Friday, July 20, 2012



Today Dr. Okrainec took us through a very interesting case of an unstable patient with an UGIB.
The medical students, R1s and R2s did a great job of stabilizing the patient and eventually saving his life! Here are some key points that came out of this morning's session.

1) Approach to the unstable patient:

  • Always remember your ABC's
    • Be cognisant of changes from a patient's baseline, a drop of more than 20mmHg from the baseline BP is significant, even if the absolute value is not in and of itself alarming.
    • Does the patient look sick? Sweating, clammy, cold extremities
    • Always reassess vitals when there is a change in pt's status and Q2-5 minutes
    • Call for help: when needed you can call a code blue to get a 1) monitor 2) ICU nurse 3) RT/anesthesia 4) crash cart
    • Gather as much information as possible: delegate a member on your team to collect information such as: meds, last blood work, past medical history, major things to look at are last creatinine, INR, hgb, wbc
    • Do a focused physical exam
    • Always plan ahead: Check that you have adequate IV access, inform the ICU of a sick patient, will you likely need blood (do you have an up to date group&screen in the lab?)
2) Approach to UGIB
  • ABCs
    • Start with getting 2 large bore (16-18G) IVs 
    • Start with fluid resuscitation
    • Get blood: Uncross matched if pt is hemodynamically unstable and low likelihood of having alloantibodies.
  • Initial Management:
    • Start Pantoloc 80mg IV bolus followed by 8mg/hr infusion
    • If hx or risk factors for liver disease and varices start octreotide
    • Consider NG tube, but careful if pt has known esophageal varices
    • Optimize clot formation:
      • Reverse INR: Octreotide + Vit K
      • Platelets: should be above 50
      • Uremia: can give DDAVP to help platelet function
  • Definitive management:
    • Call GI: for early endoscopic treatment
    • Call ICU: for possible intubation
    • If pt has liver disease and ascites consider prophylaxis for subacute bacterial peritonitis (SBP)



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