Senior Report 6.15

Case Presentation by Dr. Kevin Sprague

A 66 year-old female presents to the Emergency Department for an unrelated complaint.  You notice her eyes do not appear symmetric.  She later reports that 3 weeks prior she was hit in her left eye and had loss of vision that she attributed to swelling.  The eye was originally painful, but it is not today.  She did not seek medical attention.  She has no light perception in the left eye.  Fluorescein stain was applied.




1) What is the most appropriate next step in the acute management of this condition?

a)  measure orbital pressure

b)  administer topical timolol

c)  place a protective eye shield

d)  start broad-spectrum IV antibiotics

e)  emergent ophthalmology consultation

2) The patient above starts vomiting and then aspirates.  Which medication is relatively contraindicated?

a)  zofran

b)  lidocaine

c)  rocuronium

d)  succinylcholine

3) What is the most appropriate method for applying an eye shield for a globe rupture?

a) metal eye shield

b)  soft padded eye shield

c)  plastic eye shield

d)  pressure dressing



1) c

This patient has a delayed presentation of a scleral (globe) rupture.  Classically, this follows blunt trauma and patients present with decreased vision and pain.  The blunt trauma causes a sudden increase in intraocular pressure resulting in a scleral rupture.  The most common sites are the insertion of the intraocular muscles or the limbus.  When rupture occurs at the limbus, a teardrop pupil may be observed.  The patient may have bloody chemosis or severe subconjunctival hemorrhage.  This patient clearly had chemosis and subconjunctival hemorrhage that is less appreciated after fluorescein stain.  This patient also had a positive Seidel test.  The fluorescein stain has infiltrated the anterior chamber.  Below is a link to a youtube video demonstrating a positive Seidel test.

The first step in managing an acute globe rupture is to protect the eye from further examination or manipulation by placing a protective eye shield (and not take pictures).  Also have the patient avoid rapid eye movements. The next steps include IV antibiotics, tetanus update, NPO, and emergent ophthalmology consultation.  Timolol is not indicated.  Measuring pressure is contraindicated.

2)  d

Some texts advocate giving zofran prophylaxis since vomiting will increase intraocular pressure.  Succinylcholine can increase intraocular pressure and is therefore relatively contraindicated.

3)  a

A metal shield is the first choice.  When a metal shield is not available, a makeshift shield using plastic, paper, or styrofoam cup is the next best option.  Any eye shield that makes contact with the eye or applies pressure is contraindicated.


Marx, Hockberger, Walls.  Rosen’s Emergency Medicine, 7th Edition.  Mosby Elsevier, Philadelphia. 2010. p. 864

Robers and Hedges. Clinical Procedures in Emergency Medicine, 5th Edition. Saunders Elsevier. 2010. p. 1154

Senior Report 6.14

Case Presentation by Dr. Cameron Kyle-Sidell





1) The injuries shown above are most consistent with which of the following clinical presentations:

a)  A furnace mechanic who suffered a flash burn

b)  A golf caddy struck by lightning

c)  A maintenance man who mishandles an overhead power line

d)  A lawyer working on a home improvement project gone wrong

2) The patient above complains of significant neck pain upon presentation.  Which of the following diagnostic modalities should be most considered:

a) CT of the neck with contrast to evaluate for underlying muscle necrosis

b)  Local surgical exploration at site of pain

c)  CT of the neck without contrast to evaluate for underlying bony injury

d)  Neck fasciotomy to relieve compartmental pressure

3)  The following patient can be safely discharged from the emergency department:

a)  A woman at 24 weeks gestation who suffers an electrical injury when plugging in a hair dryer, landing on her back, who has no loss of consciousness and a normal EKG.

b)  A 35 year old male who suffers electrical injury while plugging in the microwave, with a normal EKG and no loss of consciousness and a small cutaneous burn on his forearm.

c)  A 25-year-old male who is electrocuted by a power line at work, with an EKG demonstrating T wave inversions in the lateral leads, and no loss of consciousness.

d)  An 8-year-old male who suffers an oral burn after biting an electric extension cord with swelling of the tongue and the floor of the mouth with no active bleeding.



