Emergency General Surgery

The Bleeding Volcano – Initial Management

I am the vampire at my own veins

C. Baudelaire

Sometimes in our job is possible to live firsthand in horror scenes… One of the most awful scenarios is a patient vomiting blood.

In these cases, it is easy to become scared and to lose control. The keystone is to perfectly know how to manage such patients, in order to silence that malicious voice in your head screaming “what the hell am I going to do????? Ruuunnnnn!!!”.

Upper gastrointestinal bleeding is more common than the lower one (60-70% vs. 30-40%), and it may be far more severe than the other. It should not be underestimated because it carries a mortality rate of 10%. 

The upper GI bleeding may be classified according to the bleeding source into variceal and non-variceal bleeding. The second one is the most common between the two (80% vs. 20%), and it is caused mainly by the peptic ulcer disease (≈50%).

In this post, we are not going to focus on all the causes of upper GI bleeding, but just on the commonest non-variceal source. However, the initial management is basically the same in all cases.

Initial Management

Have you ever asked yourself why our first post was about ATLS?

The ATLS is not just trauma… It is everything… It is having a precise mindset to manage things in a certain way… The correct way.

The ATLS protocol can be used even outside trauma… Even in the Emergency General Surgery setting. Consider the same approach is used in the Advanced Life Support, Advanced Paediatric Life Support, Advanced Cardiac Life Support → it’s always A-B-C-D-E!

Let’s start with the usual case scenario…

You are the surgeon on call… Again… And it was a pretty busy night.

It’s 5.30 in the morning, and the ED doctor calls you… A patient just came in vomiting blood.

You rush to the ED, and, when you enter the cubicle where the patient is, the scene is the following:

A man in his late fifties is lying flat on the bed, agitated, pale, with his mouth completely covered in blood, and screaming “Oh God… Oh God, I’m gonna die…”. Just beside him, a nurse is trying to catch an IV line, but without success… On the other side of the room, there’s your ED colleague… Paler than the patient…

The doctor tells you the patient is an otherwise healthy 58 yo man, who started vomiting blood about one hour earlier. He had no other symptoms.

How to manage a situation like this? Is it really different from that of a bleeding trauma patient?

We don’t think so… Both patients are in shock… They are bleeding to death… And you need to act as soon as possible if you want to save their asses…

So, then… Any idea?

ATLS!!! ABCDE!!! Let’s refresh it a little bit…

A – Protect the airways. If the patient has hematemesis, he/she may inhale blood, and eventually suffocate. If needed, tube the patient!!!
We would recommend at this point to insert a nasogastric tube (NGT). It may help to empty the stomach, thus reducing the risk of vomiting and, consequently, of inhalation. However, gastric lavage through the NGT is not recommended by the current guidelines.

B – If the patient is desaturating, give him/her oxygen supply.

C – You must resuscitate the patient. You must obtain an IV line (if it is difficult to secure at least two large peripheral IV lines, opt for a central line). Give the patient crystalloids, and, if needed, blood products. Even in non-traumatized patients, the coagulopathy may develop. Keep the Hb level above 7-8 mg/dL and the systolic blood pressure above 90 mmHg.

D – In this setting the letter D does not stand for “disability”, but for “drugs”. Administer proton pump inhibitors (PPI), and prokinetics. Empirical antibiotic treatment is not recommended.

  • PPI: pantoprazole 80 mg IV bolus, then pantoprazole 40 mg IV twice daily for 72 hours; afterward pantoprazole 40 mg PO daily for 4-8 weeks. There is no benefit using an IV bolus plus a continuous infusion over an intermittent therapy protocol. 
  • Prokinetics: they are useful to help to empty the stomach, thus improving endoscopic visualization of the bleeding source. The best upper GI prokinetic is erythromycin 250 mg PO or IV given 30-120 min before endoscopy (PO administration is more effective). Metoclopramide has no role.
  • Tranexamic acid: some studies reported how this drug may decrease mortality in patients with upper GI bleeding. However, there is not enough evidence to advocate its use routinely. 
  • Vasoactive medications (i.e. somatostatin, octreotide): their routine use is not recommended in patients with non-variceal bleeding. However, they may be administered if endoscopy is not available as a means to help stabilize patients before definitive therapy can be performed.
  • Antibiotics: pre-endoscopic antibiotic prophylaxis should be reserved for cirrhotic patients, who have a higher risk of infection. In these patients, it may reduce the risk of rebleeding, and, consequently, the risk of death.

E – Even in this case, the letter does not carry the same meaning as in trauma. Here, it stands for “endoscopy and/or embolization”.

But let’s go back to our patient…

…So, you decide to start your initial management using the algorithm explained.

A – The patient is not vomiting at the moment, and his airways are not at stake. However, he is lying flat on the bed. Not the best position to avoid inhalation. Therefore, you elevate his head and upper torso at 30°-45°. Moreover, you insert a NGT with an outflow of about 300 mL of blood.

B – His lung sounds are clear and there are no signs of inhalation. However, he has a saturation of 93%. You ask the nurse to give him an oxygen supply through nasal cannulas (it is safer than a mask to prevent inhalation if he would vomit again. You need to think about that too).

