Screen 3a ( if option #1 chosen)

You wonder if it won’t be long before the patient is up and mobilizing soon and therefore may not need DVT prophylaxis. Early the next morning you get a call from the nurse on the floor who tells you that the patient has awakened from sleep with a very sharp pain in his chest, is complaining of pain in his left calf and appears quite short of breath. His blood pressure is 83/47, HR is 122 and his RR is 48. You ask the nurse to draw some blood work, get an ECG and a chest xray and tell her that you are on your way. Upon your arrival the patient is non responsive, has agonal breathing and you can not detect any pulses. The crash cart is brought into the room, you quickly intubate the patient while the support staff connect the leads and monitor. You discover that the patient is in pulseless electical acitvity. Despite your quick response and skill at running the code. after 40 minutes the patient cannot be resusitated and the code is called off. (go on to Screen 3a(1)

Screen 3a(1)

It is well documented that patients with lower extremity fractures are at high risk for the development of a DVT. A recent large study using venography found that major trauma patients have a 58% incidence of venous thromboembolism. The incidence of DVT in those with lower extremity fractures and spinal cord injuries was found to be 69% and 62% respectively. Those without lower extremity fractures and trauma only to the face, chest and/or abdomen had an incidence of DVT of up to 50%.

Although randomized controlled trials are not available to suggest the best prophylaxis, enough evidence from nonrandomized trials indicate that, without the presence of absolute contraindications, DVT prophylaxis should be considered for all major trauma patients (1). (return to screen 3)

Screen 3b (If # 2, 3, 4 , 5 or 6 selected):

Intermittent pneumatic compression (IPC) devices are commonly used in trauma patients, but often cannot be applied due to lower extremity fractures, casts or bandages. Low dose unfractionated Heparin has not been found to be adequate in hip surgery DVT prophylaxis and in one nonrandomized study was found to have little prophylactic effect in multiple trauma patients. Inferior vena cava filters may be considered in selected, high risk patients when other methods of prophylaxis cannot be used.

The recent recommendation from the ACCP Consensus Conference on Antithrombotic Therapy suggests the use of IPC, warfarin, or low molecular weight Heparin (LMWH) for DVT prophylaxis in multiple trauma patients. Given this patient’s lower extremity fracture and being NPO, LMWH bid would be a suitable choice in this case (1). (go on to screen 4)

Screen 4a (If #1 chosen:)

Given that the patient is having ongoing problems with nausea and vomiting and that the NG tube is, at this time, primarily for GI decompression, it would not be advisable to begin enteral feeding via the NG tube. In general, trauma patients are in a catabolic state and some form of nutritional support should be considered depending on how long the patient will be NPO. (return to screen 4)

Screen 4b (If #2 or # 3 chosen):

There is little evidence that H2 antagonists or sucralfate differ with respect to their ability to prevent clinically significant bleeding. Sucralfate has been associated with a lower incidence of pneumonia in intubated patients and has a trend toward decreased mortality when compared to H2 antagonists (2). In a patient who is not previously on ulcer prophylaxis and must remain NPO, use of the iv H2 antagonists would be advised. In a patient who may be fed enterally, this would be chosen over sucralfate. (go on to screen 5)

If #4 chosen:

The risk of stress ulcers in trauma patients who are NPO without prophylaxis is well documented and using the wait and see approach is not advocated in this situation. (return to screen 4)

Screen 8a (regardless of answer)

The patient has some elements in the history that would have one include all of these in the differential diagnosis. Although the vomiting has not been described as forceful retching, the history of vomiting and bleeding would lead one to include Mallory Weiss syndrome in the list of possibilities. The history of increased reflux and stomach pain over the last 2 months should arouse suspicion of possible bleeding gastric / duodenal ulcers or esophagitis / gastritis The history of alcohol abuse and the elevated INR on admission should lead one to consider the possibility of hepatic dysfunction and bleeding esophageal varices. (go on to screen 9)

Screen 9b (if #2 chosen)

You return to your clinic and are pleased that at the end of the afternoon you are able to finish on time to go home and have dinner with your family. You check in on the recent trauma patient and find that he has remained stable throughout the day. (go on to screen 9b(1))

Screen 9b(1)

At about 0300 hrs you receive a call from a nurse on the ward who tells you that your patient has had an episode of emesis producing copious amounts of bright red blood and clots. The NG tube is draining bright red blood and still the patient is vomiting more blood. The BP has dropped to 82/54, the HR is 128 and the RR is 26. You ask the nurse to draw some blood work, make sure that there are 2 large bore iv’s running and to bolus the patient with 2 litres of crystalloid. Then you quickly rush off to the hospital. (go to screen 9b(2))

Screen 9b(2)

