L/S response to haemorrhage

[Melclin]

Currently in our system, per AMPDS, we go lights and sirens to any "haemorrhage, dangerous body area". Unfortunately this means we are going lights and sirens to a few fairly common job types.

- PR bleeds where people wipe themselves after passing a bowel motion, notice a small red smudge on the toilet paper, or notice a red tinge or blood clot in the toilet and call 000. :wacko:

- Epistaxis.

- Superficial lacs around the head.


My partner was complaining on the way to a nose bleed the other day and said to me, Melclin, you like research and all that, what are the numbers on fatal nose bleeds. I had no idea. We got talking about it and I became interested in the idea of looking into some evidence that might either support of discourage the idea of L/S resposes to these jobs.

Q.1 I understand it is possible to die from epistaxis although extremely unlikely in most cases, and unlikely that a L/S response makes any difference. Anyone got numbers on that?

Q.2 Are their any causes of PR bleeds that are immediately life threatening?

 

[MrBrown]

We go p1 to "dangerous" haemmorhage (code 21) which is defined as groin, vomit (bright red), vagine or rectum (if serious), neck or groin

 

[94H]

According to the NAEMD everything other than "Not Dangerous" (A-1) and "Minor" (A-2) get a lights and siren response.

Blood Thinners and "Blood Disorders" upgrade the call to a Bravo

 

[mycrofft]

Transported a guy from one ER to another hospital for specialty operation.

Type-A "hard charger" with untreated HTN, aged 45, sneezed at breakfast and ended up with us, a large bore in each arm with blood, nose packed with dripping gauze mounds, sitting up, and still angry he wold miss work on Monday. Outcome unknown.No numbers, but our guy lived right by a hospital.

Nosebleed as a symptom for intracranial vascular damage, neoplasm, DIC, skull fx, suicide GSW, etc??

 

[Melclin]

According to the NAEMD everything other than "Not Dangerous" (A-1) and "Minor" (A-2) get a lights and siren response.

Blood Thinners and "Blood Disorders" upgrade the call to a Bravo

We go p1 to "dangerous" haemmorhage (code 21) which is defined as groin, vomit (bright red), vagine or rectum (if serious), neck or groin

Is there a clearly described reason for this?

Type-A "hard charger" with untreated HTN, aged 45, sneezed at breakfast and ended up with us, a large bore in each arm with blood, nose packed with dripping gauze mounds, sitting up, and still angry he wold miss work on Monday. Outcome unknown.No numbers, but our guy lived right by a hospital.

Nosebleed as a symptom for intracranial vascular damage, neoplasm, DIC, skull fx, suicide GSW, etc??

I think its reasonable that if the person's chief and only complaint is epistaxis, its fairly unlikely that there will be much else going on. Obviously it will happen. A certain amount of diarrhoea & vomiting gets a low priority and you get there and they're all, "Oh yes I've had this chest pain, diarrhoea and vomiting for a 3 hours now", but you can't go L/S to all d&v. If a person gets shot, its unlikely to come through as a nose bleed. If they have significant complicating medical hx, that often comes up in the call. I'd be interested to know how often this happens though. As far as I can tell truly life threatening nose bleeds are pretty rare, even in pts on warfarin etc. I'd be interested to see what percentage of people I'm thinking the numbers probably don't exist. Might be a good opportunity for a study using our call sheet database....

 

[mycrofft]

I guess not a statistically high cause of death of itself.

But if there is other undisclosed info...

 

[ArcticKat]

I think its reasonable that if the person's chief and only complaint is epistaxis, its fairly unlikely that there will be much else going on.

On the contrary. It is more likely that a spontaneous epistaxis could be indicative of an underlying cause. Many cases I've had have involved people with a history of hypertension. The epistaxis was actually caused by an increase in their blood pressure and they were nearing a hypertensive crisis. The blood vessels of the nose are among the most fragile and like the weakest pipes in the plumbing, they're gonna burst when the pressure gets too high.

Another patient I had was taking unprescribed ASA once a day because she saw it on a TV commercial and thought it might be a good idea. She bled goooooooood.

 

[Melclin]

On the contrary. It is more likely that a spontaneous epistaxis could be indicative of an underlying cause. Many cases I've had have involved people with a history of hypertension. The epistaxis was actually caused by an increase in their blood pressure and they were nearing a hypertensive crisis. The blood vessels of the nose are among the most fragile and like the weakest pipes in the plumbing, they're gonna burst when the pressure gets too high.

Another patient I had was taking unprescribed ASA once a day because she saw it on a TV commercial and thought it might be a good idea. She bled goooooooood.

http://www.internationaljournalofcardiology.com/article/S0167-5273(08)00310-0/abstract



Whether or not they are linked is beside the point though. Was either the bleeding or the hypertension so immediately life threatening that it required a L/S response.That's the question I'm asking. Did you do anything for the pts that couldn't have been done with equal effect 3.5 mins later? Did you do anything for them at all, that they couldn't be told to do themselves over the phone? I've never heard of emergent hypertension control that happens over a few minutes.

 

[sir.shocksalot]

Was either the bleeding or the hypertension so immediately life threatening that it required a L/S response.

I'd wager that there isn't much at all that requires L/S response. And to be honest some of the things that you were incredulous that you got called to (epistaxis, small amounts of blood on TP, minor lacerations of any kind) are completely routine calls that we respond to on a daily basis. I would be grateful if we got to respond routine to anything at all.

That aside, I think you are spot on in that even if the epistaxis did indicate a huge, underlying, lethal disease process, is it time dependent? I think the answer is that no-one knows. In Colorado we are currently doing research on prehospital lactate monitoring and "Sepsis Alerts". Studies showed that time to massive fluid resuscitation in septic patients does affect outcomes significantly, but the question being studied now is how much time are we talking about? Are prehospital fluid resuscitation going to affect outcomes, how about prehospital recognition?

I think that time is a factor in most diseases, we just don't have enough data to say exactly how much time we are talking about (minutes? hours? days?). Here in the US, EMS people should be very aware of the data as it comes out, since we have already been proven to do nothing for trauma patients compared to transport by cop car, who knows what else we will have no demonstrable effect on. It may eventually lead to the fact that L/S response is not needed to all but critical cases as determined by dispatch (Cardiac chest pain, stroke, AMS, seizure, etc).

http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2010.00948.x/full
(data for transport of penetrating trauma by cop car)