1)  C.

The injuries pictured above are most consistent with a high voltage electrical burn.  When a patient presents with an electrical burn, it is important to establish the source of injury.  Electrical burns are typically divided into high voltage and low voltage injuries.  High voltage injury is defined as exposure to more than 1000V.  The patient pictured presented after grabbing a fallen overhead power line exceeding 10,000 V with his right hand.  High voltage injuries present as painless, depressed, yellow-gray charred craters with central necrosis. In general, high voltage injuries may largely spare the skin surface but cause extensive injury to underlying soft tissue and bone.  High voltage electrical injury can however lead to a “kissing burn” as seen running down the patient’s midline, a cutaneous burn which occurs along flexor creases when an electrical current arcs across both flexor surfaces.  These burns are important to recognize as they are often associated with significant underlying injury.  This kind of “hidden” damage is rare in low voltage injuries.

A golf caddy struck by lightning is unlikely to present with the findings in the picture. Lightning strikes act as an instantaneous current, and while its voltage can exceed 1 million volts, it rarely causes significant cutaneous burns or soft tissue damage because of its brief duration. Lightning is more likely to cause cardiac and respiratory arrest, neurologic sequelae, and autonomic instability.  There are four main types of burns that can be seen with lightning strikes: linear burns, punctate burns, feathering burns, and thermal burns. Linear burns occur where sweat or moisture has accumulated on the body, such as down a person’s chest or in the axilla.  Punctate burns resemble cigarette burns. Feathering burns show no damage to the skin itself and make a fern like pattern on the skin secondary to electron showers induced by lightning. They do not require therapy. Thermal burns occur if a person’s clothing catches on fire or if they have metal on their body that is heated by the flash.  Many people who have experienced lightening strikes will present with a combination of these types of burns.

A lawyer working on a home improvement project likely sustained a low voltage injury which creates smaller, well-demarcated contact burns at the sites of skin entry and exit than is indicated in the picture. A furnace mechanic who suffered a flash burn will normally present as a superficial partial thickness burn which more closely resembles a traditional burn as seen in victims of fires.

2)  C. 

Secondary trauma must be considered in all high-voltage exposures, especially in those involving direct current electricity.  Just as the voltage potential of electrical injuries is important to distinguish, it is important to determine if the patient was exposed to alternating current (AC) or direct current (DC).  A direct current is more often used in automobiles, batteries, and high-voltage power lines.  An alternating current is more common in homes and offices.  Exposure to each leads to muscle contractions. Direct current causes a single muscle contraction that often throws the patient away from the source while an alternating current leads to tetanic muscle contractions which can often bring the patient in closer proximity to the source.  Most electrical exposures occur to the upper extremity, and because the flexors of the upper extremity are typically stronger than the extensors, the tetanic contractions in AC exposure often cause the arm to flex and bring the source closer to the body.  While both AC and DC can lead to significant morbidity (and mortality), a direct current exposure suggests a much higher risk of secondary trauma.  Given our patient’s high voltage, direct current exposure, we should have a high degree of suspicion for secondary traumatic injury.  Our patient in fact had a loss of consciousness and sustained a contusion to the back of his head from being thrown backward during the incident.  A CT of the neck without contrast is warranted to rule out a cervical fracture from the fall.  It is not uncommon for patients to present with fractures and joint dislocations, including posterior shoulder dislocations, due to falls and forceful muscle contractions after direct current exposure.

