Airway Is the patient able to talk? - if so the airway is patent Noisy breathing suggests airway compromise: Perform head tilt, chin lift If noisy breathing persists try a Jaw Thrust If airway still compromised use an airway adjunct - Oropharyngeal/Nasopharyngeal airway Breathing Give High Flow Oxygen via a Non-rebreathe mask – 15 Litres – 100% Ensuring the patient is well oxygenated is important, but be ready to quickly removed the mask during episodes of haematemesis. The last thing you want is to cause the patient to aspirate! Assess Respiratory rate Oxygen Saturation – often decreased due to ↓ oxygen carrying capacity +/- aspiration Air entry (auscultation) - reduced air entry at lung base would support a diagnosis of aspiration Percussion – may be useful – aspiration, consolidation etc Expansion – may highlight lung collapse, aspiration etc Circulation IV Access Insert 2 x Large Bore Cannulae (14G-16G) This is essential, as patients often need significant volumes of fluid & blood to be given FAST Therefore this step should not be delayed. There’s no such thing as too much IV access in these situations! Bloods Take bloods off after inserting the cannula: FBC – Hb may be decreased – but often appears normal in the context of acute blood loss Clotting – deranged in liver disease & may indicate the need to replace clotting factors Group & X-Match – Requesting blood early is essential – in emergency use O neg blood U&E’s – ↑ Urea occurs in UGI bleeds due to digestion & absorption of blood proteins LFT’s – if liver disease is suspected then this test can help confirm the diagnosis Observations Blood pressure – in large bleeds this can fall quickly – guides amount/rate of fluid/blood given Heart rate – often tachycardic due to volume depletion – beware of beta blockers masking this Capillary refill time – central CRT gives a quick estimate of volume status – should be <2 secs ECG – most likely to see sinus tachycardia Fluids & Blood Transfusion Fluid Patients are often haemodynamically unstable - hypotension & tachycardia Fluid is useful for replacing volume loss – maintaining adequate BP for organ perfusion Crystalloid vs Colloid is debatable – studies have not demonstrated any difference in outcome The rate of fluid replacement depends on the rate of loss - BP & UO can help guide this If patient is losing significant amounts of blood, fluid replacement alone is not adequate Beware of overloading a patient with fluids – monitor for signs of pulmonary oedema Blood Transfusion Hb can be misleading in acute bleeds as it only drops once haemodilution has occurred NICE suggests Hb of <10g/dL as the cut off for transfusing blood to avoid underestimation Give compatible blood when available -rate of transfusion guided by Hb & estimated blood loss If patient is losing blood rapidly – don’t wait for X-match – give O negative blood instead Platelets & Clotting Factors Patients may have deranged platelets & clotting factors which are contributing to the bleed This is often due to pre-existing liver disease +/- splenomegaly NICE Guidance in regard to the use of platelets & clotting factors is as follows:² Platelets If a patient is not actively bleeding & haemodynamically stable don’t give platelets Only offer platelets to patients actively bleeding with a platelet count <50 x109 Fresh Frozen Plasma (FFP) Offer Fresh Frozen Plasma to patients who have either: Fibrinogen <1g/litre Prothrombin > 1.5 x normal Prothrombin Complex Give Prothrombin complex concentrate to those taking Warfarin & actively bleeding Recombinant Factor VIIa Only offer Recombinant Factor VIIa when all other methods have failed Monitor Urine Output With haemodynamically unstable patients it’s useful to monitor urine output This is because urine output provides a proxy measurement of organ perfusion If the kidneys are not getting sufficient perfusion, urine output falls Aim for a urine output of >30ml’s/Hr Terlipressin Terlipressin causes vasodilation of the splenic artery, reducing blood pressure in the portal system, it is recommended for use to all patients with suspected variceal bleeding at presentation². It should be stopped once definitive haemostasis has been achieved. Endoscopy Endoscopy should be performed on all unstable patients with severe UGI bleeding immediately after resuscitation². It should be performed within 24 hours of admission for all other patients with upper GI bleeding. This allows the diagnostic confirmation & the opportunity to treat any bleeding sites. It’s essential to get input from an experienced gastroenterologist & anaesthetist early. The type of endoscopic treatment varies depending upon the cause of the bleeding Variceal bleeding Band ligation Injection Sclerotherapy Balloon tamponade Prophylactic antibiotic therapy is recommended for patients with suspected or confirmed variceal bleeding² Non-variceal Bleed (e.g. Ulcer) Endoclips +/- adrenaline Thermal coagulation with adrenaline Fibrin or thrombin with adrenaline Patients should be kept NBM before the endoscopy & for at least 8-12 hours after If the patient is continuing to bleed then emergency endoscopic intervention is required Start an IV PPI – after endoscopic diagnosis Proton pump inhibitors (PPI’s) reduce the amount of acid produced by the stomach This is useful because high concentrations of acid increase the probability of re-bleeding As a result IV Omeprazole is given post endoscopy for at least 72 hours to reduce the chance of re-bleeding² Disability AVPU / GCS - ↓ consciousness may suggest cerebral hypo-perfusion, or hepatic encephalopathy Assess pupils – jaundice would suggest liver disease Check capillary blood glucose – often deranged in liver disease Exposure Adequate exposure is essential to ensure you don’t miss diagnostic clues: Melaena – would further support a diagnosis of UGI bleed Stigmata of Chronic Liver Disease - spider naevi, caput medusa, ascites Bruising – seen in liver disease – suggests coagulopathy Source of sepsis - leg wound, old cannula, catheter etc Reassess ABCDE It’s important to continually reassess ABCDE until the patient is stable It allows you to gauge whether the patient is improving or deteriorating It can also help indicate when further assistance needs to be sought - e.g. ITU Risk Scoring Systems Blatchford Scoring System Blatchford Score The Blatchford score is calculated prior to endoscopy and is based on simple clinical and laboratory parameters. Its principle use is to identify low risk patients who do not require any intervention (blood transfusion, endoscopic therapy, surgery). Approximately 20% of patients presenting with upper GI haemorrhage have a Blatchford score of zero. Such patients can largely be managed safely in the community, as the mortality in this group is nil. Rockall Score It is important to identify those patients who are at risk of ongoing bleeding and death. The Rockall scoring system is a validated scoring system used for risk categorisation based on simple clinical parameters. Rockall Scores can be calculated both before and after endoscopy, but the post endoscopy Rockall Score provides a more accurate risk assessment. It comprises independent risk factors which have been shown to accurately predict both re-bleeding and mortality. With increasing age there is an increased risk of death: Mortality in those aged below 40 is negligible Mortality increases to 30% in those aged over 90 Patients who have evidence of active bleeding and signs of shock have an 80% risk of death Those with a non-bleeding visible vessel at endoscopy have a 50% chance of re-bleeding Rockall Scoring System. NICE Guidelines Source
