The Unstable Patient with a Gastrointestinal Bleed

The Unstable Patient with a Gastrointestinal Bleed

By Amar Patel, MD
Resident Physician, Penn State Hershey Medical Center
Edited by Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Stephen Alerhand, MD

Dr. NickUnstable patients can make even the best EM docs seem like Dr. Nick.

This is why it is best to revert back to the ABCs (Airway, Breathing, Circulation) when dealing with an unstable patient due to an unknown etiology. For the purposes of a known GI bleed, we can apply a similar concept. The majority of the time a patient is exsanguinating from a GI source, it tends to be of upper GI origin.

Let’s walk through a situation: To begin with, unless you are the first person in the room or there are not enough personnel, you should not touch the patient. Even though this is not a code, studies have shown that there is an overall worse outcome when the team leader lays hands on the patient. Remember that immediate resuscitative measures take priority in either unstable or actively bleeding patients.

Time 0 minutes
Walk into the room of a potentially unstable patient with a GI bleed

Time 1 minute
Is he responsive? If not, do not read further than this line => pulse check and begin ACLS.

Time 1 minute 10 seconds
What type of access does the patient have? What are the most recent vitals? Is he on a monitor? If not on a monitor, ask to have him placed on monitor.

– Get most recent vitals, cycle q5-15min, and place on cardiac monitor.
– Place patient on 2L NC PRN.
– Patient should have 2 large bore peripheral IVs > IO > Central. If the patient is truly unstable, the fastest access which will allow for the greatest volume is the best choice.
– Start 2L NS bolus unless the patient is actively bleeding in front you and unstable, in which case give pRBC.

 Time 1 minute 20 seconds
Airway: If the patient responsive? Is he mentating well? Can you determine if the airway is patent? Is he acutely vomiting blood?

– If the patient is not mentating well and you suspect a GI bleed, the airway may need to be taken due to impending collapse.
– Likewise, if the patient has ongoing hematemesis, there should be little to no hesitation to take the airway to prevent aspiration of blood.
– EMCRIT link: great podcast on how to tube the critically ill GI bleeder http://emcrit.org/podcasts/intubating-gi-bleeds/

Time 1 minute 30 seconds
(assuming the patient is mentating properly)
Breathing: How do the lungs sound? Do you note chest wall crepitus?

– Of less value, but still important to do a quick listen and check for bilateral chest rise, as well as assess for lung collapse from aspiration if hematemesis has already lasted awhile

 Time 2 minutes
Circulation: Strength of pulse? Pulse pressure?

 By now, you have a few blood pressure readings, and you can determine if the patient is responding to IV fluids. If the BP is not responding and you have not started blood products, this would be the time to start. Even though there are rough cut-offs for starting FFP (fibrinogen <1 or INR >1.5) and platelets (<50,000) in an unstable patient, start at a 1:1:1 ratio with pRBC if POC tests are not available (controversial; moving towards patient-tailored resuscitation ratios).

Goal should be for improved clinical appearance of patient and MAP of >65 to allow for adequate end-organ perfusion.

*Bonus I: For known upper GI bleed, give PPI as soon as access is obtained (controversial in EM discussions, though GI specialists appreciate this as it makes endoscopy easier). Decreasing the acidity provides benefit acutely by improving platelet function, and in the long run by adding mucosal protection. Start with an 80 mg bolus followed by 8 mg/hr of Esomeprazole or Pantoprazole.

 *Bonus II: Octreotide can be given while waiting for endoscopy in: known cirrhotics, upper GI source, or high-grade volume loss (also controversial in EM discussions).

 Shock Table to Estimate Volume Loss: Better to Over-Resuscitate then Under-do it
shock estimate volume loss

Labs and Studies
Type and cross blood – most important
– CBC: remember initial hematocrit level may not reflect actual amount of blood loss
– CMP: upper GI bleeds may elevate BUN levels through digestion and absorption of hemoglobin (a BUN:Cr ratio >30 is highly suggestive of an upper GI source)
– Coagulation studies
– EKG: check for silent ischemia, which can occur secondary to decreased oxygenation

Treatment
Endoscopy is the best and final treatment for these patients, second only to resuscitation.
– For the unstable patient, the GI team should be contacted for emergent endoscopy as soon as resuscitation has been initiated.
– Give antibiotics for suspected variceal bleeds.

Final Pearls
– When in doubt, revert back to the ABCs.
– Volume resuscitation is key. If patient is unstable or actively bleeding, start blood products.
– Emergently contact GI for endoscopy of the actively bleeding or unstable patient.

Last resort intervention: Blakemore tube Placement for massive upper GI hemorrhage: http://emcrit.org/procedures/blakemore-tube-placement/

References and Further Reading

http://emcrit.org/practicalevidence/acute-upper-gi-bleeding-guidelines/
-Acute upper gastrointestinal bleeding: management. Issued: June 2012. NICE clinical guideline 141
-Bickell WH, Wall Jr MJ, et al. Immediate vs. Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries. N Engl J Med. 1994;331:1105.
-Seymour I. Schwartz. Principles of Surgery Companion Handbook pg 163
-Hearnshaw S, Brunskill S, Doree C, Hyde C, Travis S, Murphy MF. Red cell transfusion for the management of upper gastrointestinal haemorrhage. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD006613.
-Capell MS, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. Med Clin N Am 2008;92:491-509.
-Gralnek IM, Barkun AN, Bardou M. Management of acute bleeding from a peptic ulcer. N Engl J Med. 2008;359:928-937
-Cline DM, Ma OJ, Cydulka RK, Meckler GD, Handel DA, Thomas SH. Tintinalli’s Emergency Medicine, Seventh Edition. 2012; ch78
-Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010 152:101-13.
http://www.ncbi.nlm.nih.gov/pubmed/9928705
http://www.ncbi.nlm.nih.gov/pubmed/24560395
http://www.ncbi.nlm.nih.gov/pubmed/24267497
http://www.ncbi.nlm.nih.gov/pubmed/24267496

4 thoughts on “The Unstable Patient with a Gastrointestinal Bleed”

  1. Great summary. One note to add is consideration of PCC’s for your patient’s on coumadin. I believe the evidence is lacking in terms of actual patient-centered outcomes, but it leads to much faster INR reversals.

    1. Excellent point! I love the idea of PCC for the GI bleeder on coumadin. Reason I did not mention it here is as you said the evidence just isn’t there yet to show superiority. I think if there was a concern for fluid overload it would be a great option. As you stated it acts much faster then FFP in reversing the INR but unfortunately that does not necessarily mean superior outcome. However, I don’t think anyone would fault you.

      Hickey M et al. Outcomes of urgent warfarin reversal with
      frozen plasma versus prothrombin complex concentrate
      in the emergency department. Circulation. 2013 Jul
      23;128(4):360-4 PMID: 23770745

      There is some evidence for dec length of stay in the ED
      http://www.ncbi.nlm.nih.gov/pubmed/24661780

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