CDEM curriculum part 2

Question 1

How to classify an upper GI bleed vs lower GI bleed

Answer 1

Ligament of Treitz is the dividing line and crosses the small intestine at the duodenal-jejunal junction

Question 2

Initial actions and primary survey of GI bleed

Answer 2

Adequacy of the airway, breathing and circulation must be the initial concern for any pt with acute GI bleed and/or hemodynamic instability
Some pts may require intubation
IV access should be obtained during your initial eval of the pt
Minimum of 2 large-bore IVs should be placed
If not possible, a trauma line or cordis should be considered
If acutely unstable, consider transfusing un-crossmatched blood and IVF while a type and cross-match is being performed

Question 3

Esophageal tamponade- when should it be considered?

Answer 3

Severe UGIB that cannot be controlled
Unstable vital signs
No ability for emergent endoscopy

Question 4

Lab eval of GI bleed

Answer 4

CBC
Chemistry
PT
PTT
Type and cross

Question 5

Primary indication for blood transfusion in GI bleed

Answer 5

Hemorrhagic shock despite IVF resuscitation
Pts with subacute bleeding and hemsoglobin of 7 or symptomatic anemia at a hgb of 8 or 9
Hbg concentration always needs to be viewed in context to the clinical condition of the pt

Question 6

Indications to consider immediate transfusion in GI bleed

Answer 6

Massive upper or lower GI bleed
Hemoglobin dropping at a rate 3 g/dL over 2-4 hrs in the setting of active bleeding
Hemoglobin <9 in the setting of active bleeding
Anemia induced end-organ injury

Question 7

Anticoagulation with GI bleed

Answer 7

Risks and benefits of reversal should be weighed

Question 8

Location of GI bleeding- how to determine

Answer 8

Pt hx:
Hematemesis or coffee ground emesis- upper GI bleed
Melena
Hematochezia- LGIB or UGIB with significant bleeding and increased GI motility

Question 9

When can an NG tube be placed in GI bleeding?

Answer 9

If a pt has intractable emesis or if there is still a question about if the pt has an upper GI bleed

Question 10

When should a bleeding scan be considered in a GI bleed?

Answer 10

Pts with moderate lower GI bleeding (stable VS with or without administration of blood products)
Can be useful in a pt with a recurrent GI bleed, with a negative colonoscopy and endoscopy in the past for similar bleeding episode

Question 11

Pharmacologic therapy for GI bleed

Answer 11

PPIs are first line for acid suppression in pts with upper GI bleed
H2 blockers are often second line and used to reduce acid production in an outpt setting as a PO med
Somatostatins for pts with known or highly suspected variceal bleeding
Abx for a pt with a GI bleed who has a hx of cirrhosis

Question 12

Dispo in GI bleed: mild

Answer 12

Pts with a mild GI bleed can be d/c-ed:
In general, no more than a mild anemia, no active bleeding besides a pos stool guaiac or blood-streaked emesis
They need prompt f/u

Question 13

Dispo in GI bleed: more severe or acute GI bleed

Answer 13

Admission

Question 14

Decision for floor vs ICU for severe GI bleed that requires admission

Answer 14

Unstable vital signs
Rate of bleeding
Need for blood transfusion
Potential for decompensation
Comorbidities
Need for procedures/sedation only avaialble in the ICU or OR

Question 15

DDx of UGIB

Answer 15

Gastric ulcer
Duodenal ulcer
Gastritis
Esophagitis
Gastroesophageal varices
Mallory-Weiss tear
Aortoenteric fistula
Malignancy

Question 16

DDx of LGIB

Answer 16

Diverticulosis
Meckels diverticulum
Angiodysplasia
Malignancy
Colitis (d/t infection, ischemia, IBD)
Anorectal (hemorrhoids, fissures)

Question 17

Description of shock

Answer 17

A physiologic state where oxygen delivery to the tissues is inadequate to meet metabolic requirements, causing global hypoperfusion

Question 18

How can shock be described?

Answer 18

Compensated (nl BP with inadequate perfusion) or uncompensated (hypotension and inability to maintain nl perfusion)

Question 19

Hypovolemic shock physiology

Answer 19

Decreased circulatory volume

Question 20

Hypovolemic shock examples

Answer 20

Hemorrhage or fluid loss

Question 21

Cardiogenic shock physiology

Answer 21

Impacted heart pump function

Question 22

Cardiogenic shock examples

Answer 22

ACS
Valve failure
Dysrhythmias

Question 23

Distributive shock physiology

Answer 23

Pathologic peripheral blood vessel vasodilation

Question 24

Distributive shock examples

Answer 24

Sepsis
Anaphylaxis
Neurogenic

Question 25

Obstructive shock physiology

Answer 25

Non-cardiac obstruction to blood flow

Question 26

Obstructive shock examples

Answer 26

PE
Tension pneumo
Tamponade

Question 27

Classic presentation hx of shock

Answer 27

Obvious bleeding from trauma or an anatomic source (GI, vaginal, or ENT) suggests hypovolemic shock, as does decreased PO intake or fluid loss d/t vomiting, diarrhea, excess urination or otherconduit (ostomy)
CP, SOB, leg swelling, or syncope may precede the development of shock d/t a cardiac (ACS, CHF) or obstructive PE cause
Sudden onset of hives, face or body swelling whether associated with a known trigger or not can signal anaphylactic (distributive) shock
Signs of infection such as fever with cough, abdominal pain, or HA may indicate sepsis
In some cases, however, non-focal, vague sx such as weakness, altered mental status, or malaise may be the only presenting signs of any of the types of shock

