EMS Medical Terminology - Mallory-Weiss Syndrome

Mallory-Weiss Syndrome is a condition characterized by a tear in the mucous membrane of the lower esophagus or upper stomach, typically caused by severe vomiting or retching. It is an example of an eponymous medical term.

Mallory-Weiss Syndrome was first described in 1929 by George Kenneth Mallory and Soma Weiss, two American physicians at Boston City Hospital. They documented the condition in patients who had experienced upper GI bleeding following severe vomiting. 

Their work highlighted the mucosal tears at the gastroesophageal junction and led to the eponymous naming of the syndrome.

Unlike Boerhaave Syndrome, where the esophagus ruptures completely, Mallory-Weiss Syndrome involves only a partial tear of the mucosal layer. 

This condition is associated with upper gastrointestinal (GI) bleeding and is often self-limiting but can occasionally lead to significant hemorrhage.

Causes and Pathophysiology

Triggered by Severe Vomiting: The syndrome often occurs after repeated vomiting or retching episodes, usually related to alcohol intoxication, eating disorders, or acute gastroenteritis.

Other Causes: Coughing, lifting heavy objects, trauma, convulsions, or anything that increases intra-abdominal pressure.

Pathophysiology: The increased pressure from vomiting causes a longitudinal tear at the gastroesophageal junction, leading to bleeding.

Signs and Symptoms

Patients with Mallory-Weiss syndrome may present with:

• Hematemesis: Vomiting of bright red blood or "coffee-ground" emesis. A hallmark symptom.
• Melena: Black, tarry stools due to digested blood.
• Epigastric or Retrosternal Pain: Pain located in the upper abdomen or chest, which may be mistaken for other conditions like myocardial infarction.
• Signs of Hypovolemia: If bleeding is severe, look for signs such as dizziness, hypotension, pallor, and tachycardia.
• History of Severe Vomiting: Often after binge drinking or an illness causing repeated retching.

EMS Recognition and Prehospital Treatment

Patient Assessment Priorities:

• History Taking: Ask about recent vomiting, alcohol use, or illnesses that might have led to repeated retching.

Inquire about the color and amount of vomitus. Bright red blood is more suggestive of active bleeding, while coffee-ground emesis suggests older blood.

Determine any history of GI bleeding or relevant medical conditions (e.g., peptic ulcer disease, cirrhosis).

• Physical Examination: Assess for signs of hypovolemic shock: tachycardia, hypotension, altered mental status, and pallor.

Perform an abdominal exam to check for tenderness, guarding, or distension.

Check for melena, if possible.

• Differential Diagnosis: Always differentiate MWS from other causes of hematemesis or epigastric pain:

• Peptic Ulcer Disease
• Esophageal Varices (often linked to liver disease)
• Gastric Ulcers or Malignancies
• Boerhaave Syndrome

Patient Management Priorities:

• Airway Management: Ensure the airway is clear. Patients actively vomiting blood are at risk of aspiration.

Position the patient to prevent aspiration (e.g., left lateral recumbent position).

• Circulatory Support: Establish IV access and administer IV fluids (normal saline or lactated Ringer’s) if the patient shows signs of shock.

Monitor for worsening hemodynamic instability.

• Minimize Further Trauma: Advise the patient to avoid any further vomiting, coughing, or retching as it can exacerbate the tear.

Keep the patient NPO (nothing by mouth) to prevent further irritation.

Treat Nausea and Vomiting: If protocols allow, consider administering antiemetics (e.g., ondansetron) via IV to prevent further vomiting, which could worsen the tear.

• Oxygen Therapy: Administer oxygen if the patient has signs of hypoxemia or shock.

• Monitor: Continuously monitor vital signs, including heart rate, blood pressure, and mental status.

• Rapid Transport: Rapid transport to a hospital with endoscopy capabilities is crucial, as definitive diagnosis and management (e.g., endoscopic hemostasis) often require specialist care.

Key Considerations for EMS

• Monitor for Signs of Shock: Patients can quickly decompensate, especially if bleeding is significant.

• Avoid Overly Aggressive Fluid Resuscitation: While fluids are necessary to stabilize blood pressure, overloading can increase bleeding.

• Rapid Transport to Definitive Care: Most Mallory-Weiss tears are diagnosed and treated via endoscopy.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

Rawla, P., Devasahayam, J. (2023) Mallory-Weiss Syndrome. StatPearls  Treasure Island, Florida: StatPearls. Accessed September 20, 2024

Turner, A. R., Collier, S. A., & Turner, S. D. (2023) Boerhaave Syndrome. Treasure Island, Florida: StatPearls. Accessed September 14, 2024

EMS Airway Emergencies - Esophageal Varices

Esophageal Varices are abnormally dilated veins in the lower part of the esophagus that develop as a result of portal hypertension, commonly due to liver cirrhosis. 

