CDEM curriculum part 2 Flashcards
How to classify an upper GI bleed vs lower GI bleed
Ligament of Treitz is the dividing line and crosses the small intestine at the duodenal-jejunal junction
Initial actions and primary survey of GI bleed
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
Esophageal tamponade- when should it be considered?
Severe UGIB that cannot be controlled
Unstable vital signs
No ability for emergent endoscopy
Lab eval of GI bleed
CBC Chemistry PT PTT Type and cross
Primary indication for blood transfusion in GI bleed
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
Indications to consider immediate transfusion in GI bleed
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
Anticoagulation with GI bleed
Risks and benefits of reversal should be weighed
Location of GI bleeding- how to determine
Pt hx:
Hematemesis or coffee ground emesis- upper GI bleed
Melena
Hematochezia- LGIB or UGIB with significant bleeding and increased GI motility
When can an NG tube be placed in GI bleeding?
If a pt has intractable emesis or if there is still a question about if the pt has an upper GI bleed
When should a bleeding scan be considered in a GI bleed?
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
Pharmacologic therapy for GI bleed
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
Dispo in GI bleed: mild
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
Dispo in GI bleed: more severe or acute GI bleed
Admission
Decision for floor vs ICU for severe GI bleed that requires admission
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
DDx of UGIB
Gastric ulcer Duodenal ulcer Gastritis Esophagitis Gastroesophageal varices Mallory-Weiss tear Aortoenteric fistula Malignancy
DDx of LGIB
Diverticulosis Meckels diverticulum Angiodysplasia Malignancy Colitis (d/t infection, ischemia, IBD) Anorectal (hemorrhoids, fissures)
Description of shock
A physiologic state where oxygen delivery to the tissues is inadequate to meet metabolic requirements, causing global hypoperfusion
How can shock be described?
Compensated (nl BP with inadequate perfusion) or uncompensated (hypotension and inability to maintain nl perfusion)
Hypovolemic shock physiology
Decreased circulatory volume
Hypovolemic shock examples
Hemorrhage or fluid loss
Cardiogenic shock physiology
Impacted heart pump function
Cardiogenic shock examples
ACS
Valve failure
Dysrhythmias
Distributive shock physiology
Pathologic peripheral blood vessel vasodilation
Distributive shock examples
Sepsis
Anaphylaxis
Neurogenic
Obstructive shock physiology
Non-cardiac obstruction to blood flow
Obstructive shock examples
PE
Tension pneumo
Tamponade
Classic presentation hx of shock
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
PE of shock
Findings are also variable
BP alone should not be used as the sole marker to determine shock
Presentation of early shock
May present with nl or even elevated BP and nl HR, but if left untreated, tachycardia and hypotension will follow
Presentation of hypoperfused pts in shock
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
Presentation of cardiogenic shock
Arrhythmias, JVD, and dependent edema may be present
Shock index
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
Tests to be considered for shock
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
Further studies in shock
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)
How do I make the dx of shock?
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
Cardiogenic shock: HR, CVP, contractility, SVR
HR increased
CVP increased
Contractility sig decreased
SVR increased
Hypovolemic shock: HR, CVP, contractility, SVR
HR increased
CVP sig decreased
+/- increased in contractility
SVR increased
Distributive shock: HR, CVP, contractility, SVR
Increased HR
CVP sig decreased
+/- contractility
SVR decreased
Obstrutive shock: HR, CVP, contractility, SVR
Increased HR \+/- increased CVP \+/- contractility Increased SVR in tamponade, PE Decreased SVR in tension pneumo
Common lab results in shock
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
Tx of shock
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
Tx of shock: when aggressive tx of the underlying cause of shock is warranted
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
Tx of shock: monitoring
Using a urinary catheter, intraarterial BP measurement and central venous pressure monitoring
When is resuscitation of a shock state successful?
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
