Abdominal Pain/Bleeding

[Aussieaid]

Good call, Croaker. I concur with everything you said. DIC possibly from an incomplete abortion or even just the miscarriage ietself with full on septic shock.

Absence of fever does not rule out septicemia. If you have an abnormally low white count which happens rather than a high one you don't necessarily get the fever you expect to see.

Aggressive fluid resuscitation (meaning more than 2 liters as fast as possible on a pressure bag) with inotropic support is your only chance of saving her. I can see her getting liters of fluid along with blood products in a very short period of time.

The onset was not so rapid as it has been coming for days. She is just at the complete decompensation stage and has nothing left to compensate with. If her rash is that advanced she may already be too late to save.

She needs antibiotics and blood products fast along with some clotting factors.

Definitely ALS intercept if there is any length of time to the hospital. Not only for securing the airway but because you are going to need a couple of sets of hands to push fluids, start inotropes, etc. Might want to check a glucose level as well on the way but not the highest priority.

Sorry, I'm just rambling a bit because my brain is in all sorts of time zones right now!

She needs her airway secured to take control of her breathing as well. If you only have Etomidate I would still use it as you can give a shot of steroids later but Ketamine might be better if available as it can give you a slight boost in hemodynamics as well.

Of course if she is completely out you hopefully won't need anything to assist with intubation. If she has no gag just tube... You can't afford to give her any kind of medication that will affect her hemodynamics as she is already crashing and anything that takes away further from that catecholamine drive is only going to put her into full arrest faster.

[croaker260]

I would look at alternatives over etomidate still. THe steroid "solution" has all sorts of problems too. If I had nothing else I would consider a benzo, she probably doesnt need much of a push to take her down anyway...though you are absolutely right on the hemodnamic concerns.

Its really a choice of the lesser of two evils...

Or ..as they said in Master and Commander....

The lesser of two weevils!

3 points for the obscure movie reference!

[FireEMT2009]

Is she a hemopheliac? or have some other type of blood disorder that will not allow her blood to clot? The ASA and Plavix she has been taking could very well make that kind of disorder even worse. Since she is now unresponsive how do we know that the only trauma was the accident? I would start another line with ringers and run it wide open.

I would also have DFIB hold pressure on the cut...( we are already covered in her blood, a little more wont make a difference) Notify medical control of what we have, whats been done to this point and advice on what to do next. I would also be ready to intubate and support her completely as well as CPR if needed.

Oh yeah...she gets a diesel bolus as well but we are missing something....I just cant quite figure out what.

Pressure is being held, but with no avail. She never mentioned being hemophilliac during the assessment.

VERY IMPORTANT POINT: Absense of fever does not preclude an infectious process or septicemia.

Now I am going to ramble. If you want to skip ahead to treatment, feel fee to do so.

If this was without the precceding history and if her mentation was more altered with neuropathic-encephalopathic s/s ...... I would think septic shock secondary to meningitis. She is the right age for that kind of silliness...

HOWEVER, Since there is no suppotive history for meningitis, and SHE DOES HAVE the history of abdominal injury, miscariage, presumptively for a D&C, and abd rigidty, I am assuming probably some adverse sequala from the abrupted placenta/D&C, and related care. (I am assuming she isnt a closet alcoholic with end stage liver failure and coagulapathy, right? )

My guess is that she is currently in DIC, and probably secondary to septic shock, with exacerbating coagulopathy caused by her plavix/ASA a (distant) second in my mind.

Regardless, the exact etiology is academic at this point At this point she is actively (strike that...AGRESSIVELY) dying. The cut on the arm probably saved her life because it prompted the call for help.

So, to recap treatment and add some:

BLS:

O2, BVM, OPA, Suction PRN, Shock position, and the TQ on the arm lac is a good idea. If you are one of those agencies that carries hemostatic agents, use them.

A special comment on the TQ: Use a B/P cuff not a CAT or similar TQ. In this case a narrower TQ (like the CAT) may actually precipitate severe bleeding at the site of the TQ due to micro-lacerations in an already coagulopathic patient.