These varices pose a high risk of massive upper gastrointestinal (GI) bleeding, which can be life-threatening. 

When esophageal varices rupture, they can cause severe hematemesis (vomiting of blood), shock, and potentially death if not managed promptly.

Causes and Pathophysiology

- Portal Hypertension: The most common cause of esophageal varices is liver cirrhosis (often due to chronic alcohol use, hepatitis B or C, or fatty liver disease).

Portal hypertension occurs when the liver becomes scarred and obstructs blood flow, leading to increased pressure in the portal venous system.

- Collateral Circulation Formation: To relieve this increased pressure, the body forms collateral blood vessels (varices) in the esophagus and stomach. These varices are thin-walled and prone to rupture.

- Rupture and Hemorrhage: When pressure becomes too high or if the varices are mechanically disrupted (e.g., vomiting, coughing), they can rupture, leading to severe bleeding.

Signs and Symptoms of Esophageal Variceal Bleeding

EMS providers should be alert for the following symptoms in patients with a known history of liver disease or portal hypertension:

- Profuse Hematemesis: Patients often present with large volumes of bright red blood in vomit, which is the hallmark sign of a ruptured varix.

- Melena or Hematochezia: Blood may pass through the GI tract and present as black, tarry stools (melena) or bright red rectal bleeding (hematochezia), depending on the speed and severity of the bleed.

- Hypovolemic Shock: Tachycardia and hypotension are common signs. Cool, clammy skin, altered mental status, and pallor indicate worsening shock.

- Signs of Liver Disease: 

• Jaundice (e.g., yellowing of the skin and eyes)
• Ascites (e.g., swollen abdomen due to fluid accumulation)
• Spider Angiomata (e.g., visible, web-like blood vessels on the skin)
• Hepatic Encephalopathy (e.g., confusion, altered consciousness)

Prehospital Assessment

- Scene Size-Up and Initial Impression: Evaluate the scene for large amounts of blood, which can indicate massive hemorrhage.

Assess for a patient history of liver disease, alcoholism, or known cirrhosis.

- Airway & Breathing: Monitor for airway obstruction due to blood in the mouth or pharynx.

Be prepared to suction the airway frequently to prevent aspiration.

Assess respiratory status and provide high-flow oxygen if needed.

- Circulatory Assessment: Check for signs of shock (e.g., tachycardia, hypotension).

Establish large-bore IV access (18 gauge or larger) for potential fluid and medication administration.

Monitor mental status and skin condition (pallor, coolness).

- Focused History & Physical Exam: Ask about the patient’s history of liver disease, alcohol use, hepatitis, or prior variceal bleeding.

Inquire about recent triggers (e.g., vomiting, straining, recent alcohol binge) that may have precipitated bleeding.

Prehospital Treatment and Management

Managing esophageal varices in the prehospital setting is challenging and requires prompt, aggressive intervention to control bleeding and prevent shock.

1. Airway Management

- Suctioning: Keep a suction device readily available for continuous use to clear the airway of blood.

- Airway Positioning: Consider placing the patient in the left lateral recumbent position if unconscious to reduce the risk of aspiration.

- Definitive Airway: If the patient is at risk of losing their airway (e.g., massive hematemesis or altered mental status), consider early endotracheal intubation, if within your scope and if protocols allow.

2. Hemodynamic Support

- IV Fluid Resuscitation: Establish two large-bore IVs and begin fluid resuscitation with isotonic crystalloids (e.g., normal saline) if the patient shows signs of hypovolemic shock.

Avoid aggressive fluid overload, as it can increase portal hypertension and worsen bleeding.

- Blood Products: If available (e.g., in critical care transport), consider initiating blood transfusion early in patients with significant bleeding or hemorrhagic shock.

3. Medications

- Vasoactive Agents (for ALS Providers): If within your scope and protocol, consider octreotide or vasopressin, which can reduce portal pressure and control variceal bleeding (requires medical control consultation).

- Anti-Emetics: Administer antiemetics (e.g., ondansetron) to prevent retching and reduce the risk of worsening the variceal tear.

4. Rapid Transport and Early Notification

- Transport Priority: All patients with suspected variceal bleeding should be considered critical and require rapid transport to the nearest facility with endoscopic capabilities and surgical backup.

