MASSIVE GI bleed - thoughts

[pinipig523]

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So I had a guy come in with cirrhosis w/ known varices s/p banding/ligation a few days ago - had a few syncopal events prior to presentation.

Guy comes in.... retching cups of blood... I mean, probably a liter at least.

2 large bore IVs, ordered 5u of O neg blood.

We bring him to resus bay - I get my airway kit ready. I'm not messing around. I have 2 tubes ready, I have a glidescope ready, I have my bougie ready, I have 3 sets of blades, I have TWO suctions going w/ Yankeurs... I'm all set. I even had a Blakemore ready.

The guy says... "Oh no, here it comes again - and I got to take a dump!"

I'm like, "OMG.... this is NOT good."

We turn his head to the side - another liter or so comes out - bright red blood. ALL OVER my glidescope.

He then has this hypoxic seizure - then comes back.

"Are you ok?"

He's like, "I'm not sure."

"Stay with me."

He says, "I think this is where I die. Tell my parents I did my best to stay sober."

We placed a cordis in the femoral - called for MTP. We transfused the guy with 5u of blood in 5 minutes. SBP went from 55 to 110.

His hgb goes from 4 to 10.

MICU, GI, surg, IR consulted - GI attending at bedside.

We decided to hold off the intubation as long as possible. The guy's pressure holds steady - he's protecting his airway. He goes to MICU for EGD.

I figured the guy survived the initial attack, I see more patients.

Then the surg resident comes running down - "Where's the Blakemore????"

I head upstairs after the surg resident - the guy's intubated with blood all over his face, all over the bed. The GI attending can't scope the guy. Their shoving the Blakemore in...

I asked what happened - apparently, they tubed the patient. Then the patient gagged and pretty much exsanguinated his ENTIRE intravascular volume onto the bed.

I guess I just wanted to share my story.

I don't know if I did anything wrong in particular. Is there anything else that you guys recommend?

I'm not sure if I buy the whole "intubate early" idea on massive GIB. If they can protect their airway, I'd rather not mess with it and make them gag and vomit blood.

 

[dotcb]

Care was great otherwise, but in future cases like this you should intubate the patient. If they vomit blood in front of you and demonstrate instability, take the airway early.

 

[pinipig523]

You should have intubated him. If they vomit blood in front of you and demonstrate instability, take the airway early.

Why? The guy's airway is intact, his pressure is holding. Why tube him any earlier - they tube him upstairs and things fell apart.

 

[Rendar5]

So I had a guy come in with cirrhosis w/ known varices s/p banding/ligation a few days ago - had a few syncopal events prior to presentation.

Guy comes in.... retching cups of blood... I mean, probably a liter at least.

2 large bore IVs, ordered 5u of O neg blood.

We bring him to resus bay - I get my airway kit ready. I'm not messing around. I have 2 tubes ready, I have a glidescope ready, I have my bougie ready, I have 3 sets of blades, I have TWO suctions going w/ Yankeurs... I'm all set. I even had a Blakemore ready.

The guy says... "Oh no, here it comes again - and I got to take a dump!"

I'm like, "OMG.... this is NOT good."

We turn his head to the side - another liter or so comes out - bright red blood. ALL OVER my glidescope.

He then has this hypoxic seizure - then comes back.

"Are you ok?"

He's like, "I'm not sure."

"Stay with me."

He says, "I think this is where I die. Tell my parents I did my best to stay sober."

We placed a cordis in the femoral - called for MTP. We transfused the guy with 5u of blood in 5 minutes. SBP went from 55 to 110.

His hgb goes from 4 to 10.

MICU, GI, surg, IR consulted - GI attending at bedside.

We decided to hold off the intubation as long as possible. The guy's pressure holds steady - he's protecting his airway. He goes to MICU for EGD.

I figured the guy survived the initial attack, I see more patients.

Then the surg resident comes running down - "Where's the Blakemore????"

I head upstairs after the surg resident - the guy's intubated with blood all over his face, all over the bed. The GI attending can't scope the guy. Their shoving the Blakemore in...

I asked what happened - apparently, they tubed the patient. Then the patient gagged and pretty much exsanguinated his ENTIRE intravascular volume onto the bed.

I guess I just wanted to share my story.

I don't know if I did anything wrong in particular. Is there anything else that you guys recommend?

I'm not sure if I buy the whole "intubate early" idea on massive GIB. If they can protect their airway, I'd rather not mess with it and make them gag and vomit blood.

