Intubating the Gastrointestinal Bleeder

Author: Angela Hua, MD (EM Resident Physician, Mount Sinai Hospital) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) 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?

Screen Shot 2016-01-13 at 1.30.01 PM

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/

2 thoughts on “Intubating the Gastrointestinal Bleeder”

Leave a Reply

Your email address will not be published. Required fields are marked *