September 2, 2020

Take Home Points
  • Focus on resuscitating well by focusing on the basics
  • Recognize Massive GIB (MGIB) with a thorough exam of the patient and vital signs (Shock index >0.7 is ABNORMAL and signals impending shock)
  • Obtain large bore PIV access and prioritize transfusion over crystalloids for MGIB
  • Get consultants on board early
  • Give adjunctive medications that impact mortality (ie A 3rd generation cephalosporin in patients with variceal bleeding or a history of cirrhosis)

June 27, 2020

Background: Acute gastrointestinal bleeding (GIB) is a common diagnosis dealt with by emergency clinicians.  Definitive therapy for acute GIB often includes endoscopy or surgery. However, there is a myriad of pharmaceutical options (i.e. PPI, Somatostatin Analogues, Antibiotics, etc.) as well as blood products that may be instituted as part of the acute resuscitation of these patients. The role of tranexamic acid (TXA) in resuscitation of this condition is unknown.

TXA has become one of the darling medications of emergency medicine, with numerous indications, minimal side effect profile and low cost. TXA works by inhibiting blood clot breakdown (i.e. fibrinolysis).  TXA has been shown to decrease death from bleeding in other conditions (Trauma, Postpartum hemorrhage) but there is limited evidence for its use in GIB.  A systematic review and meta-analysis of seven randomized trials with just over 1600 patients [2] showed a reduction in all-cause mortality.  However, the individual trials were small and prone to a myriad of biases making these conclusions hypothesis generating at best.

May 21, 2020

Background: Upper endoscopy allows for the identification of the source of bleeding as well as hemostatic treatment for actively bleeding lesions In patients with upper gastrointestinal bleeding (UGIB).  Definitive treatment with endoscopic hemostatic treatment can potentially stop bleeding in high-risk lesions and reduce further bleeding and the need for surgery. The optimal time for endoscopy to be performed is unknown.  The definition of urgent varies depending on which study you read, ranging from 2 hours up to 12 hours. Additionally, most previous studies only enrolled patients who were not hemodynamically unstable or high-risk, which is frequently what we are dealing with in the emergency department. The Glasgow-Blatchford score is a validated risk-assessment score for the prediction of clinical outcomes, including the need for intervention and risk of death.  The score ranges from 0 to 23, with higher scores indicting a higher risk of further bleeding or death. A threshold score of ≥7 has been shown to be the most accurate predictor of whether a patient will need endoscopic treatment.2 There are conflicting results regarding urgent endoscopy (within 6 hours after admission) and mortality.

February 24, 2020

Background: Critical illness and ICU admission comes with significant consequences – not just from the primary pathology but also from the secondary effects of therapies that may be begun to correct the abnormal physiology. One of these consequences in ventilated patients is the development of stress ulcers in the gastrointestinal tract, leading to bleeding. Over two-thirds of patients admitted to the ICU will be prescribed some form of stress ulcer prophylaxis, often in the form of either a proton pump inhibitor (PPI) or a histamine-2 receptor blocker (H2RB)1. But which one is better? Are there any risks? The existing evidence of benefit of one over another is limited. Though one systematic review did show a benefit of PPIs, the reviewed data was limited2. Neither drug is without risk either. These include a potential for immunosuppression and increased risk of infections3. More evidence is needed – which is where the Proton Pump Inhibitors vs Histamine-2 Receptor Blockers for Ulcer Prophylaxis Treatment in the Intensive Care Unit (PEPTIC) randomized clinical trial comes in4.

January 20, 2020

Definition: Acute infection of the ascitic fluid in a patient with liver disease without another source of infection

Epidemiology: (Runyon 1988, Runyon 1988, Borzio 2001)

  • Incidence
    • 10-25% risk of at least one episode per year
    • 20% risk in those with ascites admitted to the hospital
  • Historically, mortality ~ 50%


  • Not completely understood
  • Increased portal systemic hypertension
    • Causes mucosal edema of the bowel wall
    • Increases transmural migration of enteric organisms into the ascitic fluid
  • Impaired phagocytic function in the liver
  • Impaired immunologic activity in ascitic fluid