SIM Code

Objectives

• Demonstrate knowledge of the etiology of GI

bleeds and appropriate interventions

• Discuss the preparation and use of GI

emergency equipment

• Describe the preparation of a GI Emergency

Cart

GI Bleed

• GI Bleeding is a common medical emergency in gastroenterology

• 300,000 hospital admissions annually in US

• Cost estimated to exceed $2.5 billion in the US per year

GI Bleed

• The location of the bleeding can be varied:

• 90% is in the upper GI

• 9% in the colon

• 1% in small bowel

GI Bleed

• Increasing evidence supports changes over the past 2 decades in the following areas due to advances in medical practice:

• clinical presentation

• causes

• incidence

• management

• outcomes

GI Bleed

• The annual mortality rate of UGIB also decreased from 17.1 to 8.2 per 100,000 during this same time period. (pt < 70yrs)

• Mortality is strongly correlated to patient age and co-morbidities. Risk factors typically include:

• Age > 60 years

• Multiple comorbidities

• Active bleeding

• Hypotension or shock

• Large volume red blood cell transfusion

• Inpatient status at time of bleed

• Significant coagulopathy

GI Bleed

• Peptic Ulcer Disease most common cause of UGIB

• Associated with H.Pylori and ASA/NSAIDS

• Source of bleed found in 90% cases

• EGD is indicated for the initial evaluation of a suspected upper GI bleed

• Approaches in management vary in different settings.

• Therapies are approximately > 85 - 90% effective

Etiology of GI Bleeding

Variceal Bleeds

Non-Variceal Bleeds • Peptic Ulcer Disease • Esophagitis

• Mallory-Weiss Tear

• Angiomata Syndromes

• Malignancy

• Dieulafoy’s Lesion

• Iatrogenic

• Gastric Antral Vascular Ectasia

Gastric Varices

• Gasric Varices

Upper GI Bleed

Sources of Lower GI Bleeding

Colonic Polyps Colonic cancers Diverticula Bleeding Non-variceal hemorrhage

Guidelines for Management

• Initial management of UGIB should consists of:

• Patient assessment

• Stabilization

• Fluid Management

• A thorough review of current medications with special attention paid to anticoagulants, antiplatelet agents or meds associated with GI hemorrhage (NSAIDS)

Proficiency in Establishing

Hemostasis • Knowledge of indications for appropriate

GI emergency equipment

• Demonstrate the preparation and use of

GI emergency equipment

Develop an GI Bleed Plan

• Create an environment in which team members remain calm and composed

• Training and experience with all GI interventional equipment

• A Clear plan that all team members are familiar with

• Good communication

• Proper tools and equipment available

SIM

Scenario • Arrives from the ED to Endo with

Upper GI Bleed

• History ( what brought her to the ED)

• V/S,EKG

• Mentation

• Sedation admin by anesthesia

• ? Bleeding site- not evident at first

• Excessive bleeding noted-unable to clear the field to locate bleed

• V/S become unstable

• HR-Tachycardia, O2

• B/P

Action: • Anesthesiologist to control

environment

• Provide Glide scope

• Obtain GI bleed accessories

• Assign staff member to check blood transfusion band ( if any)

• Check in computer if Blood is ready

• If not- Type and Screen

• Assign- recorder, runner, traffic control, assisting nurses, IV start

• Call RR, Call Code

SIM Education

Teaching

• GI Bleed box- contents

• Role definitions in GI Emergency

• How to type and cross match

• Check blood availability in computer

• Order blood in computer

• Obtain blood

• How to control the environment/team members

• When to call RR and Code

Location of Emergency Equipment

• GI Bleed Cart or:

• IV equipment

• GI accessories

• Transfusion administration equipment

• Glide Scope

• Code Cart

GI Bleed Cart

Contents of GI Bleed Cart

• GI Accessories- Clips, gold probe, Sclero needles, Bear Claw, Ligation banding kit, Code Blue Lavage

• IV equipment- NS, LR, Tubing, NS flushes, IV start sets, Tape

• Blood Administration- Hollister Transfusion set with tubes, lab blood release forms, pressure bags, Blood administration tubing

• Miscellaneous- Yankauer, Salem NGT, Surgilube, Catheter tip syringe with basin, List of important Phone numbers

