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Hi, everyone. Good evening. Welcome to this evening's might be weather. Today we're gonna be going over a bridge I lied on this is gonna put together by Doctor Lucy. Happened is, in essence, you anesthetics least burning questions that you have for us in the chart as you go along. And also just to know at the end organ is send a feedback. Next would be very grateful that out or that further do let me 100. It's a listen to think they're right. All right. Thank you. Um so hi, everyone Mornings Lizzie on Because he said I am on my ST two year of anesthetics eight ccs in southwest London on today will be covering up G. I bleed as our topic. Let's see if this work so doesn't seem like this is our sponsors of the M D. U M. Sure don't talk about it later, so the job lead. So today we'll have a quick introduction. And then I have structured teach in in a case based on format. So all that will be out. The content will be in case within three case itself. It's something a case of made up. It's not based on your events, but hopefully it makes it a bit more. Engage in on a bit more interesting as we go is a little bit difficult to make this interactive, but we will make a interactive it's possible by trying to get you to engage in the face that live comments. So it'll be a bit trial and Arab. Let's see how it goes. So obviously I bleed. So the definition of that is a hemorrhage anywhere between the mouth and the duodenum. It's a common medical presentation when whether your GP working any or on the surgical of medical wards, the inpatient hospital mortality is about 10% according to Nice. So it has a high mortality rate, and it's important pathway pathology to be outside, identify on, have some confidence in teaching a treat. Um, equally. I think it's an important topic to go through because your first proper job lead is pretty dramatic on. But it can make a lot of people panic. Teaching sessions like this are going to remove the kind of the driver behind it, but hopefully it gives you a bit more confidence and how to approach these patients when you're working as an F one. I'm working away through your medical career, so let's go to a paste presentation. I'm just gonna be this other way, so I can see. So the story is that you are the F one on call your covering the medical wards you're putting around doing this and jobs having a cup of tea when suddenly your beat goes off as a parry arrest for the award opposite you, You very diligently Drop everything through your copy over and run over to the other side of the the the ward opposite on you're the first doctor to arrive. Oh, well, sorry. Just so when you get there, you see a man in his forties he sitting up in bed. It's absolute chaos is nurses run around this lead flying everywhere on you See that all over him? There was a mix of kind of blood and brown vomitous all over the sheets. As you get there, he vomits Another kind of 300 mil of coffee ground vomit on. He looks pretty unwell, but he is responsive to you when you're talking to him. You know that the medical team is on route. The peri arrest has gone off, but in classic hospital formats, they are the other end of the hospital. In a on is a bit of a walk. So currently, you are the only doctor in front of this patient. What are you going to do? So I'll start off with this one. I think. Well, I'll go through some answers and then we'll we'll. Doctors of interaction. So obviously, if you are see this patient on the alert haven't go off the first thing you're going to school for help. Um, the golden rule that I have when I sat patients is Am I happy leaving this patient on their own? I'm I'm happy to go make a phone call and leave the patient unattended. Um, I happy to go over, um, on a gas and need that patient on their own. If the answer is no, then I need to get more help. The easiest way to get more help is to smack the alarm on the wall and start shoutin on. That will bring people in your immediate vicinity over to now. If you are on the day shift, that may mean your registrars are the junior doctor is senior nurses will come and help, but out of hours. It may be that there are no other doctors around, but you'll get a few more nurses and hate. See a to come to support you. But regardless, you'll get more people in the vicinity at that point. You can then say, right, I need someone to put up Perry arrest or cardiac arrest. I need someone to get some monitoring, and you just got more hands on board so you can start to manage the situation safely. In this situation, there's lots of people run around weight of your your directions. So with any sick patient or any patient, really, you're going to start to your 80 approach. So let's start going to an 80 approach on this patient. So the first thing you need to think about the position of a patient. This is a patient who's actively vomiting, who is still celebrating because they're talking to you. Um, so I would initially released it this patient about 45 degrees or a little bit more upright just to try and stop the risk of aspiration. Obviously, if this patient is unresponsive and can't feel a pulse, then that's not the best position of them to be in. But in this scenario, he's responding to you. So I'm sitting up a little bit on make sure that if he's going to vomit, we can can protect his airway a little bit more in terms of a his Peyton, he's talking to you in four sentences on from a breathing perspective, you've got six. That's pro bone. He's That's about 96% on