I had a similar case but without the banding a month ago, actually walked into it around shift change. Pt already had MICU and GI bedside evaluating. The person signing out shoved in a Femoral Cordis to get the multiple units of blood going in. I NG tubed the guy temporarily, (active hematemesis = no clot, imo), and I had anaesthesia come down for a non-emergent, non-RSI. The point is, the person's going to need the tube for endoscopy in this case, he's a gigantic aspiration risk, and if the Blakemore is bedside, it's useless in a non-tubed patient. Honestly, he's going to be tubed regardless, do it in as controlled a setting as possible. If you're going to intubate yourself, keep in mind that in the hemorrhagic shock pt, you need a lot less induction agent. But do it while you have a window of opportunity instead of waiting until he's in the endo suite.

Let me preface the rest of this by saying, I gave a lecture on this and did a lot of research on this topic, and these are my personal ways of going about it:

Now as for NG tubes, I'll stick em down almost any hematemesis patient to clear the stomach for a safer intubation (there's enough EBM to say it's not dangerous in your typical UGIB pt), but your guy was recently banded, so I'm honestly not sure what I would do in your case in that regard. But I'd still intubate them or have anaesthesia intubate if the pt stabilizes. Good job having all 4 services on board, that was a mistake I made in my case, not having IR notified ahead of time. Only things I'll add is that I would've been happy keeping the guy at an SBP of 90, I'd have thrown at least 4-6 units FFP at him, and the rest of the kitchen sink at him (1 dose of antibiotics, 1 dose erythromycin if GI wanted, nexium drip, and maybe octreotide drip running). some of that's EBM, some of that's not EBM.

EDIT: yes, yes, I'm not ashamed to admit it, I gave the airway away. It left me free to deal with the rest of the stuff going on.

 

[dotcb]

I don't consider actively vomiting blood to be an intact airway. Avoid the tube to leave the problem for someone else? I consider that the ED's responsibility. (Not to mention, I like intubating). He needed it done, and if he codes, much easier to run a code w/ an intubated patient.

The formal indication for the intubation is "anticipated clinical course."

 

[Rendar5]

Why? The guy's airway is intact, his pressure is holding. Why tube him any earlier - they tube him upstairs and things fell apart.

Things were probably going to fall apart regardless of whether or not they tubed him.

 

[Apollyon]

Had a conceptually related case in residency (young lady tried - and succeeded - to off herself by ethylene glycol ingestion), where the young lady had an active GI bleed. I'm not sure if there was something corrosive from the antifreeze (I hadn't heard of that), but GI was there, and I had the Minnesota tube (a/k/a the Sengstad-Blakemore tube) in hand, but, somehow, too much lube got on it, and I couldn't get a good handle on it, but we decided not to place it.

Our young lady ended up dead, so it became an academic point.

As to your patient - "no matter what you do, some people are going to die. And no matter what you do, some people are going to live". Cirrhotic with known varices? Bomb, ticking. Puking blood? Bomb is right in the midst of exploding. I thought that that would be the punchline when he said he needed to take a dump. Dump a gallon of blood.

My program director said that, when she was in residency, saw a guy with what was diagnosed on autopsy as an aorto-enteric fistula. His entire blood volume came out of his butt in less than 20 seconds.

Lest I sound like another person that posts in some off, lyrical style, I'll tell you that it sounds like you did everything right.

 

[jdh71]

\The point is, the person's going to need the tube for endoscopy in this case, he's a gigantic aspiration risk

The formal indication for the intubation is "anticipated clinical course."

👍

while everything is clear in the retroscpectascope . . .

please do NOT send these patient's to the MICU without a secured airway

it may not make you feel any better, but it sounds like this guy was a "goner" the second he rolled in regardless - the airway wasn't what killed him

 

[EM_Rebuilder]

Intubate early..... You are more skilled at this than the 'cluster' that may ensure in some ICU....

If there was that much blood.... Think sentinel bleeding from an aorticenteric fistula followed by 'the big one'. I saw one of these in residency...20 units of blood... Actually placed a Minnesota tube and the aorta got stented... Still died though.

 

[TysonCook]

...intubate early. They will get scoped (i.e. become unprotected), and it takes a huge portion of variables out of the equation.

 

[Arcan57]

I don't think anyone would fault your for placing an airway in a UGI bleed patient that says he's about to die. While it wouldn't have made a damn bit of difference (likely) in this patient, you probably would fail (or at least have significant points knocked off) the oral boards for not controlling the airway.

 

[iridesingltrack]

Is there anything else that you guys recommend?

I'm not sure if I buy the whole "intubate early" idea on massive GIB. If they can protect their airway, I'd rather not mess with it and make them gag and vomit blood.

