Chapter 31, Ep 1 of 4: Massive Upper GI Bleeding Resuscitation

What this episode covers

Episode one of the GI Emergencies chapter treats massive upper GI bleeding as a resuscitation problem before it is an endoscopic one. The organizing idea is a clock that starts when the patient arrives, where permissive hypotension protects the clot and the wrong decision made confidently is worse than none. It moves through the timeline the patient is actually on: restrictive transfusion, the balanced massive transfusion ratio and the calcium citrate chelates, anticoagulation reversal run in parallel rather than as a delay, and field-clearing erythromycin before endoscopy. It closes on the two recognition stems the boards reward, the herald bleed of an aortoenteric fistula and the two arteries where failed hemostasis sends you to interventional radiology.   Topics covered Upper GI bleeding as a resuscitation problem Restrictive transfusion target and its exceptions Massive transfusion protocol and calcium repletion Anticoagulation reversal in the first hour Pre-endoscopic erythromycin and why TXA fails Airway protection and endoscopy timing Aortoenteric fistula recognition Salvage angiography for failed hemostasis   Key decisions Transfuse to a restrictive hemoglobin trigger of seven with a target of seven to nine, raising the trigger to eight only in active acute coronary syndrome, and transfuse empirically in uncontrolled hemorrhage because the lab hemoglobin lags real-time loss by thirty to sixty minutes. Activate the massive transfusion protocol at anticipated need over ten units of red cells in twenty-four hours or four in one hour, delivering a balanced one-to-one-to-one ratio and repleting ionized calcium that citrate chelates. Reverse warfarin with four-factor prothrombin complex concentrate rather than fresh frozen plasma, reverse dabigatran with idarucizumab five grams and apixaban or rivaroxaban with andexanet alfa, and run reversal in parallel with endoscopy rather than letting the INR delay it. Give erythromycin two hundred fifty milligrams intravenously thirty to ninety minutes before endoscopy to clear the gastric field, but do not give tranexamic acid because it adds venous thromboembolism risk without benefit in arterial spurting. Scope non-variceal upper GI bleeding within twenty-four hours and variceal hemorrhage within twelve, reserving sub-six-hour endoscopy for uncontrollable hemorrhage or suspected aortoenteric fistula. Suspect aortoenteric fistula in a prior aortic graft patient with a herald bleed and image with CT angiography for periaortic gas before EGD, and send failed dual-therapy hemostasis to embolization of the gastroduodenal or left gastric artery.   For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected].

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