room er. His respiratory rate is about 26. There's no sign of assess. And when you have a quick listen, there's lots of secretions and transmitted sounds, but no kind of focal consolidation of the the or crepitations of the basis on this good global area entry. And this was that Germany. When I have his own well patient, I think it's safe to put on some oxygen just very mine in patients who have vomited again. You want to think about the benefits of having a mask over them versus having nasal cannula just again, because if they bomb it into the mask that like in the high risk of aspirating, So this patient's got a slightly increased respirator, which may be for a multitude of things he may have aspirated. He may be incredibly stressed from vomiting. Lots of blood. You may be in pain. He's got fluid losses. You may be dehydrated, so sorts of things driving the respiratory rate. My dog a little bit auction wouldn't be inappropriate. But I think from this alone your A and B ah pretty secure at this stage. So then we get on to say so. Look at his patient. He looks pale. He looks awful. You don't quick cap refill on peripherally. It's about five seconds and he is very cold touch. Essentially, it's about three seconds. You can see blood in and around his mouth. JVP looks okay. His heart sounds clear, but his tachycardia and profoundly hypertensive So what we're going to do next? Well, in a patient who's deacon in having his cardiovascular system is decompensated. The first thing you need to do is try and get some access now in order text books and all the guidelines it says get too large IV access. Well, a lot of large IV and access in both. And to keep it'll foster, which is all very well and good. Um, but I don't know How many of you have seen a big, great cannulated? They are pretty big Onda advanced. The cannula of that size and diameter can be tricky in young fit Well, patients less alone when you have someone who is in clinically in shock and peripherally Shut down. So, yes, if you Congratulations too large bore idea cannulas than good on you. I would try and aimed for the biggest cancerous possible. So it least the pink try and get to in more access. You can get the better, but you certainly need to get some access as per your ability on what's available. Once you get your upset me to think about what we're going to take from this cannula. They've been main things in. This patient is, firstly taken some blood samples. So I'm getting a full blood count. Process it hemoglobin. I'd get a renal baseline renals you can prepare to any classes have before see what the urea race, which is important in your upper gi. I bleed. Um, if there's any signs of a K, I said prerenal AKI from chronic kind of bleeding that's not been picked up on their hypovolemia getting some clot in that's gonna be important for your management of your kidney. I bleed. What is there? I know What is there a PTT on the one? The most important things you can do is get your to Reuben Saves and we'll talk about the importance of that later. Remember, these are the pink. I think most trusted the pink vials on day. Ideally, you should have two people getting these two samples and a handful out all the information on these blood tests. Another even do water there is get a B B G. It's quick, and it gives you a lot of immediate information. What? You're still waiting for the blood test to come back. So you get the VBG. Someone's runoff you've got managed to get stupid communism. Are you taking some blood? And someone else is running those off on DVD comes back on. This is the result. So you haven't got computer available? Tubal Look at previous blood results, but looking at this, uh, his hemoglobin is profoundly low. 64. He's got a bit of renal dysfunction from a base excess and bicarbonate on. Also, his lactate is 4.6 on with the patient in front of the IV, but patient who has actively vomiting blood is cardiovascular shock. Um, hypoglycemic. Shocked on be the low hemoglobin, high lapped A you suspect upper gi bleed. So let's take a little break and talk about what's chondroit the upper GI I beads. Oh, okay, so lots of different differentials for what might be driving your upper GI bleeds. Now in this situation where you have a A Q B on well, decompensated patient or etiology is maybe on the back burner. The main thing is to resuscitate in stabilize. But in patients who perhaps come by GP or present any, you might want to think about a little bit a little bit about what's driving the upper GI bleed. If it's success suspected. So the most common cause is is your peptic ulcer disease, which can make up to 50% off presentations. Um, this is actually followed by unknown cases. So about 50 cases we don't find a cause for the the bead, Um, despite it. But next sense of investigation embarrassing. Embarrass you bleedin makes up a significant proportion of the allergies as well. Other things to think about so inflammation of the esophagus and the gas. The stomach may be two medications, from vomiting from gastroenteritis. Marie vice tears from the past. It bombesin they may get a fresh bleeding within the sputum on but normally local two days. And the volumes ball Hobbs is rare is rupture of yourself. A guess again, they're gonna be quite sick. Um, you may have a V M's malignancies on maybe unfortunate to have a fissure between your GI system and your aorta. Coagulopathy zip it there as well. Just very mind you're a problem with the doesn't cause your job lead. It puts you at higher risk of bleeding if there is a