You did a nice job resuscitating this patient with PRBC. Did he require any other products, particularly FFP or PCC for elevated INR related to his liver dz? I don't know what the rest of you do but I tend to give these guys a couple units of PRBC by then I have the POC INR back; then based on these results switch to a 1:1 as needed. You could argue that this is the guy that we should consider PCCs as you want reversal of anticoagulation right now, not in several hours. Thoughts?

Also, just to add to the chorus of intubate early. This guy does require an airway, as was stated, for anticipated clinical course. Not being there I can't be certain, but I would like to think I would have done it once the pressure was up. While his improved hemodynamics are reassuring, they are temporary as you still don't have source control. Was he an anatomicaly predicted difficult airway? I would argue that if he was anatomicaly predicted to be difficult, plus the fact that he was going to be difficult just due to blood in his OP, I would be even more likely to take the airway in the ED as I wouldn't want anyone else managing this, especially when he decompensates again.

Tough case, thanks for sharing. I love GI bleeds, it's like a trauma without the trauma team meddling around.

iride

 

[Tiger26]

You did a nice job resuscitating this patient with PRBC. Did he require any other products, particularly FFP or PCC for elevated INR related to his liver dz? I don't know what the rest of you do but I tend to give these guys a couple units of PRBC by then I have the POC INR back; then based on these results switch to a 1:1 as needed. You could argue that this is the guy that we should consider PCCs as you want reversal of anticoagulation right now, not in several hours. Thoughts?

Also, just to add to the chorus of intubate early. This guy does require an airway, as was stated, for anticipated clinical course. Not being there I can't be certain, but I would like to think I would have done it once the pressure was up. While his improved hemodynamics are reassuring, they are temporary as you still don't have source control. Was he an anatomicaly predicted difficult airway? I would argue that if he was anatomicaly predicted to be difficult, plus the fact that he was going to be difficult just due to blood in his OP, I would be even more likely to take the airway in the ED as I wouldn't want anyone else managing this, especially when he decompensates again.

Tough case, thanks for sharing. I love GI bleeds, it's like a trauma without the trauma team meddling around.

iride

Awesome quote! I also agree--I intubate this stuff really early with an incredible low threshold

 

[cyclohexanol]

It definitely sounds like this guy was going to go downhill no matter what. However, I think I would have tried to secure his airway before he went to the unit. This seems like a good place to plug Scott Weingart's ETT suction apparatus (published J Clin Anesth. 2011 Sep;23(6):518-9. Epub 2011 Jul 23):

http://emcrit.org/blogpost/ett-as-suctio/

It's just a bronchoscope swivel adapter and a meconium aspirator that you slap on the top of your ETT to use as a large bore suction and allows you to use a stylet as well. We have a few pre-assembled in our airway box for just this occasion, it works brilliantly.

Scott says they do all of their tubes with the Glidescope (even massive UGIB), but once you get blood on the camera, you're screwed. I'd have a traditional DL on the gurney ready to go in case.

 

[pinipig523]

Awesome quote! I also agree--I intubate this stuff really early with an incredible low threshold

Noted - something to think about. I was stopped by the attending.

It definitely sounds like this guy was going to go downhill no matter what. However, I think I would have tried to secure his airway before he went to the unit. This seems like a good place to plug Scott Weingart's ETT suction apparatus (published J Clin Anesth. 2011 Sep;23(6):518-9. Epub 2011 Jul 23):

http://emcrit.org/blogpost/ett-as-suctio/

It's just a bronchoscope swivel adapter and a meconium aspirator that you slap on the top of your ETT to use as a large bore suction and allows you to use a stylet as well. We have a few pre-assembled in our airway box for just this occasion, it works brilliantly.

Scott says they do all of their tubes with the Glidescope (even massive UGIB), but once you get blood on the camera, you're screwed. I'd have a traditional DL on the gurney ready to go in case.

1. Thanks for the feedback on the resus... I think it was a good and very systematic way of doing it - we were able to bring him back from the brink. Not a cluster.

2. Regarding the suction - I have listened to Weingart's lecture but I could not find the components. I've dealt with bad GI bleeds before - and I decided that I need 2 suction setups up and running at max. I've noted that I've been overwhelmed when I only had 1 set up the last time I tried to intubate someone with GIB.

3. Regarding the glidescope - it's good, but I had used it on a GIB before and the camera is useless once blood smears it. So I don't use it now. My plan was to get a good look in 1-2 seconds - then shove the bougie in right away before I lose my vision.

Everything was ready and at bedside.

You did a nice job resuscitating this patient with PRBC. Did he require any other products, particularly FFP or PCC for elevated INR related to his liver dz? I don't know what the rest of you do but I tend to give these guys a couple units of PRBC by then I have the POC INR back; then based on these results switch to a 1:1 as needed. You could argue that this is the guy that we should consider PCCs as you want reversal of anticoagulation right now, not in several hours. Thoughts?

