Hi doctor, can you come and see my patient, she s just had a coffee ground vomit. Dr Rhona Hurley, FY2
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1 Hi doctor, can you come and see my patient, she s just had a coffee ground vomit. Dr Rhona Hurley, FY2
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3 Ask for more information What now? o What might you ask? o Do you have enough information about this patient? GO AND SEE THE PATIENT!!!!! o You don t know what you re dealing with o Don t just say recheck obs 1 hour/monitor o Hard when busy on call o Prioritisation
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5 ABCDE Stick with this, helpful can be used for documentation Patients can have multiple problems! If person capable can talk to them while doing this for history Bring a nurse with you Primary aim assess blood loss, shock Secondary aim underlying cause A patent or not? B RR, SpO2, Trachea central, colour of patient, resonant to percussion, breath sounds? o CXR rule out perforated oesophagus
6 ABCDE continued C o o o o o Pulse rate & rhythm, BP, CRT ECG anaemia can drive ischaemia and AF Heart sounds Postural hypotension may indicate blood loss of 20% or more IV access Preferably x 2 and large bore BUT SOME ACCESS IS BETTER THAN NO ACCESS Bloods which ones? Do you want to wait for lab Hb? Hang IV fluids if in any doubt of condition of patient If concerned MET call/major haemorrhage protocol o FBC/platelets o Get help!
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8 A note on IV fluids..
9 ABCDE D GCS/AVPU and blood glucose o Also note confusion E Exposure o Brief feel of abdomen & listen for bowel sounds o Any obvious stigmata of liver disease o Check around for any signs of haematemesis or melaena o PR necessary for occult bleeding o Check drug kardex o Fluid balance review o Consider catheter o AXR
10 After this If at all concerned get help ASAP ALWAYS better to call for nothing than to not call for something More definitive management involves interventions like terlipressin/ogd These patients can become very unwell very quickly May need HDU/ITU o Not decisions for you! DO NOT BE A HERO
11 UGI bleeds Frank bleeding Coffee ground vomiting
12 UGI vs LGI bleed Melaena UGI PR bleeding
13 May help point to cause Abdominal pain Chest pain Dyspepsia symptoms Drug history Weight loss/anorexia Jaundice Alcohol/drug history Notes review History Remember your patient very frightening experience
14 Why do hospital inpatients get UGI bleeds? Stroke/MI patients aspirin/clopidogrel/warfarin NSAIDS - PUD COPD/Asthmatics prednisolone - PUD VTE - rivaroxaban Post-operative stress ulcers Liver disease varices Post AAA repair - aorto-enteric fistula Gastric cancer/oesophageal cancer Everyone LMWH
15 Potential complications CAD patients ischaemia due to hypoxaemia Volume overload from over-transfusion/fluid resuscitation o o Renal failure/heart failure May need invasive monitoring eg central line during resuscitation Aspiration o o o Hepatic encephalopathy Stroke Dementia
16 Case 4am bleep FY1 covering GI ward/geriatrics at night Across the hospital Just to let you know, one of the patients has just vomited up a bit of blood.maybe an eggcup full but they are fine What else do you want to know? Turn up to ward and nurses away in handover
17 Case 48-year-old male Original reason for admission variceal bleed requiring HDU admission. Numerous previous bleeds. Notes state very poor prognosis, not for further endoscopy, terlipressin only. Observations BP 90/50 from 110/70, HR 110, RR 25 otherwise OK A patent B RR 18, SpO2 97%, No abnormal chest findings C Pale, clammy, tachycardic. Pulse thready. ECG longstanding T-wave inversion V1-V3. BP 85/60, HR 120, RR 30. D Alert, BM normal E Caput medusae, distended abdomen, jaundiced sclerae. Abdomen non-tender. Not passed urine all day.
18 Case How unwell is this man? Can you cope on your own? What do you need to do now? o Can be difficult to get people to DO stuff o Clear communication needed as to urgency Can you wait for cross-matched blood? Suitable ward patient?
19 Summary GI bleeds are common in hospital inpatients Many causes Can be frightening Basic management REALLY helps Always GROUP + SAVE Get help quickly Make sure the things you want done are DONE Don t assume you can get an accurate picture of the patient from the phone call
20 Any questions?
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