacement, which is called for (except in the instance of applicable permissive hypotension).

As a courtesy, can you site the "Patients treated with large volumes of crystalloid have been shown to do worse; increased degree of acidosis, hypothermia, coagulopathy, SIRS, MOF, etc..." reference? Point me in a direction where I can verify that statement for PREHOSPITAL treatment? And if you could also qualify it, are you talking PREHOSPTIAL or IN HOSPITAL? Big difference. It's an issue IN HOSPITAL.

Reason I ask...the FD I used to work for was about 30-40 minutes from the area level 1 trauma center, "flying-low." I can tell you...I've only been able to get in about 3 almost 4 liters (pressurized) on trauma patients who were hypovolemic and shocky during transport. 3-4 liters is NOTHING fluid wise for a severe trauma. But, it's all we have to work with. Now...once the patient is turned over to the ED, it becomes a VERY different story. Then, you can get the luxury of lab work, blood, "hot-admix" if need be.

I am taking this stance from a PREHOSPITAL point of view. With this in mind, you have a limited time with the patient before transferring to the ED, and limited resources.

[Arizonaffcep]

Arizonaffcep, thank you for posting those links. It's refreshing to have someone back up their arguments with that much material!

Although the ACG Guidelines do specify fluid resuscitation, they don't mention a specific bolus amount, cutoff point, or target BP other than "euvolemia" and stabilized vital signs. So, am I infusing 20 mL/kg, trying to reach an SBP of 100mmHg? Smaller boluses (250-500mL) and attempt to maintain the pt.'s BP where it's at in the 90's? Infusing that fluid will increase perfusion and raise BP, but certainly won't help a clot form.

"The goal of resuscitation is the restoration of euvolemia

and resultant stability in vital signs. Resuscitative measures

include initial fluid administration via large bore intravenous

catheters. The amount of transfusion of red blood cells

and blood products must be individualized. There are potential

adverse effects of blood transfusion; the goal of

transfusion should be to minimize the risk of complications

due to red blood cell loss and/or correction of coagulopathy,

and not to transfuse to an arbitrary level of hemoglobin/

hematocrit."

True, and I will say the guidelines are focused on an MD level for in hospital treatment, not prehospital. What was in the references and a key point is that 80% of Gi bleeds stop spontaneously. With that in mind, 100-200ml's of blood is needed to create melena. But, if it bled more than that, it can stop, and melena can still be excreted until it has cleared the system. Taken a step further, the presence of melena DOES NOT ALWAYS MEAN CURRENT BLEED. That's the point I was getting at. Keep in mind that melena TAKES TIME to create, as it must be DIGESTED...if it was an uncontrolled large hemorrhage, then it would present as lots of frank blood from the rectum or hematemisis (WITHOUT coffee ground emesis).

[Fox800]

True, and I will say the guidelines are focused on an MD level for in hospital treatment, not prehospital. What was in the references and a key point is that 80% of Gi bleeds stop spontaneously. With that in mind, 100-200ml's of blood is needed to create melena. But, if it bled more than that, it can stop, and melena can still be excreted until it has cleared the system. Taken a step further, the presence of melena DOES NOT ALWAYS MEAN CURRENT BLEED. That's the point I was getting at. Keep in mind that melena TAKES TIME to create, as it must be DIGESTED...if it was an uncontrolled large hemorrhage, then it would present as lots of frank blood from the rectum or hematemisis (WITHOUT coffee ground emesis).

Would you mind sharing your decision-making process for permissive hypotension vs. fluid resuscitation in GI bleeds?

[Arizonaffcep]

Would you mind sharing your decision-making process for permissive hypotension vs. fluid resuscitation in GI bleeds?

http://www.trauma.org/archive/resus/permis...ypotension.html

This is a good link for a huge amount of studies done. About half (ok, I didn't count, please don't hold me to that exact ratio) say permissive hypotension is good, the rest say it doesn't matter. Only a few of these specifically dealt with prehospital use of it. Be that as it may, the use of permissive hypotension is designed for uncontrolled hemorrhage. The sticky point of a GI bleed is: 80% stop on their own. This is what I've been getting at with this debate on this thread, the fact that the patient had melena means that it is not an ACTIVE large uncontrolled bleed. This situation for this patient is NOT that. It MAY in fact still be bleeding, but it's not a large bleed. It seems to me like the bleed has been occurring (I would assume without the patients knowledge) for a while, possibly a couple of days. So...this is a chronic bleed, IE, NOT ACUTE. Now...I'm not saying the patient's condition isn't acute, because it is. He obviously died. Now, there are some parts to the story which we don't have and I would assume we can't get, which is when did the melena start, although the better question is, when did the ABD pain start? As that would probably give a better indication of how long he's been bleeding. Hope that answers the question.