Hello friends,
Today’s POTD will be on upper GI bleeds and what to do when they come. UGIB can seem really terrifying sometimes but hopefully next time you have a patient with an UGIB you remember these next few steps.
Upper gastrointestinal (GI) bleeding is a potentially life-threatening emergency that requires rapid recognition and intervention. These are patients that tend to end up in our resus bay, can rapidly decompensate, require blood products and airway protection.
Step 1. Start with the ABCs!
You want to make sure the airway is protected
Intubating these patients can be very messy and tricky, suction will be your best friend in this scenario!
Access is very important especially if you expect having to transfuse these patients
Two large-bore IVs are key! If access is an issue or patient is hemodynamically stable secondary to blood loss, you may need to insert a cordis
Step 2. Once your ABCs are ensured, try to identify the source of bleeding
Is this a UGIB secondary to varices? Peptic ulcer disease? NSAIDs? Anticoagulation? Does this patient have liver disease and portal HTN? Hx of prior GI bleeds?
If you are able to maintain a history or obtain collateral than it can give you some insight as to what is going on
Step 3. What are we ordering for these patients?
Well obviously we are obtaining labs, make sure to get a CBC and a type & screen
What about medications?
Proton pump inhibitor: 80 mg pantoprazole IV
Concern about a variceal bleed? Add octreotide (this will reduce splanchnic blood flow)
Give IV antibiotics, specifically ceftriaxone, in these patients to prevent infections
Step 4. Who are we calling for these patients?
GI consult! Sometimes these patients require an emergent or urgent endoscopy
ICU! As stated before, these are very sick patients who may quickly decompensate, these patients may also be intubated
Now, lets say you did all these steps but the patient has taken a turn for the worse and requires intubation while actively vomiting blood? Good news, there is the SALAD technique!
The SALAD (Suction-Assisted Laryngoscopy and Airway Decontamination) technique is a critical approach for managing airways in patients with significant vomiting or massive upper GI bleeding, it allows you to clear the airway to optimize visualization.
How-to-perform the SALAD Technique:
1. Setup is key: Get a rigid suction (e.g., Yankauer) and connect it to continuous suction. Position the patient appropriately to prevent aspiration (head elevated or reverse Trendelenburg).
2. Decontaminate the Airway: Before attempting laryngoscopy, aggressively suction the oropharynx to remove blood, vomitus, or other secretions. Continuously suction while inserting the laryngoscope and during visualization. You are basically inserting the suction into the esophagus so that way you have a better view for intubating.
3. Insert the ET Tube: Once the airway is clear enough for visualization, proceed with intubation
Enjoy this 1 minute video on how the SALAD technique works: https://youtu.be/ZOwNSpDG6vY?si=FG1KMdrDOnXII7Xf
Resources:
EMRAP
UpToDate
WikiEM
Core Pendium -Approach to GI Bleed chapter