GI Bleed EQUIPMENT

• Drawer #1

• Hollister Blood Set / Blood Collection Equipment ( Tubes, forms, Green Blood Release Slips

• Binder with Phone #’s, Equipment list, Instructions

• Drawer #2

• Endo Clips

Sclero Needles

• Esophageal Ligation Banding Kit-

• Bipolar Gold Probe w/ 20cc SYRINGE

• Drawer #3

• Pressure Infusion bag

• IV Normal Saline

• IV LR

• IV Tubing

• Blood Administration Tubing

• IV Start Sets w/ Tape

• Normal Saline Flushes

• Drawer #4

• Salem NG tube size 14, 16 gauge

• Surgilube

• Cath Tip Syringe w/ Basin for Ice Lavage and NG Tube Insertion

• Yankauer Suction Device

• Overtube

• Code Blue Lavage

• Bear Claw (location in the unit)

• Glide Scope (located in Exam Room)

•

Calling a Rapid Response

The RRT will be considered for any of the following:

• a. Concern regarding the patient’s condition.

• b. Respiratory distress, threatened airway, or change in breathing

pattern.

• c. Acute change in blood pressure.

• d. Acute change in heart rate.

• e. Acute change in level of consciousness.

• f. Acute bleed.

• g. New, repeated, or prolong seizures.

• h. Chest pain.

• i. Failure to respond to treatment.

Calling a Rapid Response

• The primary RN will supply the RRT with patient

diagnosis, history, and events leading up to the

RRT call.

• The primary RN will also provide the RRT with

recent lab(s), electronic medication administration

record (eMAR), medical record, and the primary

care physician’s phone number.

Calling a Rapid Response

• The RRT will provide advanced patient

assessment, assist the bedside caregiver with

procedures, and provide the primary care

physician with information regarding the patient’s

condition

• The primary RN is responsible for documenting

pre and post assessments.

Type and Screen

Familiarize yourself with the transfusion ordering process in your institution

Review Blood administration policy

Order the blood

Prepare the proper ordering documentation

Verify all components of the transfusion system

Fill out lab blood release form and send with a staff member to pick up Blood

Type and Screen

• After ensuring labels are properly

completed, place blood sample

• labels

• Labeling Sheet

into impervious plastic bag and send bag to

blood bank

Obtaining Blood from Blood

Bank

• Have BA order blood through Computer

• Fill out lab blood release form and send

with a staff member to pick up Blood

• Review Blood administration policy

Be Prepared

• Simulation Training can prepare us to handle the

most difficult situations that we face in the GI

unit

• Speak up “when something doesn’t seem quite

right”

References

• Kirschniak, A., Subotova, N., Zieker, D., Königsrainer, A., & Kratt, T. (2011). The Over-The-Scope Clip (OTSC) for the treatment of gastrointestinal bleeding, perforations, and fistulas. Surgical Endoscopy, 25(9), 2901-2905. doi:10.1007/s00464-011-1640-2

• Collopy, K. T., Curtis, M., & Snyder, S. R. (2011). Gastrointestinal Bleeding: Understanding the different causes of GI bleeding will help you perform a thorough patient assessment and provide accurate care. EMS World, 40(4), 45-50.

References

• Hwang, J. H., Fisher, D. A., Ben-Menachem, T., Chandrasekhara, V., Chathadi, K., Decker, G. A., & ... Cash, B. D. (2012). The role of endoscopy in the management of acute non-variceal upper GI bleeding. Gastrointestinal Endoscopy, 75(6), 1132-1138. doi:10.1016/j.gie.2012.02.033

• Meltzer, A. C., & Klein, J. C. (2014). Upper gastrointestinal bleeding: patient presentation, risk stratification, and early management. Gastroenterology Clinics Of North America, 43(4), 665-675. doi:10.1016/j.gtc.2014.08.002

• Sami, S. S., Al-Araji, S. A., & Ragunath, K. (2014). Review article: gastrointestinal angiodysplasia - pathogenesis, diagnosis and management. Alimentary Pharmacology & Therapeutics, 39(1), 15-34. doi:10.1111/apt.12527

References

• Rajala, M. W., & Ginsberg, G. G. (2015).

Tips and Tricks on How to Optimally

Manage Patients with Upper

Gastrointestinal Bleeding. Gastrointestinal

Endoscopy Clinics Of North America,

25(3), 607-617.

doi:10.1016/j.giec.2015.02.004