C – The patient’s pressure is 80/40 mmHg and the heart rate 119 bpm. He is pale and his capillary refill time is about 4 sec. This patient is in shock, and he needs to be resuscitated immediately. However, the nurse has already tried several times to insert a peripheral IV line, and the only thing she got in is a 22G in the median basilic vein at the level of the elbow joint, where a colloid solution is trickling slowly. It is far from enough. You may need to transfuse the patient, but a 22G is not big enough to allow a good flow. Moreover, it would cause hemolysis. Therefore, you decide to insert a central line and to ask for blood. Once the line is in, you stop the colloid solution and administer a 500 mL ringer lactate bolus to the patient. His pressure goes up to 95/65 mmHg. Once the blood is ready, you start the transfusion. In the meanwhile, you drew blood for lab exams, blood type, and blood gas (you are interested in the metabolic pattern, so you don’t need an arterial blood gas). The VBG shows pH 7.24, HCO3- 18.7 mmol/L, Lac 27 mg/dL, BE -9.7 mmol/L, Hb 7.8 g/dL. The lab results show WBC 11300/mm3, Hb 7.2 g/dL, creatinine 0.84 mg/dL, urea 127 mg/dL

Remember that in case of GI bleeding (mainly upper GI bleeding) the BUN (blood urea nitrogen):Creatinine ratio will increase. This elevation is the consequence of an increase in BUN levels, whereas the creatinine is usually within normal limits. There are two theories on why this happens: it is the result of the digestion of blood along the GI tract and the reabsorption of amino acids, which are subsequently broken down into urea; and it is the consequence of renal hypoperfusion secondary to the blood loss. However, none of these fully explain the elevated BUN:Cr ratio.

D – You ask the nurse to administer to the patient pantoprazole 80 mg IV bolus, and erythromycin 250 mg IV bolus.

E – You call the gastroenterologist to perform an urgent EGDS.

Antithrombotic Drugs

Patients referring to hospitals are elder and elder, and most of them are taking antithrombotic drugs.

In case of bleeding, the choice of whether continuing or not this therapy is quite challenging.

Let’s try to make it a little bit clearer.

Antithrombotic drugs must be continued or resumed depending on the risk of cardiovascular events:

  • Aspirin for primary prophylaxis: can be interrupted
  • Aspirin for secondary prophylaxis: should not be interrupter, otherwise there is a higher risk of cardiovascular events and death in front of a similar rebleeding rate
  • Dual antiplatelet therapy
    • Stenting in the previous 30 days or acute coronary syndrome in the previous 90 days: continue both medications
    • Coronary stenting or ACS in the past: discontinuation of the second antiplatelet agent (not the aspirin) is recommended for 1-7 days

Endoscopic hemostasis may be considered in patients with INR 1.5-2.5 prior to or concomitant with the administration of reversal agents. Yet, reversal agents should be considered prior to endoscopy if INR >2.5. In both cases, the anticoagulants should be stopped.

Reversal agents depend on which anticoagulant the patient is taking:

  • Vitamin K antagonists (VKA): vitamin K 5-10 mg IV infusion over 30 min, and prothrombin complex concentrate 25-50 IU/kg according to baseline INR value (INR 2.0-3.9 give 25 IU/kg; INR 4.0-5.9 give 35 IU/kg; INR≥6.0 give 50 IU/kg). If PCC is not available, give fresh frozen plasma 15 mL/kg. INR should be rechecked after 6-8 hours; however, in case of severe hemorrhagic shock, the reversal agents may be given 30 min before the therapeutic procedure (e.g. endoscopy, surgery…) and INR checked during the procedure itself to decide whether to give more reversal agents or not.
    Remember that vitamin K must be co-administered to prevent “rebound coagulopathy”, which occurs 12-24 h after INR normalization. This happens because the half-life of warfarin is 20-60 h, where that of PCC is 6-8 h
  • Direct oral anticoagulants (DOACs): fluids to maintain diuresis, consider gastric lavage and oral charcoal if DOACs have been ingested within 2-3 h, idarucizumab to reverse dabigatran effect, consider hemodialysis for clearing dabigatran in patients with renal failure, consider off-label use of PCC (50 IU/kg)

If available, 4 factors PCC should be preferred over 3 factors PCC, mainly if an acute reversal is needed, since it is more effective.

Anticoagulants should be resumed about 2 weeks following the bleeding to reduce the risk of cardiovascular events and death.

Platelet transfusion should be considered to maintain a count of 50,000/μL in patients with severe bleeding and those requiring endoscopic hemostasis.

It is enough for now…

We have seen how to manage a patient with a bleeding peptic ulcer… Next time we are going to explore the different possible treatment options.

See ya…

References
  1. Tarasconi A, et al. Perforated and bleeding peptic ulcer: WSES guidelines. World Journal of Emergency Surgery 2020;15:3.
  2. Laine L, et al. Management of patients with ulcer bleeding. Am J Gastroenterol 2012;107:345-60.
  3. Siau K, et al. Management of acute upper gastrointestinal bleeding: an update for the general physician. J R Coll Physicians Edinb 2017;47:218-30.
  4. Sachar H, et al. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers – A systematic review and meta-analysis. JAMA Intern Med 2014;174:1755-62.
  5. Bhatt DL, et al. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use. Journal of the American College of Cardiology 2008;52. DOI: 10.1016/j.jacc.2008.08.002
  6. Ho PM, et al. Incidence of death and acute myocardial infarction associated with stopping clopidogrel after acute coronary syndrome. JAMA 2008;299:532-9.
  7. Radaelli F, et al. Management of anticoagulation in patients with acute gastrointestinal bleeding. Digestive and Liver Disease 2015;47:621-7.
How to Cite This Post

Bellio G, Marrano E. The Bleeding Volcano – Initial Management. Surgical Pizza. Published on September 5, 2020. Accessed on July 24, 2022. Available at [https://surgicalpizza.org/emergency-surgery/the-bleeding-volcano-initial-management/].

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