Upper GI haemorrhage

I: You are the ICU registrar called by the nurse of the patient in bed 5

S: Nurse reports that the lab called, and the patient’s Hb is 50. It corresponds to the progressive drop on the ABGs as well.

B: 52M who was admitted to ITU yesterday due to type 1 respiratory failure. His blood tests and CXR on admission were suggestive of community-acquired pneumonia and he required intubation due to agitation and hypoxia. He has been presumed to have a PE as well but was not stable enough yesterday to go for a CTPA after intubation and is planned to have one this afternoon instead. He is on treatment dose LMWH in the meantime

A: Hb on last ABG 52.

R: Called for help

• Initially A ETT, B SpO₂ 95% PC-SIMV, Pinsp15, PEEP 8, FiO₂ 0.45, RR 16, good bilateral air entry C HR 105bpm SR, BP 110/62 on 0.1 mcg/kg/min noradrenaline D Sedated
• During assessment patient’s noradrenaline requirement starts to go up
• Patient develops haemorrhagic/hypovolaemic shock
• Massive haemorrhage call needs to be put out
• Gastro team needs to be contacted for urgent OGD

• Initial settings:   
  • SpO₂ 94% on FiO₂ 0.45
  • PC-SIMV, Pinsp15, PEEP 8, RR 16
  • EtCO₂ 4.5kPa
  • Bilateral air entry
  • HR 105 bpm, SR
  • BP 110/62 on 0.1 mcg/kg/min noradrenaline

• Progress to:
  • SpO₂ 92% on FiO₂ 0.45
  • PC-SIMV, Pinsp15, PEEP 8, RR 16
  • EtCO₂ 4.5kPa
  • Bilateral air entry
  • HR 115 bpm SR
  • BP 90/50 on 0.25 mcg/kg/min noradrenaline

• Progress to:
  • SpO₂ 90%  on FiO2 0.45
  • PC-SIMV, Pinsp15, PEEP 8, RR 16
  • EtCO₂ 3.5kPa
  • Bilateral air entry
  • Increase HR to 120 bpm SR
  • BP 95/52 on 0.35 mcg/kg/min noradrenaline

• If bleeding managed and blood transfused- patient improves. If no steps taken to replace the lost blood volume- shock progresses to get worse.

Bedside Nurse 1:

• You are a senior ITU nurse.
• You are looking after a 52M with a community acquired pneumonia. Intubated yesterday. Night team mentioned that his Hb has been steadily downtrending on ABGs all night. The lab called to inform you that his Hb is now 50.
• You have escalated this to you SpR.
• You take direction well, and can perform tasks asked if you in a timely fashion
• If asked- you tell the SpR that you have aspirated coffee ground fluid via the NG.

Bedside Nurse 2:

• You are a new starter, first shifts in ITU
• You are keen to help, can perform basic tasks.
• Not familiar with how the massive haemorrhage call works
• Not familiar with advanced ICU procedures and terminology

HiLLO: 6