Critically unwell 58 year old with life threatening bleeding due to epistaxis. Significant airway and resuscitation concerns. Consider other sources of bleeding, including Oesophageal varices, Peptic ulcer disease etc.

1. Describe and Interpret

Anaemia – likely due to acute haemorrhage

Severe coagulopathy without lab evidence of DIC – high INR, low fibrinogen with normal aPTT, d-dimer and low normal Platelets

Platelets are low normal but with potentially poor functional capacity

Cause – severe liver disease due to alcohol as well as nutritional Vitamen K deficiency

2. Outline your steps in management

This patient requires simultaneous resuscitation and heamorrhage control:

Resuscitation

ABC approach

– Airway, Breathing – ensure airway patency, maintain oxygenation (risk of aspiration)

– Circulation – initial  ivi fluids, followed by blood if shocked (O-ve until crossmatch available)

– correct coagulopathy – Vitamen K 10mg with FFP (4 units), Cryoprecipitate, Prothrombin X

– correct electrolytes, calcium

– correct acid-base status

– keep patient warm

– monitor response and fluid status

Haemorrhage control

– Nasal packing

– Immediate ENT consult for ongoing bleeding

3. Key steps in nasal packing

PPE

Local Anaesthetic/ vasoconstrictor

Haemorrhage control – Rapid rhino/ foley’s catheter

Analgesia/ sedation (with care) – titrated morphine / Midazolam

4. Main issues with regard to Aortic stenosis

Volume dependant, fixed outflow obstruction

rate limiting factor for cardiac output – tachycardia with fixed outflow obstruction

Aims

– replace volume to restore circulation to vital organs (cerebral perfusion, HR < 100, SBP >100, MAP > 65-70), optimise prior to surgery

– avoid over resuscitation, replace blood slowly after initial stabilisation, monitor for signs of fluid overload (SOB, falling Oxygen saturation, tachypnoea)

– address coagulopathy

– notify Anaesthetics of Aortic stenosis if going to theatre

 

Adapted from 2009 fellowship examination on ACEM website