Deep Dive: GI Bleeds and Hemorrhagic Shock

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treating the bleeding patient

what is a gi bleed?

Well - bleeding. From your GI tract. But what can cause it?

The causes of a GIB can be divided into upper GI bleeds and lower GI bleeds.

Upper:

  • Gastric + duodenal ulers (esp w/NSAID use)

  • Esophageal Varices

  • Esophagitis

  • Mallory Weiss Tear

  • AVM

Lower

  • Divertulosis

  • Ischemic Bowel

  • Infectious diseases of the bowel (e.g.) colitis

  • IBD

  • Neoplasms


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Signs and Symptoms

  • Both: Orthostatic hypotension, tachycardia - or shock if it progresses far enough

  • They vary in where you find the blood -

    • UGIB: hematemesis (vomiting bright red blood), melena (dark stool)

    • LGIB: hematochezia (bright red blood per rectum/BRBPR), coffee ground emesis


treatment

first thing to think about: Source control

  • Get GI consult early - may not necessarily do an intervention, but they can request imaging to help them later

  • Early type and screen/type and cross

  • ICU or no ICU:

    • BLEED criteria: active Bleeding, Low BP, Elevated PT, Erratic MS, comorbid Disease.

    • 1 or more: should go to the ICU

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Importance of IV access

  • Giving blood is like pushing molasses through a straw: need a large bore

  • Bernoulli’s Principle - encompasses the concept that the flow of a fluid is determined by the length and the diameter of the container it flows through

    • A shorter, larger bore tube will have more  flow than a longer, smaller container

      • We often get large bore access in a active bleeding, HD unstable patient w/cordis or MAC catheters in our system although two large bore, dependable IVs can be used as well - can place with ultrasound

 
Cordis cathteter

Cordis cathteter

Trialysis catheter

Trialysis catheter

 
Arrow MAC catheter

Arrow MAC catheter


How much blood should you give?

  • In general, 1u PRBC with raise your Hgb 1 point

    • Goal Hgb for most patients: 7

    • Goal Hgb for CAD/active ACS: 9

  • So how much do you give?

    • Low Hgb but hemodynamically stable - target of 7 even if active GIB

    • Low Hgb in shock, hemodynamically unstable - resuscitation should not wait on Hgb; give blood and monitor hemodynamics (just like you would for a NS bolus)

  • Restricted blood administration improves mortality:


Other things to do

  • Place a NGT to suction (as long as no hx of varices or recent surgery)

  • Keep NPO – anything that stimulates the GI tract can compound further bleeding

  • Monitor CBC frequently, every 4-6 hours

  • Stop any aspirin, antiplatelets or VTE ppx


Slowing the bleeding - reverse And stabilize while getting source control

  • Pantoprazole for LGIB

  • Octreotide for liver/elevated portal pressures

  • Reverse coagulopathy

    • FFP – 15 cc/kg, each bag of FFP 250cc (although this varies depending on hospital)

    • Vitamin K – promotes synthesis of factors 10, 9, 7 and 2, especially good in warfarin; takes time

    • Kaycentra - Prothrombin Complex Concentrate for rapid warfarin reversal

    • Praxbind - for reversal of pradaxa

    • Andexxa - reversal for direct factor Xa inhibitors such as apixaban (Eliquis) and rivaroxaban (Xarelto)

    • TXA – esp good for intracranial hemorrhage, only use if fibrinogen okay

    • DDAVP - can be used in uremic bleeding – makes platelets sticky


Massive transfusion

  • In our institution: acute massive and uncontrolled hemorrhage, expecting to transfuse >5 or more units within one hour

  • Per AABB Technical Manual 18e in 2014: “Massive transfusion is defined as the administration of 8-10 RBC units in an adult patient in less than 24 hours or acute administration of 4-5 RBC units within one hour.”

      • One unit FFP for every 4-6 units PRBC (goal INR <1.5)

      • One unit platelets for every 2-5 units PRBC (goal platelets >50,000 if active bleeding)

    • Massive transfuser OR pressure bag blood – don’t be scared to pressure bag

  • The effect of giving lots of blood

    • Low calcium due to citrate (anticoagulant) in the bag that prevents clotting

    • Monitor calcium VERY closely

The non-bleeding anemic patient

  • What if you have a profoundly anemic patient that isn’t obviously bleeding

    • Check their abdomen: could be bleeding intraabdominally

    • Benign abdominal exam but still becoming more anemic? could be deeper (think retro-peritoneal)

  • Brief overview of other types of anemia:

    • Anemia of chronic disease is common – but it won’t drop suddenly

      • Acute: Normocytic red cells

      • Chronic: Microcytic red cells

    • Bone marrow suppression 2/2 sepsis

      • Check reticulocytes – (or baby red cells)

  • Either way, anemia without an obvious sign of bleeding is a good reason for a hematology consult

Summary

  • GI bleeds can originate from the upper GI tract - which typically presents with melena and hematemesis - or the lower GI tract, with typically presents with hematochezia

  • Source control is the only control, so getting an early GI consult for intervention is important

  • After source control always think ACCESS. Large bore, shorter length catheters as intravascular access is ideal per Bourtullis law to get blood quickly into the patient

  • Keep them NPO, place an NGT (if they don’t have a history of varices or abdominal surgery), and start a PPI or octreotide drip depending on where you think the bleed is coming from

  • Reverse coagulopathy with FFP or a host of agents to reverse anticoagulants at home

  • Massive transfusion is defined as acute massive and uncontrolled hemorrhage, expecting to transfuse >5 or more units within one hour; watch their calcium

  • In the non-bleeding profoundly anemic patient check their abdomen - and consider a hematology consult


attributions

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John HeislerComment