Question 28

PE of shock

Answer 28

Findings are also variable

BP alone should not be used as the sole marker to determine shock

Question 29

Presentation of early shock

Answer 29

May present with nl or even elevated BP and nl HR, but if left untreated, tachycardia and hypotension will follow

Question 30

Presentation of hypoperfused pts in shock

Answer 30

Often exhibit cool, pale, or cyanotic skin with: Decreased cap refill and dry mucous membranes
Confusion, altered mental status or coma
Thready pulses or tachypnea

Question 31

Presentation of cardiogenic shock

Answer 31

Arrhythmias, JVD, and dependent edema may be present

Question 32

Shock index

Answer 32

Heart rate divided by SBP
Can provide clues to the severity of the pt’s condition
Nl index ranges from 0.5-0.7
Repeated values >1.0 indicate decreased LV function and are associated with higher mortality

Question 33

Tests to be considered for shock

Answer 33

CBC and coag studies (to determine anemia/blood loss, infection, hypocoagulability)
Electrolytes
BUN/creatinine and UA; hepatic function panel (to assess liver and renal function)
CXR, EKG
Lactate (to gauge the degree of hypoperfusion)
Urine pregnancy test
More invasive testing is often required:
-ABG for O2/pH
-Central venous oxygen measurement, SVR, and CO may be measured through special central venous catheters

Question 34

Further studies in shock

Answer 34

Infectious etiology (sepsis)- blood, sputum, urine, pelvic, or wound cultures, head CT and LP, targeted imaging (US/CT)
Cardiogenic- cardiac enzymes and echo
Obstructive- CT or V/Q scan (PE), echo (tamponade)

Question 35

How do I make the dx of shock?

Answer 35

Should be strongly considered in ill-appearing pts with: -VS abnormalities (particularly tachycardia and hypotension)
-Altered mental status
-Signs of organ hypoperfusion
In most cases, the clinical picture should guide decision making

Question 36

Cardiogenic shock: HR, CVP, contractility, SVR

Answer 36

HR increased
CVP increased
Contractility sig decreased
SVR increased

Question 37

Hypovolemic shock: HR, CVP, contractility, SVR

Answer 37

HR increased
CVP sig decreased
+/- increased in contractility
SVR increased

Question 38

Distributive shock: HR, CVP, contractility, SVR

Answer 38

Increased HR
CVP sig decreased
+/- contractility
SVR decreased

Question 39

Obstrutive shock: HR, CVP, contractility, SVR

Answer 39

Increased HR
\+/- increased CVP
\+/- contractility
Increased SVR in tamponade, PE
Decreased SVR in tension pneumo

Question 40

Common lab results in shock

Answer 40

Anemia, disorders of platelets or coagulation studies
Elevated or depressed WBC with left shift
Elevated lactate level or decreased serum bicarb (suggests a shift to anaerobic metabolism and tissue hypoperfusion)
Evidence of end-organ damage: elevated creatinine, abnl LFTs, ARDS/edema on CXR, arrhythmia/ischemia on EKG or abnl cardiac enzymes, ischemic neurologic changes on CT/MRI

Question 41

Tx of shock

Answer 41

Should begin emergently
Start with the ABCs
-Intubation should be strongly considered
–Keep in mind that many drugs used in intubation, as well as pos pressure ventilation, can have neg hemodynamic effects
-Obtain IV access through large bore peripheral lines or a central venous catheter
Crystalloid fluids should be given as boluses
-Be careful with rapid fluid administration to the pt in cardiogenic shock with pulm edema
If volume resuscitation does not improve hemodynamic status, vasoactive meds may be used

Question 42

Tx of shock: when aggressive tx of the underlying cause of shock is warranted

Answer 42

Hypovolemia d/t hemorrhage may warrant surgical or interventional control
Sepsis syndromes should be treated with early goal-directed therapy (maximization of oxygen delivery, careful hemodynamic monitoring) and aggressive antibiotic tx
Cardiogenic shock may necessitate emergent angiography or surgical procedures (bypass, valve repair, IABP)
Obstructive shock d/t PE often requires anticoagulation or thrombolysis, whereas when d/t cardiac tamponade emergent drainage of the pericardial fluid may be necessary

Question 43

Tx of shock: monitoring

Answer 43

Using a urinary catheter, intraarterial BP measurement and central venous pressure monitoring

Question 44

When is resuscitation of a shock state successful?

Answer 44

Normalization of hemodynamic state (BP, HR, and urine output)
Lactate decreases by half in the first couple of hours
Nl volume status restored
Maximal tissue oxygenation
Resolution of acidosis and return to nl metabolic parameters