Upper GI Bleed Flashcards
What symptoms may a patient with an UGIB present with?
- Haematemesis
- Melaena
- Altered bowel habit
- Abdominal pain
- Syncope/pre-syncope
What is the appearance of the vomit typically seen in UGIB?
Coffee-ground texture
What causes vomit to have a coffee ground texture?
Due to presence of partially digested blood
What type of altered bowel habits may patients with an UGIB describe?
- Dark, tarry stools
- Fresh rectal bleeding
Typical location of abdominal pain in an UGIB?
Epigastric (but can be diffuse)
What can cause syncope in UGIB?
Hypovolaemia and 2ary cerebral hypoperfusion
What signs can be found on examination in UGIB?
- Tachycardia
- Abdominal tenderness
- Hypotension
- Melaena
- Haematochezia
What is haematochezia?
The passage of fresh blood per rectum (this can occur in the context of profuse upper GI haemorrhage due to the rapid transit of blood through the GI tract)
You may be asked to review a patient with UGIB due to:
a) tachycardia, b) hypotension, c) melaena and/or haematemesis.
Describe the introductory steps during a handover
- 1) Introduction
- Introduce self to whoever has requested review of patient and listen carefully to handover
- 2) Interaction
- Introduce self to patient: name & role
- Ask how patient is feeling (may provide information about current symptoms)
- 3) Preparation
- Make sure patient notes, observation chart and prescription chart are easily available
- Ask for another clinical staff member to assist you if possible
- If patient s unconscious or unresponsive start BLS
How can you assess the patient’s airway?
Is the patient talking? (if yes - patent airway)
If the patient is unable to talk (or unable to talk in full sentences), what should you inspect for?
- Signs of airway compromise
- Inspection for obstruction of airway (secretions, foreign body)
What are some signs of airway compromise?
- Use of accessory muscles
- Cyanosis
- See-saw breathing
- Diminished breath sounds & added sounds
Regardless of the underlying cause of airway obstruction, what should be done if you find one?
Seek immediate expert support from an anaesthetist and crash team. Perform a basic airway manoeuvre for the meantime.
Which basic airway manoeuvre should be used if the patient is not suspected to have suffered significant trauma with potential spinal involvement?
Head tilt chin lift
Which basic airway manoeuvre should be used if the patient is suspected to have suffered significant trauma with potential spinal involvement?
Jaw thrust
Describe the steps of the head tilt chin lift manoeuvre
- Place one hand on patient’s forehead and other under the chin
- With your index finger and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible
- Inspect airway for obvious obstruction
Describe the steps of the head tilt chin lift manoeuvre
- Place one hand on patient’s forehead and other under the chin
- With your index finger and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible
- Inspect airway for obvious obstruction
If an obvious obstruction of the airway is identified, how should it be removed?
Finger sweep or suction
Describe the steps of the jaw thrust
- 1) Identify angle of mandible
- 2) With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible
- 3) Using your thumbs, slightly open the mouth by downward displacement of the chin
Which airway adjunct should be used in a fully unconscious patient?
Oropharyngeal airway (otherwise may induce gagging and/or aspiration)
How should the oropharyngeal airway be inserted?
Insert oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which point rotate it 180 degrees.
Advance airway until it lies within the pharynx
What should you do after inserting the oropharyngeal airway?
Maintain head-tilt chin-lift or jaw thrust and assess patency of patient’s airway (look, listen, feel)
Which airway adjunct should be used in patients who are partly or fully conscious?
Nasopharyngeal airway
Which patients should the nasopharyngeal airway not be used in?
patients who may have sustained a skull base fracture
When should the patient be reassessed?
After every intervention
Which observations should be taking when assessing the patient’s breathing?
- Respiratory rate
- O2 saturation
- Auscultation
What may tachypnoea indicate in the context of an UGIB?
- Significant blood loss (>1500ml)
- Aspiration pneumonia
What is defined as tachypnoea?
>20 breaths per minute
What is the normal SpO2 range in COPD patients who are at high-risk of CO2 retention?
99-92%
Normal SpO2 range for healthy adults?
94-98%
What can cause hypoxaemia in the context of UGIB?
Aspiration pneumonia
What may a finding of coarse crackles on auscultation indicate in the context of UGIB?
Excess fluid on the lungs due to;
a) aspiration pneumonia
b) pulmonary oedema 2ary to fluid resuscitation
What can cause pulmonary oedema in the context of UGIB?
Fluid reuscitation
What 2 investigations should be done (if indicated) during the ‘breathing’ part of ABCDE?
- ABG
- CXR
What observation would indicate the need for an ABG? Why?
Low SpO2 → to qualify the degree of hypoxia
What observation would indicate the need for a CXR? Why?
May be indicated if abnormalities are noted on auscultation (e.g. reduced air entry, coarse crackles) to screen for evidence of aspiration pneumonia.
What intervention should be done if the patient has low SpO2?
Oxygen
What rate of O2 should be given (typically) to a patient with low SpO2?
15L non-rebreathe mask
What should you be careful of with a patient on an O2 mask?
BEWARE of risks of aspiration if patient vomits while wearing oxygen mask
What intervention should be performed if the patient loses consciousness and there are no signs of life?
CPR
What are 6 steps of clinical assessment of circulation in the context of UGIB?
- Inspection
- Pulse
- Blood pressure
- CRT
- Abdominal exam
- Fluid balance assessment
What is tachycardia an early sign of in UGIB?
Volume depletion (hypovolaemia)
What type of pulse can hypovolaemia cause?
Thready
How may the pulse & BP be in the context of UGIB?
- Pulse → tachycardia, thready
- BP → hypotension (late)
When do patients with UGIB tend to develop hypovolaemia?