Also, just to add to the chorus of intubate early. This guy does require an airway, as was stated, for anticipated clinical course. Not being there I can't be certain, but I would like to think I would have done it once the pressure was up. While his improved hemodynamics are reassuring, they are temporary as you still don't have source control. Was he an anatomicaly predicted difficult airway? I would argue that if he was anatomicaly predicted to be difficult, plus the fact that he was going to be difficult just due to blood in his OP, I would be even more likely to take the airway in the ED as I wouldn't want anyone else managing this, especially when he decompensates again.

Tough case, thanks for sharing. I love GI bleeds, it's like a trauma without the trauma team meddling around.

iride

1. I ordered 6u FFP also. 10u platelets too.

2. I hear you regarding the intubate early. I think that you're right that I should've pushed for intubation right after the guy was brought back from the brink. That was probably as "stable" as he was going to get.

 

[Hawkeye Kid]

The formal indication for the intubation is "anticipated clinical course."

This is an incredibly important point, and one that I think we often fail to recognize. If, based on experience, you're pretty sure that someone is going to need a tube in the next few hours, it's better to control the airway urgently (ie, at least semi-controlled setting) rather than emergently (by definition a less controlled setting). One could also argue to think about your hospital's resources/set-up in making this decision. It makes a difference if you're admitting to a critical care attending who is skilled at airway management or to a resident-run ICU where someone with much less experience will be responsible for managing the patient's airway.

In the end, I agree with everyone else on this case: this patient was likely going to die no matter what you did (or didn't do).

 

[dchristismi]

I also had a catastrophic variceal bleed as a resident. We did intubate when he went unresponsive and the geyser of blood hit the ceiling, but I was also trying to hold off... knowing that there was a VERY good chance he'd not get extubated. A few minutes with family is priceless. He didn't make it, and the medicine residents spoke about it in hushed tones as one of the goriest codes they'd ever seen.

Agree with the above. These are all ticking time bombs and you don't know how much time is left.
(And also agree that I don't want medicine intubating him - I want ME intubating him.)

 

[gutonc]

He didn't make it, and the medicine residents spoke about it in hushed tones as one of the goriest codes they'd ever seen.

The variceal bleed codes are about the most horrifying thing we witness in the MICU.

 

[Arcan57]

The variceal bleed codes are about the most horrifying thing we witness in the MICU.

Trachs eroding into the inominate...

 

[gutonc]

Trachs eroding into the inominate...

Yeah...but we see a lot more ESLD folks (in our hospital anyway which is a major liver txplant center) than we do chronically trached ones...at least in the MICU.

Actually, the absolute worst code I've ever seen was the esophageal tumor that eroded into the aorta and perfed. It was over in less than 5 minutes but it was truly horrifying.

 

[la gringa]

i spent all night up as a senior resident in the MICU trying to get a hep B cirrhotic banded for the zillionth time... of course, being our (pinipig's and mine) residency hospital, he spoke only Mandarin Chinese...

thankfully, he was DNR but was iffier about when to intubate. great fun trying to run a translation from a hypotensive pt actively vomiting blood over the phone... eventually family showed up and eventually GI got the bleeding to stop.

he really didn't want to be intubated (again) b/c he knew he'd probably never get extubated. i was trying to sedate him enough for GI to do the EGD but keep his pressure up and not have him lose his airway. never seen that much blood from an alive person...

i would have pushed to intubate the guy in the ED, unless the plan was to go to the OR and have anesthesia do it. in nearly any hospital, the ED and OR are far better equipped to deal w/ a disaster like this than a MICU....

 

[jdh71]

I also had a catastrophic variceal bleed as a resident. We did intubate when he went unresponsive and the geyser of blood hit the ceiling, but I was also trying to hold off... knowing that there was a VERY good chance he'd not get extubated. A few minutes with family is priceless. He didn't make it, and the medicine residents spoke about it in hushed tones as one of the goriest codes they'd ever seen.

Agree with the above. These are all ticking time bombs and you don't know how much time is left.
(And also agree that I don't want medicine intubating him - I want ME intubating him.)

I can and have intubated more than one active GI bleeder, even with all the red stuff there - you all aren't the only cowboys in the building. This isn't about YOU intubating versus the MICU people. It's about intubating before things get messy when NO ONE wants to be intubating.

