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Twists and turns of "hematemesis" children
Written by | Li Wei
A while ago, we received a shocking newborn: it was only a small amount of vomiting blood, and there was no abnormality in other examinations, we thought it might have swallowed the mother's blood during childbirth, but we didn't expect the condition to deteriorate rapidly......
Case review: Admitted to hospital with "vomiting blood 1 time".
The patient was a male and was admitted to the hospital for 1 day with "vomiting blood once".
The child was admitted to the hospital with "vomiting blood once", and on the second day of birth, he showed symptoms of vomiting blood, non-projectile vomiting, the vomit was bright red blood, 1-2ml/time, the crying voice was slightly weak, no fever, convulsions, convulsions, irritability, moaning and other discomforts. Transferred from the outer hospital by 120, he was admitted to the department with "gastrointestinal bleeding?". Since birth, the child has generally been in good condition, poor feeding, poor sucking, low urine volume, and dark green paste in the stool. The family members reported that there were no special circumstances after their death.
Personal history: G3P3, 39+6w, 3100G, natural delivery in the outer hospital, apgar score 8-9-9. There was a small amount of bruising on the bridge of the nose, and the family members reported that the bridge of the nose collapsed after birth, and the father and grandmother pinched the bridge of the nose in order to show beauty.
Maternal pregnancy history: singleton, intrauterine distress: none, normal amniotic fluid volume, no umbilical cord around the neck, no placental abnormality.
Feeding history: Initiation time: 1st day after birth, artificial, small amount of feeding, 2 hours apart. The mother was in good health during pregnancy, and there was no pregnancy-induced hypertension syndrome and placenta previa.
Physical examination: T 37.0°C, P 140 beats/min, R 30 beats/min, BP 86/45mmHg; conscious, energetic, reactive, ruddy skin, no yellow staining, rash and hemorrhagic spots on the skin and mucous membranes of the whole body, normal breath sounds in both lungs, no obvious dry and wet rales. THE ABDOMEN IS SOFT, THE BOWEL SOUNDS ARE NORMAL, THE LIVER IS 1CM BELOW THE COSTAL MARGIN, THE UMBILICAL CORD HAS NOT FALLEN OFF, AND THE UMBILICAL CHAKRA IS NOT RED. The primordial reflex is incompletely elicited, and muscle tone may be.
Post-admission testing:
血常规：WBC 19.05×109/L、 RBC 5.58×1012/L、Hb 189g/L、PLT 265×109/L、CRP 1.80mg/L；
Six coagulation items: prothrombin time 20.4s, PT international normalized ratio 1.84↑, activated partial prothrombin time 49.6s↑, thrombin time 19.0s, fibrinogen 1.7g/L↓, plasma D-dimer determination 1.58mg/L↑, fibrin (pro)degradation product 8.90mg/L↑.
Figure 1: Abdominal x-ray was performed on admission and showed no obvious abnormalities
Diagnosis and treatment ideas
Vomiting of fresh blood or blood in the nasogastric tube or blood in the stool within 1 day of birth is often secondary to ingestion of maternal blood during delivery, and the vomit antialkali test can confirm the mother's Hb. The amount of vomiting blood in the child was small, and there was no obvious abnormality, so it was considered that the maternal blood may have been swallowed at birth, and the observation continued. Vitamin K1 is given to prevent bleeding, penicillin to prevent infection, and rehydration is given to support symptomatic treatment.
Abrupt change in condition: The child vomits a large amount of blood
Figure 2: The child suddenly vomited blood in large amounts
On the day of admission, at about 15:00, the child suddenly vomited a large amount of blood, bright red in color, accompanied by blood clots, about 30ml. Suction and lateral decubitus should be taken to prevent aspiration.
Several possibilities quickly crossed my mind: pulmonary bleeding, gastrointestinal bleeding?
HOWEVER, THE BREATH SOUNDS IN BOTH LUNGS WERE NORMAL, THE RETRACTION SIGN WAS NEGATIVE, NO OBVIOUS DRY AND WET RALES WERE HEARD, THE ABDOMEN WAS SOFT, THE BOWEL SOUNDS WERE NORMAL, 1 CM BELOW THE COSTAL MARGIN OF THE LIVER, AND THE BP WAS 85/48 MMHG. The status is obviously inconsistent with pulmonary bleeding and gastrointestinal bleeding, and is temporarily excluded.
Excluding the above, what are the other possibilities?
I quickly recalled the details of the consultation, and remembered that the patient's family said that they had squeezed the bridge of the child's nose, and the child had no obvious gastrointestinal bleeding.
I then ordered the child to be escorted to the otolaryngology department for nasal endoscopy, and sure enough, the nasal endoscopy showed that the left nasal cavity was bleeding from the olfactory cleft.
Figure 3: Nasal endoscopy showing bleeding from the left nasal olfactory fissure
After finding the cause of hematemesis, we immediately called for an otolaryngology consultation.