ALS:

1- ETT placement, va RSI/MAI if required, but do not use ETOMIDATE (mixed research on its adverse effects on adrenal response and survival in septic shock situations)

2- 2 large bore IV's, Start significant fluid resuscitation. I know there is a lot of information about permissive hypotension, but 99% of that is in traumatic cases. In SEPTIC shock, and in DIC, restoring perfusion to the gut and kidneys is paramount, and fluid resuscitation is key. Therefore, I would open the lines up and reassess Q 500-1000cc but probably wouldn’t slow down until I got past 2 liters.

3- Start the vasopressors now concurrently with your crystalloid infusions. Again I am presuming DIC secondary to septic shock, but in this case EPI drips (2-10 mcg/.min...mix 1 mg in 250 cc) is going to be a better than dopamine, though you may have to do both. if you carry levophed, that is probably your best choice.

4- When/if you get some breathing room...Since she is going to get multiple lines, start a third. YES a THIRD line. Use a twin cath (multi lumen) because many of the meds she needs to get NOW are not compatible with each other. Start it now while she has some vasculature left to hit. Yes she is probably getting a swan and a multi-lumen central line later...but only if she lives that long.

Some thoughts: CHF is not an immediate concern, you have PPV in place which will stave off any pulmonary edema. In most other 20-something-year-olds their cardiovasculature can take 2-4 liters with no problem. Since we don’t have a lot of history on her non-specific cardiac issues, we cant assume that is the case with her, but we do KNOW she is dying right in front of us. If we dont start large volume resuscitation concurrently with vasopressors, she wont live long enough to die from CHF.

One more thought: Yes this looks like DIC/MODS and possibly septic shock as I described above, but the only time I have seen septic shock try to kill someone this quick with (presumably) this sudden onset of DIC is bacterial meningitis, and I have heard that same thought repeated by several well respected docs in my area. THEREFORE: While none of the history points to this, It costs nothing to mask up all providers as well, and use the HEPA filters on the vent. Cover all your bases.

One final thought: If she doesnt code, andshe doesnt respond to dopamine, epi, and volume rescusitation, I would get orders (or in my SWO's..invoke a clause that allows me todo this without calling due to her trying to die right in front of me... ) to increase her Dopamine beyond 20/mcg/min to about 30 mcg/kg/min...at this dose it mimics (kinda) Levophed.

Unless I carry levophed, which most services do not. At this point, your pulling out all the "stops".

I like the DDXs on this patient so far, very good thinking. I also agree with her aggressively dying on you. But I do have one concern with giving vasopressors for this patient.

On the vasopressor issue if you look at the vascular system as a milk jug; in this scenario it is the lack of fluid not the size of the container. You already perfuse bleeding that hasn't had any signs of slowing down and signs of internal bleeding. Remember a big contraindication to vasopressors is hypovolemia. She is definately showing the signs and symptoms of hypovolemia which would make vasopressors contraindicated on this patient. (Not being a know it all or smart alec here just stating some food for thought). So you are giving a fluid resuscitation.

Sorry I didn't get to revisit this thread yesterday. I was sitting in the county courthouse waiting for my turn to be one of the 12 angry men, and spent 8 hours in a lobby for $25. Not that I'm not used to sitting around for long, extended amounts of time with nothing to do, I'm just not used to doing it with 200 others.

In any case, I quoted DFIB because given the evidence from page 2, that's exactly how I would have handled the call. After you described the "rash", which sounds like a SubQ bleed (large subdermal hematoma, maybe), and then I was gently reminded of the ASA and Plavix, the light bulb came on. Sadly, I don't know how many of my classmates would pick up on that aspect, because our pharmacology section was dreadfully short ("This is oral glucose, this is oxygen, this is an epi-pen, this is an inhaler. Any questions?").

Regardless, I would try for the ALS intercept but otherwise lights and siren, 80mph to the nearest facility. Pt supine or in Trendelenburg, recheck vitals after loading, then every 5 minutes. O2 via NRB if tolerated. Tourniquet the arm, then hope the traffic gods play nice with us on the way. St Diesel, pray for us.

