Scary case - variceal bleed and possible intubation

pinipig523 · Aug 20, 2013

So, we had a case today - GI bleed, likely (actually confirmed by GI) to be a variceal based on presentation of a lady w distended abd, etoh hx, scleral icterus. Found in our ER bathroom with a pint of blood in a bucket, bright red. HR 150, SBP 90.

So I did the usual - reglan 10 iv, zofran 4 iv, octreotide and protonix boluses and drips. IVF x2L, uncrossmatched blood x 2u, ceftriaxone 1g iv. Also, we got our airway cart ready and I had the OR bring down the glidescope. Also 2 canisters of suction ready and plugged in.

FFP ordered also.

PH was 7.5, hgb was 7.7, inr was 2.0.

Now - my question was when to intubate and how was the best way to do so. Pt was still aox3, maintaining airway and she was not vomiting at that moment... put the pt on o2 and GI was on their way. Now, there was an episode when the patient was about to hurl bloody vomit and she vagal'd down... sbp went down to 60 and HR went up to 150 again... this was after she responded to fluids and was at 110 HR and 110 sbp for some time.

I thought - this was it, she was going to hurl, and I was going to take control of airway.

Luckily, for her, the second rounds of zofran and reglan (love me the reglan... shuts the LES) worked and she kept it all in and sbp bounced back to 110.

I was prepared to intubate.... but didn't have to since she maintained airway and went to ENDO suite and got the varices banded by GI. GI said it was non-bleeding at that time.

I didn't want to intubate immediately because I've had bad experiences with early intubations in patients with variceal bleeds. If they buck the vent, it's over... usually that amount of pressure leads to profound bleeding. Or if you miss the tube, the blood very easily takes over the entire post pharynx and you cannot see beyond the bloody mess and aspiration galore.

So - question for you pros.

1. When do you usually pull the trigger on intubation of massive UGIB? What's the threshold that you lay out for yourself?
2. And how do you do it and if you have tips?
3. Do you guys tend to use facilitated intubation (no paralytics so pt can manage and keep the Lower Esophageal Sphincter closed)?

Arcan57 · Aug 20, 2013

pinipig523 said:
So - question for you pros.

1. When do you usually pull the trigger on intubation of massive UGIB? What's the threshold that you lay out for yourself?
2. And how do you do it and if you have tips?
3. Do you guys tend to use facilitated intubation (no paralytics so pt can manage and keep the Lower Esophageal Sphincter closed)?

Not a pro, but my thoughts:

1) When they start losing their mental status or if there's a procedure that's going to need control of the airway prior to attempting (primarily a Blakemore tube but occasionally at GI's request prior to EGD)

2) I keep them sitting upright and stand on the end of the stretcher over them with a glidescope and plenty of suction.

3) I think this is one of those situations where first pass success is crucial (especially if the patient is already acidotic from shock they may not tolerate hypercapnea from delay in intubation) so they get put down with RSI and I rely on gravity to keep their stomach contents in their stomach.

EMIM2011 · Aug 20, 2013

pinipig523 said:
no paralytics so pt can manage and keep the Lower Esophageal Sphincter closed)

http://bja.oxfordjournals.org/content/56/1/37.full.pdf

WilcoWorld · Aug 20, 2013

Arcan57 said:
2) I keep them sitting upright and stand on the end of the stretcher over them with a glidescope and plenty of suction.

That's a neat idea - I like it.

Arcan57 said:
3) I think this is one of those situations where first pass success is crucial (especially if the patient is already acidotic from shock they may not tolerate hypercapnea from delay in intubation) so they get put down with RSI and I rely on gravity to keep their stomach contents in their stomach.

Agreed.

I'd add that this is a good patient to have digital intubation as a back-up on. If you can't see anything, because of blood, fiberoptics aren't going to help. However, if the patient is fully paralyzed, you'll probably have no trouble feeling the epiglottis with your gloved hand and feeding the ETT right into the trachea.

If this is a technique you're unfamiliar with, try it next time you've got an airway mannequin - you'll be surprised at how intuitive/easy it is.

dotcb · Aug 20, 2013

If the patient seems unstable - fluctuating or persistent abnormal vital signs, or vomiting blood in front of me - I intubate them. If I'm concerned about their ability to protect their airway - I intubate them.

The patient is going to need to be intubated for endoscopy, so not doing it in the ED is not really saving the patient from anything, it's just giving that task to someone else. Yeah, it's nice for GI to be able to talk to the patient and consent for endoscopy, but usually it's a critical patient, and the priority is on safety and patient care. If you're on the fence - I'd intubate and not pass this buck to someone else.

This is one of those cases where I might VL, but be ready with DL in case blood obscures your view. Tilt the head of the bed at least a bit up. This is true RSI, no bagging if you can avoid it. Prepare for a stomach full of blood.

