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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
By Kane Guthrie FCENA
Upper GI Bleeds
• Understand the causes• Goals of resuscitation• Pharmacological resuscitation• Procedural resuscitation
Upper GI Bleeds in ED
• Its challenging• Effective Mx = good PT outcomes• Underlying comorbidities ∧ complexities• Team approach• Pharmacology & procedural approach
Upper Vs Lower
• Consider upper first– More life threatening
• Haematemisis = Upper GI source• Bright red blood not always = LOWER GI
Case Study
• 52 Male• Chronic ETOH abuse• Known varices
C/O – Vomiting blood post binge
What to Look for!
His Vitals
The Upper GI Bleeder
Multi Team Approach:• ED, ICU – resuscitate• Gastro – scope• Interventional Radiologist – therapeutic Ix• Surgeons – surgical intervention
The Source
• Duodenal ulcers- 28%• Gastric ulcers- 26%• Gastritis- 13%• Varices - 12%• Esophagitis - 8%
• “Massive GI Bleed Mortality rate 20-39%”
The DDx!
• Intranasal• Intrapulmonary
Remember!
Early Interventioncan mean
difference between
Life & Death
The 3 Goals of Resuscitation
1 Provide Intravascular Volume Resuscitation
2 Optimise Oxygen-Carrying Capacity
3 Reverse Coagulopathy
Initial Resuscitating
• Start with ABCDE• x2 Large bore IVC – Bloods• Full monitoring• Get specialties involved• Arrange blood products• Consider limitations of care!
Intravascular Volume Resuscitation
• Limit crystalloid fluid –to early phase
Prepare for transfusion:• HB <80• Coagulopathy• Persistent hypotension
Intravascular Volume Resuscitation
• PRBC’s not enough• Replace clotting factors• Consider massive transfusion protocol• “PRBC:FFP:platelet ratio 1:1:1”
• Tranexamic Acid?
Optimise Oxygenation
Signs of decreased O2 delivery:– Decreased LOC– Evidence of cardiac ischaemia– Increased lactate– Cold peripheries
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
Intubating Isn’t Easy!
1. Intubate early2. Empty stomach (NGT)3. Intubate with HOB at 45°4. Preoxygenation5. Limit BVM6. Use experience7. Prepare for vomit
Reverse Coagulopathy
• Tailor to etiology.
Causes:• Anticoagulation• Shock– Metabolic acidosis –tissue hypoperfusion
• Chronic disorders– ETOH abusers
Pharmacological Interventions
• Proton Pump Inhibitors• Somatostatin• Vasopressin
Proton Pump Inhibitors
• Suppress gastric acid production• Potential reduction haemorrhage during scope
The evidence though:
Somatostatin
• (Octreotide)Reduces:• Portal venous blood flow• Splachinic vasoconstriction
=decrease GI Bleeding
Use• Variceal GI bleeds• Limited evidence – low side effect profile
Vasopressin
(Telipressin)• Reduces portal hypertension• Splachnic vasoconstrictor• Can cause ischaemia
• Last ditch effort in bleeding varices
Antibiotics
• Infection on varices– Causes bleeding
• Give antibiotics (broad spectrum)
Procedural Interventions
• Endoscopy• Balloon Tamponade
Endoscopy
• Diagnostic & therapeutic tool
Interventions:• Clips• Banding• Thermocoagulation• Sclerosant injection % adrenaline
Balloon Tamponade
Balloon Tamponade
• Temporising rescue device
Indicated:– Endoscopy not available– Endoscopy not successful
• Need to secure airway prior
Questions
Take Home Points
• Early recognition• Team approach is needed• Resuscitate with blood products• Advocate for early intervention