Acute GI Bleeds: Management

• Are they alert enough to protect airway if upper GI bleed?
• Will they need to be intubated for an upper endoscopy?

• Have they already aspirated and require intubation for respiratory distress?
• Will they need to be intubated due to IV fluids and pulmonary edema?

• Ideally 2-3 Large Bore IVs (18-16 guage)
• Anything will do though including IO if situation is dire
• Sheath is better than a triple lumen for resuscitation (shorter and larger bore)
• Minimize crystalloids (they need blood products) but if that's all that is available - use it
• Call a "code bleed" if unstable (dedicated porters to bring blood products)
• Vasopressors to maintain MAP >60 while resuscitating
• 2 blood warmers (blood can't clot if hypothermic) and/or the Level 1 Rapid Infuser 
• Maintain a normal calcium - 1 gram (ampule) Calcium Chloride per 4 units of PRBCs (calcium is an essential cofactor for the internal and external caascade).
• Don't forget to replace fibrinogen

***ALSO SEE ANTICOAGULATION REVERSAL AND MASSIVE TRANSFUSION SECTIONS

• A GI bleed should not require vasopressors once the resuscitation is over
• Your job is over when the vasopressors come off and the heart rate and blood pressure normalize
• As long as hemodynamics remain unstable - continue transfusions (do not stop to send a CBC and coags and wait for results)

• Page attending ICU MD
• Page GI for Endoscopy
• If Esophageal bleed suspected, patient may require a gastric balloon (Blakemore) to tamponade
• If CT angiogram required, page Interventional Radiology

• ABG every 2 hours to monitor Lactate and Calcium X 6
• CBC, INR, FIbrinogen every 4 hours X 3
• If CT angiogram required, page Interventional Radiology