ChrisPAinED Posted April 11, 2022 Share Posted April 11, 2022 I had this patient not to long ago with CC of abdominal pain and vomiting blood. Patient was immediately triaged with vitals that were a bit worrisome. HR in 130s BP around 90/40 O2 was 96% RR of 18. After looking at history patient tells triage nurse she has had joint pain for the last few months and has been taking 1 ibuprofen 800mg tab a day for pain but the pain recently got worse and they decided to try taking 2 800mg tabs twice the day prior. Well they did it again the next day (that night they presented) and they started vomiting blood and started having pain. Well now I see the patient and I see a patient who is semi alert, a little confused, but responsive. Which triage nurse said she wasn't confused a few minutes ago. So we called a rapid response. 1 litter normal saline was given via rapid infuse. CBC, BMP, CRP, LFT, and type and cross was sent off immediately. GI was called and we did a CT with and without contrast order stat. GI said to stabilize best as possible before they will even see the patient. So kept giving fluids via rapid infuse until type and cross came back then gave some blood. Vitals started to stabilize and patient was taken for a urgent scope. Which GI stoped the bleed and patient was admitted for supportive care. I am going to make the guess that the patient was instructed to stop the ibuprofen for a while and not to take 2 ever again. Also going to guess when discharged they had a referral to see a rheumatologist and follow up with GI and primary care. So for PA students a good thing to know is you got to focus on stabilizing while investigating. Like we did with fluids via rapid infuse. Also not ibuprofen has a GI bleed risk and that taken at a higher than recommended dose can be very dangerous like all medications including OTC meds. Before patient got wheeled away to procedure sweep for scoping I saw that there BP improved and mental status improved so a reminder for PA students is mental status can show how well is patients perfusion. Any questions PA students or any thoughts other PAs? Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted April 13, 2022 Share Posted April 13, 2022 Protonix drip? 1 Quote Link to comment Share on other sites More sharing options...
ChrisPAinED Posted April 13, 2022 Author Share Posted April 13, 2022 7 hours ago, ohiovolffemtp said: Protonix drip? Yeah GI tried it before deciding to scope. You know GI don't like to scope in ED especially at night jk lol Quote Link to comment Share on other sites More sharing options...
MediMike Posted April 13, 2022 Share Posted April 13, 2022 The trend has really moved towards resuscitation before endoscopation (that's not a real word). Biggest advice I have for acute upper GIB: Is the airway patent or does it need protection? Access: Large bore peripherals are a zillion times better for resus than a central line (unless you're placing a sheath or an HD cath) Poiseuille's law and all that fanciness Type and screen early PPI bolus (the drip thing is down to opinion at this point, if I recall the evidence is the same for BID pantoprazole vs infusion) No octreotide unless you think portal HTN If there is coagulopathy reverse it. I'm lucky enough to have PCC that nobody questions me on. Try to avoid overloading someone with 10u FFP. TXA has no evidence in GIB, actually a trend towards harm I believe. No evidence for NG tubes unless you're looking to lavage and try to determine upper vs lower source If you're thinking a lower GIB and are getting imaging strongly consider a CTA, that way if it's somewhere that GI can't get at you can have IR take a look at embolization Also don't resuscitate them to a BP of 180. Too much fluid dilutes your clotting ability, too much product can increase your bleeding via increased transmural pressure. That was my TEDTalk. 1 Quote Link to comment Share on other sites More sharing options...
ChrisPAinED Posted April 13, 2022 Author Share Posted April 13, 2022 3 minutes ago, MediMike said: The trend has really moved towards resuscitation before endoscopation (that's not a real word). Biggest advice I have for acute upper GIB: Is the airway patent or does it need protection? Access: Large bore peripherals are a zillion times better for resus than a central line (unless you're placing a sheath or an HD cath) Poiseuille's law and all that fanciness Type and screen early PPI bolus (the drip thing is down to opinion at this point, if I recall the evidence is the same for BID pantoprazole vs infusion) No octreotide unless you think portal HTN If there is coagulopathy reverse it. I'm lucky enough to have PCC that nobody questions me on. Try to avoid overloading someone with 10u FFP. TXA has no evidence in GIB, actually a trend towards harm I believe. No evidence for NG tubes unless you're looking to lavage and try to determine upper vs lower source If you're thinking a lower GIB and are getting imaging strongly consider a CTA, that way if it's somewhere that GI can't get at you can have IR take a look at embolization Also don't resuscitate them to a BP of 180. Too much fluid dilutes your clotting ability, too much product can increase your bleeding via increased transmural pressure. That was my TEDTalk. Ok we shall make endoscopation a new word. I love this reply. You gave a lot of Good information for anyone getting into emergency medicine. Great work you are way better at teaching then me lol Quote Link to comment Share on other sites More sharing options...
Apollo1 Posted April 14, 2022 Share Posted April 14, 2022 (edited) How is a CRP changing your management? Also, consider inserting a TL;DR in there. Edited April 14, 2022 by Apollo1 1 Quote Link to comment Share on other sites More sharing options...
ChrisPAinED Posted April 14, 2022 Author Share Posted April 14, 2022 10 hours ago, Apollo1 said: How is a CRP changing your management? Also, consider inserting a TL;DR in there. CRP was ordered for the joint pain, when patient was admitted rhumatology was called (not by me) to see them so I since off a CRP for them in advance. Quote Link to comment Share on other sites More sharing options...
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