What can you tell me about active variceal hemorrhage

[Smash]

I would argue that if you pour in fluid and pop clots, you will help kill the patient, whereas if you hold off they will unfortunately die from their disease process. Maybe a subtle distinction, but an important one I think.

 

[8jimi8]

During one of my clinical rotations at the ER (for an EMS cert). We had a woman come in with active variceal bleeding. Hep C+ and hypotensive. We gave Oneg in the level 1 transfuser initially 4 units. Intubated, got a subclavian triple and then My clinical partner (another student) transported with me to the ICU (as well as an ER doc and a few other nurses, RT etc.)

When we got there, I was at the HOB while a GI specialist dropped the scope and began clipping bands and sclerosing the bleeds. We were monitoring pressures such as 60/20. She lived at least 1 day, i know that because i returned the next day for my 2nd 12.

Altogether we gave her 8 units of blood and 2 liters of fluid. I remember bicarb getting pushed after an ABG, but i dont quite remember what our sedation/paralytic package was. Nor do i remember our hemodynamic medications.

I was just looking last night at Vasopressin off label uses. it is VERY high dosages of vasopressin. As a vasopressor the max i've used in a code was 1 unit/min. The usual maintenance dose is 0.04 units/min (2.4 cc/hr on a 60gtt) I seem to remeber seeing doses as high as 4 or 6 units / minute to stop bowel bleeding. I didn't know it could be used for UGIB. Can you imagine what the pt's blood pressure would be doing?!!


Anecdotally,
i reported that the patient was a likely right mainstem (due to silent left sided breath sounds).

My student friend and I were mistaken for ER doctors. and the ICU nurses went white, when they realized that there wasn't a doc with them.

Uh... sorry... we're "paramedic" students (my partner lied). We were just earning our basics then.

That was a long time ago, I was a 3rd semester nursing student and had just finished my week long EMT-B skills boot camp.

 

[usalsfyre]

During one of my clinical rotations at the ER (for an EMS cert). We had a woman come in with active variceal bleeding. Hep C+ and hypotensive. We gave Oneg in the level 1 transfuser initially 4 units. Intubated, got a subclavian triple and then My clinical partner (another student) transported with me to the ICU (as well as an ER doc and a few other nurses, RT etc.)

When we got there, I was at the HOB while a GI specialist dropped the scope and began clipping bands and sclerosing the bleeds. We were monitoring pressures such as 60/20. She lived at least 1 day, i know that because i returned the next day for my 2nd 12.

Pretty well the level of care that's required to save these people.

Altogether we gave her 8 units of blood and 2 liters of fluid. I remember bicarb getting pushed after an ABG, but i dont quite remember what our sedation/paralytic package was.

Probably succs and an apology :unsure:.

 

[mycrofft]

Reminiscent of dissecting aortic aneurysm.

"There I was, helpless...".

 

[NomadicMedic]

I have an ER doc I was talking to last night who is interested in doing a podcast with me about this subject. If I can nail down a time with him between packing for the new job, I'll do it!

 

[johnmedic]

What I've been taught recently & what I've read shows that the standard of care is crystalloids/colloids & catecholamine pressors. Yes, that includes uncontrolled hemorrhages. My mental math, however, does come to the conclusion that with how fast NS extravasates the attempted BP maintenance would be so fleeting that it's not worth it due to the blood you're essentially pushing out. So I'm gonna lean: Yes on pressors, no on just running NS wide open.

Obviously, there are valid arguments on the futility of either.

2005 article:
http://www.vitris.at/pdf/lit/stadlbauer-editorial-hem-shock-anesth-analg-2005.pdf

 

[usalsfyre]

johnmedic,

That's a pretty ambiguous article that references a couple of animal studies and two case reports of patients who got vasopressin AFTER anatomical control of hemorrhage. Pretty shaky. There's definitely a place for catecholamine pressors in hemorrhagic shock BUT a)I'd put it AFTER surgical control of hemorrhage and b)Even IF the place for pressors is pre-surgery, I'm not sure the average medic has the physiologic know-how to pull it off.

 

[johnmedic]

Thanks usalfyre, so you're not for pressors pre-hemorrhage control, are you for running crystalloids? Or just expedite until you're at the ED? Yeah, the article isn't entirely relevant but I felt like the first couple paragraphs did a good job of summarizing what I've been taught about the subject of uncontrolled hemorrhage not exclusive to esophageal varices. Also posted because the article states the accepted standard of care, granted it's not specific to EMS.

 

[usalsfyre]

Ehhhh...I'm not sure. I'm DEFINTELY not for crystaloids/colloids and pressors, standard of care or not. This is diluting down blood and squeezing it out faster...

With blood products it gets a little murkier. Keep in mine when you read anesthesia literature and the say "fluid" they mean "packed red cells, platelets and FFP" when it comes to trauma. Catecholamine depletion is a very real issue in these patients, so they may indeed need pressors if their hypotension is refractory to adequate fluid resuscitation. But we can't really tell that because we're not giving blood.

 

[8jimi8]

don't forget that normal saline will end up negatively affecting the patient's pH. LR is the fluid of choice in this situation, as the strong ion difference is balanced against the dilutional effect of fluid administration.

 

[Smash]

I'm definitely not for crystalloids/pressors either, but bear in mind that with vaasopressin the idea is that we are reducing portal pressure to limit further bleeding. I remain dubious as to it's value, but that is the rationale. It is certainly different from using noradrenaline or phenylepherine or something like that.

"Standard of Care" is a pernicious little phrase often used as a excuse for poor decision making. I like it not.

 

[bigbaldguy]

I have an ER doc I was talking to last night who is interested in doing a podcast with me about this subject. If I can nail down a time with him between packing for the new job, I'll do it!

Let me know if you do this I would like to hear it.

 

[usalsfyre]

I'm definitely not for crystalloids/pressors either, but bear in mind that with vaasopressin the idea is that we are reducing portal pressure to limit further bleeding. I remain dubious as to it's value, but that is the rationale. It is certainly different from using noradrenaline or phenylepherine or something like that.

But "vasopressin" wasn't what was mentioned. "Pressors" were what was mentioned. I agree there "may" (and it's a big may) be some utility to vasopressin, I doubt the decision making ability of the routine field medic to NOT hang a bag if dopa and go to town...

 

[Smash]

But "vasopressin" wasn't what was mentioned. "Pressors" were what was mentioned. I agree there "may" (and it's a big may) be some utility to vasopressin, I doubt the decision making ability of the routine field medic to NOT hang a bag if dopa and go to town...

Vasopressin was bandied around on pages 1-3 for a bit after the second poster mentioned hanging a dopamine infusion (which just doesn't make sense) Most people consider vasopressin to be a pure pressor, which is why I brought it up. And I agree, the decision making is not likely to be up to scratch for the most part, which is why I dislike the defaulting to "I was told it is standard of care" argument.

I think pressors in general for hemorrhagic shock should be contraindicated in the field. Different story in an OR with blood and products and potential problems like adrenal insufficiency or Waterhouse-Friedrichson syndrome, but we aren't really in a position to deal with those things.