Listen to this:
http://emcrit.org/podcasts/intubating-gi-bleeds/

Daiphon · Aug 20, 2013

Great points all. I personally always bougie these patients... bloody mess, but can usually suction enough (holding Yankauer in dependent position with my laryngoscope hand) to see a hole for my Eschmann - once that's in, easy peasy*.

*knocking on wood as I write this.

-d

Sent from my DROID BIONIC using Tapatalk

Rendar5 · Aug 20, 2013

I don't do a full upright intubation as above, but I usually have them in reverse trendelenberg for the intubation. If I can let anaesthesia do it, though, I do (as in the case where they're going to go to the endo suite and not gonna crash on me), but if they're requiring a full-blown resus, just tube em even if airway is intact for now. takes the airway out of the picture. I also find that their sedative needs are extremely lowered when they're truly hypovolemic.

Bostonredsox · Aug 20, 2013

Arcan57 said:
Not a pro, but my thoughts:

1) When they start losing their mental status or if there's a procedure that's going to need control of the airway prior to attempting (primarily a Blakemore tube but occasionally at GI's request prior to EGD)

2) I keep them sitting upright and stand on the end of the stretcher over them with a glidescope and plenty of suction.

3) I think this is one of those situations where first pass success is crucial (especially if the patient is already acidotic from shock they may not tolerate hypercapnea from delay in intubation) so they get put down with RSI and I rely on gravity to keep their stomach contents in their stomach.

This is how it goes at my shop. ED calls for admit to ICU. I accept pt. If airway is stable I say send them up. 9/10 I tube them upstairs as I know GI will not be comfortable sticking the scope in with an unprotected airway.

and definitely RSI with them somewhat upright in bed to try and protect them from aspiration. My strat as well.

I also have been part of a few nasty variceal bleed airways. I recommend having your difficult cart at bedside so your fully prepared, even if the pt has favorable anatomy and isn't actively vomiting. As you stated, it can be quite nasty in there.

Groove · Aug 21, 2013

Arcan57 said:
Not a pro, but my thoughts:

1) When they start losing their mental status or if there's a procedure that's going to need control of the airway prior to attempting (primarily a Blakemore tube but occasionally at GI's request prior to EGD)

2) I keep them sitting upright and stand on the end of the stretcher over them with a glidescope and plenty of suction.

3) I think this is one of those situations where first pass success is crucial (especially if the patient is already acidotic from shock they may not tolerate hypercapnea from delay in intubation) so they get put down with RSI and I rely on gravity to keep their stomach contents in their stomach.

I had a similar case last year during residency and did this exact thing with direct and had good results. I had the pt at about 45 degrees and just stood up on the end of the stretcher and had a couple of nurses stabilizing me as I leaned over and RSI intubated with suction. Gravity really helped in this case as I didn't have a massive deluge of blood obscuring my view. I think you really just have to get creative with these... I had several back up devices and a blade available anticipating a failed first direct attempt but it actually worked very well.

Personally, I'd have a low threshold to tube these at the slightest change in mental status as chances are they are massively hemorrhaging and let's face it.... I'd rather establish the airway while they have a pulse, and at 45 degrees in the bed than during a full on code....on their back...trying to part the red sea with a Mac.

pinipig523 · Aug 21, 2013

Update - GI found varices, non bleeding at time of scope and banded. Anesthesia did not have to intubate, pt survived.

Great points about keeping some reverse trendelenberg... That's what I was planning on. I had 2 auctions ready because I had issues with filling up and overwhelming a single suction system before.

She just looked so good to me in the interim but I can see how intubating early could've been advisable as well.

VentdependenT · Aug 24, 2013

EMIM2011 said:
http://bja.oxfordjournals.org/content/56/1/37.full.pdf

LESphincter tone has NOTHING to do with airway protection. Believe it or not, neither does GAG. Its all about the cough reflex.

Once you knock em out their airway is NO LONGER PROTECTED.

Vomiting blood? RSI baby. Dont forget the cricoid pressure, but even that is FAR from a guarantee.

Go to sleep= paralyse em. Otherwise use brutane or some sort of awake to keep em breathing. BTW an awake pt who has been numbed up appropriately CANNOT PROTECT THEIR AIRWAY.

EMIM2011 · Aug 25, 2013

VentdependenT said:
LESphincter tone has NOTHING to do with airway protection..

Never said that it does.

Scary case - variceal bleed and possible intubation

pinipig523

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Arcan57

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EMIM2011

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WilcoWorld

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dotcb

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Daiphon

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Rendar5

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Bostonredsox

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Groove

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pinipig523

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VentdependenT

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EMIM2011

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