Abdominal Pain/Bleeding

[nypamedic43]

With the ASA and Plavix, that explains why the cut wont top bleeding. Put another pressure dressing on it. I am also guessing that the rash is a subq bleed. Oxygen at 15 liters by NRM. Get her on the stretcher and into the ambulance. Start an IV of ringers, draw bloods (if you have it) or saline, I would also put iher in modified trendelenburg and give her a 250mL bolus, then cut it back to KVO and reassess BP. Cardiac monitor. With the ASA and Plavix, her INR may be too high.

[DFIB]

Since Terri is meeting me in 5 minutes we are going to be ok.

I would get a tourniquet on arm to stop the bleeding which is more obvious now because every drip is one I will have to get out of my ambulance.

I would transport supine because my patient is A&O and change to a trendelemburg if her alertness and general impression deteriorate. I would medicate her with O2 according to her SPO2 reading via a non rebreather mask. My driver will travel with lights and siren. I suspect an serious abdominal internal bleed that could be stem from several reasons.

It could be a spontaneous bleed that developed post-partum that is aggravated by anticoagulants. She could have a perforated uterus post D&C.

She could still have and incomplete placental birth. I am leaning toward the first.

Has she had any kind of abdominal trauma?.

Since it has been 15 minutes I need another set of vitals.

[nypamedic43]

After 2-3 weeks the vaginal bleeding should have stopped by now. The car accident involved abdominal trauma that caused the miscarriage. What quadrant is her belly distended and rigid? Lower quadrants I would guess a perforated uterus because of the D and C. If the impact from the accident was enough to cause abruptio placentae,she could also have a ruptured uterus that they didn't catch earlier or made worse because of the D and C.

I'm not sure about the TQ. I would use it as a very last resort, if additional dressings and pressure didn't get the bleeding to stop. I would also would not be hosing fluid in. Giving the 250 mL bolus should be enough to bring her pressure up but she is already starting to decompensate and ringers or saline don't carry oxygen, so I would be careful about that.

It's pretty obvious that we are behind the 8 ball with her.

[FireEMT2009]

After 2-3 weeks the vaginal bleeding should have stopped by now. The car accident involved abdominal trauma that caused the miscarriage. What quadrant is her belly distended and rigid? Lower quadrants I would guess a perforated uterus because of the D and C. If the impact from the accident was enough to cause abruptio placentae,she could also have a ruptured uterus that they didn't catch earlier or made worse because of the D and C.

I'm not sure about the TQ. I would use it as a very last resort, if additional dressings and pressure didn't get the bleeding to stop. I would also would not be hosing fluid in. Giving the 250 mL bolus should be enough to bring her pressure up but she is already starting to decompensate and ringers or saline don't carry oxygen, so I would be careful about that.

It's pretty obvious that we are behind the 8 ball with her.

Her abdomen is distended throughout it in the entirety.

As you get her to stand she goes unresponsive and falls back into her chair and does not regain consciousness.

Her airway is patent and open at this time, her breathing is 22 bpm and regular, pulse of 170 weak in carotid, no radial. The pressure bandage is still bleeding through steadily. You also notice blood now coming from around the IV itself.

You start your fluids infusing now.

Since Terri is meeting me in 5 minutes we are going to be ok.

I would get a tourniquet on arm to stop the bleeding which is more obvious now because every drip is one I will have to get out of my ambulance.

I would transport supine because my patient is A&O and change to a trendelemburg if her alertness and general impression deteriorate. I would medicate her with O2 according to her SPO2 reading via a non rebreather mask. My driver will travel with lights and siren. I suspect an serious abdominal internal bleed that could be stem from several reasons.

It could be a spontaneous bleed that developed post-partum that is aggravated by anticoagulants. She could have a perforated uterus post D&C.

She could still have and incomplete placental birth. I am leaning toward the first.

Has she had any kind of abdominal trauma?.

Since it has been 15 minutes I need another set of vitals.

She is on O2 and you are transporting with Nypamedic with the patient in the condition above. The only Hx for abdominal trauma is after her car acciden that caused the abrupto plancentae. (she say

With the ASA and Plavix, that explains why the cut wont top bleeding. Put another pressure dressing on it. I am also guessing that the rash is a subq bleed. Oxygen at 15 liters by NRM. Get her on the stretcher and into the ambulance. Start an IV of ringers, draw bloods (if you have it) or saline, I would also put iher in modified trendelenburg and give her a 250mL bolus, then cut it back to KVO and reassess BP. Cardiac monitor. With the ASA and Plavix, her INR may be too high.

Does it? Plavix and ASA are only antiplatelets which means they would resist the agreggation of platelets but would allow for some clotting over time. You have been fighting a bleed for over 15 minutes without signs of any clotting. She is on the 15 lpm NRB. She is in the modified trendelenburg as well.

Cardiac monitor shows a rate of 170 with occasional PVCs.

Where do you go from here?

(sorry for the backwards responses I dunno how they got that screwed up.)

Edited December 16, 2011 by FireEMT2009

[DFIB]

She is quickly moving beyond my scope of practice. insert an OPA and begin ventilating with a BVM. Follow whatever Terri tells me to do.

Would she benefit from vitamin K?

Does she have Dengue or septicemia? I am not sure why I am asking since she has no fever.

Could she have Von Willebrand disease, Leukemia?

What is her temperature now?

Notify receiving hospital so they can have blood, and surgical team on standby.

Edited December 16, 2011 by DFIB

[nypamedic43]

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.

[croaker260]

Does she have Dengue or septicemia? I am not sure why I am asking since she has no fever.

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".

Edited December 16, 2011 by croaker260

[CPhT]

Since Terri is meeting me in 5 minutes we are going to be ok.

I would get a tourniquet on arm to stop the bleeding which is more obvious now because every drip is one I will have to get out of my ambulance.

I would transport supine because my patient is A&O and change to a trendelemburg if her alertness and general impression deteriorate. I would medicate her with O2 according to her SPO2 reading via a non rebreather mask. My driver will travel with lights and siren. I suspect an serious abdominal internal bleed that could be stem from several reasons.

It could be a spontaneous bleed that developed post-partum that is aggravated by anticoagulants. She could have a perforated uterus post D&C.

She could still have and incomplete placental birth. I am leaning toward the first.

Has she had any kind of abdominal trauma?.

Since it has been 15 minutes I need another set of vitals.

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.

[DFIB]

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.

Is she a hemopheliac?

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

Edited December 16, 2011 by DFIB

[nypamedic43]

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