Otolaryngologist recommends the following:
In adults, electrocoagulation can be used to stop bleeding, nostril tamponade and other treatments, but neonatal nasal mucosis is delicate and delicate, electrocoagulation hemostasis may cause further damage to the nasal mucosa and aggravate bleeding, so electrocoagulation is not recommended to stop bleeding. However, it is important to note that newborns do not breathe through the mouth, and nostril packing can cause asphyxia.
Nasal endoscopy shows that the bleeding has stopped at this point, and eventually the otolaryngology department recommends that the paediatrician treat it first, and repeat the nasal endoscopy if necessary. After returning to the ward, vitamin K1 and hemostatic allergy were given intravenously. There was no further bleeding in the afternoon, and the nasal endoscopy was rechecked at 20:00, and there were no further nosebleeds under the nasal endoscopy.
Seeing this, you may have thought that this case was the end of the case, but after we were glad that there was no more bleeding on the nasal endoscopy, the child developed a large amount of blood in the stool......
The condition changed again: the child had a large amount of blood in the stool
Figure 4: Massive blood in the stool
At about 21:40, the child had a large amount of bloody stool, and while I was frightened, my brain had already begun to automatically investigate the cause of the bleeding: Considering the bleeding in the nasal olfactory cleft area?
Urgent blood pressure was measured at 76/35mmHg, CRT>=3S, and bleeding spots appeared at the site of the child's indwelling needle and skin, considering that the child may have a large amount of bleeding and coagulation mechanism disorders caused by the consumption of coagulation factors, the normal saline was immediately expanded with 10ml/kg, and the blood pressure was 85/46mmHg after expansion, and the child's other vital signs were stable, and blood pressure, CRT, etc. were regularly monitored, and DIC, blood routine, electrolytes and other conditions were urgently checked at the same time.
Soon, the results of the inspection returned:
Figure 5: Stool routine
Red blood cells, hemoglobin, and platelets after admission:
You can only choose one of the two for checking and matching blood!
After the child has a large amount of blood in the stool, blood is drawn to urgently check the DIC, blood routine, electrolytes, etc., and at the same time apply to the blood bank for transfusion of red blood cells, fresh frozen plasma or cryoprecipitate.
However, the neonatal situation is special, the child was admitted to the hospital had a blood draw for relevant examinations, and now there are two major bleeding, it is not easy to draw blood, the nurse has made many efforts, only two tubes of blood are drawn;
After communicating with the family, the family agreed not to do the examination for the time being, and the blood was matched first, but at this time, the news came from the blood bank that the blood bank was short of blood, and there was no cryoprecipitate for the time being, and unless the hemoglobin was lower than 70g/L, there were no red blood cells, and only 20ml/kg of fresh frozen plasma was given first.
Fortunately, after the infusion of fresh frozen plasma, the child's bleeding symptoms gradually improved, and the next day the fresh frozen plasma was transfused again 20ml/kg.
However, due to the shortage of blood in the blood bank, red blood cells could not be obtained, so he was given daily infusion of iron sucrose, and was discharged from the hospital after 5 days, and was instructed to take oral iron after discharge and have regular reexaminations.
Case Thinking: Don't Pinch the Bridge of the Newborn's Nose Casually!
According to the literature inquiry, the nasal olfactory cleft area is one of the common bleeding sites of refractory nosebleeds, mostly paroxysmal arterial hemorrhage, with the characteristics of concealed location, large amount of bleeding, and fierce bleeding, such as accompanied by nasal septum deviation, middle turbinate gasification and other abnormal nasal anatomical structures, which will lead to the bleeding site is difficult to see, compression and hemostatic bleeding, repeated bleeding can easily cause bleeding and hemorrhagic shock in patients, in this case neonatal nasal losif area injury is massive bleeding.
Neonatal nosebleeds are rare, and neonatal nosebleeds and neonatal nasal cleft bleeding were searched on Wanfang Medical Network, but the system did not retrieve relevant records. However, the nasal bone of newborns is fragile, and it is easy to bleed heavily when encountering injuries, and otolaryngology treatment is more difficult than that of adults, so the best way to prevent external injury of newborns is to publicize to parents in advance in conjunction with pediatric obstetrics, and do not pinch the bridge of the newborn's nose, squeeze the breast, tie the horse teeth and other dangerous behaviors to avoid accidental injury.
The nasal bone development of newborns is weak, and in the case of injury, DR, CT and other imaging imaging are poor, and simple imaging examination is easy to misdiagnose. If nasal injury is suspected, multidisciplinary consultation should be invited in time, specialist treatment should be actively sought, and nasal endoscopy and other specialized examinations should be performed to identify the location of the injury and guide subsequent treatment.
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Bibliography:
[1], Li Yanli, Liu Xuebing, Ma Wei. Clinical diagnosis and treatment analysis of 53 cases of nosebleeds in olfactory cleft area [J]. Chinese Journal of Modern Medicine,2017,19(02):63-64.
[2], Xu Ting, Wang Xingwei, Xie Donghua. Analysis of some causes of refractory epistaxis[J]. Chinese Journal of Otolaryngology Skull Base Surgery,2010,16(02):128-130.
Practical neonatology[M].People's Medical Publishing House.599-602.
Editor in charge: Xiang Yu
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