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so now let's talk about the management
of a GI bleed the first most important
step is to establish adequate IV access
by this we mean placing at least two
large-bore peripheral IVs which are 18
gauge or larger or placing a centrally
placed large bore catheter the goal is
to be able to rapidly infuse blood
products and fluids so to understand why
this is important we'll have to go back
to your physics knowledge so recall from
poi cells law in physics that flow or Q
in this equation is affected
exponentially by the radius and
inversely by the length so why we care
about a large-bore IV is because we want
a short length and a wide radius in our
catheter to make sure that we can
maximize the flow through the catheter R
the next step in management is fluid
resuscitation you want to give
crystalloid fluids such as normal saline
or lactated ringers solution next you
should consider transfusing the patient
with blood products so we'll break it
down by each type of blood product first
you should consider packed red blood
cells or prbcs in the general we use a
transfusion threshold of a hemoglobin
less than 7 for most patients however
you might consider a higher transfusion
threshold of less than 8 for patients
who have coronary artery disease or have
active bleeding the next blood product
you should consider is platelets in
general we transfuse platelets for
patients who are actively leading when
their baseline platelets are less than
50,000 there are other blood products
you can consider such as fresh frozen
plasma or FFP - correct underlying
coagulopathy
however that is beyond the scope of this
lecture the next step in management is
to give medications to stabilize the
leading so all patient
should receive a proton pump inhibitor
this is to reduce acid secretion in the
stomach and hopefully slow the rate of
bleeding if they have an upper GI bleed
next you can consider giving vasoactive
medications such as octreotide but this
is only if you suspect a variceal bleed
the last thing you can consider is any
reversal agents for anticoagulants that
your patient takes if they are available
the last step in management after you
have fluid resuscitated and stabilize
the patient is to consult the GI
specialist this is so that they can
perform both diagnostic and therapeutic
interventions to control the bleeding so
now let's move on to talk about the
various diagnostic and therapeutic
studies we have available so the gold
standard for diagnosing and controlling
a GI bleed is upper or lower endoscopy
there are other options we have
available including push enter us Coupee
this is a more complicated type of
endoscopy by which we are able to
visualize the small bowel which is
otherwise unable to be reached by either
upper or lower endoscopy the next test
you may consider our nuclear
scintigraphy which is a tagged red blood
cell skin or CT angiography by either of
these modalities you can detect slower
rates of GI bleeding however keep in
mind that both of these tests are
imaging tests only and so you may find
the location of the bleeding but you
will not be able to intervene the last
test we have available is standard and
geography this is usually performed by
interventional radiologists who can
thread a catheter through the grain up
into the vessels that may be
contributing to the bleeding this is
also a therapeutic intervention if they
are able to find and embolize the vessel
that is causing the bleeding so now that
we've gone through all of that let's
return to our case we had mr. Gibb who
was a 56 year old man who's coming in
with some concerning GI symptoms he does
have a history of NSAID and
all use and he has signs on exam of
hypovolemia anemia and some localizing
symptoms of epigastric pain he is also
shown to be anemic so now we know that
his symptoms of coffee ground emesis and
dole epigastric pain are concerning for
an upper GI bleed in addition his risk
factors of heavy and said and alcohol
use place them at risk for a
differential of peptic ulcer disease
potentially gastritis or cancer so we
are asked what is the best next step in
management now we know that the first
step is always to establish adequate
peripheral IV access and note that he
already has supine hypotension so he
should be given aggressive fluid
resuscitation at this time he currently
does not meet the threshold for a packed
red blood cell transfusion with a
hemoglobin of 11 but he is presenting
with general bleeding so a proton pump
inhibitor should be started thank you
very much for your attention
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