Worst code of my career, as most notable for how disturbing it was, a GI bleeder. Med student finds me asks me to come stat to patients room. A GI bleeder from the ED - NO TUBE - that the GI fellow can't get to stop bleeding, and the GI fellows I work with are a top ****ing notch bunch by my reckoning, so when I see panic on one of their faces, it's a problem. He's trying to tamponade the with the scope, and we can't get the Minn tube in and patient to TIPS until we've secured the airway. It was difficult to the get the DL in the mouth around the scope and ended up needing to use a miller, but had enough of a view after suction to get a tube in. When the scope came out, the blood just bubbled out like a freaking horror show - so much blood - I was very disturbed by the picture of it all for a long time. Minn tube went in, and patient went to TIPS. An added bonus for me, the IR guy let me do most of the TIPS - only time that'll ever happen in my career (no rads resident around that evening).

Bottom line, as you already said, this should be the ED's airway, and it should be in a long time before the patient gets to the unit.

 

[jdh71]

Yeah...but we see a lot more ESLD folks (in our hospital anyway which is a major liver txplant center) than we do chronically trached ones...at least in the MICU.

Actually, the absolute worst code I've ever seen was the esophageal tumor that eroded into the aorta and perfed. It was over in less than 5 minutes but it was truly horrifying.

Second worst bleeder I ever saw as a resident was a guy with a posterior pharyngeal tumor, apparently inoperable, that eventually eroded into the patient's internal carotid. It was gushing out of his nose when I got there, and it was over in about 5 minutes too.

 

[pinipig523]

Spoke to my ER attending again today and asked what was the reasoning as to why did we not intubate early.

His answer made sense:

1. The board answer is to intubate early.
2. The reality is that he has seen a lot of these and these are intubateable even at its worst.
3. The reason why he did not want to intubate was because he wanted us to focus on the resuscitation first. Yes, he had a possibly bad airway but he was hemorrhaging. If we had intubated the guy, we would lose his mentation while we were resuscitating, we would have to resort to playing with his pressures as we would have to know the guy out and what does propofol/versed do? It lowers MAP... and what does hemorrhagic shock do? It results in a lower MAP. He did not want us to be going this route.
4. If we intubate earlier, the guy would be on the brink of bleeding out, losing pressure, and us playing with sedation without over sedating the guy - we would probably end up going a little light on the sedation - the guy would buck against the vent and then would rupture another varicose vessel. More blood.

And lastly, why did we not intubate early?

5. He said that he was confident with our manpower. He had TWO senior 4th year residents (not counting the 2nd year resident who was stunned at what happened to the patient) in the resus bay at the same time. He said that I had the airway and that if the patient lost it, he was confident that I would get the airway. He said that the other senior 4th year resident was in charge of the cordis and MTP. He was there watching over everything and he knew exactly that the patient was still stable.

He said that the patient was brought back from the brink. The guy had a HR of 80, SBP 130 - after our MTP. Yes, he was probably only stable for 10-20 minutes before his hgb began to drop again, but the guy was awake and completely with it.

After our resuscitation, the guy shook my attending's hand and told him "Thanks doc."

He also said 1 final thing:
1. If he was alone in the community - he would intubate the guy immediately. He said that he would not want to be in the position to be placing a cordis when the guy finally loses his airway.

He said the main reason why he did not want to intubate early was because he had full control of the situation, he had 2 senior residents, and the goal was to bring him back from the brink of death while maintaining mentation so we could better monitor our resuscitation and avoid any extra meds that would play with his pressures.

Finally, he tells me that just because the board says that you intubate, you use your head and your clinical experience. If you have a better idea of what to do and you can justify it, then do it. Don't forget to think.

I think the guy's a genius... he is one of my favorite attendings.

 

[Tiger26]

Spoke to my ER attending again today and asked what was the reasoning as to why did we not intubate early.

His answer made sense:

1. The board answer is to intubate early.
2. The reality is that he has seen a lot of these and these are intubateable even at its worst.
3. The reason why he did not want to intubate was because he wanted us to focus on the resuscitation first. Yes, he had a possibly bad airway but he was hemorrhaging. If we had intubated the guy, we would lose his mentation while we were resuscitating, we would have to resort to playing with his pressures as we would have to know the guy out and what does propofol/versed do? It lowers MAP... and what does hemorrhagic shock do? It results in a lower MAP. He did not want us to be going this route.
4. If we intubate earlier, the guy would be on the brink of bleeding out, losing pressure, and us playing with sedation without over sedating the guy - we would probably end up going a little light on the sedation - the guy would buck against the vent and then would rupture another varicose vessel. More blood.

And lastly, why did we not intubate early?

