HDA-masiva-S.Swadron-20121

7/30/2019 HDA-masiva-S.Swadron-20121

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Bad BleedsThe Gut

Stuart Swadron, MD FRCPC FACEP

Associate Professor and Vice-Chair of EducationProgram Director, Residency in Emergency Medicine

Los Angeles County-University of Southern California Medical Center

domingo 24 de junio de 12


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Bad Bleeds

An Approach to Panic



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Protecting Oneself!



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Blood in the Basin



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Localizing the Bleeding

THE BACK OF THROAT key to epistaxis



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Localizing the Bleeding

HEMOPTYSIS HEMATEMESIS

Dark BrownBright Red

FrothyFood

Acidic

Coffee Grounds

Alkaline



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The Chain of Survival

Severe Anything



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The Chain of Survival

EmergencyPhysician

Endoscopist

InterventionalRadiologist

Surgeon

Hematologist



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Massive Hemoptysis

WHERE ARE YOUR FRIENDS?



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General Principles

AIRWAY AND BREATHING

vs.



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General Principles




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General Principles

EtomidateNonrebreather




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General Principles

Colloid

CIRCULATION

Crystalloid

vs.



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General Principles

Level One

CIRCULATION

Packed RBCs



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General Principles

FFP Platelets DDAVP

CIRCULATION



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General Principles

PCC Factor VIIa

CIRCULATION



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General Principles

SIGNS FROM ABOVE



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General Principles

A SIGN FROM ABOVE



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SummarySEVERE GI HEMORRHAGE

Intubate earlyThink IRand surgeryright away



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How do I know if its massive?

Massive GI Hemorrhage



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1 You will feel it




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1 You will feel it2 There are pitfalls of the pulse




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1 You will feel it2 There are pitfalls of the pulse

3 If in doubt, assume its massive




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How do I distinguish an upper from alower GI bleed?




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1 You can be duped




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1 You can be duped

2 If in doubt, assume its upper




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1 You can be duped

2 If in doubt, assume its upper

3 Dont skimp on the NG tube




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How do I distinguish variceal from non-variceal hemorrhage?




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1 You can be duped




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1 You can be duped

2 If in doubt, assume its variceal




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1 You can be duped

2 If in doubt, assume its variceal

3 Dont skimp on the NG tube




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Summary


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Assume upperAssume variceal



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What drug should I hang?




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What drug should I hang?

Octreotide 50 g Bolus followed by 50 g/ Infusion

VERY SAFE




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If the bleeding stops am I done?




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If the bleeding stops am I done?

Endoscopy is still needed urgentlyNo clear criteria



Emergent Endoscopy


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Emergent Endoscopy

Recent Literature

Yan BM, Lee SSGastroenterologyMay 2003

EMERGENCY MANAGEMENT OFBLEEDING VARICES: DRUGS, BANDS ORSLEEP?

Opinion

Evidence from a multitude of clinical trials and meta-analyses comparingendoscopic and pharmacological treatments suggests near equivalence inefficacy for initial hemostasis, mortality and rate of rebleeding


Emergent Endoscopy


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Emergent Endoscopy

Recent Literature



OpinionThis raises the question of whether on-call gastroenterologists should beperforming emergency endoscopic treatment in the middle of the night orstart pharmacological treatment and delay endoscopy until optimal patientand working conditions the next morning.


Emergent Endoscopy


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Emergent Endoscopy

Recent Literature



Opinion

Although the literature cannot yet definitively answer the question posed, theauthors suggest that delaying endoscopic treatment until the next morningmay be the most reasonable practical approach.


M i GI H h


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What else can I do?



M i GI H h


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What else can I do?

Balloon tamponade if:

Bleeding not stopping

Endoscopist overcome

Patient transfer



M i GI H h


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MR. LINTON MR. MINNESOTA

1 balloon 2 balloons3 ports 4 ports




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LINTON TUBEDEMONSTRATION


SummaryS G O G


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SEVERE GI HEMORRHAGE


Use octreotide empiricallyUse balloon tamponade if bleeding persists

PRE-SCOPE

Assume upperAssume variceal




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What about gastric varices?





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What about gastric varices?

Gastricvarices

Diffuse portalhypertensivegastropathy

MEDICAL MANAGEMENTEMERGENT TIPS / SURGERY





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Scope Findings:Esophageal Varices


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Esophageal Varices

Just bled!Might have bled


Scope Findings:Peptic Ulcer Disease


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Peptic Ulcer Disease

Might have bled Just bled!



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What drugs should I initiate once I knowthe source?

g




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What drugs should I initiate once I knowthe source?

VARICEAL NON-VARICEAL (Ulcer)

Proton Pump InhibitorsAntibiotics

NON-VARICEAL

g




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What techniques are used endoscopically?

VARICEAL NON-VARICEAL (Ulcer)

Injection + CoagulationBanding

NON-VARICEAL

g




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Is endoscopy ever contraindicated?




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1 Surgical abdomen




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1 Surgical abdomen2 Ventricular tachycardia?


Massive Hematemesis


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What is TIPS and who does it?


Massive Hematemesis


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What is TIPS and who does it?


Massive Hematemesis


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TIPS



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Is there any role for the surgeon?




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Is there any role for the surgeon?

YES!




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What if this turns out to be lowerGIbleeding?




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What if this turns out to be lowerGIbleeding?

1 Still ok to chase upper source first




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What if this turns out to be lower GIbleeding?

1 Still ok to chase upper source first2 Most severe LOWER GI bleeds are:

Diverticular bleeding

Angiodysplasia

NEED

IR/ SURGERY




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Add antibiotics for varicesAdd PPIinfusion for PUD


Use octreotide empiricallyUse balloon tamponade if bleeding persists

PRE-SCOPE

POST-SCOPE

Assume upper

Assume variceal


MassiveGI Bleed

Resuscitation

Intubate if airway not protected ormajor bleed. Consider intubation


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for any EGD.Oxygen for everyone.

2 large bore IV or central accessType and screen if very stableType and cross for all othersImmediate hemoglobin

Order CBC, coags, chem 7

+/- NG tube

Proton PumpInhibitor IV

Octreotide forvarices

Antibiotics in ESLD

SBP < 90? NS bolus!Coagulopathic? FFP! Platelets!Anemic and hypotensive?O negative or matched PRBC!

GI consult and EGD Colonoscopy

Intervention viaEGD

+/- InterventionalRadiology, Surgery

Minnesota or Linton tube totamponadeTemporizing measureIntubation needed

Source found EGD not available, too much blood or transport needed

No source ofbleeding found


HDA-masiva-S.Swadron-20121

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