Thread by @srrezaie

Bloody Hell: GI Bleed Management in the ED at #ACEP21

Upper vs Lower GIB at #ACEP21

Low BP = Assume UGIB
BRBPR w/Clots = LGIB
BUN/Cr >30 = UGIB
NGL = NOT Helpful

EVEN GI guidelines don't support NGL #ACEP21

The American College of Gastroenterology 2012 guidelines state NGL is not required in pts with UGIB for diagnosis, prognosis, visualization, or therapeutic effect

Indications for Massive Transfusion Protocol (MTP) in GIB #ACEP21

-Low BP w/Brisk Bleed
-Shock Index >1
- >4U PRBCs/hr

Targets of Resuscitation for GIB #ACEP21

-Extrapolated from Trauma Lit
-Hb >7g/dL
-Plt >50k
-INR <1.5 - 2.0
-Fibrinogen >1g/L
-Lactate <2mmol/L
-Calcium >2mmol/L

What to Transfuse in GIB #ACEP21

-Hb <7 --> PRBCs
-Plt <50k --> Plts
-INR >1.8 --> FFP
-Fibrinogen <1 --> Cryo

Octreotide #ACEP21

-In sickest pts, until better data refutes...
-DECREASES bleeding
-DECREASES need for surgery
-NO real mortality data

Proton Pump Inhibitors (PPIs) #ACEP21

-PPI + PUD --> No Diff in Mort; Reduces rebleeding
-PPI + Undiff UGIB --> No Diff in mortality or rebleeding
-PPI Bolus = Drip

Antibiotic Prophylaxis in Cirrhotic Patients #ACEP21

-REDUCES: Mortality, Bacterial Infxns, Rebleeding, & Hospital LOS
-Mortality NNT = 22
-Bacterial Infections NNT = 4

Erythromycin in UGIB #ACEP21

-250mg, 30min prior to EGD IMPROVES:
-Visualization
-Decreased need for 2nd EGD
-Need for PRBCs
-Hospital LOS

Treatments that DO & DO NOT Improve Mortality in GIB #ACEP21

-DO IMPROVE
-Antibiotic PPx in Cirrhotic Pts
-Restrictive Transfusion (Hb<7g/dL) in HD stable pts

-DO NOT IMPROVE
-Somatostatin Analogues
-Erythromycin
-NGL
-PPIs

TAKE HOME MESSAGES in GIB #ACEP21

-HD Unstable, Hematemesis, BUN/Cr >30 = Assume UGIB
-BRPBR + Clots = Assume LGIB
-NGL = Painful and Doesn't Help

TAKE HOME MESSAGES in GIB #ACEP21

-Abx PPx in Cirrhotics = Saves Lives
-Octreotide = Decreases Bleeding and Need for Surgery
-PPI: Bolus = Drip
-Erythromycin = Helps with Visualization During EGD

TAKE HOME MESSAGES in GIB #ACEP21

-HD Stable GIB = Restrictive Transfusion (Hb<7)
-HD Unstable GIB = Transfuse Regardless of Hb
-Know Indications for Massive Transfusion Protocol