UPPER GI BLEED Flashcards
MANAGEMENT
A - STRIDOR.
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.
D - CHECK GLUCOSE. GCS, PERRLA, lateralizing signs
E - EXPOSURE, TAKE DOWN DRESSINGS
A - Intubate for Massive UGIB:
Direct laryngoscopy
Avoid over bagging
Two high volume suction devices
Head of bed elevated
Use bougie
NGT aspiration after the rescue
C - 2 large bore IV’s
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.
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
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
Hematemesis
Ground Coffee Emesis
Melena
Epigastric Pain
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
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
Peptic Ulcer Disease (MCC)
Erosive Gastritis, Esophagitis, Duodenitis
Esophageal and Gastric Varices
Mallory Weiss Tear
Dieulafoy Lesion
Arteriovenous Malformation
Malignancy