5. He said that he was confident with our manpower. He had TWO senior 4th year residents (not counting the 2nd year resident who was stunned at what happened to the patient) in the resus bay at the same time. He said that I had the airway and that if the patient lost it, he was confident that I would get the airway. He said that the other senior 4th year resident was in charge of the cordis and MTP. He was there watching over everything and he knew exactly that the patient was still stable.

He said that the patient was brought back from the brink. The guy had a HR of 80, SBP 130 - after our MTP. Yes, he was probably only stable for 10-20 minutes before his hgb began to drop again, but the guy was awake and completely with it.

After our resuscitation, the guy shook my attending's hand and told him "Thanks doc."

He also said 1 final thing:
1. If he was alone in the community - he would intubate the guy immediately. He said that he would not want to be in the position to be placing a cordis when the guy finally loses his airway.

He said the main reason why he did not want to intubate early was because he had full control of the situation, he had 2 senior residents, and the goal was to bring him back from the brink of death while maintaining mentation so we could better monitor our resuscitation and avoid any extra meds that would play with his pressures.

Finally, he tells me that just because the board says that you intubate, you use your head and your clinical experience. If you have a better idea of what to do and you can justify it, then do it. Don't forget to think.

I think the guy's a genius... he is one of my favorite attendings.

With regard to induction and later sedation, hemorrhagic shock is profoundly anesthetic--they generally do well with small doses (i.e. 1/10) of induction doses and large dose paralytics with subsequent small boluses of fentanyl (i.e. 25-50 mcg PRN) or versed

 

[pinipig523]

With regard to induction and later sedation, hemorrhagic shock is profoundly anesthetic--they generally do well with small doses (i.e. 1/10) of induction doses and large dose paralytics with subsequent small boluses of fentanyl (i.e. 25-50 mcg PRN) or versed

Until you resuscitate from shock and he starts to buck the vent.

 

[n2b8me]

😉

 

[jdh71]

Spoke to my ER attending again today and asked what was the reasoning as to why did we not intubate early.

His answer made sense:

1. The board answer is to intubate early.
2. The reality is that he has seen a lot of these and these are intubateable even at its worst.
3. The reason why he did not want to intubate was because he wanted us to focus on the resuscitation first. Yes, he had a possibly bad airway but he was hemorrhaging. If we had intubated the guy, we would lose his mentation while we were resuscitating, we would have to resort to playing with his pressures as we would have to know the guy out and what does propofol/versed do? It lowers MAP... and what does hemorrhagic shock do? It results in a lower MAP. He did not want us to be going this route.
4. If we intubate earlier, the guy would be on the brink of bleeding out, losing pressure, and us playing with sedation without over sedating the guy - we would probably end up going a little light on the sedation - the guy would buck against the vent and then would rupture another varicose vessel. More blood.

And lastly, why did we not intubate early?

5. He said that he was confident with our manpower. He had TWO senior 4th year residents (not counting the 2nd year resident who was stunned at what happened to the patient) in the resus bay at the same time. He said that I had the airway and that if the patient lost it, he was confident that I would get the airway. He said that the other senior 4th year resident was in charge of the cordis and MTP. He was there watching over everything and he knew exactly that the patient was still stable.

He said that the patient was brought back from the brink. The guy had a HR of 80, SBP 130 - after our MTP. Yes, he was probably only stable for 10-20 minutes before his hgb began to drop again, but the guy was awake and completely with it.

After our resuscitation, the guy shook my attending's hand and told him "Thanks doc."

He also said 1 final thing:
1. If he was alone in the community - he would intubate the guy immediately. He said that he would not want to be in the position to be placing a cordis when the guy finally loses his airway.

He said the main reason why he did not want to intubate early was because he had full control of the situation, he had 2 senior residents, and the goal was to bring him back from the brink of death while maintaining mentation so we could better monitor our resuscitation and avoid any extra meds that would play with his pressures.

Finally, he tells me that just because the board says that you intubate, you use your head and your clinical experience. If you have a better idea of what to do and you can justify it, then do it. Don't forget to think.

I think the guy's a genius... he is one of my favorite attendings.

I think I missed the part of your story where the attending, the two 4th year residents, and the second year resident continued at the bedside of the patient during his hospital course . . .

 

[Hernandez]

I'm with the other, intubated early, and hypothetically, the worse thing that could be done is get pissy when the MICU tells you we ain't accepting the pt until he's resuscitated for a hgb of 3.6 as that's not stable to transport even if his BP has a MAP of 70 (for now), especially when I'm dealing with an unstable case of massive hemoptysis and am elbow deep in bloody bronch.......and then you proceed to ship that pt with 2 24 gauge pinky IVs to IR for TIPS with no airway.......where he codes......that's just not cool.......not that you would do that, but I'm CERTAIN other ER docs might......