Surgical exploration of the neck and fasciotomy are not indicated at this time.  While significant underlying muscle necrosis and edema can occur leading to increased compartmental pressures, this is far more common in the extremities.  In the absence of hard signs such as progressive neurologic dysfunction and vascular compromise, early surgical intervention is generally not indicated.  While careful monitoring for increased compartmental pressures is required, unnecessary surgical intervention including fasciotomy can lead to a prolonged hospital course including multiple ensuring surgeries and significant rehabilitation time.  A CT with contrast is not the diagnostic modality of choice to evaluate for cervical fractures or compartment pressures.

3)  B.

A 35 year old male who suffers electrical injury while plugging in the microwave with a normal EKG and no loss of consciousness and a small cutaneous burn on his forearm can be safely discharged. Current recommendations suggest that all patients who present to the emergency department after suffering an electrical injury to a low or high voltage source should have an EKG  performed to evaluate for arrhythmias and cardiac injury.  Patients who experience low-voltage injury with no EKG abnormalities, no loss of consciousness, or other significant injury can be safely discharged home with appropriate wound care.

A pregnant patient with a viable fetus requires fetal heart monitoring due to the potential for placental abruption. Ultrasound may also be indicated if the patient experiences symptoms such as vaginal bleeding, decreased fetal movement, or persistent abdominal pain to assess for fetal viability. Electric burns can increase uterine activity and affect uteroplacental circulation, which can require aggressive resuscitation in the hospital. Fetal complications as a result of electrical trauma include IUGR, spontaneous abortion, oligohydraminos, and cessation of fetal movement.

The child with an oral burn and tongue swelling has evidence of possible airway compromise.  He should be closely observed to monitor for further swelling.  If this patient had no intraoral swelling, he could be discharged home.  One of the most common injuries seen in children is an oral arc burn which occurs with biting of an electrical cord.  These patients can have delayed bleeding up to 2 weeks after the incident from the labial artery when the initial eschar separates, however observation to monitor for this delayed bleeding is unnecessary.  Parents should be properly educated on the chance for rebleeding and instructed to return should such bleeding occur.

Any patient with a high voltage injury with or without EKG abnormalities requires admission to a burn center due to the possible for significant hidden underlying injury.


Emergency Medicine Practice.  Electrical Injuries:  A review for the emergency clinician.  October 2009, Volume 11, Number 10.

Intern Report 6.13

Case Presentation by Dr. Sarah Michael

CC: I can’t breathe!

A 21-year-old female is transported to the emergency department after an apparent domestic dispute. On arrival, it is apparent that she has multiple stab wounds to her chest and abdomen. She is alert and oriented but in acute distress. Her blood pressure is 98/64, pulse 112, respirations 32 and oxygen saturation 94% on nonrebreather mask. There is no jugular venous distension. You can appreciate a small degree of tracheal deviation. An eFAST is performed which includes the following findings.




1. The most appropriate next step in the management of this patient is:

A: Needle decompression of the right hemithorax

B: Left-sided chest tube

C: CT of the chest, abdomen and pelvis

D: Emergent transport to OR

2. The patient’s clinical status remains unchanged.  A repeat U/S shows the following:


Now the most appropriate next step is:

A: Chest tube placement

B: Intubation

C: Finger thoracostomy

D: Chest x-ray

3. Which of the following is true regarding the patient’s belongings?

A: They should be placed in a plastic bag and remain with her.

B: They should be placed in paper bags and offered to the police.

C: If ED staff handles them they lose their forensic value.

D: Blood-soaked items should be placed in biohazard waste.

Answers & Discussion:

1. The answer is A, needle decompression.

The patient in the vignette is in shock and her physical exam is concerning for a  tension pneumothorax with respiratory distress and hypotension. Notably, JVD may be absent in the hypotensive patient. In order to correctly answer the question, you need to be able to interpret the eFAST findings.

An eFAST (extended FAST) exam includes the normal FAST structures as well as the lung at the 3-4 intercostal space on the anterior chest wall. This is the most superior aspect of the chest in a supine patient and the location where you would expect air to accumulate.  You’re given 3 images to interpret.

