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The Upper GI Bleeder
This document discusses the management of upper gastrointestinal bleeding. It begins by outlining the goals of resuscitation, which are to provide intravascular volume resuscitation, optimize oxygen-carrying capacity, and reverse coagulopathy. It then discusses various pharmacological and procedural interventions that may be used, including proton pump inhibitors, somatostatin, vasopressin, endoscopy, and balloon tamponade. The key takeaway message is that early recognition and a multidisciplinary team approach are needed to resuscitate the patient and identify the source of bleeding in order to optimize outcomes for those experiencing an upper GI bleed.
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The Upper GI Bleeder
- 1. The Upper GI Bleeder ByKane Guthrie FCENA
- 2. Upper GI Bleeds • • • • Understandthe causes Goals of resuscitation Pharmacological resuscitation Procedural resuscitation
- 3. Upper GI Bleedsin 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 • 52Male • Chronic ETOH abuse • Known varices C/O – Vomiting blood post binge
- 6. What to Lookfor!
- 7.
- 8. The Upper GIBleeder 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 differencebetween Life & Death
- 12. The 3 Goalsof Resuscitation 1 Provide Intravascular Volume Resuscitation 2 Optimise Oxygen-Carrying Capacity 3 Reverse Coagulopathy
- 13. Initial Resuscitating • • • • • • Start withABCDE 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’snot enough Replace clotting factors Consider massive transfusion protocol “PRBC:FFP:platelet ratio 1:1:1” • Tranexamic Acid?
- 16. Optimise Oxygenation Signs ofdecreased O2 delivery: – Decreased LOC – Evidence of cardiac ischaemia – Increased lactate – Cold peripheries
- 17. Optimise Oxygenation • Giveblood 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. Intubateearly Empty stomach (NGT) Intubate with HOB at 45° Preoxygenation Limit BVM Use experience Prepare for vomit
- 20. Reverse Coagulopathy • Tailorto etiology. Causes: • Anticoagulation • Shock – Metabolic acidosis –tissue hypoperfusion • Chronic disorders – ETOH abusers
- 21. Pharmacological Interventions • ProtonPump Inhibitors • Somatostatin • Vasopressin
- 22. Proton Pump Inhibitors •Suppress gastric acid production • Potential reduction haemorrhage during scope The evidence though:
- 23. Somatostatin • (Octreotide) Reduces: • Portalvenous blood flow • Splachinic vasoconstriction =decrease GI Bleeding Use • Variceal GI bleeds • Limited evidence – low side effect profile
- 24. Vasopressin (Telipressin) • Reduces portalhypertension • Splachnic vasoconstrictor • Can cause ischaemia • Last ditch effort in bleeding varices
- 25. Antibiotics • Infection onvarices – Causes bleeding • Give antibiotics (broad spectrum)
- 26. Procedural Interventions • Endoscopy •Balloon Tamponade
- 27. Endoscopy • Diagnostic &therapeutic tool Interventions: • Clips • Banding • Thermocoagulation • Sclerosant injection % adrenaline
- 28.
- 30. Balloon Tamponade • Temporisingrescue device Indicated: – Endoscopy not available – Endoscopy not successful • Need to secure airway prior
- 31.
- 32. Take Home Points • • • • Earlyrecognition Team approach is needed Resuscitate with blood products Advocate for early intervention