Case - mouth bleeder

[pgg]

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Who's riled? It's not me.

I'm glad to hear you're not upset.

 

[Planktonmd]

I live on O'ahu. Just a visit to Maui. Friends (neurorads and her husband - Microsoft exec) are staying on Maui. The brought the nanny with them!

So, if you are living the good life as you claim why are you you so bitter???

 

[loveoforganic]

Wow, you can afford Maui with your EM salary?

Propantrollol delivery

 

[fakin' the funk]

A normotensive patient with HR in the 100s (by your wording, I am thinking like 100-110 - not 150), with a reason for tachy (like fear, which hemoptysis and equivalents can do, along with physio factors). "Some basic labs" - like a CBC? 20 minutes. You don't state what the H&H was. I'm guessing it wasn't bottomed. Or maybe it was equivocal.

But when does he go from 120/80/HR 100 to 56/33/HR 150? And, for the forceful management dictated after, it is illogical that whomever pre-oped this guy (presumably in the ED) didn't dictate putting more fluid into him - unless the anesthesiologist agreed that the pt looked good. And, prospectively, I believe we all have to consider whether putting 4 liters into a pt with CAD is not going to make things worse.

But the animus towards the ED is clear. Were they aware of such disdain, or were you collegial and smiling? I know that there has to be a villain, but, to a certain subset on SDN, it's always the ED, with the black hat and Snidely Whiplash mustache, who are actively trying to kill the patients, until <fill in specialist> swoops in on a white horse and saves the day.

My point is, taken from a more objective perspective, as I can see this guy in my mind's eye, I wonder if he appeared to be such a bomb waiting to blow up, from the way the story was laid out.

Let me say first and foremont that I appreciate your input.

I will also say that I omitted some specifics (H+H, EM management) because it's a tad wordy and this is an anesthesiology forum. The focus in on an intraoperative/immediate preoperative management. The details of a broad initial ddx, appropriate workup, and narrowing of such ddx with appropriate therapy are a bit beyond us.

I also realize that there is bias towards timecourse and resources in this thread. I am an anesthesiology resident and I can afford to direct my attention to POUR in, which is to say, PERSONALLY HAND-PUMP in, 1-2L of NS in a 10 minute period. I also have anesthesia attendings (and techs!) available to me to lend a helping hand. You or others may object to my word choice but it reflects the availabilty of personnel and intensity of care that we provide in the OR.

It may also be a little inflammatory to say the EM docs "trickled" in the same volume over 2 hrs. But in this case those are the true volumes and times over which they are administered. No one said, or implied, that any EM doc made this clinical situation worse (i.e. "made an arteriotomy").

In all likelihood (and according to ED records) this patient arrived in the ED looking reasonably viable and in MAYBE the region of a 10-20% blood loss. However during that stay he certainly decompensated, and I then received a patient in frank hemorrhagic shock with 1 PIV. This is a dude bleeding at a constant rate from his mouth, and I personally like to blame the patient whenever possible. I mean, no one MADE him smoke and cause his tongue SCC and CAD... right?!

So overall I would agree that I put up some passive criticism towards the EM docs, WHILE ACKNOWLEDGING the limitations they have on their care and...more importantly... the natural clinical history of a sick-ass dude trying to bleed outta his mouth.

Cheers A 😀

 

[fakin' the funk]

Why do you say that? How did his hemodynamics react to induction/ventilation?
Like i said i would have given more blood products to this guy: from the values you gave he probably has lost 40% of blood mass so probably a solid 2L.
If he's been oozing/bleeding for a long time so he's been consuming coagulation factors hence the FFP. I would add platelets too.

They coulda been better and they coulda been worse. I think this was a slow steady bleed in the range of 500-1000ml/hr. As in, a bleed that a single 18g PIV can match or correct.

I still don't know the answer about whether or not we shoulda given platelets. I think if ALL the clopidogrel is all tied up with current, deactivated platelets, that if we give some fresh ones they'll work just fine and help stop the bleed. But I don't know.