The first image is of Morrison’s pouch, the most sensitive FAST view for intraperitoneal free fluid. This patient has a renal fat pad that could be mistaken for free fluid. You should be able to appreciate that the structure is lenticular with internal echoes and bounded by the hyperechoic line of the renal capsule.  This is known as the double line sign and is a frequent cause of a false positive FAST examination. Therefore, it is not a reason to rush the patient to the OR. If it’s helpful, think about it as a renal corollary of the pericardial fat pad that can sometimes mimic pericardial effusion.

6.13 ans -1j

The second image shows you a normal M-mode ultrasound of the right lung. You can see the “seashore sign” with an abrupt transition between the chest wall and lung parenchyma at the pleura. It would be imprudent to place a chest tube on the unaffected side.  

6.13 ans-2

The third image shows you the lung point of the left lung, indicating the presence of a pneumothorax. This is the place on the chest wall where the lung transitions from pneumothorax to being against the chest wall. In M-mode, you’d be able to see both the “seashore” and “barcode” signs vary with respiration.  In a setting concerning for tension, needle decompression is the way to go.  Intubating the patient before decompression risks further destabilization.   Fixing a tension pneumothorax may also prevent the need for intubation.

6.13 ans-4

2: The correct answer is A, chest tube placement.

In the trauma patient with persistent respiratory distress and decreased breath sounds after needle decompression, you should consider chest tube placement for presumptive hemothorax per ATLS guidelines. Chest tube placement is certainly indicated given the ultrasound image, which demonstrates a massive hemothorax. There is near complete consolidation of the lung as it floats in a sea of fluid. The M-mode graphic shows the movement of the lung edge with respiratory variation.

6.13-ans 3

The patient may need intubation for respiratory failure (and definitely for her trip to the OR). But intubation before tension is resolved would likely worsen the tension and could be disastrous.  Similarly, tension pneumo- or hemo-thorax is a clinical diagnosis and treatment should not be delayed by imaging.

Thoracotomy in the OR is indicated for patients who have a chest tube output of 1500 cc or greater of blood during the first hour. Given the appearance on ultrasound, more than 1500 cc would be expected. However, the tension should be relieved at once and not delayed by transportation to the OR.

Finger thoracotomy should be considered and is an option if you are uncertain of the diagnosis of hemothorax. In this case the diagnosis is not in doubt and chest tube is required.  A chest tube is also indicated once a decompressive needle thoracostomy is performed.  Furthermore, a hemothorax this large will likely re-accumulate very quickly.

3. The correct answer is B.

The patient is a victim of a violent crime and her clothing, through which she was stabbed, likely contains valuable forensic evidence. Caring for the patient obviously takes priority over the preservation of such evidence, but steps can be taken to maintain evidence integrity so long as they do not delay care. When removing a patient’s clothing, try to avoid cutting through stab or bullet holes and always wear gloves. In some cases, the frequent changing of gloves can help to keep from cross-contaminating evidence.  Even if evidence is collected or handled suboptimally in the provision of care for the patient, it is not worthless and should still be made available to investigators.

After being removed from the patient, clothing should be placed in separate paper bags and given to law enforcement. The paper bags will allow the blood to dry in a way that does not promote the formation of mildew, which can destroy the evidence. Blood soaked items should be placed in separate plastic bags followed by separate paper bags. Law enforcement should be informed that the items are soaked so they can be dried appropriately.

If law enforcement declines the evidence, it should be returned to the patient.

Riviello, edited by Ralph J. (2010). Manual of forensic emergency medicine : a guide for clinicians. Sudbury, Mass.: Jones and Bartlett Publishers. ISBN 978-0-7637-4462-5.

Intern Report 6.12

Case Presentation by Dr. Aditee Jodhani

CC:  I’m vomiting blood

55 year old female with past medical history of HTN, DM, cirrhosis, IVDA and alcohol abuse presents to the ED for hypotension associated with several episodes of hematemesis. The patient states that 3-4 days ago she began having bloody stools and generalized weakness.  She approximates two liquid BMs per day that are mixed blood.  She also describes being nauseated and had 2 episodes of hematemesis over the last 3 days.  Pt denies any symptoms of fever or abdominal pain.

