AMI with GI Bleed

[docB]

I had a rough case yesterday. 60 yo male presents with CP and 4-5 mm AVR STEMI with reciprocal ST depressions, BP 80/40, cool, pale, diaphoretic. As I'm getting things rolling (cath lab, heparin, etc.) I'm running the list and the pts says he's been having black stools. Rectal reveals a boatload of maroon stool and gross blood. So I'm screwed. Within a few minutes the pt's internist and cardiologist were there and we're all trying to figure out the next step. Can't give heparin to an active bleed. Can't give NTG with the hypotension. Integrellin is out. Pt's H/H turned out to be 8 and 25. BP is improving with IVF. So cards and medicine decided to transfuse and watch to see if the guy improved with blood. They thought the MI might have been due to decreased perfusion from the anemia. I pointed out that the EKG wasn't showing a diffuse subendocardial type of MI like you'd get with low flow, it was showing a right sided MI which was getting worse. Pt went up to the unit. About 2 hours later I get called to a code in the cath lab and it's that guy. We got him back but he died the next morning. What a tough case. I think that was the first time I ever really saw a STEMI in a pt with a real, active GI bleed. I don't recommend it.

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[Sessamoid]

I had a rough case yesterday. 60 yo male presents with CP and 4-5 mm AVR STEMI with reciprocal ST depressions, BP 80/40, cool, pale, diaphoretic. As I'm getting things rolling (cath lab, heparin, etc.) I'm running the list and the pts says he's been having black stools. Rectal reveals a boatload of maroon stool and gross blood. So I'm screwed. Within a few minutes the pt's internist and cardiologist were there and we're all trying to figure out the next step. Can't give heparin to an active bleed. Can't give NTG with the hypotension. Integrellin is out. Pt's H/H turned out to be 8 and 25. BP is improving with IVF. So cards and medicine decided to transfuse and watch to see if the guy improved with blood. They thought the MI might have been due to decreased perfusion from the anemia. I pointed out that the EKG wasn't showing a diffuse subendocardial type of MI like you'd get with low flow, it was showing a right sided MI which was getting worse. Pt went up to the unit. About 2 hours later I get called to a code in the cath lab and it's that guy. We got him back but he died the next morning. What a tough case. I think that was the first time I ever really saw a STEMI in a pt with a real, active GI bleed. I don't recommend it.

Yeah, I've had a similar case. You're pretty much stuck with transfusion and praying.

 

[mikecwru]

I had a rough case yesterday. 60 yo male presents with CP and 4-5 mm AVR STEMI with reciprocal ST depressions, BP 80/40, cool, pale, diaphoretic. As I'm getting things rolling (cath lab, heparin, etc.) I'm running the list and the pts says he's been having black stools. Rectal reveals a boatload of maroon stool and gross blood. So I'm screwed. Within a few minutes the pt's internist and cardiologist were there and we're all trying to figure out the next step. Can't give heparin to an active bleed. Can't give NTG with the hypotension. Integrellin is out. Pt's H/H turned out to be 8 and 25. BP is improving with IVF. So cards and medicine decided to transfuse and watch to see if the guy improved with blood. They thought the MI might have been due to decreased perfusion from the anemia. I pointed out that the EKG wasn't showing a diffuse subendocardial type of MI like you'd get with low flow, it was showing a right sided MI which was getting worse. Pt went up to the unit. About 2 hours later I get called to a code in the cath lab and it's that guy. We got him back but he died the next morning. What a tough case. I think that was the first time I ever really saw a STEMI in a pt with a real, active GI bleed. I don't recommend it.

You could argue that the pt's GIB gave him a physiologic stress test over a diseased R coronary system, no? But yes, I get your point you would typically see a diffuse pattern. I think you did exactly the right thing with transfusing, but you didn't mention fluids, etc, for a suspected RV infarct. Not that my opinion is worth anything.

mike

 

[docB]

I think you did exactly the right thing with transfusing, but you didn't mention fluids, etc, for a suspected RV infarct. mike

Yeah, the IVF is what go him from 80/crap to crap and a half (95/60) but it wasn't enough to be able to give nitro. Pressors would had killed him faster. The thing about this guy was that I've seen lots of pts with a little rectal bleeding or guiac + brown stool and I'll still heparinize them. This was the real deal, no holds barred, active GI bleeding. This was a real contraindication.

I was talking to one of my partners about it and said "I guess the moral is Don't have your MI while squirting blood out of your butt." He suggested we make that the marketing tag line for the hospital. So if you see that on a billboard you'll know where it came from.

