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The patient tells you that he started vomiting blood about 2 hrs ago. It was dark and old blood initially, but now is fresh. He normally drinks a dozen tallies of beer a day, but for the past week has been having that plus a bottle of scotch.

He knows that the alcohol has damaged his liver but he has never vomited blood before.

On examination, he is pale, distressed and diaphoretic but not jaundiced.

His initial observations are: Temp= 35.5, P=118, BP =90/40, SaO2=93%, RR=26

His abdomen is soft with epigastric discomfort and hepatomegaly.

FONTS

We've got a bleeder!

Case 2

Case 1

Triage has received a call from the ambulance about a patient that they are bringing in: a 45yo male known to be a chronic alcoholic with a large haematemesis. He is pale, tachycardic and hypotensive. Their ETA is 5 minutes.

A 66 yo man is brought to Emergency by ambulance complaining of black, tarry bowel motions for the past 48 hr.

His past history includes hypertension, ischaemic heart disease with an AMI five years ago for which he had stents x2, mild COAD and osteoarthritis.

His current medications are: Aspirin, Clopidogrel, Metoprolol, Coversyl Plus, Ventolin prn, Voltaren prn. He is a former smoker with a 20 pack/year history and drinks alcohol infrequently.

Outline your team preparation for this patient's arrival.

On further questioning, you discover that he has had a flare up of his arthritis over the past two weeks and he has been using Voltaren 100mg tds over this time.

He occasionally feels a little dizzy if he gets up “too quickly”, but states that this has been “going on for years”.

His initial observations are: Temp= 37.1, P=56, BP=115/60 with no postural drop, RR=18, SaO2=97% on room air.

On examination, he is alert and looks well. He is warm and well perfused peripherally. His abdomen is soft with some mild epigastric discomfort.

What is the most likely cause of this man’s symptoms?

The patient arrives and is brought into the resuscitation area. He is holding a vomit bag half filled with fresh blood and his shirt and pants are covered as well. His initial obs with the ambos were: HR 120 BP 70/40. Normal saline was commenced on route and his latest BP was 95/50.

Is it possible to differentiate between upper and lower GIT bleeding on history and examination?

What are the key features in his history and examination?

What investigations would you order?

What is your management of this patient?

What is this patient's disposition?

FBC: Hb 98, WCC, 11.4, Plat 152.

ELFTs: Na 134, K 4.2, Urea 14.3, Cr 101, LFTs unremarkable.

Coags: PT 12, APTT 35, INR 1.1.

ECG: normal sinus rhythm 55/min, Q waves inferiorly.

CXR: increased CTR, clear lung fields, no effusions.

What are the likely causes for this man's presentation?

FBC: Hb 72, WCC 20.1, Plat 58.

ELFTs: Na 128, K 3.6, urea 17.8, creat 122, bilirubin 36, ALP 350, GGT 698, ALT 476, AST 521, LDH 508, Prot 47, Alb 28.

Coags: PT 36, APTT 45, INR 3.4.

X-Match: A pos, 6 units.

ABG: pH 7.30, pCO2 29, pO2 76, bicarb 20, BE -3.6, Lactate 2.5.

What are the important features on assessment?

What are your immediate resuscitation priorities?

What investigations do you want?

What is your ongoing management?

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