PMH: alcoholism, IVDA, hep C, cirrhosis, anemia, PUD, internal hemorrhoids

PSH:  Last colonoscopy and EGD was 10/23/12 which showed internal hemorrhoids and a large duodenal bulbar ulcer respectively.  IVC filter placed during same admission

Medications: acetaminophen/hydrocodone, docusate, iron, folic acid, bactrim and thiamine but patient has been noncompliant

Allergies: Aspirin

Family History: denies DM and HTN

Social History: Denies smoking, positive for alcohol and heroin use

Physical Exam:

Vitals: P105, BP94/66 T36.2 (oral) R14

Gen: slightly lethargic

Head: Normocephalic, atraumatic

Eyes: Pupils equal, round and reactive to light. No sclera icterus

ENT: Mucous membranes slightly dry. Dry blood seen around her mouth.

Neck: is supple. Trachea midline. No JVD.

Respiratory: Normal respiratory effort. Good breath sounds heard bilaterally.

Cardiovascular: Regular rate and rhythm, S1 and S2 are auscultated, no murmurs, rubs or gallops.  Pulses palpable in the lower extremities

Abdomen: Soft, nontender, nondistended. +BS.  No rebounding or guarding. Was unable to palpate liver edge, no ascites present.

Musculoskeletal: Full range of movement in all extremities.  Cap refill ❤ sec in all four extremities.

Skin: Warm and dry. No rashes or lesions.

Neurologic: Alert and orient to person, and time. Cranial nerves II-VII intact. Patient is lethargic, does answer questions, but is slow to respond.  Per sister at bedside, patient is not at baseline.


Electrolytes: 142/4.7/110/22/12/1.6 anion gap 10, glucose 89

CBC: 7.9/9.7/30/194

Coag: INR 1.29 PT 13.4 PTT 33

LFTs: AST: 75 ALT: 45 alk P: 141 lipase 269, ammonia 122, albumin 2.0, bilirubin total 1.5, bilirubin direct 1.1

FOBT: positive

EKG: ventricular rate of 100 beats per minute.  Axis is normal.  PR interval is 122 milliseconds.  QRS duration is 72 milliseconds.  QTC is 410 milliseconds.  No acute ST or T-wave abnormalities seen.  There is good R wave progression.  Twelve-lead ECG is interpreted as sinus rhythm with no evidence of acute ST-segment elevation MI.

ED course:

While in the ED the patient had three more bloody bowel movements and one episode of hematemesis. The patient refused NGT placement.  She was given antiemetics, and started on a pantoprazole drip.  She received 1 unit of PRBCs and was given 2 L of fluids. The surgery service was consulted.  Due to patient’s PMH of chronic alcohol abuse there was concern that the hematemesis was caused by esophageal varices.


1.) What prophylactic medication is recommended for cirrhotic patients with confirmed varices to prevent bleeding?





2.)   In addition to a pantoprazole drip, what other medication is important to start in patients with a history of cirrhosis and have an active GI bleed?

a.)Magnesium sulfate

b.) Solumedrol

c.) Octreotide

d.)  Ursodiol

3.)  In the above clinical scenario, what is the patient’s Child’s score and class at admission?

a.)2; class A

b.)8; class B

c.)10; class B

d.)15; class C


Discussion & Answers:

1.)A;  Cirrhotic patients with diagnosed esophageal varices should be started on beta blockers, specifically propranolol. Beta blockers reduce the likelihood of acute bleeding as well as ascites, SBP, hepatic encephalopathy and hepatorenal syndrome.  Nonselective beta-blockers prevent bleeding in more than half of patients with medium or large varices.  Along with propranolol patients can also be started on isosorbide mononitrate.  However not all patients respond to pharmacological treatment and other interventions should be considered (discussed below).

