Haematemesis

First of all, call for help. You cannot manage an emergency alone—it involves teamwork. Call for help and involve your seniors. Second, this patient has potentially lost a lot of blood. Start with ABCDE—Airway, Breathing, Circulation, Disability, Exposure. Airway: Ensure it is patent. Can he talk? Is there any gurgling or stridor? Beware of blood in the oropharynx in a patient with haematemesis. If necessary, use suction to remove the blood. Breathing: Are there any signs of respiratory distress (tachypnoea, use of accessory muscles, low saturations)? Circulation: Does he have a pulse? Is he in shock (tachycardia, narrow pulse pressure, hypotension, cold peripheries)? Disability: what is the patient’s Glasgow Coma Score (GCS)? Always calculate this in an emergency as a GCS ≤8 (or rapidly dropping towards that point) suggests that the patient may soon require intubation to protect their airway. If you can’t remember the components of a GCS in an emergency, use the AVPU score (patient is Alert, responds to Voice, responds to Pain or is Unresponsive), where an avPu score (i.e. a patient who is responding to painful stimuli but not voice) is roughly equivalent to a GCS = 8. Exposure: The patient may have suffered multiple trauma and/or have various sites of blood loss. Although it is unlikely, what the hostel staff perceived as drunken behaviour may in fact represent behaviour from an unwitnessed assault resulting in significant head injury, and the haematemesis may reflect a stab wound to the chest or abdomen. Always expose the patient or you will be caught out by unsuspected findings. Mr Tucker is in shock, often defined as a BP <90/60 mmHg. He needs fluid resuscitation: • Apply high flow oxygen (15 L/min). • Get intravenous (IV) access: insert a large-bore (14G–16G) cannula and if you can’t do it yourself, ask a senior to help. They may need to resort to ultrasound-guided peripheral vascular access, to intraosseus access or to central venous access. • Send bloods for: ■ Venous blood gas: this will give you a rapid estimate of the patient’s haemoglobin.