September 2, 2020

REBEL Core Cast 39.0 – Upper GI Bleed

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)

REBEL Core Cast 39.0 – Upper GI Bleed

Definition and Recognition of Massive GI Bleeding (MGIB)

  • Not one consensus definition exists
  • Any bleeding from the GI tract (upper or lower) that results in
    • Hemodynamic instability (hypotension, dysrhythmias)
    • Poor perfusion (AMS, syncope, pallor, delayed capillary refill, decreased pulses)
    • Overt and rapid bleeding
    • Transfusion of 2 units pRBC in initial resuscitation
  • Spend time at the bedside looking for these things
    • AMS
    • Skin temperature, color
      • Pallor
      • Mottling
      • Capillary refill
    • Vital signs
      • Hypotension
      • Hypoxia
      • Shock Index (HR/SBP)
        • > 0.7 is ABNORMAL
        • > 1.0 may signal a need for massive transfusion
  • Characteristics that may predict the need for immediate intervention
    • UGIB
      • Tachycardia (LR 4.9)
      • Syncope (LR 3.0)
      • Hx of malignancy or cirrhosis (LR 3.7)
      • NG lavage returning BRB (LR 3.1)
    • LGIB
      • Similar for LGIB
      • Tachycardia
      • Syncope
      • HD instability
      • Active rectal bleeding
      • Non-tender abdominal exam
      • ASA use
      • Hx/o renal failure, liver failure, malignancy
  • A NORMAL HR is predictive for a NON-massive GIB
    • Check if patient is on a BB or CCB that may mask tachycardia
  • Localizing the bleed
    • Hematemesis
      • UGIB
    • Melena
      • Usually UGIB or
      • Proximal LGIB
    • Hematochezia
      • Usually LGIB or
      • Brisk UGIB (very sick patients!)

Basic Resuscitation First!

  • Reliable peripheral IV access
    • Short and fat lines!
    • IO if peripheral fails
  • Blood > crystalloid
  • Reverse anticoagulants
  • Secure the airway if needed
  • Get your consultants on board early (endoscopy/GI, surgery)

Adjunctive Medications

  • Proton pump inhibitors (PPI)
    • Cochrane Review
      • No effect on mortality, rebleeding, need for surgery
      • Decrease high risk stigmata in patients with peptic ulcer disease (PUD)
    • Bottom line: Doesn’t affect mortality so don’t prioritize during the initial resuscitation.  May give bolus after.
  • Octreotide
    • Somatostatin analog, vasoconstricts the splanchnic circulation
    • No effect on mortality in undifferentiated GIB
    • However, can decrease
      • Initial bleeding
      • Total transfusion
      • Need for surgery
    • Bottom line: Doesn’t affect mortality so don’t prioritize during the initial resuscitation.  May give bolus + infusion after.
  • TXA
    • Reduces the breakdown of fibrin clots, fibrinogen, and other plasma proteins
    • Recently published HALT-IT Trial provided good quality evidence
      • No difference in 5 day mortality due to bleeding
      • There WAS an increase in VTE (adverse events)
    • Bottom line: Not recommended to give routinely
    • If TEG/ROTEM demonstrates excessive fibrinolysis then TXA would be indicated
  • Antibiotics – Cephalosporins!
    • Decreases mortality in patients with variceal bleeding or undifferentiated bleeding in patients with cirrhosis
      • These patients are immunocompromised at baseline and GI bleeding puts them at risk for subsequent sepsis
      • 3rd generation cephalosporin
        • Ceftriaxone 1 gram
        • Cefotaxime 2 grams

Take Home Points:

  • Focus on resuscitating well by focusing on the basics
  • Recognize 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)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Anand Swaminathan, "REBEL Core Cast 39.0 – Upper GI Bleed", REBEL EM blog, September 2, 2020. Available at: https://rebelem.com/rebel-core-cast-39-0-upper-gi-bleed/.
The following two tabs change content below.

Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author

Latest posts by Anand Swaminathan (see all)

No Comments

Post A Comment

Time limit is exhausted. Please reload CAPTCHA.

0