Resources: Abraldes, Tarantino, Turnes, Bosch. Hemodynamic response to pharmacological treatment of portal hypertension and long-term prognosis of cirrhosis.  Hepatology. 30 DEC 2003 DOI: 10.1053/jhep.2003.50133

2.)C;  In addition to protonix, an octreotide drip should also be started.  The mechanism of action of octreotide is not completely clear. It is believed to reduce portal pressure and splanchnic blood flow.  Another alternative medication is vasopressin, but is used less frequently due its effect of worsening coronary ischemia.  A new drug similar to vasopressin but with less side effect is terlipressin it is a somatostatin analogue that also acts to reduce portal hypertension through splanchnic vasoconstriction. A study done out of Japan from 2009 showed equal efficacy of terlipressin to octreotide and reduced hospital stay, but there was no clinical improvement.

Resource: Terlipressin vs. Octreotide in Bleeding Esophageal Varices as an Adjuvant Therapy with EBL: A randomized double-blind Placebo-controlled Trial.  The American Journal of Gastroenterology 2009. 104:617-623.

3.)B;  8; class B.  Bilrubin 1.5, albumin 2.0, INR <1.29, physical exam no ascites, mild hepatic encephalopathy -pt not at her baseline per family but can still respond to questioning, ammonia 122.

Measure 1 point 2 points 3 points
Total bilirubin, mg/dl  <2 2-3 >3
Serum albumin, g/dl >3.5 2.8-3.5 <2.8
PT INR <1.7 1.71-2.30 > 2.30
Ascites None Mild Moderate to Severe
Hepatic encephalopathy None Grade I-II (or suppressed with medication) Grade III-IV (or refractory)








Points Class One year survival Two year survival
5-6 A 100% 85%
7-9 B 81% 57%
10-15 C 45% 35%






Pathophysiology of varices: Figure 1

Hepatic cirrhosis causes increased resistance and thus increased pressure (portal hypertension) in the portal vein that leads to backup of blood in the tributaries, (eg inferior mesenteric vein, periumbilical veins, gastroesophageal veins, and superior mesenteric vein). The gastroesophageal vessels are located in an area with little supporting tissue and easily become distended and more likely to bleed.  In the setting of worsening liver failure and associated coagulopathy, bleeding is significant risk in these patients.


Some common signs on physical exam consistent with portal hypertension are gynecomastia, caput medusae, ascities, and bilateral lower extremity swelling.


Figure 2

Unfortunately esophageal varices cannot be identified on physical exam; they are diagnosed by endoscopy.  Over 70% of cirrhotic patients with UGI bleeding is thought to be due to esophageal varices. Therefore, all cirrhotic patients with an UGI bleed should be considered variceal bleeders until proven otherwise.  These patients have a mortality of 16% at presentation. Classically, patients with varices present with melana or hematochezia as well as hematemesis.  Initial vital signs are prognostic.  Mortality approaches 30% in patients with signs of shock or their SBP is <100mmHg or HR is >100bpm at presentation.

Workup:  Addressing the ABCs is critical.  Early intubation is recommended in order to decrease aspiration and facilitate optimal endoscopy, especially in patients with decreased mental status caused by hepatic encephalopathy. These patients need good intravenous access, 2- large bore IVs or cordis catheter.

In addition to routine labs, coagulation studies are helpful in determining whether or not the patient has liver disease-induced coagulopathy.  It is also recommended to obtain, blood cultures, troponin and lactic acid.  A hemoglobin less than 10g/dl is associated with a poorer prognosis in patients.  It is important to obtain an ECG.  One study indicated that over 50% of patients admitted to the ICU for GI hemorrhage had evidence of cardiac injury. A nasogastric tube should be placed. There is unfounded concern that placing an NG tube will lead to increased bleeding in patients with varices.  NGT placement is important to prevent the risk of aspiration and also can be used to perform a NGT lavage to help determine if the bleed is proximal to the duodenum and if it is still active.

