GI BLEEDING Flashcards
MANAGEMENT: UNSTABLE
A - STRIDOR.
INTUBATE MASSIVE UGIB
-suction
-direct laryngoscopy
-avoid supine or recumbent
-bougie
-NGT insertion after
B - RESPIRATORY RATE. >/ 30, 02 sats 90% on Fi02 30%. Work of breathing. Tracheal Position. Chest wall crepitus / chest rise.
C - MOTTLED APPEARANCE. GCS. Pallor. Cap Refill. Distal Pulses. Palpate Abdomen.
-2 large bore IV’s
-Bolus 1-2 L NS
D - CHECK GLUCOSE. GCS, PERRLA, lateralizing signs
E - EXPOSURE, TAKE DOWN DRESSINGS
DRE
MASSIVE TRANSFUSION PROTOCOL:
Pack 1: 4 pRBC
Pack 2: 4 pRBC and 4 Plasma
All subsequent packs: 4 pRBC and 2 plasma
Platelets and fibrinogen PRN based on lab results
BLOOD TRANFUSION
Hemoglobin <70 g/L
Hemoglobin <80 g/L with ACTIVE acute coronary syndrome (ACS).
Normal hemoglobin with ACTIVE bleeding and hypotension.
Example order:
Prepare and transfuse (1-2) units PRBCs IV over 1 h per unit.
If giving more than 4 units of blood in the stable patient
Transfuse 1-2 unit FFP IV.
ANTICOAGULANT REVERSAL
Warfarin: Octaplex (PCC) 80 mL IV & Vit K 10 mg IV
4-6 U FFP if PCC not available
Heparin: 1 mg Protamine per 100 units of unfractionated Heparin
NOAC: Octaplex (PCC) 80 mL IV
4-6 U FFP if PCC not available
Dabigatran: Idarucizumab 5 g IV
MEDICATION MANAGEMENT
Pantoprazole: 80 mg bolus followed by 8 mg / h IV for uncontrolled bleed
OR
40 mg BID IV
If Variceal or Cirrhosis:
Octreotide 50 mcg bolus followed by 50 mcg per hour IV infusion
Ceftriaxone 1 g IV
Pre-Endoscopic medications: Erythromycin 3 mg/kg IV over 20 min or
Metoclopramide 10 mg IV once
Early consultation with surgery
Temporizing
EMERGENT SURGICAL CONSULT
GI Consult
+/- Surgical consult if unstable, bleeding not stopping.
For massive lower GI bleed (LGIB), consider Interventional Radiology consult.
TEMPORIZING STRATEGIES
Linton Tube
Blakemore Tube
INVESTIGATIONS
CBC
Type and Crossmatch
PT/INR
LFT
Cr
BUN
DOCUMENTATION
CLINICAL FEATURES: UPPER GI BLEED
Hematemesis
Ground Coffee Emesis
Melena
Epigastric Pain
CLINICAL FEATURES: LOWER GI BLEED
Hematochezia
ASK ABOUT:
Recent vomting
Severe Illness: sepsis, trauma, respiratory failure on mechanical ventilation
Toxic Ingestion
PMhx: GI Bleed, Peptic Ulcer, H. Pylori Infection; Liver Disease, Coagulopathy; Immunosuppression; Aortic graft
colonic diverticuli, hemorrhoids, IBD, colorectal cancer, coagulopathy.
Meds: NSAID use, Anticoagulant use
SoHx: Alcohol Abuse, Smoking
RED FLAGS
Fatigue
Weakness
Chest Pain
Syncope
Orthostatic Symptoms
Tachycardia
Hypotension
PHYSICAL EXAM
Tachycardia
Orthostatic Hypotension
Hypotension
Inspection of vomitus
ENT
Epigastric Tenderness
DRE
DDx: LOWER GI BLEED
Diverticulosis
Colitis
Adenomatous Polyps
Malignancy
Inflammatory Bowel Disease
Vascular Ectasia
AVM
Anorectal disease (fissure, hemorrhoids)
Ischemic Colitis / Mesenteric Ischemia
DDx: UPPER GI BLEED
Peptic Ulcer Disease (MCC)
Erosive Gastritis, Esophagitis, Duodenitis
Esophageal and Gastric Varices
Mallory Weiss Tear
Dieulafoy Lesion
Arteriovenous Malformation
Malignancy
