CAA205: Medical Emergencies for Out-of-Hospital Practice Assignment

This case study analyzes a 62-year-old female patient presenting with lethargy, shortness of breath, abdominal cramping, and loose bowel movements, indicative of a lower GI bleed. The report delves into the aetiology and pathophysiology of the condition, exploring potential causes like osteoarthritis, NSAID use, and diverticulosis, and their impact on the patient's symptoms. The clinical assessment section examines the patient's history, vital signs, and symptoms, highlighting the reasoning behind the clinical diagnosis and the significance of findings like tachycardia, pallor, and dizziness. It also covers the importance of assessing the patient's oxygen saturation level, haemoglobin level, and the need for fluid resuscitation. Finally, it discusses the paramedic's management of the condition, including initial risk assessment, monitoring of vital signs, and the use of interventions such as oxygen therapy, fluid resuscitation, and pharmacological interventions. The document emphasizes the importance of understanding the causes of dyspnea, assessing the patient's haemoglobin level and oxygen saturation, and employing appropriate interventions to stabilize the patient before transfer for further evaluation.

Medical Emergencies for Out-of-Hospital Practice
Medical Emergencies for Out-of-Hospital Practice
Name of the Student
Name of the university
Author’s note

1Medical Emergencies for Out-of-Hospital Practice
Introduction (150)
The case scenario centres round a 62 years old female, whose main complaint was
lethargy and shortness of breath. She had explained that she had been experiencing abdominal
cramping and mild distension for the past few weeks. She was having loose bowel movement
and had been feeling dizzy and breathless. She was having a past history osteoarthritis. She had
been a chain-smoker and a social drinker, although she had claimed that she does not have
affinity towards drugs and alcohol. All the vital signs and the symptoms, indicated towards lower
GI tract bleeding.
This report aims to provide an account of the aetiology and the pathophysiology of the
condition, the clinical reasoning based upon the assessment made, clinical assessment and
decision making and finally the paramedics management of the condition.
Aetiology and pathophysiology 500
The case study presents that patient B had been suffering from shortness of breath plus
additional discomfort with some cramping in the abdominal region. However, there are several
reasons for experiencing shortness of breath, GERD can also cause shortness of breath, as the
acid creeping in the oesophagus might enter the lungs, especially at the time of sleep. It can
cause swelling in the airways and can cause breathing problems (1). Acute GIT bleeding can be
defined as that taking place from the colon , rectum or the anus and presenting as either
hematochezia or the melena, having an annual prevalence of hospitalization of about 36/1000,0
population. There are several causes of GIT bleeding. Some of the common causes for GIT

2Medical Emergencies for Out-of-Hospital Practice
bleeding are haemorrhoids, peptic ulcers, inflammation or tear in the oesophagus, diverticulosis
or diverticulitis and ulcerative colitis. Elderly patients having osteoarthritis have a heightened
risk of developing serious gastrointestinal events like gastrointestinal bleeding. The non-
steroidal anti-inflammatory drugs that are used in case of Osteoarthritis can be an important risk
factor for lower GIT bleeding. A meta-analysis have revealed that NSAIDs has contributed to the
development of mucosal injury. The complications involve bleeding, perforation and obstruction
(2). Lower GIT bleeding can be defined as three types of bleeding activity, occult, rapid and
slow bleeding. It can be assumed that the patient is suffering from slow bleeding, which can
finally lead to chronic hemodynamic loss. The oxygen delivery in the body can be further
compromised due to the chronic occult blood loss. They delivery of the oxygen can be further
challenged by the acute reduction in the cardiac output causing followed by a diminished
intravascular volume, ultimately leading to a compensatory increase of the heart rate. Restoration
of the Plasma volume might take many days before the homeostasis can be restored (3). Bleeding
might also takes place from colonic diverticula, consisting of the mucosa and serosa. They are
generally formed in the area of structural weakness in the wall of the colon, where the vasa recta
tends to penetrate through the mucolaris for supplying the mucosa (4). Small bowel
inflammatory disease can cause melena. Bleeding in these disorders is mainly caused by single
or multiple ulcerations.
Clinical assessment reasoning (800)
It is evident from the case study, that the concerned patient is a 62 years old female,
having a chief compliant of shortness of breath. It has been stated that the patient had been
suffering from osteoarthritis. Osteoarthritis can cause scarring within the lungs due to long term
inflammation causing shortness of breath, fatigue, dry cough, loss of appetite and weakness. The

