Deep Dive: GI Bleeds and Hemorrhagic Shock
GI bleeds are common in the ICU and may present as melena, hematemesis, or hematochezia. Management focuses on rapid recognition, early vascular access, resuscitation with blood products, correcting coagulopathy, and parallel source control with GI consultation to prevent progression to hemorrhagic shock and death.
What Is a GI Bleed?
A gastrointestinal (GI) bleed refers to bleeding anywhere along the digestive tract, divided into upper GI bleeds (ulcers, varices, esophagitis, Mallory-Weiss tear) and lower GI bleeds (diverticulosis, colitis, ischemic bowel, neoplasms).
Upper GI bleeds often present with melena (dark, tarry stool) or hematemesis (vomiting blood).
Lower GI bleeds typically cause hematochezia (bright red blood per rectum).
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
Hemodynamic Clues in GI Bleeding
Early signs include tachycardia and orthostatic hypotension, with progression to shock if untreated. Hypotension, pallor, confusion, and elevated BUN may accompany active bleeding. 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
The First Step: Vascular Access
For unstable patients, two large-bore IVs or a Cordis catheter are essential.
Short, wide catheters allow faster transfusion flow.
Central lines may be needed if pressors are required or IV access is difficult.
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
Trialysis catheter
Arrow MAC catheter
Blood Transfusion Strategy
Goal hemoglobin: ≥7 g/dL (or ≥9 g/dL in patients with acute coronary syndrome).
Actively bleeding patients require volume resuscitation guided by hemodynamic stability, not just hemoglobin levels.
Use type and cross early; order emergency release blood if necessary.
In general, 1u PRBC with raise your Hgb 1 point
Goal Hgb for most patients: 7
Goal Hgb for CAD/active ACS: 9
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
Continuous drip vs BID pushes - see RebelEM for a great overview
Octreotide for liver/elevated portal pressures
Correcting 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
Key takeaways
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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