Airway
Early RSI by senior EM/anaesthetist if:
- Severe uncontrolled haemorrhage
- Severe encephalopathy
- Inability to maintain O2 sats
- Aspiration pneumonitis
Breathing
- High flow oxygen via reservoir bag
- Sats monitoring
- Check for aspiration or infective pneumonia
- Blood gases (VBG please [risk bleeding if ABG])
- CXR
Circulation
- IV access- minimum 2 x 16 gauge cannulae
- X-match 6 units of blood, ( FBC, U&Es, clotting, LFTs)
- IV fluid – crystalloid (not colloid), then blood
- Aim for SBP 80 - 90 mmHg [permissive ↓BP (Ref)]
- Correct PTT
- Central venous access (compressible site)
- Pressure monitoring (ideally correct clotting first)
- Catheterise (monitor hourly output)
- Vitamin K 5-10mg slow IV and PCC 50µg/kg or FFP 15ml/kg, ± platelets
Stop the bleeding
Therapeutic
- 2mg Terlipressin [Cochrane] in all unstable patients (beware myocardial ischaemia - Mx with GTN patch/infusion)
- Call on call endoscopist (switchboard)
- Scoping will confirm Dx and allow band ligation
- Performed as soon as patient stable
- May be performed as a life saving procedure in any critical area
Balloon tamponade (Sengstaken tube)
- Must always be preceded by ETT & sedation
- Reserved for severe uncontrolled haemorrhage
- Insert the lubricated, fully deflated Sengstaken-Blakemore tube orally/nasally
- Stop between the 50&60cm mark on the tube
- Inflate the gastric balloon (50mL of air)
- Confirm position with CXR, then inflate (additional 200mL of air) to 250mL total
- Apply continuous gentle (1-2 kg) traction. It is rarely necessary to inflate oesophageal balloon
- Mark the depth of the tube. If it moves >3cm (over next 10 min as it warms), consider the possibility of a hiatal hernia and balloon migration (repeat CXR)
- Continue gastric port aspiration to check for bleeding below the tube
- If bleeding continues, consider inflating the oseophageal balloon to 40mmHg
At CUH, patients presenting hypotensive (Sys BP < 100mmHg) or Hb < 10 g/dl should be admitted under the surgical team on call. (Letter).
Differential diagnosis
- Peptic ulceration, Portal hypertensive gastropathy
- Gastric or duodenal varices
- Aorto-enteric fistula
Further management
- Prophylactic antibiotics [Cochrane]
- [NICE] (Ciprofloxacin or Ceftazidine) in confirmed variceal bleeds (Ref )
Links/References
- Gav P, Chapman R. Modern Management of Oesophageal varices. >Postgrad Med J. 2001;77:75-81
- Bernard B, Grange JD. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology 1999;29:1655-61
- EBOC level 1(a or b) evidence for management variceal haemorrhage Athens password needed
- Nice Guideline 141 - Mx Upper GI Bleed - June 2012
- wikimedia.org
- Powell M, Journey JD. Sengstaken-Blakemore Tube. [Updated 2022 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558924/