3Medical Emergencies for Out-of-Hospital Practice
medicines taken for osteoarthritis might be the reason for the gastrointestinal bleeding (4).
Again, it has also been found that older adults with osteoarthritis after a standardised physical
activity has produced an increasing fatigue. Blood loss in the gastrointestinal tract the can cause
iron loss during the exercises (5). Sometimes, patients with lower GIT bleeding might not
display, abdominal pain, but abdominal cramping might occur due to the inflammation of the GI
tract. Inflammation of the GIT tract might cause diarrhoea. Inflammation in the can affect the
transit time of the bowel allowing the food to pass more quickly and allowing for less absorption
time for the absorption of water, causing a watery stool. Black, tarry stool refers to melena,
which indicates gastrointestinal bleeding. Again, the chance of Hematochezia cannot be
discarded and can indicate lower GIT bleeding. If a patient develops anaemia due to chronic
bleeding. Patients might feel tired or fatigued due to internal bleeding. It has been stated that GIT
bleeding for a prolonged period of time might go unnoticed and can cause fatigue. In an anaemic
condition, the body lacks enough healthy red blood cells for carrying adequate oxygen to the
body tissues. Having anaemia can make a person exhausted, especially after an exercise (6).
Oxygen deficiency in the brain can cause dizziness in elderly patients as the blood vessels in the
brain might swell causing pressure and headaches. The vital signs of the patient shows an
increased rhythm (tachycardia) of heart. Increased rhythm of heart is due to the reason that the
heart pumps more to keep up with the high oxygen demand. Tachycardia generally increases
with increase loss of blood, since the heart has to pump more vigorously to keep up with the
oxygen demand. The heart rate in the standing position is a bit higher than the normal heart rate,
which can indicate towards any sort of bleeding like rectal bleeding of GI tract bleeding. This is
due to the rapid pumping of the heart. It should be mentioned that hypovolemia due to GIT
bleeding can also show pallor and greater capillary refill time (7). Anaemia due to GIT bleeding

4Medical Emergencies for Out-of-Hospital Practice
can cause increased pallor, that is pale colour of the skin due to the reduce amount of oxy-
haemoglobin and pallor can also be visible in the conjunctivae of the eyes on physical
examination of the patient. Pallor can be more evident in the face and the palms. It should be
kept in mind that pallor is not a symptoms of mild anaemia, but can be used in the detection of
severe anaemia. This shows that the patients had been suffering from acute anaemia, due to
lowed GIT bleeding. Palmer crease pallor generally remains within the ratio of 7.9 for the
diagnosis of anaemia, increasing the post-test chance of anaemia (8). Presence of a palmer pallor
in the eyes, hands and the mucosa should prompt the physician to send the patients for a compete
blood count for the other diagnosis of anaemia. However, conjunctival pallor has been noted to
have been appearing more frequently in patients having severe anaemia and hence should be
sensitive than the other signs. Paleness and cool skin can be due to the reduced flow of blood or
by a decreased number of red blood cells. Anaemia due to GIT bleeding can be associated with
the dry mouth symptoms like atrophic glossitas and burning mouth. It has been found from the
animal models that iron deficiency anaemia has been associated with lower salivary peroxidase.
Thus the saliva secretion rate is decreased due to the symptoms of anaemia (9). Thus dry oral
mucosa in the patient can be because of the anaemia present. Poor skin turgor is present due to
dehydration or due to moderate or severe blood loss. It is evident from the case study, that the
patient was having loose bowel for some days. Diarrhoea can cause fluid loss leading to less skin
turgor. Again, the case study has revealed, that the patient suffered from abdominal distension,
which is common in patients having inflammatory disease in the abdomen. They display some
recurrent symptoms of bloating. The pathophysiology of bloating remains ambiguous, although
some of the evidences the supports the potential mechanism including the hypersensitivity of the
gut (10). Some of the important risk factor for gastrointestinal bleeding can be drugs, unhealthy

5Medical Emergencies for Out-of-Hospital Practice
lifestyles. Cigarette smoking is a risk factor for the development of gastrointestinal disorders like
Crohn’s disease and peptic ulcer. The composition of the cigarette is a complex molecular
composition. The harmful component present in cigarette smoke such as the carbon monoxide
the and light aldehyde and several other compounds like nicotine, polycyclic aromatic
compound, heavy metals and nitrosamines are found in the particulate state (11). They are
absorbed by the mucous membrane, alveoli, skin and gastrointestinal system. It has been alos
found that chronic inhalation of cigarette smoke has been found to be associated with
proliferation of the cell, enhanced immune response and altered endothelial function. About 60
mutagenic and carcinogenic compounds have been found in cigarette smoke, causing the chance
of inflammation. The oxidative stress caused by the compounds causes’ tissue damage leading to
inflammation of the gastro-intestinal tract (11). It should be noted that the patient had been under
iron tablets to deal with chronic anaemia. But, it should be noted that St. John’s Worts are not
taken under any sort of prescriptions, which can have negative impact on her health. The patient
is elderly and entirely relies upon pension and hence, the scope cannot be discarded that he often
misses her medicines also does not follow a healthy diet. There are special recommended diets
that the can be followed during gastrointestinal bleeding and bloating. It is necessary to have
small meals more often till the digestive system health (12). It is necessary to avoid caffeine or
spicy food and food that causes nausea, hurt burn or diarrhoea needs to be avoided.
Clinical management and decision making
It is necessary to understand the causes of dyspnoea in the pre-hospital period, in order to
rule out differential diagnosis of the dyspnoea, as difficult breathing or shortness of breath can be
caused by a respiratory and cardiac disorders (13). After assessing the airways, it is necessary for
the paramedics team to assess the haemoglobin level of the patient, as the patient displayed

