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The Upper GI
Bleeder
By Kane Guthrie FCENA
Upper GI Bleeds
•
•
•
•

Understand the causes
Goals of resuscitation
Pharmacological resuscitation
Procedural resuscitati...
Upper GI Bleeds in ED
•
•
•
•
•

Its challenging
Effective Mx = good PT outcomes
Underlying comorbidities ∧ complexities
T...
Upper Vs Lower
• Consider upper first
– More life threatening

• Haematemisis = Upper GI source
• Bright red blood not alw...
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 – therapeu...
The Source
•
•
•
•
•

Duodenal ulcers- 28%
Gastric ulcers- 26%
Gastritis- 13%
Varices - 12%
Esophagitis - 8%

• “Massive G...
The DDx!
• Intranasal
• Intrapulmonary
Remember!

Early Intervention
can mean
difference between

Life & Death
The 3 Goals of Resuscitation
1 Provide Intravascular Volume Resuscitation
2 Optimise Oxygen-Carrying Capacity
3 Reverse Co...
Initial Resuscitating
•
•
•
•
•
•

Start with ABCDE
x2 Large bore IVC – Bloods
Full monitoring
Get specialties involved
Ar...
Intravascular Volume Resuscitation
• Limit crystalloid fluid –to early phase
Prepare for transfusion:
• HB <80
• Coagulopa...
Intravascular Volume Resuscitation
•
•
•
•

PRBC’s not enough
Replace clotting factors
Consider massive transfusion protoc...
Optimise Oxygenation
Signs of decreased O2 delivery:
– Decreased LOC
– Evidence of cardiac ischaemia
– Increased lactate
–...
Optimise Oxygenation
• Give blood so oxygen can get to the tissue
Initially:
– Provide High Flow 02

Crashing:
• Intubate ...
Intubating Isn’t Easy!
1.
2.
3.
4.
5.
6.
7.

Intubate early
Empty stomach (NGT)
Intubate with HOB at 45°
Preoxygenation
Li...
Reverse Coagulopathy
• Tailor to etiology.
Causes:
• Anticoagulation
• Shock
– Metabolic acidosis –tissue hypoperfusion

•...
Pharmacological Interventions
• Proton Pump Inhibitors
• Somatostatin
• Vasopressin
Proton Pump Inhibitors
• Suppress gastric acid production
• Potential reduction haemorrhage during
scope

The evidence tho...
Somatostatin
• (Octreotide)
Reduces:
• Portal venous blood flow
• Splachinic vasoconstriction
=decrease GI Bleeding

Use
•...
Vasopressin
(Telipressin)
• Reduces portal hypertension
• Splachnic vasoconstrictor
• Can cause ischaemia
• Last ditch eff...
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 % ad...
Balloon Tamponade
Balloon Tamponade
• Temporising rescue device
Indicated:
– Endoscopy not available
– Endoscopy not successful

• Need to s...
Questions
Take Home Points
•
•
•
•

Early recognition
Team approach is needed
Resuscitate with blood products
Advocate for early int...
The Upper GI Bleeder
The Upper GI Bleeder
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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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Transcript of "The Upper GI Bleeder"

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