You arrive at the hospital to find the patient unresponsive and with a BP of 48/0 despite the fluid boluses that were given. The nurses have already brought in the crash cart and the tracing on the monitor is consistent with PEA. You attempt to intubate the patient but because some blood has been aspirated and there is lots of blood in the oropharynx it is a difficult intubation. After several attempts the intubation is successful. At this time, however, the patient has no blood pressure and despite your best efforts is not able to be resuscitated. (go on to screen 9b(3))

Screen 9b(3)

Given that the patient has had an upper GI bleed with an alteration in vitals and abdominal symptoms, it would be best to have a definitive diagnosis now as opposed to possibly searching for one in the middle of the night. A wait and see approach in this situation would not be advised. (return to screen 9)

Screen 9c (if #3 chosen)

Consulting a Gastroenterologist at this time would be ideal in terms of obtaining a definitive diagnosis and outlining a further plan of management. (go on to screen 10)

Screen 9d (if #4 chosen)

You try to reach the Orthopedic surgeon and find that he cannot be contacted. (return to screen 9)

Screen 10a (if #1, 2, or 3 chosen):

Not replacing the tube would be an option if the GI consultant was able to see the patient within a short period of time to perform endoscopy, especially if the patient is bitter and resistant to having the tube in place. If there was going to be a time delay and you wished to have a gastric tube for decompression or to monitor the gastric fluid for further bleeding it would be beneficial to have the tube in place.

For many physicians there is a fear of initiating a variceal bleed with the placement of a gastric tube in a patient with known varices. Several studies however, dealing with patients who have end stage liver disease and esophageal varices, have not found an increased rate of bleeding with instrumentation of the esophagus (3). Despite this, care should be taken in placing the gastric tube, either orally or nasally, in patients with esophageal varices, especially those with coagulopathies or a previous history of upper GI bleeding. (go to screen 11)

Screen 10c (If #4 chosen):

Given that the gastroenterologist has already been consulted to endoscope the patient and hopefully provide some definitive management to this patient’s problem, reconsulting for placement of an NG tube would not be worthwhile. (return to screen 10)

Screen 12a (if #1 chosen)

As you are wheeling down the corridor your patient has a large emesis producing copious amounts of blood. His BP drops to 50/0 and then he has a cardiorespiratory arrest. As you are running the code you wish that you had selected a different option. (go back to screen 12)

Screen 12b (if #2 chosen)

After examining the patient you see that he is alert, talking and able to protect his airway. He has good air entry into both lungs and is maintaining his oxygen saturation at 95%. Because of his tachycardia and decreased blood pressure you ask that he be given a litre bolus of crystalloid via his 2 large bore iv’s. Wanting to see if he may require a transfusion or if there is any correctable coagulopathy you order a repeat CBC, INR and PTT. (go on to screen 13)

Screen 12c (if #3 chosen)

After receiving the bolus of fluid and arriving in the endoscopy suite the patient appears to be having difficulty catching his breath. His oxygen saturation is 83% on room air. You start oxygen, 5.0L/min via nasal prongs, and the saturation improves to 96%. The gastroenterologist asks what the patients Hg came back at after this recent bleed and you realize that a CBC has not been sent yet. (return to screen 12)

Screen 12d (if #4 chosen)

These blood tests will provide you with some useful information, but given the patients recent deterioration you do not have the time to wait for the results before initiating further management. (return to screen 12)

Screen 13a (If #1, 2, 3 or 4 chosen)

There are several studies ongoing with regards to the indications of red blood cell transfusion. Some believe that in the face of chronic anemia, that the Hg level can fall below 70 g/dl before considering a transfusion. In the situation of a finite blood loss of less than 300 cc and the patient has no change in their hemodynamic profile, and full hemostasis has been achieved, then, it is reasonable to consider no transfusion and replace volume lost with crystalloid using the 3:1 rule.

In recent guidelines by the American Society of Anesthesiology Task Force (4) they advise against using transfusion triggers such as specific Hg or Hct levels. They suggest that the decision to transfuse be based on individual patient assessment and their risk for complications from inadequate oxygenation.

In this situation, with a patient who has had a bleed with hemodynamic compromise, a drop in hemoglobin from 109 to 78, and who may well have some ongoing bleeding, it would be a good decision to request two units of packed cells for transfusion. In light of the elevated INR it would be wise to consider transfusing some fresh frozen plasma. (go on to screen 14)

Screen 14a (If #1 or #4 chosen):

The goal of endoscopic treatment of esophageal varices is to prevent rebleeding. Without treatment to obliterate the varices, the overall risk of rebleeding is 60 - 70% (5) Injection sclerotherapy and band ligation have been shown to be almost equivalent in initial hemostasis (6).

The benefits of sclerotherapy are the low cost, relative ease of technique, rapidity of use, and outpatient follow up for obliteration therapy. The complications include ulceration, stricture formation, bleeding, perforation and systemic effects such as bacteremia, sepsis, and pleural effusions. Band ligation of varices, when compared to sclerotherapy, has fewer local and systemic complications, lower rebleeding rates, and fewer number of endoscopic treatments required for obliteration of varices. It’s disadvantages include a restricted field of view with heavy bleeding, difficulty in treating gastric varices of the cardia in the retro flexed position, and misfiring of bands.