point that it's leading so clogged up, the is not a cause of the dry bleed, but it was certainly exacerbate er on if they're small ulcers or they're using for my gastritis. If you have a quick locked the that's gonna be a much more dramatic effect than the people with the normal population screen. They're just in terms of pathophysiology. We're not going to. It's too much because this is the bit that I find a bit more dry, but we'll go into the two biggest causes. Your peptic ulcer disease in your variceal bleeding. So when we talk about peptic ulcer disease, this is referring to both gastric 100 in the horses. There's lots of causes, but the most common is hate pylori. The bacteria drugs, particularly steroids and then sets on smoking alcohol stress can contribute briefly. A peptic ulcer is a defect in the mucosal layer of your system. Usually there's a good balance between gastric acid production on protection of the mucosal lining. But causes such as hate pylori drugs, alcohol can disrupt this balance. And put your mucosa are high risk of being impeached on damage occurring. So bit of a busy slide this. But briefly, if you think about your hate pylori and your end sets, of course. So I hate pylori is a gram negative bacillus eyes, actually, In most you know, ulcers. People will be positive for H. Pylori on in a large percentage of the gastric ulcers. They'll be positive, too. It basically is is inflammatory response, so it drives lots of neutrophils. Macrophage is lymphocytes to the mucosa layer, which was the delayed start to break down, and you start to get injury. Symptoms can be very mild to initially started with indigestion epigastric paying a bit of bloating in, um, all the way through to having potentially observations which present with coffee ground vomiting. Melena on. Presently, since since anemia, your investigations essay from a non surgical or interventional point of view would be your your MRI, a breath test we'll still answered in tests which again can be carried out. GP land, I think, still answered. And test was what we used to use when I was doing my GP placement. Remember, they have to be off the PPI if they're gonna have the stool antigen test done. Otherwise, you'll get force negatives equally. You can do biopsies with Theo G. D. Set in. If there's a suspicion on that contest. The page pylori as well on treatment really easy, its course of PPI and to antibiotics on Germany that has good effect on replicating the bacteria. Then you, uh, the most common cause is your end, said See, I have a proof in depression ac on besides work by inhibiting your cocks pathway. So now we have our new selective cox two inhibitors like Park oxypsn, which try and limit the side effects of diabetes and kidney damage. But in your ibuprofen Dictaphone, AC it blocks take a cox one. I know cops Two pathways on essentially the cox one pathway is where you get most of the side effects on day. One of those is that you get a dump in and down of prostaglandins, which are protective to aggression. You closer. So dumb down the prostaglandins for the high risk of damage and because of injury from Yeah, and then if you moved to Paris, See, So Barris is are linked people to hypertension, which can happen secondary to chronic liver disease such as cirrhosis, portal, brain from basis, and you basically get a backflow so you get a build up resistance within the portal venous system. You try the body trusted recruit excess vessels from the stomach system to try and increase the blood flow. Because of this backlog on that's done by the release of nitrous oxide and other growth factors. Because of this backlog you get on this diet a shinin your gastric esophageal systems within the being assistance on this is where the virus is come from. On on. If you look in the top right, you can see an O D D picture where you got these big, swollen veins and you think of the thickness of the vein or the very thin on that puts in the high pressures in the portal system within the virus Is that the been, um, venous war, that high risk of breaking and rupture on, they can have quite dramatic. Um uh, bleeding from that I reproduce whatever, like exactly as I'm sitting in the dog. So they're Teo main pathologies behind your oxygen. I bleed, which important to think about in your management. So let's get back to our patients. So your patients that is again, remember, is looking on. Well, you manage to get some IV access blood dependent. So what's your next step? So maybe if we open this up to the Facebook live, what would you like to do next? You've got two candles in blood dependent you sent off. Your cross match is, but you haven't put any interventions in place at the moment. You still what? You'll be immediate. They reminded me of the laptop and hemoglobin for give you a couple of minutes. Let's see if anyone can put some ideas of what they'd like to do next in this situation. And then hopefully one of my colleagues will tell me if anyone's put me think and discuss it when we get in. Any takers from my eyes and ears and Facebook, I think we just went into her. But wait, there's some to kill. I'm just talking to myself. Please respond. So the first thing we've got is 80. Yeah. Lovely. So immediately to assessment. Remember, we looked at our airway and out. Breathe in. And this is our circulation section. So you're correct. So within our 80 we've looked up. Hope so. There. Tachycardia and hypertensive. Um, they probably shot down. So you're, um you can't move on from two today and we've