Intubating the Gastrointestinal Bleeder

Author: Angela Hua, MD (EM Resident Physician, Mount Sinai Hospital) // Edited by: Alex Koyfman, MD (EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital, @EMHighAK) and Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF)

Case:

54 year-old male with a history of cirrhosis and esophageal varices is brought in by EMS vomiting coffee-ground emesis. Initial vital signs are as follows: T 98.2   HR 117   BP 78/49   O2 95%. He is lethargic but arousable and weakly follows commands. GI states they will come in for endoscopy but requests an intubation for the procedure. How can you manage this airway?

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The challenges of intubating a GI bleeder:

  • View obscured by hemorrhage (and other bodily fluids)
  • Hemorrhagic shock and hemodynamic instability
  • Risk of aspiration
  • Staff risk of body fluid contact

 

Endotracheal Intubation (ETI) Recommendations:

Rapid Sequence Intubation (RSI)

  • Wear PPE
    • Goggles, mask, gown, gloves
  • Resuscitate before you intubate (see separate section below for more details)
    • Fluids
    • Blood products (FFP, RBCs, platelets, cryoprecipitate)
    • Reversal of coagulopathy
    • Vasopressor drip or push-dose pressor if needed prior to ETI
  • Empty the stomach
    • NGT placed on suction; varices are not a contraindication [1,2]
    • Prokinetics: metoclopramide 10mg IV, erythromycin 250mg IV [3]
  • Intubate with patient in head up 45 degrees position (Semi-Fowler position)
    • May decrease aspiration risk
  • Preoxygenation and apneic oxygenation
    • High flow nasal cannula, facemask
    • Avoid NIV in actively vomiting patient
    • Maximize preoxygenation to minimize bagging
    • If need to bag, do it gently and slowly
  • Intubation medications
    • Paralytics (e.g. Rocuronium 1.2mg/kg IV) – agents actually increase the lower esophageal sphincter tone [4]
    • Use hemodynamically stable dose of induction agent such as ketamine IV or etomidate IV. Use half of normal dose due to hypovolemia in patients
  • Equipment
    • 2 suction set-ups
    • Meconium aspirator (can attach to ET tube and suction as you go)
    • Bougie
    • LMA
    • Video laryngoscopes may be obscured by blood and vomit
    • Cricothyroidotomy materials at bedside
  • Aspiration
    • If patient vomits, place in Trendelenburg to help keep emesis out of lungs
    • SIRS response may require ongoing fluid resuscitation
    • Aspiration pneumonitis: bronchodilators and lung protective ventilation, but no antibiotics for the aspiration episode

 

Resuscitation

  • Place on cardiac monitor
  • Immediate IV access, preferably 2 large bore IVs (minimum 18 gauge)
  • Fluid boluses if presence of tachycardia, hypotension, or active bleeding
  • If vital signs remain abnormal after initial fluid bolus, consider early transfusion of blood products
  • Antibiotics for variceal bleeding: ceftriaxone or cefotaxime

 

Transfusion

  • No set rules, although generally indicated in persistent hypotension
  • Factors to consider: rate of active bleeding, absolute hemoglobin level, rate of hemoglobin drop, end-organ injury [5]. See CDEM’s approach to gastrointestinal bleeding for further guidelines
  • Target hemoglobin? Villanueva study showed better outcomes (mortality, re-bleeding) with restrictive strategy and early source control with endoscopy; transfusion threshold of 7g/dl and target of 7-9g/dl [6]
  • Correction of clotting disorder: give cryoprecipitate for fibrinogen repletement. Consider fresh frozen plasma, and vitamin K can also be given for an elevated prothrombin time.
  • Platelet transfusion should be performed if the patient has a severe GIB with platelet count less than 50,000/ml
  • HALT-IT trial will soon be able to give possible evidence for tranexamic acid (TXA) in Upper GI bleeding. Over 3600 patients (goal of 8000) recruited so far:http://haltit.lshtm.ac.uk [7]

 

Intubating the hypotensive patient: for further pearls and pitfalls for intubating these patients, please refer to this post: http://www.emdocs.net/intubating-critically-ill-patient/

Please see a prior emDocs post on managing the unstable GI bleeder, with a step-by-step approach: http://www.emdocs.net/unstable-patient-gi-bleed/

 

Bottom Line/Pearls & Pitfalls

  • Appropriately resuscitate (fluids, blood) as much as possible prior to intubation
  • Nasogastric tube, erythromycin, metoclopramide; useful prior to intubation
  • Pre-oxygenate well, minimize bag-valve ventilation
  • If must use BVM, remember to bag slowly as patient high risk for vomiting and aspiration
  • Position in semi-Fowler position for intubation, but place in Trendelenburg if vomiting
  • If persistently hypotensive: push-dose pressors peri-intubation, half dose induction agents, double dose paralytics
  • Must have plan B for airway: video and direct laryngoscopy tools, Bougie, intubating LMA, cricothyroidotomy set up
  • If aspiration occurs, be aware of SIRS response, judicious fluids, no antibiotics necessary

 

References / Further Reading

  1. Lopez-Torres A, Waye JD. “The safety of intubation in patients with esophageal varices.” Am J Dig Dis 18(12): 1032-4.
  2. Ritter DM, Rettke SR, Hughes RW Jr, et al. “Placement of nasogastric tubes and esophageal stethoscopes in patients with documented esophageal varices.” Anesth Analg 67(3): 283-5.
  3. Czarnetzki C, Elia N, Frossard JL. “Erythromycin for gastric emptying in patients undergoing general anesthesia for emergency surgery: a randomized clinical trial.” JAMA Surgery 150(3): 730-7.
  4. Cotton BR, Smith G. “The lower oesophageal sphincter and anaesthesia.” Br J Anaesth 56(1): 37-46.
  5. Farris S. CDEM Self Study Modules: Approach to Gastrointestinal Bleeding. http://www.cdemcurriculum.org/ssm/approach_to/gi_bleed.php
  6. Villanueva C, Colomo A, Bosch A. 0” Transfusion strategies for acute gastrointestinal bleeding.” N Engl J Med 2013; 368(1):11-21
  7. HALT-IT trial. http://haltit.lshtm.ac.uk
  8. http://lifeinthefastlane.com/ccc/intubation-of-the-gi-bleeder/
  9. http://emcrit.org/podcasts/intubating-gi-bleeds/

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