Transcript CPC Present 051802

Hematemesis in Blunt Trauma
Case Presentation
Presenter: Paris Lovett, MD
Beth Israel Medical Center,
New York
May 18, 2002
37y Male, Ped. Struck
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Struck by motorbike
LOC and Amnesia
Pain: neck, R. arm, lower back
Upper abdo pain for several weeks, worse
now. No History of GI blood loss
AOB tonight
Other History
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Past Medical History: Alcohol abuse.
Consumes 100-200g daily
Allergies: No known drug allergies
Medications: No medications
Family History: Unremarkable
Social History: Smoker – 1 pack/day x 20
years
Vital Signs
Triage:
BP 107/67
HR 80
RR 18
T 98.5
Sat 97%
Primary Survey
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Airway: Speaking comfortably
Breathing: Normal air entry bilaterally,
normal breath sounds
Circulation: Cool extremities. Pulses 2+
x 4 limbs
Neuro: GCS=15 but post-traumatic amnesia
Secondary Survey
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General: Awake and alert; arrived in C-collar and spinal board,
but ambulating against advice prior to being seen. Obvious
closed fracture of right forearm with deformity
Skin: Pale skin creases and conjunctivae. Moist mucous
membranes
HEENT: No evidence of trauma to face, base of skull or cranial
vault. Pupils midsized and reactive. Oropharynx normal. Neck
nontender and no deformity. C-collar in situ. No JVD. Trachea
midline
Cardiovascular: S1-S2 + nil. RRR. No murmurs, rubs or
gallops
Respiratory: No evidence of trauma to chest. Ribs and
sternum nontender. Lungs clear to percussion and auscultation.
Normal air entry bilaterally
Secondary Survey cont’d
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Abdomen: Diffuse tenderness. No guarding, no
rebound and no percussion tenderness. Hypoactive
bowel sounds
Rectal: Normal tone and sensation. Prostate and
rectal mucosa normal. Stool dark brown but not
melanotic. Guaiac positive
Back: No bruising. Nontender. No deformity.
Extremities: Right forearm deformed with swelling.
Neurovascular status intact. Other limbs atraumatic
Neurological: Post-traumatic amnesia and mild
intoxication. Otherwise normal and nil focal findings
Emergency Department Course
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75 min after arrival, massive bright red
hematemesis, covering resuscitation room floor
Vitals remained stable
IV, labs, rapid electronic HCT, Xmatch, monitor,
EKG, 3L NS Stat
NGT inserted and returned 200ml fresh blood
Sent for CT scan
Vital Signs in the CT suite
150 min:
BP 70/40
HR 96
RR 20
Sat 98%
Became hypotensive in CT suite
 Given 3 units O-pos packed RBCs and
further crystalloid resuscitation. Vitals
stabilized
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Labs
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Rapid HCT – 22% (prior to transfusion)
Laboratory CBC tube (prior to transfusion) lost
CBC after multiple further transfusions
14
17
140
106
9
127
42
127
3.3
21
0.7
EtOH – 88
LFT – AST 172; ALT 57; ALP 63; GGT 168; TB 0.7; DB 0; TP 4.4; Alb 1.9