Truly Bleeding to Death

     Attack One responds to a call for a man hemorrhaging. The crew arrives on scene to find a very ill 23-year-old man standing weakly over a kitchen sink, coughing bright red blood out of the site of a displaced tracheostomy tube. The young man's family had discovered him in distress, coughing over the sink, and during the episode he had dislodged the tube and started bleeding profusely through the hole where it had been.

     The young man cannot speak, but his family is able to share his history. About three months ago he was found to have thyroid cancer. He underwent surgery about three weeks ago, and followup radiation therapy was underway. He'd had no prior problems with the tracheostomy. His family advised that the tumor was on the right side of his neck.

     The patient is very pale, unable to speak, and has bright red blood covering his tracheostomy tube. He can follow instructions and shake his head yes and no to questions. He shakes no when asked if he has any pain or if he knows what the bleeding may be coming from. In the upright position, he is able to maintain and protect his airway. His pulse oximetry reading, 98% without supplemental oxygen, means the crew has a few minutes to develop its approach.

Prehospital Management
     The patient is not able to control his coughing episodes, which produce significant amounts of bright red blood. One of the crew members covers himself with a gown, goggles and gloves and examines the dislodged tracheostomy tube. It's an uncuffed tube that got coughed out, about the same size as one of the crew's endotracheal tubes (7.0 mm).

     The tube is too bloody and dirty to try to replace in the patient. The paramedic examines the area around the tracheostomy, and the site and source of the bleeding are unclear. Without an obvious source, it is not possible to put direct pressure on the site to stop the bleeding.

     As this brief examination concludes, the patient becomes light-headed, and the crew has to assist him to the ground. The bleeding continues, so the patient must be positioned to maintain his airway. The site and source of the bleeding still aren't identified, but if the tumor is on the right side of the man's neck, it's likely the bleeding is on that side as well. Given the recent surgery and radiation therapy, it's possible the tumor site was irritated and is now the site of the bleeding.

     The crew is aware of the principle of "putting the sunny side up." This means that in protecting the ability of the patient to maintain an airway and breathe, it is best to place the injured area in a gravity-dependent position, and leave the more functional side in position to breathe and oxygenate. This principle is applied to manage patients requiring transport in a reclining position but on their side, as with chest trauma (put the uninjured side up), lung cancer (allow the patient to lie on the side with the cancer) and in late-term pregnancies (place the woman on her left side to keep pressure off the inferior vena cava and allow blood to return to the heart).

     The young man is placed on his right side, and an intravenous line is started to provide volume to replace his blood loss. He continues to bleed, and with some of the blood going down his airway, he is developing some respiratory distress. The crew contacts medical control by radio, and the emergency physician and paramedics agree that they will need to place a tube into the tracheostomy site to control the airway and attempt to control the bleeding.

     This will require a larger-size endotracheal tube, with a low-pressure high-volume balloon, which will have a better chance to control the bleeding. An 8.0mm tube is chosen, and the patient is told what the paramedic will be doing. Suction is prepared in case the bleeding can't be controlled. To make the insertion easier, small amounts of lubricant are placed on the tube and tracheostomy site. The fully protected paramedic will do the procedure, since the patient's coughing is certain to spray blood on him. To determine how far the endotracheal tube will need to be inserted, the paramedic measures it against the tracheostomy tube that had come out.

     The ET tube is inserted to the desired length, and the balloon inflated with a small amount of air. Within a few seconds the bleeding stops, and the patient's coughing decreases significantly. The patient is given about a liter of IV fluid. He continues to feel light-headed, so the crew maintains him in a reclining position on his right side.

     Transportation to the hospital where the patient's surgery was performed takes a little extra time, but his bleeding remains under control, and his vital signs stabilize.

Hospital Course
     On arrival at the hospital, the patient is comfortable, and bleeding has stopped completely. Evaluation by ED staff still cannot locate the exact site of the bleeding. The patient is taken to surgery a few hours later, and the source of the bleeding is identified by putting a small scope into the endotracheal tube and looking into the trachea. The site was, in fact, on the right side of the trachea, where the tumor was breaking down with the radiation treatments. The surgeon treats the bleeding area with coagulating chemicals, then places a larger tracheostomy tube with a cuff.

     The patient is released from the hospital two days later and begins a long-term recovery process from the cancer.

Case Discussion
     Sunny side up! This is a great axiom to remember in dealing with emergency conditions that compromise airway/breathing and certain other conditions. By putting the injured, ill or damaged area in the most gravity-dependent position, the better-functioning part of the body can sustain life until definitive treatment is provided.

     Emergency providers generally control bleeding through use of direct pressure, but some areas of the body can be difficult to access or apply pressure to. In this case, a tube was inserted and pressure applied using the balloon.

Jim Augustine, MD, FACEP, serves on the clinical faculty in the Department of Emergency Medicine at Emory University, Atlanta, GA. He also serves as Medical Director for the Atlanta Fire Department, which includes operations at Hartsfield-Jackson Atlanta International Airport. He has served 23 years as a firefighter and EMT-A, and is a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.