 

[SoCuteMD]

Just finishing up my MICU senior month. One of the (many) things I've learned this month is that I would tube these patients ASAP. These patients decline faster than almost any other patients I've seen, without any warning.

Also, GI always wants these patients intubated for the scope, so might as well do it while they are pseudo-stable.

 

[ORL10]

Yeah i second the sentiment on this board, nothing you could have done, this patient was not going to make it regardless. However, in our shop we get called to intubate on the floors and I have been asked to help anesthesia/CRNA's in the ICU intubate (we don't have fellows) so I would control the airway immediately for 2 reasons:
1. I anticipate this guys is going to crash
2. So I can avoid getting called to the floor in 20 minutes, (I know taking me away from working up another undifferentiated chest pain complaint). You know once you tube him his pressure will drop, so you need to be prepared for that, but having the patient intubated makes scoping him at least a semi-reasonable feat for GI.

I wonder if there is any role for resuscitating these guys like penetrating trauma patients headed to the operating room relatively quickly that are hypotensive . And by that i mean shooting for a target SBP lower than normal (knowing that cirrhotics on a good day have SBP's in the 90-100's) until they have an intervention completed. I know the reality of watching a sick patient with markedly abnormal vital signs is sometimes tough to do, but we will do this in a penetrating chest trauma patient to avoid "popping the clot"??


In the end, hindsight is 20/20, and I wasn't there so I can only say what I think I would have done.

 

[SoCuteMD]

I wonder if there is any role for resuscitating these guys like penetrating trauma patients headed to the operating room relatively quickly that are hypotensive . And by that i mean shooting for a target SBP lower than normal (knowing that cirrhotics on a good day have SBP's in the 90-100's) until they have an intervention completed. I know the reality of watching a sick patient with markedly abnormal vital signs is sometimes tough to do, but we will do this in a penetrating chest trauma patient to avoid "popping the clot"??


In the end, hindsight is 20/20, and I wasn't there so I can only say what I think I would have done.

I wonder the same thing. The one time I brought it up in the MICU no one liked the idea (it was actually on a non-GI bleed patient).

 

[Rendar5]

I wonder if there is any role for resuscitating these guys like penetrating trauma patients headed to the operating room relatively quickly that are hypotensive . And by that i mean shooting for a target SBP lower than normal (knowing that cirrhotics on a good day have SBP's in the 90-100's) until they have an intervention completed. I know the reality of watching a sick patient with markedly abnormal vital signs is sometimes tough to do, but we will do this in a penetrating chest trauma patient to avoid "popping the clot"??

Massive UGIB's and especially massive ENT bleeds in my mind get put into this category.

And to the person who mentioned needing minimal sedation for intubation and maintenance, it's definitely true. In my case, anaesthesia intubated with 100mcg fentanyl and 4mg versed, iirc. There was a great emrap lecture I heard from a trauma anaesthesiologist I think from Maryland schock trauma who spoke about permissive hypotension, and he would talk about alternating between bolusing blood and pushes of maintenance agents so that he could titrate both up at the same time, as maintenance agents do drop the BP, but giving blood decreases the effect of low dose maintenance and treats the shock. So he'd be able to slowly fill up the tank, and titrate up to a normal maintenance dose while at teh same time maintaining a SBP in the 70's-90's.

Of course that's not what I'd expect any ED physican to do, but the principle is interesting. it's a more active way of maintaining permissive hypotension while still treating the shock.

 

[Rendar5]

I wonder the same thing. The one time I brought it up in the MICU no one liked the idea (it was actually on a non-GI bleed patient).

Yeah it's a surgical concept that hasn't gotten the way to the medical literature yet SoCute. I'm not surprised your MICU did not like the idea. what type of patient was it if you don't mind my asking?

 

[SoCuteMD]

Yeah it's a surgical concept that hasn't gotten the way to the medical literature yet SoCute. I'm not surprised your MICU did not like the idea. what type of patient was it if you don't mind my asking?

Spontaneous retroperitoneal hematoma that was anticoagulated and requiring pressors/transfusions (both FFP and PRBCs)

 

[pinipig523]

Just finishing up my MICU senior month. One of the (many) things I've learned this month is that I would tube these patients ASAP. These patients decline faster than almost any other patients I've seen, without any warning.

Also, GI always wants these patients intubated for the scope, so might as well do it while they are pseudo-stable.

Only problem is that if you intubate too early, you are intubating a hemodynamically unstable patient. Any induction agent will stop his catecholamine surge and you'll lose pressure immediately. This may even push the guy to arrest.

