My Talk for emergency nurses on resuscitating the upper GI bleeder in the emergency department!

1. The Upper GI
Bleeder
By Kane Guthrie FCENA

2. Upper GI Bleeds
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Understand the causes
Goals of resuscitation
Pharmacological resuscitation
Procedural resuscitation

3. Upper GI Bleeds in ED
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Its challenging
Effective Mx = good PT outcomes
Underlying comorbidities ∧ complexities
Team approach
Pharmacology & procedural approach

4. Upper Vs Lower
• Consider upper first
– More life threatening
• Haematemisis = Upper GI source
• Bright red blood not always = LOWER GI

5. Case Study
• 52 Male
• Chronic ETOH abuse
• Known varices
C/O – Vomiting blood post binge

6. What to Look for!

7. His Vitals

8. The Upper GI Bleeder
Multi Team Approach:
• ED, ICU – resuscitate
• Gastro – scope
• Interventional Radiologist – therapeutic Ix
• Surgeons – surgical intervention

9. The Source
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Duodenal ulcers- 28%
Gastric ulcers- 26%
Gastritis- 13%
Varices - 12%
Esophagitis - 8%
• “Massive GI Bleed Mortality rate 20-39%”

10. The DDx!
• Intranasal
• Intrapulmonary

11. Remember!
Early Intervention
can mean
difference between
Life & Death

12. The 3 Goals of Resuscitation
1 Provide Intravascular Volume Resuscitation
2 Optimise Oxygen-Carrying Capacity
3 Reverse Coagulopathy

13. Initial Resuscitating
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Start with ABCDE
x2 Large bore IVC – Bloods
Full monitoring
Get specialties involved
Arrange blood products
Consider limitations of care!

14. Intravascular Volume Resuscitation
• Limit crystalloid fluid –to early phase
Prepare for transfusion:
• HB <80
• Coagulopathy
• Persistent hypotension

15. Intravascular Volume Resuscitation
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PRBC’s not enough
Replace clotting factors
Consider massive transfusion protocol
“PRBC:FFP:platelet ratio 1:1:1”
• Tranexamic Acid?

16. Optimise Oxygenation
Signs of decreased O2 delivery:
– Decreased LOC
– Evidence of cardiac ischaemia
– Increased lactate
– Cold peripheries

17. Optimise Oxygenation
• Give blood so oxygen can get to the tissue
Initially:
– Provide High Flow 02
Crashing:
• Intubate early
Stablised:
• Titrate oxygen to need
• Considered humidified

18. Intubating Isn’t Easy!
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Intubate early
Empty stomach (NGT)
Intubate with HOB at 45°
Preoxygenation
Limit BVM
Use experience
Prepare for vomit

20. Reverse Coagulopathy
• Tailor to etiology.
Causes:
• Anticoagulation
• Shock
– Metabolic acidosis –tissue hypoperfusion
• Chronic disorders
– ETOH abusers

21. Pharmacological Interventions
• Proton Pump Inhibitors
• Somatostatin
• Vasopressin

22. Proton Pump Inhibitors
• Suppress gastric acid production
• Potential reduction haemorrhage during
scope
The evidence though:

23. Somatostatin
• (Octreotide)
Reduces:
• Portal venous blood flow
• Splachinic vasoconstriction
=decrease GI Bleeding
Use
• Variceal GI bleeds
• Limited evidence – low side effect profile

24. Vasopressin
(Telipressin)
• Reduces portal hypertension
• Splachnic vasoconstrictor
• Can cause ischaemia
• Last ditch effort in bleeding varices

25. Antibiotics
• Infection on varices
– Causes bleeding
• Give antibiotics (broad spectrum)

26. Procedural Interventions
• Endoscopy
• Balloon Tamponade

27. Endoscopy
• Diagnostic & therapeutic tool
Interventions:
• Clips
• Banding
• Thermocoagulation
• Sclerosant injection % adrenaline

28. Balloon Tamponade

30. Balloon Tamponade
• Temporising rescue device
Indicated:
– Endoscopy not available
– Endoscopy not successful
• Need to secure airway prior

31. Questions

32. Take Home Points
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Early recognition
Team approach is needed
Resuscitate with blood products
Advocate for early intervention