6Medical Emergencies for Out-of-Hospital Practice
pallor and lethargy, dizziness, that indicates towards severe anaemia. Paramedics should also
measure the oxygen saturation level of the patient, as in the case of pulmonary the complications,
it is the oxygen saturation level, that is generally compromised , as there remains a chance of
hypoxia, where additional supplementation of oxygen are required (14). In case of hypervolemia,
the paramedics team should ensure that the patient receives fluid resuscitation. Pharmacological
interventions like vasoactive agents and antibiotics can be given in case of GI tract bleeding,
together with the evidence on the use of gastrointestinal bleeding (15).
Discussion of the paramedic management 400
The initial management is the evaluation of risk and the stratification of the risk. History
taking, physical examination, and laboratory examination needs to be obtained at the time of the
presentation of the patients for assessing the intensity of the bleeding. It is necessary to monitor
the haemoglobin levels . It is also necessary to monitor the heart rate as of blood pressure might
become lower and hypotension can shunt the passage of blood to the vital organs. In case the
patient becomes hypotensive, they can be positioned in the reverse tredelenburg position (16). In
case of occult bleeding, blood products can be given. A 12 lead ECG is required; as having low
blood volume will definitely affect cardiovascular health. In case the patient becomes
hemodynamically instable should be able to receive intravenous fluid resuscitation with the goal
of normalising the blood pressure and the heart rate, before the patient is being transferred for an
endoscopic intervention and evaluation (17). There is an in-office test that can be performed,
known as the haemoglobin rapid test that can be performed using a few drops of blood obtained
from a finger prick. The advantage of this test is that it can be obtained within a few minutes and
only a drop of blood is required. Secondly, it is necessary to assess for the presence of any

7Medical Emergencies for Out-of-Hospital Practice
comorbidities. The current pharmacology treatments needs to be considered (18). The physical
examination should include the measurement of the vital signs including the postural changes.
In order to restore a normal breathing pattern, the patient can be positioned in such a way
to facilitate airway and lung expansion. The patient can be encourages to take some sustained
deep breaths, highlighting slow inhalation, holding end inspiration for a few seconds, needing the
patient to yawn. In case the patient is in shock, the paramedics staffs can initiate fluid
resuscitation for maintain perfusion. Large bore, short length catheters needs to be used or
delivering the volume quickly (19). 500 mL of normal saline solution or lactated Ringer’s
solution over 30 minutes need to be given to the patient. However, the rate of the resuscitation
will depend on whether the patient is thermodynamically unstable. Reduced blood volume might
need oxygenation and oxygen can be supplemented by the help of nasal cannula. Oxygen can
also be provided using simple mask. Two large calibre (19 gauze) peripheral intravenous
catheters or central venous line needs to be inserted. In case the patients who are
hemodynamically stable, two 16 gauze intravenous catheters can be given. In case the
haemoglobin level becomes too low, blood transfusions can be given. The haemoglobin needs to
be maintained at greater than 8g/dL (20). It is necessary to assess whether the patient requires an
intubation. While mobilising the elderly patient, the paramedics’ workers should take appropriate
measures at the time of ambulation. Patient should be moved to the emergency triage for
automated blood pressure monitoring, electrocardiograph, Glasgow Blatchford score in order to
take necessary actions.

8Medical Emergencies for Out-of-Hospital Practice
Conclusion (150)
The Paramedics are the first line of contact during any emergency clinical condition. It is
evident from the case scenario that the patient had been suffering from anaemia, due to a lower
GIT bleeding. The patient is suffering from shortness of breath and chest tightness and often
feels lethargic to do any task. The pallor in her hands and the conjunctiva, and clearly indicates
towards anaemia. Again, abdominal cramping can be due to the inflammation in the GI tract.
Tarry and black stools indicated GI tract bleeding. Hence initially, it is to understand whether the
patient had been suffering from hypovolemia or if the oxygen saturation of the patient is too low
to get oxygen supplementation. Fluid resuscitation might be necessary to maintain hydration, as
the patient was suffering from loose bowel. Accordingly, intravenous fluids can be given to
maintain hydration and tissue perfusion. Lastly, the paramedics workers should try to consult a
physician as soon as possible.

