Hematemesis in Blunt Trauma Case Presentation Presenter: Paris Lovett, MD Beth Israel Medical Center, New York May 18, 2002 Hello, and thank you for inviting me to make this presentation. I’m going to talk about a case of massive hematemesis occurring in the setting of blunt trauma.

37y Male, Ped. Struck 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 To begin: A thirty-seven year-old man arrives at the ED by ambulance after having been struck by a motorcycle. He complains of pain in the neck, right arm, and lower back. Later he says that he has had upper abdominal pain for several weeks and that the pain is worse now. He denies any history of hematemesis, hematochezia or melena. He has been consuming alcohol tonight, and seems mildly intoxicated. He reports LOC and post-traumatic amnesia, and could not give details of the traumatic event.

Other History 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 In further history, he says he drinks 10-20 standard alcoholic drinks every day, and smokes cigarettes. He denies allergies, takes no medications, remembers no significant family medical history.

Vital Signs Triage: BP 107/67 HR 80 RR 18 T 98.5 Sat 97% Here are the vital signs at time of triage.

Primary Survey 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 On primary survey, ABC’s are intact, and the only positive finding is on neurological exam. He is fully oriented, with a Glasgow Score of 15, but doesn’t remember the impact or being picked up by the ambulance. He is, as mentioned, mildly intoxicated

Secondary Survey 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 On secondary survey, he was awake and alert, on a board and in a collar, with an obvious closed fracture of the right forearm. He ambulated against advice. Examination of head, neck and chest demonstrated only pallor, and was otherwise unrevealing.

Secondary Survey cont’d 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 Examination of the abdomen showed diffuse tenderness. There was no guarding, no rebound and no percussion tenderness. Hypoactive bowel sounds were present. The rectal exam showed normal tone, sensation and prostate. Stool was dark brown but not melanotic. Guaiac testing was positive. His back exam was normal. No bruising, tenderness or deformity. Extremities: Obvious right forearm deformity. Neurovascularly the arm was intact. The other limbs were atraumatic. On further neurological exam there were no abnormal findings.

Emergency Department Course 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 To describe his emergency department course: 75 minutes after arrival he produces massive bright red hematemesis covering the floor of our resuscitation room. His vitals remained stable however. IV access was gained, labs drawn, crystalloid given, EKG and Xrays taken. Nasogastric tube returned 200ml fresh blood. The patient was sent to CT suite, for scans of head, neck, abdomen and pelvis, with IV contrast.

To give some idea of the scale of the hematemesis, here is a photo of our resuscitation room

And here is an “artist’s” reconstruction of the scene that night, created to preserve patient confidentiality

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 I said the vitals were stable, yes? Well, then he went to the CT suite, and as is customary for visitors to the CT suite, he became hypotensive. He was transfused and given further crystalloid. After that his vitals stabilized and remained acceptable.

Labs EtOH – 88 Rapid HCT – 22% (prior to transfusion)         Labs Rapid HCT – 22% (prior to transfusion) Laboratory CBC tube (prior to transfusion) lost CBC after multiple further transfusions 14 140 106 9 Here are the labs. Please note that the pre-transfusion CBC was lost in transit. The rapid hematocrit, using the gempremier system, cam back at 22%. The other studies and images follow. 17 127 127 3.3 21 0.7 42 EtOH – 88 LFT – AST 172; ALT 57; ALP 63; GGT 168; TB 0.7; DB 0; TP 4.4; Alb 1.9

Here is the 12-lead EKG

The chest Xray

The right forearm lateral view

Pelvis Film

Cross table lateral C-spine

AP C-spine

And, finally, the Odontoid view And now I will yield the floor to Dr. Peter Peacock. I look forward to hearing her thoughts on this case of massive hematemesis occurring in blunt trauma. Thank you.