The patient’s vital signs at presentation were: heart rate, 98 beats/minute; blood pressure, 146/85 mm Hg; respiratory rate, 20 breaths/minute; and temperature, 98.6°F. Oxygen saturation was 96% on room air. The HEENT examination was unremarkable. Examination of the heart revealed a normal rate and regular rhythm with a grade of 1/6 systolic murmur, heard best at the left sternal border. The breath sounds were equal bilaterally and clear to auscultation; the abdominal examination was unremarkable. The patient had an AVF in his left forearm that was not actively bleeding. There was a palpable thrill and a bruit present on auscultation over the site; there was no increased warmth or drainage.
The EP ordered a complete blood count (CBC) on the patient. The hemoglobin and hematocrit levels were essentially unchanged from a previous CBC 1 month prior, and the platelet count was normal. After approximately 1 hour of observation in the ED, there was no rebleeding at the site, and the patient was discharged home.
Unfortunately, the bleeding resumed the following day. The patient went into cardiac arrest and died at home prior to arrival of emergency medical services. The patient’s family sued the EP and hospital for discharging the patient home without first obtaining a surgical consult. The EP and hospital settled the case with the family for $2 million.
Discussion
Many patients who present to the ED with bleeding from the vascular access site can be managed simply with direct pressure, typically for a minimum of 5 to 10 minutes. In more severe cases, the EP can apply direct pressure with an absorbable gelatin sponge (eg, Gelfoam). If the patient presents soon after completion of dialysis, the EP should consider heparin anticoagulation as the etiology. In such cases, the use of IV protamine should be considered. One milligram of protamine can reverse 100 units of heparin. Since typically 1,000 to 2,000 units of heparin are administered at dialysis, a dose of 10 to 20 mg of protamine IV should be sufficient to reverse bleeding.
Other strategies to control hemorrhage from the access site include the use of topical thrombin or an IV drip of desmopressin. Once bleeding has been controlled, the patient should be observed for a minimum of 1 to 2 hours in the ED. If the bleeding still cannot be controlled, emergent consultation with vascular surgery services is required. Placing a suture at the site, or the use of a tourniquet proximal to the access site, can be used as a temporary measure until the surgeon arrives. The disadvantage of applying direct pressure is that it can cause thrombosis within the fistula or graft. However, given the alternative, this is an acceptable risk.
It is unfortunate that this case settled because it does not appear that any malpractice was committed. Vascular surgeons do not come to the ED to see functioning, nonbleeding AVFs. There was no published information explaining why the patient experienced rebleeding 10 to 12 hours after the initial event (perhaps some minor trauma precipitated it). Even if this patient had been observed in the ED for 8 hours, he would not have experienced rebleeding in the ED, but the tragic outcome would remain the same.