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)