Recently I was asked to speak at the Texas College of Emergency Physicians (TCEP) conference April 2018. The particulars of this session were, five, 10 minute lectures on new indications for old drugs. My topic was the use of octreotide and somatostatin for undifferentiated upper gastrointestinal bleeding. This is a particular topic I have been getting more and more requests for, but didn’t really know the evidence behind why I was doing it. Does it help my patients or just another expensive medication, that takes up an IV with no clear patient oriented outcome?...Read More
Background: Upper gastrointestinal hemorrhage (UGIH) is a commonly seen complaint in the ED. Currently, endoscopy is the standard therapy shown to not only help with diagnosis, but also risk stratify patients and potentially offer effective hemostatic treatment of acute nonvariceal UGIH. What is frequently an area of debate, is the optimal timing of endoscopy. Even more frustrating is the different definitions of early endoscopy ranging anywhere from 1hr up to 24hrs after initial presentation.
Now on one hand, earlier timing of endoscopy could be associated with suboptimal resuscitation and potential hemodynamic instability. On the other hand, delayed endoscopy delays hemostasis from endoscopic therapy and increases the risk of rebleeding and need for surgery. I think we all agree that we should resuscitate our patients before endoscopy (or as I like to say resuscitate before you endoscopate), but is there a population of patients with UGIH that require sooner than later endoscopy? To talk about this topic we have a special guest Rory Spiegel. You can find Rory on twitter as @EMNerd_ or on the EMCrit blog where he discusses methodological issues with studies...Read More
Upper gastrointestinal bleeding remains a common reason for emergency department visits and is a major cause of morbidity, mortality, and medical care costs. Often when these patients arrive, the classic IV-O2-Monitor is initiated and hemodynamic stability is assessed. One of the next steps often performed includes the initiation of proton pump inhibitors (PPIs).
The ultimate question however is does initiation of PPIs reduce clinically relevant outcomes (i.e. mortality, rebleeding, need for surgical intervention) in upper gastrointestinal bleeds (UGIB)?...Read More
Background: How many of you have had this scenario…patient comes into ED, just ate a big steak and now they can’t swallow. You call gastroenterology, who asks… “Did you try glucagon yet?” OK, well maybe not exactly like that, but you get what I am asking. Esophageal foreign body impactions are a rare entity, that cause quite a bit of discomfort to patients and have the potential for esophageal necrosis and perforation. The definitive treatment for removal is endoscopy with direct visualization and removal of the object causing the obstruction. This procedure is invasive, time consuming, requires a gastroenterologist, as well as procedural sedation. Due to the time it takes to set up for this procedure, many consultants will ask to try medical therapy first. There are several options including carbonated beverages, calcium channel blockers, sublingual nitroglycerin, proteolytic enzymes, benzodiazepines, and last but not least intravenous glucagon. This review will focus on the use of glucagon for esophageal foreign bodies....Read More