Things get busy and that's understandable. I'm glad you revisted it, things have changed a little since you have been gone. I understand the pharmacology aspect of EMT-B class, barely any knowledge due to always wanting to call for ALS on the bad major calls.

You are running code run. Still got 20 minutes to the hosptial.

I should have jumped on the toxic shock/septicemia idea when it was first mentioned but the absence of fever derailed me. Darn, shoot dadnabit, doggonit and any other exclamation you wish to insert.

If this is the case the patient is buggered before the call went out.

Hemophilia discriminates against women but her clotting ability is definitely done. I wonder if runing a PTT would help at this juncture? Just kidding.

I missed the no fever thing as well....dammit!!!! I mean I read it but it didn't click. Grrrrrr!!!!

We all miss things, keep on trucking I am liking what I am reading so far.

Good call, Croaker. I concur with everything you said. DIC possibly from an incomplete abortion or even just the miscarriage ietself with full on septic shock.

Absence of fever does not rule out septicemia. If you have an abnormally low white count which happens rather than a high one you don't necessarily get the fever you expect to see.

Aggressive fluid resuscitation (meaning more than 2 liters as fast as possible on a pressure bag) with inotropic support is your only chance of saving her. I can see her getting liters of fluid along with blood products in a very short period of time.

The onset was not so rapid as it has been coming for days. She is just at the complete decompensation stage and has nothing left to compensate with. If her rash is that advanced she may already be too late to save.

She needs antibiotics and blood products fast along with some clotting factors.

Definitely ALS intercept if there is any length of time to the hospital. Not only for securing the airway but because you are going to need a couple of sets of hands to push fluids, start inotropes, etc. Might want to check a glucose level as well on the way but not the highest priority.

Sorry, I'm just rambling a bit because my brain is in all sorts of time zones right now!

She needs her airway secured to take control of her breathing as well. If you only have Etomidate I would still use it as you can give a shot of steroids later but Ketamine might be better if available as it can give you a slight boost in hemodynamics as well.

Of course if she is completely out you hopefully won't need anything to assist with intubation. If she has no gag just tube... You can't afford to give her any kind of medication that will affect her hemodynamics as she is already crashing and anything that takes away further from that catecholamine drive is only going to put her into full arrest faster.

What is making you all think septic shock on this patient? I am curious?

I would look at alternatives over etomidate still. THe steroid "solution" has all sorts of problems too. If I had nothing else I would consider a benzo, she probably doesnt need much of a push to take her down anyway...though you are absolutely right on the hemodnamic concerns.

Its really a choice of the lesser of two evils...

Or ..as they said in Master and Commander....

The lesser of two weevils!

3 points for the obscure movie reference!

Well during transport you are now hearing gurgling coming from her airway. You open her airway and find blood filling up her mouth. You also have her on the heart monitor and are now seeing the occasional PVCs becoming more and more common as time goes on.

[Happiness]

So since she had a D&C it would be possible that there was perferation of the wall, that may have been small at first. With the passing of time the perferation became larger as she became more active, or there was internal damage that wasn't detected in the original accident. Kind of like a piece of torn material that gets bigger over time. This is also going to be aggrivated by the ASA and Plavix. Both of those drugs can cause the black rash....

[Aussieaid]

It's possible she just has DIC but the majority of times that you see DIC it's usually secondary to sepsis or major trauma. It does happen as a primary condition and more likely with a OB/Gyn emergency, just not as common so the assumption is that it is secondary to sepsis. Her history does not rule out or in, sepsis.

At this point you are going to treat the patient the same way and she will most likely end up on antibiotics anyway if she survives that far.

You are correct in saying that the "tank" needs to be filled and aggressive fluid resuscitation is the priority but you are most likely going to need inotropes as well. Often it happens at the same time because she is going to be bleeding out as fast as you pour fluids into her and you need the inotropic support to attempt to maintain some perfusion to the vital organs until you can control the bleeding. As much fluid as she is going to require including lots of blood products you often need to start the inotropes so you can cut back on the fluids eventually. Otherwise everything is going to pretty much be third spaced and not stay where it needs to be for hemodynamic support anyway.