I do like your initial thought that a 40% blood loss deserves some FFP. That was certainly in the mix (in the end), but not in the immediate first 5-10 minutes management.

 

[fakin' the funk]

So this pt had both a radical neck and a drug eluding stent 4 months ago?? Someone please shoot the cardiologist who didnt place a bare metal stent on a pt who just either had or was about to have a radical neck.

You assume much about the coordination of care in our medical system!

 

[fakin' the funk]

A couple of mask breaths were given between all those MAC/GS views, which led to the NEXT problem...that a fair amount of blood got sent down the trachea, which we become aware of AFTER the tube's in he becomes hypoxemic. So we do bronch and clear out frank clots in the R main and all the segmental bronchi in the RML and RLL.

So alright it's a case of hemorrhagic shock combined with a classic scenario of a expected difficult intubation with a full stomach.

But...I will say that the thing that most helped this guy live to fight his SCC another day was a therapeutic bronchoscopy performed by an anesthesiologist. No pulm consult needed. No RT and wrist-band-checking needed. We did it in 5 minutes and fixed a life-threatening emergency. So I will throw out a commercial for the students and residents out there, that knowing bronchial anatomy and knowing how to wrangle an adult FOB to diagnose and treat acute respiratory disorders is something all anesthesiology residents should know.

 

[Oggg]

I was thinking if you can resuscitate him and the airway is not exploding with blood, you could try airway blocks. Glossy pharyngeal. SLN. maybe transtracheal an leave a catheter in. Maybe NGT to decompress the stomach. The patient becomes an aspiration risk of course. Keep him upright. On the boards I think if you tell them you'll just spray him down, it won't work. Of course if he aspirates you probably have to suction and induce with poor preox

Also you can sometimes locate the CT membr and 2nd & 3rd tracheal rings via ultrasound. So you can mark it in prep for a trach.

 

[IlDestriero]

I was thinking if you can resuscitate him and the airway is not exploding with blood, you could try airway blocks. Glossy pharyngeal. SLN. maybe transtracheal an leave a catheter in. Maybe NGT to decompress the stomach. The patient becomes an aspiration risk of course. Keep him upright. On the boards I think if you tell them you'll just spray him down, it won't work. Of course if he aspirates you probably have to suction and induce with poor preox

Also you can sometimes locate the CT membr and 2nd & 3rd tracheal rings via ultrasound. So you can mark it in prep for a trach.

Blocks are great, and I suspect they're a dying art.🙁 Residents can't even do a light wand.🙄 God forbid the glidescope isn't available.

BTW, if you say you're going to do the airway blocks on the oral, they won't work either, or you'll get an expanding hematoma...

 

[pgg]

I was thinking if you can resuscitate him and the airway is not exploding with blood, you could try airway blocks. Glossy pharyngeal. SLN. maybe transtracheal an leave a catheter in. Maybe NGT to decompress the stomach. The patient becomes an aspiration risk of course. Keep him upright. On the boards I think if you tell them you'll just spray him down, it won't work. Of course if he aspirates you probably have to suction and induce with poor preox

Also you can sometimes locate the CT membr and 2nd & 3rd tracheal rings via ultrasound. So you can mark it in prep for a trach.

Airway nerve blocks have their place, but wouldn't be my first choice in someone s/p a radical neck +/- XRT, altered anatomy, probable coagulopathy, and angry/bleeding tissues.

Likewise, with regard to the pre-induction NGT, I'd be very reluctant to insert anything blind in a guy with a bleeding mass at the base of his tongue, just asking for trouble IMO.

 

[Apollyon]

Propantrollol delivery

I didn't get this. Can you explain? Honest question. And if you're calling me a troll, you're maybe not clear on the definition.

 

[loveoforganic]

I didn't get this. Can you explain? Honest question. And if you're calling me a troll, you're maybe not clear on the definition.

I didn't quote you, the poster I quoted was clearly trolling, the poster I quoted is an anesthesiologist, I made an anesthetic delivery pun. How is that possibly directed at you?