corrected. See? So what things we put in place to correct. See, Thank you for the response. Thank you for engaging with me. Someone said fluid resuscitation accidents me to start putting some intervention statements. I think fluid to certainly appropriate, we can go through food resuscitation on what things we would pick. So I would think about flourishing to think about what fluids we would use, what volumes we would use and how quickly will give thumb. So someone said 500 mg. This over 15 minutes. Yeah, perfect talking. That's a good. So if we think about our resuscitation, we're doing small bonuses of fluid. So rather than 1 m over a long period of time, we're going to bolus is a fluid. So I hit 500 nose is appropriate. And a 50 year old with large volume loss is, um, on over 50 minutes. Yes, that I would in this patient hurt them up and squeeze it through his quickly as I could. I would even possibly go for given the how much blood I've see and how hypertensive turkey partic might even okay, more than 500. But I think 500 is perfectly appropriate in a good response. Any other thoughts? We're also getting some comments about the types of fluids. So it showed him feel right. Crystalloids colloid blood. Yeah. Yeah. Good. Excellent. So everything about our fluids I went going to too much detail cause I think there was a presentation previously and going into more detail about fluids. But you have your crystalloids in your colleagues, your colleagues, as many your human albumin your Jennifer used in which don't use any more blood products and then your crystalloids, your heartburn's and your sodium chloride. So I think for resuscitation purposes, normally we reduce crystalloids. So you're, I think, sodium chloride. Hartmann's is appropriate provide or plasmalyte providing that your potassium is okay. But I think whoever said blood again a sex and shout, given that we have ongoing bloody fluid loss is that we know it's blood on blood for blood is, uh, on appropriate resuscitation technique. Lovely. Is there any other additions to that before people? The only other thing that we mentioned is broad spectrum antibiotics. Yeah, so I think Ford section right about IX is an interesting one. So presumably, I think I think in a long it could this be a sepsis picture would be my inclination or potentially we're going down the barrel seal route. So I think given the fact we have blood everywhere, my top differential for the patient read and shop would be hypovolemia secondary to hemorrhage. So we've got blood loss is differentials for, um, hyperkalemic states include sepsis. So tachycardia hypertensive certainly have over the high lactate. You're certainly think accepts. This is a differential in the station. He doesn't have a temperature. We have a low hemoglobin with witness blood loss, so it's low down my differentials. But there's no reason why that remain. You think about antibiotics at later stage. So I think definitely part got in the back of your mind. I think that's a good suggestion. Anything else? That's what we've got a bit. So thank you for your responses are they were really good. Say the main thing I think most you saying that we need to resuscitate me to resuscitate and try and stabilize this patient. So I think if I was sensation already fluids on blood products. So flu is being oppressed. Annoyance on blood products being your colloid option So brief. Use a station. I think we went through this. When you're resuscitated, you'll give this that one. Well, patients. So the hypertensive tachycardia are the septic? Are they bleeding? Are they in a hypovolemia estate? So thinking about your fluid status examination is this patient hae properly make you anemic hyperbole? MC, if they're going towards the hypo feeling again to need to start to resuscitate um particularly if you have someone who is decompensated so again, when you review in patients is his patient well or unwell? Are they compensated or decompensated on? That's gonna give you an idea about doing it to go down the resuscitation, doing a very good 80 and making sure everything stabilized or kind of relax and take. You know this is more remain tenants or, you know, the less in while. But I need to maybe put some measures in place to stop the decompensated in terms of what So as we said, it's crystalloid. So your 0.9% sodium chloride or Hartmann's plasmalyte as per your trust, just remember to think about potassium and your heart is president light. But to go Listen, these patients, you got a gas, which will give you a baseline calcium on, provided it's not through the roof. I think whatever is on hound in emergency is appropriate and then normally in terms of your volume, and you're doing 2 50 to 500 no bonuses over 15 to 20 minutes and you're reassess in after each bolus has gone through. In your smaller frail populations, 250 would be more appropriate particulars of background of renal disease, heart failure, which may put them at a slightly more risk of third space in if you give them too much fluid too quickly. But in young patients, 500 mil Um, stop is a paper, and the key thing with your 80 assessment on your resuscitation is that every time you put an intervention and you need to reassess, you can't move onto the next thing until you reassess and happy. There's been improvement in your management, and then we're going to blood products. So in these patients, So if you think about an upper GI, I bleed. You're considering blood products if it's ongoing, bleeding or hematemesis Melena Onda with his sign