Except for securing her airway, pouring the fluids into her, starting the inotropes and stepping harder on the gas pedal I don't know what more you might carry in the ambulance that is going to help here (unless you carry blood products, Vit K or anything else useful like that). Drive faster, partner!! The PVC's, I feel are a sign of a dying heart so I would not be treating them specifically.

Croaker, the risks of using Etomidate versus benzos is still lower I would think in this instance. The amount of benzos you need to give to achieve the same ideal intubating conditions would most likely tip this patient over the edge and you would have a hard time getting her back. The risk of using etomidate is not as high as previously thought either. Ketamine would be the ideal choice here.

http://chestjournal.chestpubs.org/content/early/2010/07/21/chest.10-0790

(Sorry, I couldn't get the link function to work properly).

[croaker260]

OK, thanks for the input on vasopressors, please take this in the spirit it is intended.

Hypovolemia is a RELATIVE contraindication...refractory hypovolemia is not. In other words, it is perfectly appropriate to to do vasopressors and fluids simultaneously or after fluids or other efforts have failed. This is common practice in most any large IICU setting, especially in the treatment of DIC and septic shock. A good friend of mine recently had a young 20s female with DIC and septic shock on a CCT transport ...14 drips (3 pressors) and in excess of 8 liters of fluid.....in the first day.

SO, I would do still do BOTH.

2- I am confused by the gurgling bloody airway...is this around my tube, or are you simply stating I have justification to intubate...because I had justification 30 seconds into this call ( "Anticipated clinical course").

RE: Septic Shock: Why do I think this is a possibility?

• Recent surgical procedure (D&C ) gone wrong leading to septic shock and peritonitis...
  
• OR micro emboli from the D&C showering the gut (i.e. intestines) and causing necrotic Bowell and peritonitis (this is my personal bet)...
  
• OR a previously undisclosed reason (Tampon in too long, Rough sex with a paramedic, who knows? Where is Dr. House when you need him)...
  

To those who believe it is simple over medication and /or traumatic rupture....Yes Yes it could be simple bleeding but if it was a traumatic rupture it would have happened a long time ago....in the first week post MVC or after the D&C and either cause would have killed her quicker. In this stage, finding out the why is secondary to keeping her alive long enough to make use of the information .

The rigid painful ABD in the absence of recent trauma with the DIC and the rash/SQ hemorrhagic discoloration strongly implies septic shock the other s/s and shock ---->DIC with SEPTIC SHOCK.

Croaker, the risks of using Etomidate versus benzos is still lower I would think in this instance. The amount of benzos you need to give to achieve the same ideal intubating conditions would most likely tip this patient over the edge and you would have a hard time getting her back. The risk of using etomidate is not as high as previously thought either. Ketamine would be the ideal choice here.

http://chestjournal....1/chest.10-0790

(Sorry, I couldn't get the link function to work properly).

Excellent comments man, really. Ketamine is not as common over here as it is over there for RSI... Dont ask why ..... there is no clear reason other than an abuse stigma. I agree it would be the better option than Etomidate.

As for Etomidate in sepsis.. clearly it is dose dependent and to a lessor degree age dependent....but every time one study shows it is a big deal, another one shows something different. Lets agree its a consideration and a judgement call neither right nor wrong but depending on what else you have to work with.

Edited December 16, 2011 by croaker260

[FireEMT2009]

OK, thanks for the input on vasopressors, please take this in the spirit it is intended.

Hypovolemia is a RELATIVE contraindication...refractory hypovolemia is not. In other words, it is perfectly appropriate to to do vasopressors and fluids simultaneously or after fluids or other efforts have failed. This is common practice in most any large IICU setting, especially in the treatment of DIC and septic shock. A good friend of mine recently had a young 20s female with DIC and septic shock on a CCT transport ...14 drips (3 pressors) and in excess of 8 liters of fluid.....in the first day.

SO, I would do still do BOTH.

2- I am confused by the gurgling bloody airway...is this around my tube, or are you simply stating I have justification to intubate...because I had justification 30 seconds into this call ( "Anticipated clinical course").

RE: Septic Shock: Why do I think this is a possibility?

