ABC Red Flags.

"Medic 71, respond to the 300 block of Main St., in the alley, for the female party vomiting blood."

When we pulled up to the scene we could immediately see a pool of blood on the sidewalk with a river leading into the alley. Ut Oh.

We found the patient sitting on the ground being supported by bystanders. She was pale, lethargic, and looked like she was already dead, despite her pulse. Her shirt was covered in bright red blood - so were several bystanders - and she looked over at us approaching, opened her mouth, and let out another seemingly 100 mL of blood, "Help."

We quickly picked her up, secured her to the stretcher, and got her into the truck. This wasn't the time to sit around on scene. I requested a driver from the fire crew on the scene, and we immediately started transporting.

The patient was a 38-year-old female. I'd met her before. She was one of the local homeless folks who lived in our response area. She was usually pleasant but a hell of a drinker. She had all the usual disorders that come with years of daily drinking: Cirrhosis, Hepatitis, etc. I've actually picked her up for GI bleeding in the past - but not this kind.

She was tachy in the 120s and hypotensive at 72/42. She was tachypneic and her sats were unreadable - this was expected with her cold extremities. She was in a bad spot today. We placed her on O2 via NC and then started an IV - which I still to this day can't believe my partner got - and placed her on the monitor.

She had been complaining of nausea throughout the day with some upper abdominal pain. Her abdomen was distended - she looked pregnant - and tender to palpation. It looked to be an unhealthy mix of both a belly full of blood and baseline ascites.

She had three more episodes of hemoptysis/hematemesis, the last of which required some suctioning…
Ultimately, we gave her a fluid bolus and transported her - there isn't much we could do for esophageal varices. She needed GI and some blood so we bypassed the closest hospital and went to the big one where we knew they had 24/7 GI services and a liver team. When we called in we requested the trauma/resus bay and informed the ED staff they would need a "code blood" and possibly an airway.

Really, the role of EMS in the case is supportive. We manage the ABCs and transport them to the appropriate location - a role that shouldn't be understated.

This patient had a few of what I like to call, "ABC red flags."

First, her airway was sketchy... There are roughly three blanket reasons to intubate someone: (1) A failure to oxygenate or ventilate, (2) A failure to protect the airway, and (3) The anticipated clinical course.
She was oxygenating and ventilating fine - her SpO2 wasn't reading because her finger wasn't being perfused, NOT because her O2 sucked. Where I was the most concerned was her ability to protect her airway and obviously, she did not have a promising clinical course.

She was lethargic and by the time she vomited that third time en route, she was in and out of consciousness. We actually needed to suction her airway by then. This, normally, would be a strong indicator that the patient would need to be intubated - but not with that blood pressure. She was WAY too hypotensive to push meds on. So did she need a tube? 

Probably, but we couldn't do so in a safe way. We thought the better part of Valor in this case was to hold off until she could get some blood.

Which brings me to my next ABC red flag... Her breathing was okay, but her circulatory state was not. She was in a bad place and was in obvious hypovolemic shock. Our assumption at the time was that she was swallowing a lot more of the blood than she was spitting up because we watched her belly grow even during our 10-minute transport.

Ideally, this patient would have been a great candidate for prehospital blood, right? But unfortunately, we didn't have that. We have her two 250 mL boluses which helped a little, but not much. We were hesitant to give much more.

When we got to the ED we went straight to the resus bays and gave a report:

"Hey everyone, this is Jane Doe, she's a 38-year-old female with a history of cirrhosis, hepatitis, and alcohol abuse who presents with upper GI bleeding concerning for varices. She has had 4 episodes of frank red bleeding in our presence and has required suctioning to maintain her airway. She is hypotensive and tachycardiac. Her last BP was only 72/44 and her HR has been over 120. She's got one IV and has received around 500 mL of saline. Any questions?"

There were none. She immediately got 2 units of PRBCs before more blood was called for. GI was alerted early and came down to the room before we even left the bedside. They planned on intervening but needed the patient intubated first. She was resuscitated and around 30-40 minutes later was successfully intubated. She also received pantoprazole, ceftriaxone, and octreotide.

So what happened? Why was she bleeding like this? This patient has a long-standing history of EtOH abuse, drug use, and chronic liver disease secondary to cirrhosis.

The liver does a lot of really important things... like, legit, hundreds of them. One of the important things the liver does is filter stuff. Essentially all of the blood that goes through the GI tract dumps into the portal circulation and then flows through the liver where it is filtered. When the liver is damaged, scar tissue forms. This is called cirrhosis. This scar tissue makes it harder for the blood from the portal circulation to flow through the liver - so it backs up. This is called portal hypertension.

Eventually, portal hypertension can become so bad that the blood needs somewhere else to go... So it diverts around the liver to get back to the vena cava. This diversion is called a portosystemic shunt. This pathogenesis is responsible for a lot of the complications you see in liver failure patients, but today we are focusing on the varices part. Varices are enlarged veins under high pressure - something the weak-walled veins are not meant to be under.

One of the downstream effects of portosystemic shunts is esophageal varices. Here, veins in the esophagus become engorged when they are placed under high pressure. When one of these pops, you essentially get a hole in the vein that has an arterial pressure to it. It's sort of like an arterial bleed in the esophagus. This is obviously bad.

Ultimately, the treatment is a combination of supportive care and stopping the bleeding - just like a bleeding trauma patient.

The resuscitation is very similar to that of trauma patients. Maintain MAP >65 or SBP >90 (-ish), limit crystalloids, and resuscitate with blood products. If the patient is anticoagulated - reverse it.

Where things differ is the end-treatment and some of the supporting meds. Usually, the end goal is to get the patient to the GI folks so they can do an esophagogastroduodenoscopy (EGD). They will usually band the bleeding varices to tamponade them. From a medical management perspective, these patients will usually receive octreotide, ceftriaxone, +/- pantoprazole. 

Octreotide causes splanchnic vasoconstriction and therefore can control variceal bleeding by reducing the portal pressure. Basically, it reduces the amount of blood going into the portal system which reduces the pressure and can thus, hopefully, reduce the pressure in those varices. Ceftriaxone is an antibiotic. It's used in patients with varices and presumed liver disease for spontaneous bacterial peritonitis prophylaxis, of which these patients are at increased risk of.  Finally, pantoprazole is a proton pump inhibitor. This is less important in varices but more important in upper GI bleeding in general. It lowers the amount of acid in the gut - the number one cause of UGIB is ulcers.

Notice that TXA was not mentioned. You generally don't give TXA in GI bleeding patients (including varcies). The HALT-IT trial showed that TXA does not reduce deaths from GI bleeding while also showing an increased risk of thromboembolic events. It's a similar concept as to why we don't give TXA to trauma patients >3 hours from the time of injury. In GI bleeding we don't actually know how long the patient has been internally bleeding.

Another thing you may see or hear about in esophageal varices is something called a Blakemore or Minnesota tube. These are esophageal tamponade devices - you should look them up!
So what happened to this lady?

She received all the drugs, and 7 units of blood products, and was intubated and taken for EGD where two bands were placed, stopping her bleeding. She was also found to have an ulcerative bleed and was treated for that as well. She was discharged a week or two later.

Have you treated a patient with esophageal varices before? If so, tell me about it below!

Any questions? Ask away!

Thanks for reading!

-Dean Stockley