9Medical Emergencies for Out-of-Hospital Practice

10Medical Emergencies for Out-of-Hospital Practice
References
1. Amin SK, Antunes C. Lower gastrointestinal bleeding.
2. Sostres C, Gargallo CJ, Lanas A. Nonsteroidal anti-inflammatory drugs and upper and lower
gastrointestinal mucosal damage. Arthritis research & therapy. 2013 Jul;15(3):S3.
3. Lanas, Angel. “A review of the gastrointestinal safety data--a gastroenterologist's
perspective.” Rheumatology (Oxford, England) vol. 49 Suppl 2,Suppl 2 (2010): ii3-10.
4. Stein J, Connor S, Virgin G, Ong DE, Pereyra L. Anemia and iron deficiency in
gastrointestinal and liver conditions. World journal of gastroenterology. 2016 Sep
21;22(35):7908.
5. Kim SH, Yun JM, Chang CB, Piao H, Yu SJ, Shin DW. Prevalence of upper gastrointestinal
bleeding risk factors among the general population and osteoarthritis patients. World journal of
gastroenterology. 2016 Dec 28;22(48):10643.
6. de Oliveira EP, Burini RC, Jeukendrup A. Gastrointestinal complaints during exercise:
prevalence, etiology, and nutritional recommendations. Sports Medicine. 2014 May 1;44(1):79-
85.

11Medical Emergencies for Out-of-Hospital Practice
7.Gaiani F, De'Angelis N, Kayali S, et al. Clinical approach to the patient with acute
gastrointestinal bleeding. Acta Biomed. 2018;89(8-S):12–19. Published 2018 Dec 17.
doi:10.23750/abm.v89i8-S.7861
8. Manesh RS, Kohlwes RJ. Palmar Crease Pallor. J Gen Intern Med. 2015;30(7):1034.
9. Mohammed AA. Update knowledge of dry mouth-A guideline for dentists. African health
sciences. 2014;14(3):736-42.
10. Seo AY, Kim N, Oh DH. Abdominal bloating: pathophysiology and treatment. J
NeurogastroenterolMotil. 2013;19(4):433–453.
11. Berkowitz L, Schultz BM, Salazar GA, et al. Impact of Cigarette Smoking on the
Gastrointestinal Tract Inflammation: Opposing Effects in Crohn's Disease and Ulcerative Colitis.
Front Immunol. 2018;9:74. Published 2018 Jan 30.
12. Brethauer SA, Chang J, Neto MG, Greve JW. Gastrointestinal devices for the treatment of
type 2 diabetes. Surgery for Obesity and Related Diseases. 2016 Jul 1;12(6):1256-61.
13. Akin S, Ergin E, Kazan S, et al. Assesment of the patients presenting with severe anemia to
the emergency internal medicine clinic. North Clin Istanb. 2014;1(2):84–88. Published 2014 Dec
8.
14. Gomez MF, Aljure O, Ciancio G, Lynn M. Hemoglobin‐Based Oxygen Carrier Rescues
Double‐Transplant Patient From Life‐Threatening Anemia. American Journal of Transplantation.
2017 Jul;17(7):1941-4.

12Medical Emergencies for Out-of-Hospital Practice
15. Lam KL, Wong JC, Lau JY. Pharmacological treatment in upper gastrointestinal bleeding.
Current Treatment Options in Gastroenterology. 2015 Dec 1;13(4):369-76.
16. Petrov A, Kinsky M, Prough DS, Petrov Y, Petrov IY, Henkel SN, Seeton R, Salter MG,
Khan MN, Esenaliev RO. Optoacoustic monitoring of central and peripheral venous oxygenation
during simulated hemorrhage. InPhotons Plus Ultrasound: Imaging and Sensing 2014 2014 Mar
3 (Vol. 8943, p. 894336). International Society for Optics and Photonics.
17. Astin R, Puthucheary Z. Anaemia secondary to critical illness: an unexplained phenomenon.
Extreme physiology & medicine. 2014 Dec;3(1):4.
18. Strate LL, Gralnek IM. ACG Clinical Guideline: Management of Patients With Acute Lower
Gastrointestinal Bleeding [published correction appears in Am J Gastroenterol. 2016
May;111(5):755]. Am J Gastroenterol. 2016;111(4):459–474.
19. Gralnek IM, Neeman Z, Strate LL. Acute lower gastrointestinal bleeding. New England
Journal of Medicine. 2017 Mar 16;376(11):1054-63.
20. Duan C, Li T, Liu L. Efficacy of limited fluid resuscitation in patients with hemorrhagic
shock: a meta-analysis. International journal of clinical and experimental medicine.
2015;8(7):11645.