• Recent surgical procedure (D&C ) gone wrong leading to septic shock and peritonitis...
  
• OR micro emboli from the D&C showering the gut (i.e. intestines) and causing necrotic Bowell and peritonitis (this is my personal bet)...
  
• OR a previously undisclosed reason (Tampon in too long, Rough sex with a paramedic, who knows? Where is Dr. House when you need him)...
  

To those who believe it is simple over medication and /or traumatic rupture....Yes Yes it could be simple bleeding but if it was a traumatic rupture it would have happened a long time ago....in the first week post MVC or after the D&C and either cause would have killed her quicker. In this stage, finding out the why is secondary to keeping her alive long enough to make use of the information .

The rigid painful ABD in the absence of recent trauma with the DIC and the rash/SQ hemorrhagic discoloration strongly implies septic shock the other s/s and shock ---->DIC with SEPTIC SHOCK.

Excellent comments man, really. Ketamine is not as common over here as it is over there for RSI... Dont ask why ..... there is no clear reason other than an abuse stigma. I agree it would be the better option than Etomidate.

As for Etomidate in sepsis.. clearly it is dose dependent and to a lessor degree age dependent....but every time one study shows it is a big deal, another one shows something different. Lets agree its a consideration and a judgement call neither right nor wrong but depending on what else you have to work with.

Thanks croaker, I was just referring from the contraindications that were listed in my pharm book, it doesn't give realitive contraindications it just lists it as contraindications in general. I hope you truly didn't think I was being a smart ass or anything by mentioning that cause I truly wasn't.

it is justification for airway management, since you selected ETT, you pass it without the use of any drugs, sedatives or paralytics.

Thanks for the information I need to do a little deeper studying of drug contraindications then apparently.

I agree it could be sepsis I was just curious to your thinking.

[DFIB]

FireEMT2009

Well during transport you are now hearing gurgling coming from her airway. You open her airway and find blood filling up her mouth. You also have her on the heart monitor and are now seeing the occasional PVCs becoming more and more common as time goes on

Begin suction with a French tip. I would consider modifying the tip with a naso-gastric tube so I could suction deep into the bronchi through though ETT. I would keep an eye on the SPO2 and ventilate and suction intermittently as needed. Make sure goggle strap is tight and face mask is pulled up. Put on a face shield if available.

In the mean time my medic does all that cool stuff you do with the meds.

We have a policeman or someone driving our ambulance.

Edited December 17, 2011 by DFIB

[island emt]

I'm wonder if after the trauma induced abrutio and D&C if they did an ultrasound of abdomen.

Lack of clotting factors and other S&S make me wonder about Splenic damage. I do agree with the DIC diagnosis. The "rash is a good indication of that.

The earlier post about the two anticoagulants prescribed was meant to point some of those that were not getting the why she was bleeding profusely.

She is a pt that is certainly circling the drain and in dire need of resuscitation by any & all means available NOW!

[FireEMT2009]

Begin suction with a French tip. I would consider modifying the tip with a naso-gastric tube so I could suction deep into the bronchi through though ETT. I would keep an eye on the SPO2 and ventilate and suction intermittently as needed. Make sure goggle strap is tight and face mask is pulled up. Put on a face shield if available.

In the mean time my medic does all that cool stuff you do with the meds.

We have a policeman or someone driving our ambulance.

Your patient now has an ETT in place confirmed correctly by condensation in the tube, capnography, breath sounds, and espoghageal dectector.

I'm wonder if after the trauma induced abrutio and D&C if they did an ultrasound of abdomen.

Lack of clotting factors and other S&S make me wonder about Splenic damage. I do agree with the DIC diagnosis. The "rash is a good indication of that.

The earlier post about the two anticoagulants prescribed was meant to point some of those that were not getting the why she was bleeding profusely.

She is a pt that is certainly circling the drain and in dire need of resuscitation by any & all means available NOW!

Good call, what would your treatment be Island?

This patient is definately not doing well, I fully agree with that.

Even after suctioning you still find that her airway is still filling up with blood, and that your IVs still have blood coming from around them and the hand is still bleeding vigorously.