😕😕

 

[Planktonmd]

I didn't quote you, the poster I quoted was clearly trolling, the poster I quoted is an anesthesiologist, I made an anesthetic delivery pun. How is that possibly directed at you?

😕😕

Did you just call me a troll?
I did like the pun though!
But all joking aside I was really curious how an ER guy can afford vacations in Maui with his salary... no trolling intended.

 

[Whiskeypunch]

.

 

[Multifidus]

So, etomidate sux MAC3 we get a Grade 4, those submandibular tissues were tight (as the patient had told us!) and the oropharyngeal anatomy all distorted by his left tongue mass. Glidescope just barely gets a Grade 2ish view, the lens gets a little gooped up with all the blood in so we actually have to take the whole blade out and wipe the lens down a couple times. Next view manage to goose the tube, blood outta the ETT like crazy, suction applied to ETT, then ETT out. Next view with more anterior Brutane applied, in the airway with CO2 and chestrise and all that good stuff.

A couple of mask breaths were given between all those MAC/GS views, which led to the NEXT problem...that a fair amount of blood got sent down the trachea, which we become aware of AFTER the tube's in he becomes hypoxemic. So we do bronch and clear out frank clots in the R main and all the segmental bronchi in the RML and

Good case. I'm not sure about the "Brutane" in a guy with tongue base lesion and unknown bleeding source. That could have made things a lot worse. I think if a gentle glidescope DL didn't work (which I would have tried to do awake/sedated), my next plan would have been a brief attempt at fiberoptic, followed by discussion of tracheostomy. I think you guys did a good job and got things done, but I'm not sure it was really the safest approach.

 

[loveoforganic]

Did you just call me a troll?
I did like the pun though!
But all joking aside I was really curious how an ER guy can afford vacations in Maui with his salary... no trolling intended.

Trolling reply, not a troll in general

 

[Oggg]

Good point about airway blks being difficult after neck dissection.

 

[DScully]

Emergency medicine is really hard.

I agree. Besides, who knows what happened between EM hand-off and the point when pt was actually in the OR? Transport can take forever (IF they are coming, which a lot of times might not even be true)....and patients' conditions can change in a heart beat.

However, this was a great case! Thanks for sharing!

 

[DScully]

No RT and wrist-band-checking needed.

I agree 100%.

Another story - pt was having some emergent surgery (evacuation of subdural hematoma or something like that), and the RN was asking the family what the patient's religious preference was on her RN pre-op sheet. I wanted to strangle her so much at that moment...

 

[Apollyon]

I agree 100%.

Another story - pt was having some emergent surgery (evacuation of subdural hematoma or something like that), and the RN was asking the family what the patient's religious preference was on her RN pre-op sheet. I wanted to strangle her so much at that moment...

What if the pt was a Jehovah's Witness? They'll sue (and win) for violating their religious freedom. I'm just saying.

 

[Planktonmd]

I agree 100%.

Another story - pt was having some emergent surgery (evacuation of subdural hematoma or something like that), and the RN was asking the family what the patient's religious preference was on her RN pre-op sheet. I wanted to strangle her so much at that moment...

They have a check list that they have to fill because the hospital makes them do it and if they don't they get fired.
And the religious preference is important when some one is dying actually it might be more important to that patient than the surgery we are about to perform.

 

[DScully]

They have a check list that they have to fill because the hospital makes them do it and if they don't they get fired.
And the religious preference is important when some one is dying actually it might be more important to that patient than the surgery we are about to perform.

Good point about the Jehovah's Witness. It will be a mistake if we neglect this and that we end up violating their rights.

However, on the other hand, what I cannot stand is the fact that there are so many things we do just because it is the hospital 'policy' or because we don't want to get fired by someone else who makes up the rules.

I am not saying that there shouldn't be rules but I believe that rules are simply rules. In general, one should follow them but following anything blindly without any good reasoning or sound judgment is as bad as not following any anything. At least that's what I think.