The Upper GI Bleeder
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My Talk for emergency nurses on resuscitating the upper GI bleeder in the emergency department!
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The Upper GI Bleeder
- 1. The Upper GI Bleeder By Kane Guthrie FCENA
- 2. Upper GI Bleeds • • • • Understand the causes Goals of resuscitation Pharmacological resuscitation Procedural resuscitation
- 3. Upper GI Bleeds in ED • • • • • Its challenging Effective Mx = good PT outcomes Underlying comorbidities ∧ complexities Team approach Pharmacology & procedural approach
- 4. Upper Vs Lower • Consider upper first – More life threatening • Haematemisis = Upper GI source • Bright red blood not always = LOWER GI
- 5. Case Study • 52 Male • Chronic ETOH abuse • Known varices C/O – Vomiting blood post binge
- 6. What to Look for!
- 7. His Vitals
- 8. The Upper GI Bleeder Multi Team Approach: • ED, ICU – resuscitate • Gastro – scope • Interventional Radiologist – therapeutic Ix • Surgeons – surgical intervention
- 9. The Source • • • • • Duodenal ulcers- 28% Gastric ulcers- 26% Gastritis- 13% Varices - 12% Esophagitis - 8% • “Massive GI Bleed Mortality rate 20-39%”
- 10. The DDx! • Intranasal • Intrapulmonary
- 11. Remember! Early Intervention can mean difference between Life & Death
- 12. The 3 Goals of Resuscitation 1 Provide Intravascular Volume Resuscitation 2 Optimise Oxygen-Carrying Capacity 3 Reverse Coagulopathy
- 13. Initial Resuscitating • • • • • • Start with ABCDE x2 Large bore IVC – Bloods Full monitoring Get specialties involved Arrange blood products Consider limitations of care!
- 14. Intravascular Volume Resuscitation • Limit crystalloid fluid –to early phase Prepare for transfusion: • HB <80 • Coagulopathy • Persistent hypotension
- 15. Intravascular Volume Resuscitation • • • • PRBC’s not enough Replace clotting factors Consider massive transfusion protocol “PRBC:FFP:platelet ratio 1:1:1” • Tranexamic Acid?
- 16. Optimise Oxygenation Signs of decreased O2 delivery: – Decreased LOC – Evidence of cardiac ischaemia – Increased lactate – Cold peripheries
- 17. Optimise Oxygenation • Give blood so oxygen can get to the tissue Initially: – Provide High Flow 02 Crashing: • Intubate early Stablised: • Titrate oxygen to need • Considered humidified
- 18. Intubating Isn’t Easy! 1. 2. 3. 4. 5. 6. 7. Intubate early Empty stomach (NGT) Intubate with HOB at 45° Preoxygenation Limit BVM Use experience Prepare for vomit
- 20. Reverse Coagulopathy • Tailor to etiology. Causes: • Anticoagulation • Shock – Metabolic acidosis –tissue hypoperfusion • Chronic disorders – ETOH abusers
- 21. Pharmacological Interventions • Proton Pump Inhibitors • Somatostatin • Vasopressin
- 22. Proton Pump Inhibitors • Suppress gastric acid production • Potential reduction haemorrhage during scope The evidence though:
- 23. Somatostatin • (Octreotide) Reduces: • Portal venous blood flow • Splachinic vasoconstriction =decrease GI Bleeding Use • Variceal GI bleeds • Limited evidence – low side effect profile
- 24. Vasopressin (Telipressin) • Reduces portal hypertension • Splachnic vasoconstrictor • Can cause ischaemia • Last ditch effort in bleeding varices
- 25. Antibiotics • Infection on varices – Causes bleeding • Give antibiotics (broad spectrum)
- 26. Procedural Interventions • Endoscopy • Balloon Tamponade
- 27. Endoscopy • Diagnostic & therapeutic tool Interventions: • Clips • Banding • Thermocoagulation • Sclerosant injection % adrenaline
- 30. Balloon Tamponade • Temporising rescue device Indicated: – Endoscopy not available – Endoscopy not successful • Need to secure airway prior
- 31. Questions
- 32. Take Home Points • • • • Early recognition Team approach is needed Resuscitate with blood products Advocate for early intervention