Screen 14b (If #2 chosen):

Screen 14c (If #3 or 4 chosen):

Pharmacological agents such as vasopressin and octreotide decrease portal pressure by constriction of the splanchnic vasculature. Vasopressin has been associated with side effects such as arrhythmias and myocardial, mesenteric and cutaneous ischemia: some amelioration of such has been achieved with the addition of iv nitroglycerin. It is not effective for the prevention of long term bleeding or decreasing mortality(7).

Octreotide, a long acting analogue of somatostatin, in some meta analysis has been found to be more efficacious than vsopressin in controllong the acute hemorrhage(7). Side effects such as headache, chest pain, and abdominal pain were lower in the octreotide group. Other studies suggest that octreotide is as effective as sclerotherapy in controlling initial hemmorhage from varices (8) and that a combination of sclerotherapy and octreotide was more effective than sclerotherapy alone in controlling the acute variceal bleed. (return to screen 14)

Screen 14d (If #5 chosen)

Given that this patient has already had a significant bleed from the esophageal varices and the risk for rebleeding is 60 - 70% (5) doing nothing at this time would not be advised. (return to screen 14).

Screen 16a (If # 1 chosen):

Octreotide is a long acting analogue of somatostatin and has been studied for its use in the acute bleeding situation and for prophylaxis of recurrent bleeding. In some studies it has been found to be as efficacious as sclerotherapy for arresting an acute bleed and when compared to other vasoactive drugs was found to be better at controlling the initial hemorrhage. In studies looking at using a continuous insfusion of octreotide (25 ug and 50 ug/hr iv) over 5 days after the initial bleed, it was found that it decreased the rebleeding rate, decreased the need for balloon tamponade, and decreased the number of units of red cells needed for transfusion (7,8). Its use in this case would be indicated. (go on to screen 17)

Screen 16b (If #2 chosen):

Propranolol has been found to decrease the portal pressure and in some studies nadolol and isosorbide mononitrate have been shown to decrease the risk of rebleeding when started after treatment of the initial bleed has been completed (9). (return to screen 16)

Screen 16c (If #3 chosen):

Vasopressin has been studied in the treatment of acute variceal bleeding and has been associated with arrhythmias and myocardial, mesenteric and cutaneous ischemia. In a study comparing it to octreotide it was found to be less efficacious in controlling the initial bleed and after 24 hours of drug infusion, complete control of bleeding was higher in the octreotide group. Side effects such as headache, chest pain and abdominal pain were fewer in the octreotide group (7). (return to screen 16)

Screen 16d (If #4 chosen):

Prophylaxis regimens have been described in the literature and found to be useful in most patients with an episode of esophageal bleeding. Using none in this situation would not be indicated. (return to screen 16)

Screen 19a (if #1 chosen)

Serial endoscopy is performed to obliterate the remaining varices to prevent recurrent rebleeding. The choice of banding or sclerotherapyis largely left to the comfort level of the endoscopist. Sclerotherapy has been shown to decrease the number of rebleeding episodes and may improve short term survival related to bleeding. Band ligation is associated with fewer local and systemic infections, lower rebleeding rates and fewer endoscopic sessions to reach obliteration of varices(6). Residual varices may be small and difficult to band and therefore may require sclerotherapy for complete obliteration. (return to screen 19)

Screen 19b (if #2 chosen)

After initial management of bleeding beta blockers such as propranolol or nadolol have been shown to reduce the risk of recurrent bleeding and some studies suggest that beta blockers used along with sclerotherapy may be more effective at reducing the risk of rebleeding than either treatment alone. (return to screen 19)

Screen 19c (if #3 chosen)

Within 6 to 12 months of the initial bleed from esophageal varices, the risk of rebleeding, if no further intervention is taken, is between 50% to 80%(7). Therefore, no further management would only be an option if, after careful explanation of all the options and risks, the patient refused to have any further treatment. (return to screen 19)

Screen 19d (if #4 chosen)

Portocaval shunting can be accomplished by two methods. TIPS (transjugular intrahepatic portocaval shunt) is a radiologic procedure for treatment of portal hypertension and its complications. A connection is made between the right hepatic vein and the portal confluence and is buttressed with an expandable stent. It is indicated in acute variceal bleeding that cannot be controlled with medical or endoscopic means or recurrent bleeding refractory to medical or endoscopic treatment. It has specific indications and contraindications as well as complications that should be considered before its use.

Surgery offers another method for portosystemic shunting with various shunts that can be performed for specific situations. Surgery also offers other therapies for bleeding esophageal varices such as esophageal transection and devascularization, and liver transplantation. Orthotopic liver transplant is usually reserved for people with end stage liver disease and in whom bleeding is controlled. (go on to screen 20)