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The Upper GI Bleeder
 

The Upper GI Bleeder

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My Talk for emergency nurses on resuscitating the upper GI bleeder in the emergency department!

My Talk for emergency nurses on resuscitating the upper GI bleeder in the emergency department!

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    The Upper GI Bleeder The Upper GI Bleeder Presentation Transcript

    • 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 Intervention can 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. 2. 3. 4. 5. 6. 7. Intubate early Empty stomach (NGT) Intubate with HOB at 45° Preoxygenation Limit BVM Use experience 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