Massive GI Bleeds
Gastrointestinal
Context
- Massive upper GI bleeds originate proximal to the ligament of Treitz in distal duodenum.
- Etiologies include duodenal ulcers, gastric ulcers, gastritis, esophageal varices and esophagitis.
- Patients with known varices still often bleed from peptic ulcer disease.
- Upper GI bleeds carry higher morbidity and mortality than lower GI bleeds.
- Medications like pantoprazole and octreotide do not have mortality benefit, so utilize your access points for resuscitative measures.
- Initiate resuscitation based on the clinical picture rather than Hb level as this can be deceiving.
- Remember that in patients with cirrhosis, beta blocker use may mask tachycardia and obscure their shock index.
Recommended Treatment
Initial Approach:
- Resuscitate before intubate.
- Start preoxygenation early with high flow nasal cannula.
- Get two large bore (plain suction tubing or Du Canto suctions) at bedside.
- Know where the Blakemore or Minnesota tube is in your facility.
Initial Targets:
| Marker | Goal |
| MAP | > 60 mmHg |
| Hemoglobin | > 70 g/L |
| Platelets | > 50 x 109/L |
| Temperature | > 36 oC |
| Calcium | > 2 mmol/L |
| Lactate | < 2 mmol/L |
| Urine output | > 0.5 mL/kg/hr |
Transfusion Approach:
| Transfusion Type | Threshold |
| pRBC Transfusion | Hemodynamically unstable
Shock index > 1 Clinical assessment: volume blood loss, bleeding, briskness, symptomatology |
| Massive Transfusion Activation | Received 4U uncrossmatched pRBC
Received 4U pRBC in 1 hour Shock Index > 1 |
Airway Approach:
| Preparation | Recommendation |
| Preoxygenation | High flow NP +/- apneic oxygenation |
| Suction | Double large bore suction |
| Medications | Ketamine 0.5 mg/kg
Rocuronium 1.5 mg/kg Push dose pressors ready |
| Patient Positioning | Head of bed 45o
If vomit then Trendelenburg |
| Laryngoscope | DL > VL
C-MAC
|
Tips for Airway Decontamination and Securing the Airway:
- Du Canto catheter and the SALAD approach.
- Use a Seldinger approach with suction tubing to secure the airway and suction as you go. Tape a flexible stylet to outside of the distal end of suction tubing with silk tape. Bend to preferred ETT shape. Under DL, suction as intubate. When through the cords, cut end of suction tubing. Insert a bougie through the suction tubing. Exchange tubing for ETT.
| Problem | Solution |
| Can’t see | Go where the bubbles are
Assistant presses on chest for forced exhalation |
| Bad view but see the cords whilst suctioning | Seldinger technique
Suction through cords Cut tubing Bougie through tube Exchange for ETT |
| Accidentally intubated the esophagus | Leave the ETT alone
Inflate balloon and reduce airway contamination Advance ETT in esophagus so the end is flush with teeth Tape over the end of ETT BVM patient before second attempt
|
Temporizing methods for ongoing hemorrhage:
- Review Sengstaken-Blakemore Tube Insertion.
- Review Minnesota Tube Insertion.
Definitive Management:
- Endoscopy for variceal ligation and sclerotherapy. For ulcers, clips, thermocoagulation, sclerosant injections alone or with epinephrine.
- CTA abdomen with non-contrast, arterial and venous phase for localizing bleeding site.
- Decision for OR vs IR depends on etiology of bleed and stability of patient.
Criteria For Hospital Admission
Admit to ICU.
Criteria For Transfer To Another Facility
Depending on stability of patient and local ability to continue patient monitoring and management.
Criteria For Close Observation And/or Consult
Will be required for all patients. ICU, GI and/or general surgery consultation depending on local practice patterns.
Criteria For Safe Discharge Home
All patients will be admitted.
Quality Of Evidence?
High
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
Moderate
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
Low
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Justification
Moderate. Resuscitation targets based largely on expert opinion. Recommendations regarding massive upper GI bleed management is largely extrapolated from trauma literature.
Related Information
Reference List
Dworzynski K, Pollit V, Kelsey A, Higgins B, Palmer K. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ (Clinical research ed.). 344:e3412. 2012.
Open Airway. SALAD. https://openairway.org/salad/. Accessed May 14, 2021.
Villanueva C, Colomo A, Bosch A. Transfusion for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368(14):1362-3.
Wolpaw, J. April 15, 2019. Episode 115: The Contaminated Airway with Steve Freiberg. Available at: https://podcasts.apple.com/ca/podcast/anesthesia-critical-care-reviews-commentary-accrac/id1116485154?i=1000434980499. Accessed May 14, 2021.
RESOURCE AUTHOR(S)
DISCLAIMER
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated May 14, 2021
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