 

[kinetic]

60 yo male presents with CP and 4-5 mm AVR STEMI with reciprocal ST depressions ...They thought the MI might have been due to decreased perfusion from the anemia. I pointed out that the EKG wasn't showing a diffuse subendocardial type of MI like you'd get with low flow, it was showing a right sided MI which was getting worse.

Not to get picky with terminology, but a few things (and I'm not saying I'm Mr. Expert here, especially since I'm flippin' pancakes for a livin' *nyuk nyuk*; it's just my opinion):

Anemia does two things. First of all, there is reduced oxygenation due to the lowered hemoglobin level in the blood. However, that is technically different from "decreased perfusion," which implies that blood is not reaching tissue (you may consider it a semantic argument, but in my opinion it's a rather important distinction, especially in the case of an AMI). It's not a question of the blood not REACHING tissue, but rather of blood reaching tissue but with reduced oxygen-carrying capacity.

However, the second effect is also that the heart has to actually increase its work in order to supply adequate oxygen to the tissues; anemia is not a "low flow" state, but the opposite -- it's a "high flow" state. This in turn places a lot of pressure on already under-oxygenated myocardium and may precipitate an MI where there is disease (i.e., blockage). In other words, you're running a stress test on an individual, as mikecrwu stated, and he's crapping out.

Regardless, you're right, it's not a good thing to have frank melena.

 

[jashanley]

The worst of both worlds. I had a cardiologist tell me......to keep the anticoagulation going even if they start dropping their crit. I like everyone else have a tough time believing this and carrying it out......His excuse, you can continue to transfuse but you can't stop the clot from progressing withour the meds. In this case, I think you did the right thing. His MI was from the GI bleed and the strain on the heart; I would have transfused, transfused, transfused. Tough. Sorry to hear it. I hate cases like that.

 

[Sessamoid]

I was talking to one of my partners about it and said "I guess the moral is Don't have your MI while squirting blood out of your butt." He suggested we make that the marketing tag line for the hospital. So if you see that on a billboard you'll know where it came from.

I'll keep an eye out for the billboard next time I'm in Vegas.

 

[ERMudPhud]

Not to get picky with terminology, but a few things (and I'm not saying I'm Mr. Expert here, especially since I'm flippin' pancakes for a livin' *nyuk nyuk*; it's just my opinion):

Anemia does two things. First of all, there is reduced oxygenation due to the lowered hemoglobin level in the blood. However, that is technically different from "decreased perfusion," which implies that blood is not reaching tissue (you may consider it a semantic argument, but in my opinion it's a rather important distinction, especially in the case of an AMI). It's not a question of the blood not REACHING tissue, but rather of blood reaching tissue but with reduced oxygen-carrying capacity.

However, the second effect is also that the heart has to actually increase its work in order to supply adequate oxygen to the tissues; anemia is not a "low flow" state, but the opposite -- it's a "high flow" state. This in turn places a lot of pressure on already under-oxygenated myocardium and may precipitate an MI where there is disease (i.e., blockage). In other words, you're running a stress test on an individual, as mikecrwu stated, and he's crapping out.

Regardless, you're right, it's not a good thing to have frank melena.

You are right which is why we try to keep Hct's above 30 or so in cardiac patients but in addition in the setting of an acute GI bleed the associated hypotension probably creates decreased perfusion as well.

 

[ERMudPhud]

The worst of both worlds. I had a cardiologist tell me......to keep the anticoagulation going even if they start dropping their crit. I like everyone else have a tough time believing this and carrying it out......His excuse, you can continue to transfuse but you can't stop the clot from progressing withour the meds. In this case, I think you did the right thing. His MI was from the GI bleed and the strain on the heart; I would have transfused, transfused, transfused. Tough. Sorry to hear it. I hate cases like that.

If you've ever watched somebody bleed out from a big bleed despites multiple large bore IV's and 2 cordis's with blood on the rapid infuser you might not agree. Before anticoagulation and thrombolytics lots of people survived their MI's but a thrombolysed large GI bleed can bleed faster than you can transfuse. I'd say cross your fingers and transfuse on the way to the cath lab. I'm surprised your cardiologists waited so long to cath him. You can transfuse him enroute to the cath lab and get an answer within minutes. If he's blocked open him up, if its just from his bleed you can transfuse in the cath lab as easily as in the ICU.

 

[Apollyon]

In other words, you're running a stress test on an individual, as mikecrwu stated, and he's crapping out.

Regardless, you're right, it's not a good thing to have frank melena.

Especially apropos since docB is in "Sin City".

Where's Gil Grissom when you need him?

