Case #83 "Wrong Chief Complaint"
by Charlene Babcock Irvin, MD, FACEP
EMS arrives with a 55 y/o female with a chief complaint of vomiting blood. According to them she just vomited about 1 cup in the ambulance.
As you approach the patient, you note she is having respiratory distress, and holding an emesis basin in front of her (that is half full of bright red blood). A non-breathing mask is around her neck and also has blood in it like she vomited with the mask on.
As you ask for the six things that all sick patients get (IV, oxygen, monitor, undress the patient, get a set of vital signs, and draw blood), you do a quick evaluation.
One of the questions I always find helpful to ask is: “Are you having any problems breathing?” The answer tells me their level of consciousness (did they understand and can they answer the question), which implies a blood pressure to at least perfuse the brain. How they answer me tells me information about the status of their airway (is their speech slurred because of loose dentures, etc.) Finally the answer to the question gives me their subjective assessment of their breathing status. In one question, you have a good idea of the ABC’s.
When I asked her she nodded, and answered with a clear but breathless ‘Yes’. She refused to lie back on the stretcher (she was to dyspnic).
As you are trying to get more history, she begins to cough, then gag, then cough some more, then another cup of frothy red blood mixed with darker blood is vomited up. As you need to abort attempts at getting more history information, you switch to a quick physical exam.
Her vital signs revealed a blood pressure of 125/60, HR=120, RR=28, and Sat (back on the 100% NRB just before she vomited) = 100%. Ear temp was normal.
HEENT: Remarkable for blood in the oropharynx, otherwise unremarkable. No obvious active bleeding site identified.
Heart: Tachy, but unremarkable.
Lungs: Rales left base, otherwise negative.
Abd: Soft non-tender.
Ext: Negative.
Neuro: GCS=15, unremarkable.
Questions:
1. Given that some of the blood is frothy and bright red, where is the blood coming from? Why is it mixed with darker blood?
2. What causes this?
3. What is the life saving procedure you will need to call the specialists in to do? And what can you do to save her life?
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