Not until there has been significant blood loss (i.e. 1500-2000 mls)
How may urine output be affected by UGIB?
Urine output is maintained until there has been significant blood loss → oliguria indicates significant blood loss
What is oliguria defined as?
<0.5ml/kg/hour in an adult
What factors affect a patient’s fluid status?
Urine output, vomiting, oral fluids, IV fluids, drain output, stool output
What clinical sign may be present in the context of UGIB?
Pallor (anaemia)
How may UGIB affect CRT?
CRT may be prolonged (>2 seconds) both peripherally and centrally
How may a patient’s peripheries feel in UGIB?
Cool 2ary to hypovolaemia and peripheral vasoconstriction
Why may ascites be present on abdominal examination in UGIB?
2ary to cirrhotic liver disease
How can cirrhosis lead to UGIB?
Portal hypertension can lead to oesophageal/gastric varices which can bleed
Why may abdominal tenderness be present in the context of UGIB?
Duodenal ulcer (perforation)
Classification of haemorrhagic shock
Describe the HR as blood is increasingly lost
Gradually becomes tachycardic as more blood is lost
<100 → 100-120 → 120-140 → >140
Describe the BP as blood is increasingly lost
Normal until significant amounts of blood is lost
Normal → normal → decreased → decreased
Describe the RR as blood is increasingly lost
Steadily increases (tachypnoea) as more blood is lost
14-20 → 20-30 → 30-40 → >40
Give 2 reasons to cannulate a patient in the context of UGIB?
- Blood tests
- Adequate IV access is essential in UGIB as patients rapidly deteriorate with haemodynamic instability
What type of cannula should be used?
Two large bore cannulae (14-16G)
During what stage of ABCDE should a patient be cannulated?
C
What blood tests should be done in the ‘circulation’ assessment of a UGIB?
- FBC
- U&Es
- LFTs
- Group and cross match
- Coagulation screen
Why is an FBC useful in UGIB?
Assess degree of anaemia (guide transfusion)
How can U&Es be affected in the context of UGIB?
High urea due to the digestion and absorption of blood proteins
Why is a group and crossmatch essential in the context of UGIB?
To confirm patient’s blood group and request blood products
Why are LFTs and a coagulation screen useful in UGIB?
- LFTs → evidence of liver disease (e.g. cirrhosis)
- Coagulation screen → screen for coagulopathy and inform resuscitation efforts
Give some potential interventions in the ‘circulation’ aspect of UGIB?
- IV fluid resuscitation
- Blood transfusion
- Platelets
- Fresh frozen plasma and cryoprecipitate
What urine output should you aim for in a patient with UGIB?
>30ml/hour
Which patients require IV fluid resuscitation?
Hypovolaemic patients
What fluid/over how long should be given to hypovolaemia patients?
500ml bolus of 0.9% sodium chloride (or Hartmann’s solution) over 15 mins
How much fluid should be given to hypovolaemic patients at risk of fluid overload (e.g. heart failure)?
250ml boluses
After each fluid bolus, what should you do?
Reassess for clinical evidence of fluid overload (e.g. auscultation of the lungs, assessment of JVP)
If the patient is losing significant volumes of blood, fluid replacement alone is inadequate. What else is needed?
Blood transfusion
Prophylactic antibiotic therapy may be needed in patients with what type of bleed?
Variceal
What diagnostic investigation should be performed on all unstable patients with severe UGIB immediately after resuscitation (or within 24 hours of admission for all other patients)?
Endoscopy
Why should a PPI be offered before an endoscopy?
to reduce probability of re-bleeding
When assessing the patient’s ‘disability’, how can you quickly assess the patient’s consciousness?
AVPU scale
In UGIB, what can cause a patient’s consciousness level to be reduced?
Hypotension
Hepatic encephalopathy
Describe the steps of AVPU
- Alert → patient fully alert, although not necessarily orientated
- Verbal → patient responds when you talk to them (e.g. words, grunt)
- Pain → responds to painful stimulus (e.g. supraorbital pressure)
- Unresponsive
What 2 other factors can you use to assess the patient’s ‘disability’?
- Pupils
- Drug chart review for medications that can cause reduced level of consciousness
What drugs can cause a reduced level of consciousness?
Opioids, sedatives, insulin, oral hypoglycaemic medications
What aspects of the patients pupils should be assessed?
- Size & symmetry
- Direct & consensual pupillary responses
What investigation should be performed in the ‘disability’ aspect of UGIB? Why?
Capillary blood glucose → hypo/hyperglycaemia can cause reduced level of consciousness
N.B. blood glucose may be already available e.g. from ABG, venepuncture
What is a normal fasting plasma glucose?
4.0-5.8 mmol/l
What plasma glucose is defined as hypoglycaemia?
<3.0 mmol/l
What scale can be used for a more detailed assessment of consciousness?
GCS
What GCS requires urgent help/airway securing?
= 8
What is the ‘exposure’ aspect of ABCDE concerned with?
A more comprehensive examination of the patient
Completing the physical examination
Getting full overview of patient’s condition
The ‘exposure’ aspect of ABCDE in UGIB may involve an inspection of the patient for signs of chronic liver disease and/or coagulopathy. What are 7 signs?
- Spider naevi
- Caput medusae
- Bruising
- Ascites
- Peripheral oedema
- Evidence of trauma/bleeding
- Petechiae
What are petechiae?
Petechiae are pinpoint, round spots that appear on the skin as a result of bleeding.
What can cause petechiae?
Thrombocytopenia
Give 2 other potential observations/examinations in the ‘exposure’ aspect of UGIB. Explain why.
Rectal exam - assess for evidence of bleeding
Temperature - if fever present, consider infection
Why should all acutely unwell patients be catheterised?
To monitor urine output