If the guy's airway is patent, mentating, and you have enough manpower - why not resuscitate the guy first, then intubate the guy?

That's what we ended up doing - they just ended up doing the intubation in the MICU with anesthesia at bedside.

 

[Arcan57]

Only problem is that if you intubate too early, you are intubating a hemodynamically unstable patient. Any induction agent will stop his catecholamine surge and you'll lose pressure immediately. This may even push the guy to arrest.

If the guy's airway is patent, mentating, and you have enough manpower - why not resuscitate the guy first, then intubate the guy?

That's what we ended up doing - they just ended up doing the intubation in the MICU with anesthesia at bedside.

Point by point:

1) We intubate hemodynamically unstable patients all the time. The hemodynamic effects of induction agents are magnified in hypovolemic states, but to make a blanket statement that any induction agent will likely kill hypovolemic patients is fear-mongering.

2) It's not necessarily a man-power issue, it's a "how many people fit at the head of the bed" issue. This guy is going to need a variety of invasive procedures, most of which are enhanced by, if not frankly requiring, intubation. Waiting until he crashes to tube him means an extra minute or two that GI can't be scoping or shoving a Blakemore tube down him.

Also, if you're worried that he's going to buck the vent and burst a varice, then aren't you really worried he's going to start actively vomiting while awake and rupture a varice? Unless he's DNR and you're trying to let him say good-bye to his family, neither consciousness or the ability to move are going to be his friends for the next couple of hours.

 

[Hamhock]

To pull ideas from the other thread (RSI drugs), how about:

1. Resuscitate to the point that a bit of PPV will not eliminate venous return/pt arrest

2. intubate and sedate with ketamine

I would certainly have intubated after the guy shakes my hand.
-------
Overall, I agree with everyone else: tough case and it's unlikely anything would have changed the outcome.

HH

 

[SoCuteMD]

Only problem is that if you intubate too early, you are intubating a hemodynamically unstable patient. Any induction agent will stop his catecholamine surge and you'll lose pressure immediately. This may even push the guy to arrest.

If the guy's airway is patent, mentating, and you have enough manpower - why not resuscitate the guy first, then intubate the guy?

That's what we ended up doing - they just ended up doing the intubation in the MICU with anesthesia at bedside.

So what would be your endpoint for intubation if you don't want to intubate hemodynamically unstable patients? We intubate hemodynamically unstable patients all the time. Waiting to intubate a variceal bleeder is potentially catastrophic. I'd rather do it at the "hemodynamically unstable" stage than the "peri-code" stage, which comes right after the guy simultaneously vomits a liter of blood and passes another liter of bright red blood per rectum, oh, and also aspirates.

You can resuscitate and then intubate the guy, but I wouldn't wait until the patient is in the MICU to intubate. There is too much potential badness that can happen - and what if it happens en route to the MICU?

 

[Rendar5]

Only problem is that if you intubate too early, you are intubating a hemodynamically unstable patient. Any induction agent will stop his catecholamine surge and you'll lose pressure immediately. This may even push the guy to arrest.

If the guy's airway is patent, mentating, and you have enough manpower - why not resuscitate the guy first, then intubate the guy?

That's what we ended up doing - they just ended up doing the intubation in the MICU with anesthesia at bedside.

Your approach does have validity, but I wouldn't say that you resuscitated the guy first and then intubated, which is what most people seem to be espousing. You resuscitated and then did not intubate. Someone else did at a later time. All hemorrhagic shock patients drop pressures, as I'm sure you've seen in your trauma patients. Just means you need lower doses of induction agents and maintenance agents. And it means you should be actively resuscitating them at the time of intubation. As for bucking, you have the option of paralyzing the patient. They should be in the endo suite within one dose of rocuronium. I'm not saying you did anything wrong, as there is more than one way to skin a cat in EM. I'm just pointing out that your and your attending's worries have pre-emptive solutions available that make alternate approaches just as viable.

 

[future_dr_house]

Only problem is that if you intubate too early, you are intubating a hemodynamically unstable patient. Any induction agent will stop his catecholamine surge and you'll lose pressure immediately. This may even push the guy to arrest.

If the guy's airway is patent, mentating, and you have enough manpower - why not resuscitate the guy first, then intubate the guy?

That's what we ended up doing - they just ended up doing the intubation in the MICU with anesthesia at bedside.

Why not use some push dose pressors to pre-empt the lower bp once you induce?

I'm only an intern but each of these cases I've had we intubate early as everyone has stated above for anticipated course.

 

[dotcb]

It's OK to try a few quick things (bolus, hang blood, a push pressor, etc.) prior to intubation to avoid post-intubation arrest, but intubating unstable patients is what we do...