Deep Dive: GI Bleeds and Hemorrhagic Shock

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

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

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

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:
- TRICC - in critical care
- TRISS - in septic shock

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
- Continuous drip vs BID pushes - see RebelEM for a great overview
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.”
- 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

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GI, Hemodynamics, Critical Care, ShockJohn HeislerDecember 17, 2018GIComment