REBEL Core Cast 39.0 – Upper GI Bleed

Sep 02, 20
REBEL Core Cast 39.0 – Upper GI Bleed

Take Home Points

  • Focus on resuscitating well by focusing on the basics
  • Recognize Massive GIB (MGIB) with a thorough exam of the patient and vital signs (Shock index >0.7 is ABNORMAL and signals impending shock)
  • Obtain large bore PIV access and prioritize transfusion over crystalloids for MGIB
  • Get consultants on board early
  • Give adjunctive medications that impact mortality (ie A 3rd generation cephalosporin in patients with variceal bleeding or a history of cirrhosis)

REBEL Core Cast 39.0 – Upper GI Bleed

Definition and Recognition of Massive GI Bleeding (MGIB)

  • Not one consensus definition exists
  • Any bleeding from the GI tract (upper or lower) that results in
    • Hemodynamic instability (hypotension, dysrhythmias)
    • Poor perfusion (AMS, syncope, pallor, delayed capillary refill, decreased pulses)
    • Overt and rapid bleeding
    • Transfusion of 2 units pRBC in initial resuscitation
  • Spend time at the bedside looking for these things
    • AMS
    • Skin temperature, color
      • Pallor
      • Mottling
      • Capillary refill
    • Vital signs
      • Hypotension
      • Hypoxia
      • Shock Index (HR/SBP)
        • > 0.7 is ABNORMAL
        • > 1.0 may signal a need for massive transfusion
  • Characteristics that may predict the need for immediate intervention
    • UGIB
      • Tachycardia (LR 4.9)
      • Syncope (LR 3.0)
      • Hx of malignancy or cirrhosis (LR 3.7)
      • NG lavage returning BRB (LR 3.1)
    • LGIB
      • Similar for LGIB
      • Tachycardia
      • Syncope
      • HD instability
      • Active rectal bleeding
      • Non-tender abdominal exam
      • ASA use
      • Hx/o renal failure, liver failure, malignancy
  • A NORMAL HR is predictive for a NON-massive GIB
    • Check if patient is on a BB or CCB that may mask tachycardia
  • Localizing the bleed
    • Hematemesis
      • UGIB
    • Melena
      • Usually UGIB or
      • Proximal LGIB
    • Hematochezia
      • Usually LGIB or
      • Brisk UGIB (very sick patients!)

Basic Resuscitation First!

  • Reliable peripheral IV access
    • Short and fat lines!
    • IO if peripheral fails
  • Blood > crystalloid
  • Reverse anticoagulants
  • Secure the airway if needed
  • Get your consultants on board early (endoscopy/GI, surgery)

Adjunctive Medications

  • Proton pump inhibitors (PPI)
    • Cochrane Review
      • No effect on mortality, rebleeding, need for surgery
      • Decrease high risk stigmata in patients with peptic ulcer disease (PUD)
    • Bottom line: Doesn’t affect mortality so don’t prioritize during the initial resuscitation.  May give bolus after.
  • Octreotide
    • Somatostatin analog, vasoconstricts the splanchnic circulation
    • No effect on mortality in undifferentiated GIB
    • However, can decrease
      • Initial bleeding
      • Total transfusion
      • Need for surgery
    • Bottom line: Doesn’t affect mortality so don’t prioritize during the initial resuscitation.  May give bolus + infusion after.
  • TXA
    • Reduces the breakdown of fibrin clots, fibrinogen, and other plasma proteins
    • Recently published HALT-IT Trial provided good quality evidence
      • No difference in 5 day mortality due to bleeding
      • There WAS an increase in VTE (adverse events)
    • Bottom line: Not recommended to give routinely
    • If TEG/ROTEM demonstrates excessive fibrinolysis then TXA would be indicated
  • Antibiotics – Cephalosporins!
    • Decreases mortality in patients with variceal bleeding or undifferentiated bleeding in patients with cirrhosis
      • These patients are immunocompromised at baseline and GI bleeding puts them at risk for subsequent sepsis
      • 3rd generation cephalosporin
        • Ceftriaxone 1 gram
        • Cefotaxime 2 grams

Take Home Points:

  • Focus on resuscitating well by focusing on the basics
  • Recognize MGIB with a thorough exam of the patient and vital signs (Shock index >0.7 is ABNORMAL and signals impending shock)
  • Obtain large bore PIV access and prioritize transfusion over crystalloids for MGIB
  • Get consultants on board early
  • Give adjunctive medications that impact mortality (ie A 3rd generation cephalosporin in patients with variceal bleeding or a history of cirrhosis)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

The post REBEL Core Cast 39.0 – Upper GI Bleed appeared first on REBEL EM - Emergency Medicine Blog.

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