Welcome to Wednesday Wrap-up!
Each week after conference the TOKC Blog team will post a follow up to a lecture or discussion point that came up during conference so that those who were there can continue the conversation and those who missed out can join in. All you need to do to participate is register with the blog and post your comments.
During the M&M conference this morning, a case of a lower GI bleed was presented. Don’t worry, I won’t mention any of the details, but I have recently had several cases of varying severity and was curious how everyone deals with the management of these patients. Everyone knows if you talk to internal medicine and surgery about this topic, you will get two very different responses. Initial management begins with the ABC’s and establishing IV access. That means two large bore IV’s and/or cental access if necessary. Typically you will begin resuscitation with crystalloid but switch to PRBCs quickly if necessary. Resuscitation needs to be agressive with these patients as they can decompensate fast. These patients will also require continuous monitoring and frequent hematocrits as it is not always obvious how much bleeding is occurring. But my question is what is your algorithm for identifying the source of bleeding? Colonoscopy, angiography, nuclear medicine scan? What are your criteria for calling surgery or critical care? I personally am generally calling both GI and surgery if my patient has any risk factors such as advanced age, gross blood on rectal exam, abnormal vital signs, or taking anticoagulants. And how do you deal with the medicine vs surgery conflict with regard to final disposition. Weren’t we all taught that LGIB’s should be admitted to surgery? The last point I wanted to raise was the use of platelets and DDAVP in patients on ASA or plavix. Under what circumstances are you using these agents?
Please post your thoughts below as I would really like to hear from both the faculty and residents on how you are dealing with these issues.
Thanks for reading,
JK
mritchie
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I treat these patients as profoundly sick until they are proved otherwise. I have seen a ton of GI bleeders that went south a lot faster than I thought they would. I really encourage people to go heavy on these patients early. Get the blood lab going on some units. You can always cancel them.
I find myself switching to pRBCs much faster these days. You can NEVER tell how much they are bleeding until you are behind the 8-ball already. I call GI, surgery, and CCM as soon as I think they are actively bleeding. There is no reason not to. I have never reversed plavix with platelets but would be open to it. Most of the time with these huge bleeds you need plasma, cells and platelets all together, however I usually don’t do much different if they are on Plavix. Everyone is ASA so I really don’t do much about those peeps.
In regards to the use of DDAVP, I have used it for patients with renal failure who also are having a GI bleed. The evidence comes mostly from case reports, but it can’t hurt.
The blog is awesome! thanks for setting it up.
I agree with Doty. Getting blood ready is the most important thing we can do from the ED. Most mistakes or delays can be overcome if you have blood immediately available and a large bore IV ready to go. Additionally, don’t be shy about transfusing. If someone has borderline vitals and clear cut GI bleed I would rather give less IV fluids and start transfusing early.