of cardiovascular shock. So hypertension tachycardia a change in routine urine output. They might have a change in the consciousness level, um, with the ongoing bleed and suggested that if they're not in shock, they're heading towards that. Generally, we start with pat red blood cells that's your mainstay of replacing blood for blood that bit later will go into the other options in terms of effort, pee and cryo on reversing croak lot of these on ideally with your the best way that we could get blood products. It's a cross match. Blood to say a B A compatibility. Now, if you have patients who already have group and saves in the lock on you send in the most recent sample. These patients can get blood products within 10 15 minutes. In patients who you don't have any cross match is or group and saves in up, it can take up to our to get your ab oh compatible blood on. That's what you use a very mind that there's logistics to 80 and I think when you're in medical school, you get very used to talking through your 80. But the logistics of it don't become clear into your standard in that situation on realize, and actually it's going to take an hour from a blood test to come back. The VBG machine is down the corridor. I need to lose somebody to go and run that gas for May, and it's been taken out for my blood products to get to me. What can I do in the meantime, causing this patient who's actively beaten hypertensive tachycardia in cardiogenic shock. You don't have an hour till wait for blood products before you get you do adequate resuscitation. So in which case we can think about. Okay? We were waiting for a baby. Oh, cross match is all right, Labia. Blood to be crossed, matched in the blood. In the meantime, we can use the universal blood products. So Negative. So my next question to you is you're standing there. You got lots of nurses around you. You spoken to blood bank on, but they're cross matching blocks, but it's gonna take a now our Where you gonna find you're in active blood? Where in the hospital do we keep her? So again, I'll give you a couple of minutes to have a think. Think about where patients are most likely to be bleeding on where we need a negative blood on hand. And think about where you could physically send someone to pick up negative blood from. So someone said from the salty fridge medication in the fridge. It says So. I said the first one was at the histology. Yes, I am. They reportedly there would be blood up in blood bank so ever your blood transfusion? Um, lab is they would probably have some in the fridge. Get eyes. No idea in any of those bottles where my blood transfusion labs, which is probably really bad. I don't think I've ever had to go there, But there may be nurses important thing that you know where to go. Um, medication. Fridge is No, we don't have a negative. Blood is not on every world, which is why it's important. You know where it is. It is absolutely so in. If you run down to the theaters, there will be a an emergency fridge with O negative blood that you can take that from to go Blood transfusion up. Um, mainly there it is, a surgical theaters anywhere else with that one more common in the blood bank. But you can activate Major. Have a hemorrhage for it to go overboard. Just go get the blood. Yeah. Good. So absolutely, we're going to major damage protocol shortly. S o. If you have someone here taking the situation, you should be putting out all sorts of cause. Remember, in the context of this, just expecting your med ready to turn up a perirectal as going out. Um, So I would know. Expect anyone to stand there and start going to their 80 without calling for putting some sort of arrest or major hemorrhage. Pull out of this scenario. Yes. So you can certainly get major hemorrhage and you can get your port is to turn up again. Your port is converted to blood bank. Pick up the blood to come back again. But that's still going to take time. And it may be I don't help. You know, if the ball to the other side hospital, you got the call out. I see No to get to you. So certainly good options. That port is coming to major hemorrhage. Cool. Um, in terms of let's go through the other option. So you play places where people going to bleed and people need to grab for an active blood. Is your major your fetus? So such with it is your maternity department, Onda your recess room. So you know any department so they're in mind wherever you are in the hospital. If you know that actually just down the corridor is an eternity, it may be quicker for a junior nurse to run down to never insanity, get two years elected blood. Oh, neck blood and run back and you can start putting those up. Remember what? Whoever's being son first He didn't send the senior sister who knows everybody and how everything works. Send someone who is relatively junior but knows whether got him equally. If you're going to take blood from somewhere, you must tell somebody so they can restart the fridge so that there is a protocol of when you get there to say in the major hemorrhage I'm taking a negative blood on. You need to start now, but as a backup option to give you and again, this is no the absolute you have to do it. But if you have someone who is unwell in front of you, you're struggling to get a B a compatible blood. It's good to know where you're a negative blood resource is our so that you can quickly run and get them and then quickly were against too much detail. This but the other part blood products is thinking about Do I need to get alternative products? Do I need