 

[Annette]

I know your pain. Had a sweet 70 year old lady with a GI bleed, hgb of 5, and an MI. She was a Jehova's witness. Our treatment? Epo and prayers- well, mainly lots of prayers!

 

[docB]

Not to get picky with terminology, but a few things (and I'm not saying I'm Mr. Expert here, especially since I'm flippin' pancakes for a livin' *nyuk nyuk*; it's just my opinion):

Anemia does two things. First of all, there is reduced oxygenation due to the lowered hemoglobin level in the blood. However, that is technically different from "decreased perfusion," which implies that blood is not reaching tissue (you may consider it a semantic argument, but in my opinion it's a rather important distinction, especially in the case of an AMI). It's not a question of the blood not REACHING tissue, but rather of blood reaching tissue but with reduced oxygen-carrying capacity.

However, the second effect is also that the heart has to actually increase its work in order to supply adequate oxygen to the tissues; anemia is not a "low flow" state, but the opposite -- it's a "high flow" state. This in turn places a lot of pressure on already under-oxygenated myocardium and may precipitate an MI where there is disease (i.e., blockage). In other words, you're running a stress test on an individual, as mikecrwu stated, and he's crapping out.

Regardless, you're right, it's not a good thing to have frank melena.

You make a good point however this guy had both. He was anemic (Hb=5) with its decreased oxygen capacity due to his ongoing GI bleed and he had a low flow state (hypotension) likely due to hypovolemia, also due to the GI bleed, and his right sided MI.

I'm surprised your cardiologists waited so long to cath him.

Yeah, that really should have happened quicker but I think he was deluding himself that the blood would fix the whole thing. Like I said though the EKG showed a right sided MI not a diffuse subendocardial picture. I'm not really second guessing him because I know that he felt the guy would have terrible odds at that point and might do better after being tanked up. It was a rough case on everyone.

I'll keep an eye out for the billboard next time I'm in Vegas.

I'm working on a cool graphic to go with it.

 

[kinetic]

You make a good point however this guy had both. He was anemic (Hb=5) with its decreased oxygen capacity due to his ongoing GI bleed and he had a low flow state (hypotension) likely due to hypovolemia, also due to the GI bleed, and his right sided MI.

What the hell? If this was an acute bleed, his Hgb/Hct shouldn't have tanked out so quickly (assuming he wasn't shooting out occult blood from his anus).

 

[docB]

What the hell? If this was an acute bleed, his Hgb/Hct shouldn't have tanked out so quickly (assuming he wasn't shooting out occult blood from his anus).

I think the guy had probably been bleeding for 2-3 days. Long enough to drop his H/H. When I saw him he had bled enough to become hypovolemic and drop his BP as well.

 

[ERMudPhud]

Thanks DocB,

Less than 24 hours after reading about your case and thinking, "Whew!, thank god I haven't had one of those in a while." Mine was Hgb=7. BP 70/40 with bright red blood out of both ends. Fortunately he had the more diffuse subendocardial picture and got better quickly(<15 min) with O- on the rapid infuser.

 

[docB]

Thanks DocB,

Less than 24 hours after reading about your case and thinking, "Whew!, thank god I haven't had one of those in a while." Mine was Hgb=7. BP 70/40 with bright red blood out of both ends. Fortunately he had the more diffuse subendocardial picture and got better quickly(<15 min) with O- on the rapid infuser.

Nothing makes me feel better than spreading my misery around to others.

 

[kinetic]

Nothing makes me feel better than spreading my misery around to others.

Must ...resist ...obvious ...ED ....joke. Contain ...self ...

 

[docB]

Must ...resist ...obvious ...ED ....joke. Contain ...self ...

Just for that I paged all my consultants at 3am to the local strip club.

 

[Seaglass]

Damn you all and your jinx-ing posts! Wouldn't it be my luck to have an acute GI bleeder suddenly become acute GI-AMI while I'm covering on night-float. Actually I don't think it will end up being AMI but WHAT THE HELL ANYWAY. There's power in these posts people. Use it wisely. BTW, I heard Macgyver was in a car wreck . . .

 

[Whisker Barrel Cortex]

Just for that I paged all my consultants at 3am to the local strip club.

Reminds me of the time a bunch of our radiology residents were playing poker and paged the poor guy on call to a massage parlor with the pager extention for the on call family practice resident (pass around call pager).

 

[kinetic]

Reminds me of the time a bunch of our radiology residents were playing poker and paged the poor guy on call to a massage parlor with the pager extention for the on call family practice resident (pass around call pager).

Just another day at work for the radiology department. Saving lives.

 

[Whisker Barrel Cortex]

Just another day at work for the radiology department. Saving lives.

This was at midnight, not in the middle of the day.