GI Bleed

Question 1

GI Bleed

ASAP:

Answer 1

ABCs, 2 LB IV and bolus, O2, monitor, EKG

Question 2

GI Bleed

GI Bleed Hx:

Answer 2

BRB PO vs PR vs melena, cirrhosis, liver failure, varicies, EtOH, PUD, ASA, NSAIDs, prior bleed, anticoag use (why?), coagulopathy, recent endoscopy, abd surgery, trauma, diverticulosis; SAMPLE hx

Question 3

GI Bleed

Exam:

Answer 3

Perfusion, liver stigmata (jaundice, asterixis, caput medusae, hepatomegaly, ascites), rectal/ hemoccult, anoscopy,  NGT lavage/gastroccult

Question 4

GI Bleed

Labs:

Answer 4

T&C
CBC
BMP
Trop/CK/MB
LFTs
Coags
UA  
Lipase  
Ammonia
CXR
Fibrinogen

Question 5

GI Bleed

Treatment: If shock…

Answer 5

2-6 u O neg or typed PRBCs,
FFP 10-15 ml/kg (if coagulopathy),
PLT 1 u (if ASA or plt <50k)

Question 6

GI Bleed

Treatment: Reverse bleeding disorders:

Answer 6

Vit K if INR high- 10 mg IV
DDAVP (0.4 mcg/kg IV over 10 minutes) if plt or renal disorder

Question 7

GI Bleed

Treatment: If massive hematemesis…

Answer 7

Intubate to protect airway; Slegstaken- Blakemore tube for rescue only

Question 8

GI Bleed

Treatment: If Upper GI bleed…

Answer 8

Protonix 80 mg IV then 8 mg/hr for PUD
Helps with rebleeding
Octreotide 50 mcg IV then 50 mcg/hr for varicies
Decrease splanchnic blood flow
Prophylactic antibiotics for variceal bleed- 3rd generation Cephalosporin
Vasopressin/terlipressin

Question 9

GI Bleed

Consults:

Answer 9

Call GI (upper) or Surgery (lower),   IR for tagged RBC scan vs embolization; ICU for admit.

Question 10

GI Bleed

Blatchford score (before endoscopy):

Answer 10

Hb, BUN, initial systolic, sex, HR >100, melena, recent scope, hepatic disease, HF
If zero low risk for life threatening events can discharge patient.

Question 11

GI Bleed

Rockall score (after endoscopy):

Answer 11

Age, shock, comorbidities, diagnosis, major stigmata or recent hemorrhage
<3 low risk of rebleeding or death- use for disposition

Question 12

GI Bleed

Coagulopathy management in cirrhotic

Answer 12

Rebalance homeostasis due to all clotting factors decreasing
TEG- look at R time
FFP lowers INR, can make worse bleeding (diluting, increase BP, short half life-transient benefit)
Platelets help
Fibrinogen- target > 150- decrease requirement of other supplements
Have increased proteins→ hyperfibrinolysis can give TXA (fibrinolysis inhibitor)
Cirrhotics are hypotensive at baseline- don’t over resuscitate them- can exacerbate bleeding
Labs- cbc, fibrinogen, TEG
Platelets- if <50K, TEG reduced MA
Cryoprecipitate- fibrinogen <150, TEG reduced MA
TXA- TEG with hyperfibrinolysis (LY-30 > 3%), low fibrinogen, refractory bleeding
Avoid FFP unless true hypocoagulopathy- (Prolonged R time)

Question 13

GI Bleed

Lower GI bleed History

Answer 13

History of, age > 50, clots per rectum
NG lavage- if positive endoscopy
If exsanguinating- invasive angiography
If not exsanguinating- CT angio

Question 14

GI Bleed

Upper GI bleed History

Answer 14

History of, Age < 50, epigastric discomfort, BUN/Cr > 30, cirrhosis endoscopy→ banding or IR or surgery

Question 15

GI Bleed

Intubation in massive GI bleed

Answer 15

-Empty stomach, give reglan (nausea, increase LES), HOB at 45, preoxygenate,   sedation med (BP), need to paralyze, have everything ready, meconium aspirator, bag slowly