Although lavage is helpful for identifying the location of the bleed, a negative lavage cannot rule out a GI bleed. Do not use guaiac cards, to test aspirate for blood, they are inaccurate.

Patient should be transfused with PRBCs to keep hemoglobin above 8g/dL.  In coagulopathic patients, fresh frozen plasma and platelets can be transfused.  Over-transfusion can lead to worsening portal hypertension and does not reliably correct coagulopathy. FFP should be transfused when there is an elevated PT and platelets should only be transfused at levels are below <50,000.  Clinicians should monitor for the development of DIC in patients undergoing massive transfusion.

Patients with variceal hemorrhage should be started on several pharmacologic therapies early in the ED course.  Pantoprazole should be bolused at 80mg and then infused at 8mg/h. Octreotide drip should be bolused at 50 micrograms then infused at 25-50micrograms/hr for 2-5 days.

Patients can also be started on erythromycin 200mg IV to prepare for endoscopy.  Erythromycin accelerates gastric emptying and reduces need for repeat endoscopy.  Antibiotics norfloxacin 400mg bid or ceftriaxone 1g/d for 5-7 days should also be started in the ED.  Release of bacterial endotoxins cause vasodilation and worsens liver function. Early treatments help to reduce early rebleeding.

These patients need early consult to a Gastroenterologist and interventional radiologist for potential TIPS procedure.  TIPS is also commonly used as a prophylactic procedure for esophageal varices.  It is associated with reduced risk of rebleed and reduced mortality.  However, TIPS as a salvage procedure increases the risk of hepatic encephalopathy.

Endoscopic band ligation (EBL)and sclerotherapy are the most frequently used treatments for acute hemorrhage, however EBL is thought to be superior.

Salvage procedures:

Balloon tamponade is used for actively exsanguinating patients using a Sengstaken-Blakemore tube (figure 3).  There is a high complication rate associated with the procedure, including aspiration pneumonia, airway obstruction, and esophageal perforation.  Recombinant factor VIIa can be used as an adjunct therapy.  Some studies show no improved control of bleeding or prevention of rebleeding, but there is an improvement in 6-week mortality.


Figure 3.

Patient’s Course:  The patient was admitted to the MICU. In the MICU, a cordis catheter and triple lumen central line were placed. Blood and vasopressors (norepinephrine) were administered.  Her hemoglobin was monitored Q6.  She had 2 more episodes of hematemesis, which led to endotracheally intubation and insertion of a NG tube.  The following morning she developed worsening hematochezia and a rectal tube was placed that collected continuous bright red blood. The massive transfusion protocol was initiated and repeat endoscopy showed varices.  A TIPS procedure was performed. Despite the TIPS procedure she continued to have rectal bleeding.  Lactulose was administered. A tagged RBC study was preformed that also revealed a LGI bleed.  The location could not be isolated by angiography. The patient developed DIC and multiple electrolyte abnormalities.  Family was informed of the poor prognosis and subsequently agreed to place the patient in palliative care. The patient was transferred to the floor and eventually received a trach and PEG.  She was then moved to hospice in early January. She returned back to the hospital for malnutrition was treated and discharged back to the hospice.



1.)Hartman, Aldeen.  Focus On: Variceal Hemorrhage, ACEP news Feb 2011.

2.)Bosch, Abraldes, Berzigotti, Garcia-Pagen.  Portal Hypertension and Gastrointestinal Bleeding. Seminars in Liver Disease. Vol 28, No 1 2008.

3.)Portal Hypertension. Accessed Feb 20, 2013.

4.)Tintinalli, Judith. Upper GI Bleeding. Tintinalli’s Emergency Medicine A Comprehensive Study Guide 7th Edition.  P543-545, 2011.