- Early Notification: Notify the receiving hospital as early as possible about the suspected diagnosis, so the facility can mobilize appropriate resources.

Differentiating from Other GI Bleeds

- Peptic Ulcer Disease: Often presents with coffee-ground emesis and less profuse bleeding.

- Mallory-Weiss Syndrome: Similar to varices but generally involves small, non-life-threatening mucosal tears with moderate bleeding.

- Gastric Cancer or Erosive Gastritis: May have chronic, low-volume bleeding rather than acute hemorrhage.

Who Discovered Esophageal Varices?

Esophageal Varices themselves are not attributed to a specific individual. They were gradually recognized as a consequence of portal hypertension in patients with liver disease, a concept that evolved over centuries of clinical observation. 

The condition was first described in detail in the early 20th century, as the understanding of cirrhosis and portal hypertension advanced. 

The development of endoscopy in the mid-20th century allowed for more precise diagnosis and management of this life-threatening condition.

Key Considerations for EMS Providers

- Early Recognition: Suspect esophageal varices in any patient with massive hematemesis and a history of liver disease or alcohol abuse.

- Airway Safety: Suctioning and airway management are critical to prevent aspiration.

- Shock Management: Focus on maintaining perfusion with controlled fluid resuscitation.

- Definitive Treatment is Hospital-Based: EMS management is primarily supportive, with rapid transport to a facility that can perform endoscopy and possible surgical interventions.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Meseeha, M., & Attia, M. (2023) Esophageal Varices. StatPearls. Treasure Island, Florida: StatPearls. Accessed September 28, 2024

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS Gastrointestinal Emergencies - Particular Patient Presentations

In the realm of emergency medical service provision, encountering gastrointestinal emergencies is not uncommon. From gastrointestinal bleeding to acute appendicitis, EMS Providers must be prepared to assess, manage, and provide timely intervention for these critical conditions. Understanding the signs, symptoms, and underlying causes of such emergencies is essential for swift and effective patient care.

Here are some examples of gastrointestinal emergencies an EMT might encounter:

Gastrointestinal Bleeding:

Signs and Symptoms: Hematemesis (vomiting blood), Melena (black, tarry stools), Hematochezia (bright red or maroon-colored stools), weakness, lightheadedness, and abdominal pain.

Examples: Peptic ulcers, Esophageal varices, Gastritis, Diverticulosis, colorectal cancer.

Appendicitis:

Signs and Symptoms: Right lower quadrant abdominal pain, nausea, vomiting, low-grade fever, rebound tenderness.

Example: Inflamed or infected appendix.

Gastroenteritis:

Signs and Symptoms: Diarrhea, vomiting, abdominal cramps, fever, dehydration.

Example: Viral or bacterial infection of the gastrointestinal tract.

Bowel Obstruction:

Signs and Symptoms: Abdominal pain and distension, nausea, vomiting (may be feculent), constipation, inability to pass gas.

Example: Blockage of the intestines, often due to adhesions, hernias, or tumors.

Pancreatitis:

Signs and Symptoms: Severe abdominal pain radiating to the back, nausea, vomiting, abdominal tenderness.

Example: Inflammation, often due to gallstones or excessive alcohol consumption.

Cholecystitis:

Signs and Symptoms: Right upper quadrant pain, nausea, vomiting, fever, tenderness.

Example: Inflammation of the gallbladder, often due to gallstones.

Diverticulitis:

Signs and Symptoms: Left lower quadrant abdominal pain, fever, nausea, change in bowel habits.

Example: Infection or inflammation of small pouches (diverticula) in the colon.

Gastrointestinal Perforation:

Signs and Symptoms: Sudden, severe abdominal pain, rigid abdomen, guarding, rebound tenderness.

Example: A hole or tear in the gastrointestinal tract, often due to trauma or ulceration.

Gastrointestinal (GI) emergencies pose significant challenges for EMS Providers in the field and can vary widely in terms of severity and presentation. Whether managing cases of GI bleeding or identifying and responding to appendicitis, quick and accurate assessment is essential for ensuring positive patient outcomes.

EMS Providers should follow local assessment protocols and communicate effectively with the receiving facility to ensure the best possible care for the patient. Additionally, maintaining good infection control practices and ensuring proper hygiene is essential when dealing with gastrointestinal emergencies, as many are infectious in nature.

By familiarizing themselves with the signs, symptoms, and potential causes of these emergencies, EMS providers can better navigate these critical situations and provide timely and effective care to those in need.