How to stop bleeding!

712 - deep fore arm laceration

A 22-year-old male, aluminum factory worker, was brought by his friend to the ED after he accidentally fell on a sharp glass, 30 minutes ago. The patient presented with moderate bleeding from lacerations in his forearm. He was feeling dizzy and in severe pain.
Co-Morbid Conditions: None
Hand dominance: right-handed
Occupation: Aluminum factory worker
Denies smoking and use of the illicit drug
Last tetanus booster: unknown
Temperature oral: 36.7 C
Peripheral pulse rate: 91 bpm, regular
Respiratory rate: 17 bpm
Blood pressure: 164/75 mmHg
Oxygen saturation, on room air: 100%
GSC: 15/15

This is a deep laceration. Bleeding is one of the critical problems here. Because blood loss is a deadly situation, even with a simple laceration, we should concern about vascular injury. However, in the ED, our role is not the finding the actual problem in the early moments. Our role is to stop the bleeding immediately with some simple maneuvers or applications. Of course, this case should be evaluated for foreign body (direct visualization, x-ray, US may help), tendon and muscle injuries as well as nerve injuries. But, bleeding control is the first priority.

To learn about management, please read the chapter below.

Basics of Bleeding Control by Ana Spehonja and Gregor Prosen

17 years old girl, previously known healthy, vomited blood!

720 - variceal bleeding

17 years old girl, previously known healthy, vomited blood!
This is an extremely serious symptom. Although this patient’s vitals were totally in the normal range, actively vomiting blood should warn physicians to act immediately to protect further deterioration in the patient. This may even include early airway protection because we simply do not want them to aspirate any blood. Having a normal vitals with this picture does not mean anything, and should not create a relaxing environment in the treatment/resuscitation bay. Honestly, this patient should go directly to resuscitation bed from the triage.

Steps are straightforward. Protect the airway if necessary, start oxygen like in any other critically ill patient during/for primary evaluation(survey). Open the two large bore IV line, give fluid bolus, order type, and cross, and be ready for any deterioration in the BP and starting blood (ORh-). Obviously, even starting a transfusion earlier may be appropriate. Activating GI team for emergency endoscopy is necessary. However, some institutions may not have this luxury 24 hours. Therefore, other measures such as mechanical compressions with Sengstaken-Blakemore tube and some medications can be an only option. This patients final diagnosis was Variceal Bleeding. 

To learn more about management please read two GI bleeding chapters below.

Massive Gastrointestinal Bleeding by Dan O’Brien

Gastrointestinal Bleeding by Moira Carrol, Gurpreet Mudan, and Suzanne Bentley

From Experts To Our Students! – GIB

GI Bleeding in 12 min

Gastrointestinal Bleeding​

by Moira Carrol, Gurpreet Mudan, and Suzanne Bentley, USA

A 61-year-old man with a history of liver cirrhosis secondary to chronic EtOH abuse presents to the Emergency Department (ED) with a complaint of vomiting bright red blood that began prior to arrival. He arrives actively vomiting; a significant amount of blood is noted in his emesis basin. He is now complaining of dizziness and appears pale.

Overview

Gastrointestinal bleeding (GIB) can be generalized into two categories based on the site of bleeding. Upper GIB (UGIB) is defined as any bleeding that occurs proximal to the ligament of Trietz near the terminal duodenum. Lower GIB (LGIB) is any bleeding that occurs distal to the ligament extending to the rectum. Most GIB seen in the ED is attributed to UGIB with an incidence of 90 per 100,000 population. LGIB, on the other hand, presents with a rate of 20 per 100,000 population. LGIB is more commonly seen in the elderly but has a wide range of presentations and causes. As a result, the approach to LGIB has been less standardized.

In a patient without kidney disease, a BUN to Creatinine ratio is an important parameter to decide UGIB presence.

What is the magic number of BUN/Cr ratio?

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BUN/Cr

In a patient without kidney disease, a BUN to Creatinine ratio that is elevated to greater than or equal to 36 is strongly associated with UGIB.
Answer