to get something to reverse Quite a lot of these. So you sensibly bottle with your right. Your I know you're a PTT on again thinking about the drug chart, what this patient may be on which may influence do any to reverse anything. So these are some s again platelets may need to be transfused on. We have quite a high. You qatari Quite low 11 of pale. It's before we transfuse, bitten and cave the warfarin and the news with your fancy options for your deluxe on what? Not again. You would not be expected to start any of this management without senior discussion or least talking Team Atala. Gee, about, um, you certainly wouldn't be expected. I don't think you really should be doing them interventions like this that you're anyone stage until you have no get into Mezrich. Level on. Do these decisions could be balanced. So please don't start prescribing at the next set up for because I told you to. And basically to be aware of, actually, is there are the reversal agents for these medications do anything thinking about having to look at the drug chart. Is there anything else I can reverse or need to be thinking about? That could be exacerbating my situation. So major hemorrhages, what we were talking about earlier someone brought up. So I'm making you quite a lot of work in the see gyn, but thinking about your major hemorrhage. Cool. So when would you put out where? What constitutes a major hemorrhage? What does it actually means? That when you put the call out, he's gonna get the call on what? What happens and he will arrive. So that's even get any answers for this one. We don't do, uh, two dogs, I but they don't have to listen to me talking particle. So when do you put major every school out? What would be your criteria? What does that actually mean? And who turns up people the corner? Because, remember, whenever you couldn't now, peri rest a cardiac arrest, a major hemorrhage. Cool. You need to understand why you're putting out on who's gonna turn up to help you. So in some trust that I worked out, if you put a perirectal out beneath it just doesn't turn up the only turn up the cardiac arrest schools. Another trust, they turn up to all of them. So you just need to be a bit aware of why I'm I put in this call out. Who do I actually want to turn out to help me on? Is this the best call for the about to be done. So you got any thoughts of major hemorrhage? Cool. Coming through, I'll say. Oh, yeah. Get a couple of seconds. Otherwise, I'll tell you is Yeah. So someone suggested when the patient was blood. More than three liters of blood. Yeah. I mean, I always say three so blood? Absolutely. Um, quite a lot of blood. I mean, three liters. 100% I think, isn't it? Yeah. A large volume of bleeding. This is certainly appropriate. We'll do it through the corn translocation of a major hemorrhage in a second, I think is interesting. With major hemorrhage, we think about fall. Um, so it's incredibly difficult to judge volumes of a liquid when it's over bed sheets in different formats of its involvement in Melena. You know, it's incredibly difficult to quantify. So I think clinically sometimes a little bit easier. We got any other thoughts coming through or Yeah, we've got a couple more. A couple people talk about Matt, teams from medical emergency teams or on also, someone suggested bleeding in excess of about 150 Most for a minute. Yeah, up here again. Yeah. I think that's, uh that is part of the criteria for major hemorrhage again measuring 100 50 million per minute. Blood loss is incredibly difficult in person. Um, so I think, really the These are all good ideas, and it's talking about volumes is interesting because I think it emphasizes how difficult it is to quantify by do that. I think you're correct. 115 or per minute is part of the criteria. Very good. I met teams up to two medical emergency teams. Eso your med Reg. Your estate shows on call. The F ones on call was certainly arrive on the risk of resuscitation team and some trust to your seat caught nurses. You're critical care outreach team. Turn up good. Is there any also Show me vomit gets monsters. Just another thing that's come through this thing happened to it's right shoulder. Yeah, I agree. So let's have a look in a slide on. We'll talk through, so I agree. So the actual criteria, we said, is more than 150 Mill permit s o world on that person who came up with that or the same 30% of circulating volume in three hours. So about 1.5 liters or profusely dumb two hours. I think profuse bleeding rather know it's going 115 or per minute if someone has had played. And then, absolutely, in terms of 30% circulating volume, if you lost 30% it is circulating volume. I think you're in about Class three Shock so clinically they're going to be hypertensive toxicologic not passing much urine. Confused, combative talk neck. So I think in terms of your judgment. First, see, clinically, does this patient like they are losing a lot of blood and decompensation from it. And secondly, I would argue, if you're there anything, you know what? This person is losing a lot of blood. I can't quantify it because it's absolute carnations, blood everywhere they look on. Well, I would have a low threshold for major hemorrhage called all Now in terms of actually put in the major damage call out. What it means is that is alert in the blood, like the blood transfusion. Love that some point blood point products maybe requires on it. Also, in some trust alerts the consultant or registrar hemotologist on call on the point of that is to emphasize that this