At the University of Miami game you come across a 62 year old male who got hit in the chest by an angry fan swinging a football helmet. A trauma patient with chest pain, JVD, arrhythmias, and hypotension MOST likely has:

Why TXA is generally NOT used in variceal hemorrhage 1. Variceal bleeding is a pressure problem, not a clotting problem - Esophageal varices bleed due to portal hypertension - The bleeding source is high-pressure venous flow - TXA stabilizes clots, but it does not reduce portal pressure - Without lowering pressure, clots are easily displaced and bleeding continues 2. Large clinical trials showed no benefit and possible harm In major GI bleeding studies (including variceal bleeds): - No reduction in mortality - No reduction in rebleeding - Higher risk of thromboembolic events (DVT, PE) - Higher risk of seizures at higher doses As a result, modern GI and hepatology guidelines do not recommend TXA for routine upper GI or variceal bleeding.

Unlike peritoneal dialysis, hemodialysis:

Compared to peritonitis, hepatitis would more likely present initially with:

Start a nebulizer FIRST when the primary problem is bronchospasm, not fatigue Clinical picture favoring nebulizer first - Mild to moderate respiratory distress - Wheezing is prominent - Good air movement - Speaking in full sentences or short phrases - SpO₂ ≥ 90% on low-flow oxygen - Normal mental status - Minimal accessory muscle use - EtCO₂ normal or mildly elevated Why this makes sense - Bronchodilators reduce airway resistance - Treats the root cause (bronchoconstriction) - May prevent progression to respiratory fatigue - CPAP would add unnecessary positive pressure early Examples - COPD patient with wheezing after exertion - Emphysema patient with an acute bronchospastic component - “Tight” lungs but not tiring Start CPAP FIRST when the problem is work of breathing or hypoxemia Skip straight to CPAP (with neb inline if possible) when you see: - Severe respiratory distress - Accessory muscle use / tripod positioning - One- or two-word dyspnea - SpO₂ <90% despite O₂ - Tachypnea >25–30 - Signs of fatigue - Diminishing breath sounds (air trapping) - Rising EtCO₂ or mental status changes Why - CPAP reduces work of breathing immediately - Prevents respiratory muscle exhaustion - Neb alone may be too slow or ineffective The “gray zone” (very common in EMS) Best practice in many systems: - CPAP + inline nebulizer simultaneously This addresses: - Airway collapse + air trapping (CPAP) - Bronchospasm (nebulizer) This is especially useful when: - Patient is borderline severe - You don’t want to delay either therapy - Transport time is >10–15 minutes