does not mean immediate delivery of blood products. You don't put a call out on someone runs towards you with blood. It's alerting the blood to be ready for the cool. That will say we need these blood products were activated. Major hemorrhage protocol on in that respect is important to know who arrives. So the Met seem absolutely well, don't ever said that to your uncle. Medical team, your medical register. All your s h O U F. Ones on call will turn up to help you see more, even more hands on board. Um, you also get intensive care, anything test to turn up because of that critically on. Well, they're going to need to have a support potentially on the trips. Exception. Think someone said earlier, Porter, a really important part of the major hemorrhage protocol turn up because they will physically be running backwards and forwards from you to the lab to collect the blood and bring it to you. And you also get a surgeon who turns up so certainly out of ours the search court struggle arrive because it got me to think about definitive management if if we can, If the bleeding doesn't stop on its own, there's ongoing losses need to physically stop, please. Um, out of hours, it would depend on your trust. And if it's a big surgery center or a small D g h, um, out of ours in my DTH, we don't have a gastro Rachel consultant or cool, so they will return. Not some major hemorrhage, but in hours they may get the alert. Three. So the main people is your medical team, your eye to anesthetic team surgical team on the porters. That port in you won't get the blood immediately. You have to really have an allocated person who will bring the blood bank on gas, the blood to be cross mashed and delivered. Good. Well, this doesn't come across very well, but in terms of just we talked about hemorrhagic drop a shock, how to clinically quantify it. So I think the definition earlier was it was 1.5 liters every three hours of blood loss, or about 100 50 Norpramin it. So we're talking about, um, Stage three, stage four, hemorrhagic shock. I think originally, this is in relation Teo trauma. But I think it qualifies across or hemorrhagic shock. So if you have patients with this huge volume of blood loss. We're going to talk cardiac low BP post precious low, the tack of neck. They got low urine output. Um, and they're getting combative and confused. So even if you can't measure your, um, than the mill permanent of blood loss in a patient, you can still clinically think, actually, how how well is this patient? But the only thing about it is the patient who lost a liter of blood in front of a had no more BP was a bit tachypnea take I I think with any blood loss, I probably threshold. But the major hemorrhage l because remember the test I could get back. Remember, the worst case scenario is that if you put a major hemorrhage out on a low, these people turn up. The worst case scenario is that you get stepped down on D seniors in there and they take over car. You're not wasting any blood products because until you bring the loud to ask them to start cross match in on giving the patient details. No blood is being produced is just putting him on standby. So, as we said before he ever suggested about using your own judgment, I would have a low threshold on. But if you're out of your depth, you need help and someone is actively bleeding. Major damage price because appropriate. This was taken a shooting from Charmin Cross on Homicide. This is the transfusion protocol, which I thought was quite a nice summary. So when we are speaking to the lab when you're at your parent, your major hemorrhage full. One person is allocated to be the person who is the liaison between the emergency on the blood bank. It's one person only They, uh the person who sits by the phone, and the job is to bring the blood bank, give the patient details and request the different packs of blood. No one else should be making those phone calls, because then it just gets confusing. And there's no they may be delays in in the delivery of the blood. Different trust, different protocols. But generally we talked about pack a pack, be your pack a is your pack blood cells and FFP on. So when we say yes, when it's this is a major hemorrhage me to start transfusing the person nominated will bring the blood bank with patient details and say, Please, can you stop producing pack a day on D? Then the port is to collect them. Um, at which point the blood bank will continue to produce four packs of red blood cells, four packs of FFP that's cross matched on. We'll continue to produce that until the person who is on the very intelligent that is no longer required. Once that's going through, see pup red blood cells, parts of FFP, and you're squeezing those three. The other day. Even start considering is pat be, which is your platelets and your cryo. And again, if you got large volume bleeds, you need to start replacing clotting factors as well. And platelets. You can't just keep replacing with packed red cells so packed be can also be initiated. And again, it is the responsibility of the person who is ringing, liaising with the lab to bring them and get the, um, blood organized on. Remember that you must know that person needs to tell the lab if the patient has south passed away or the patient's going to be a teacher or that they have now been stabilized. They need to bring them and say we no longer need you to keep producing pack a day. I'm just over on the right hand side. There is just a reminder about how long it takes for not products to be crossed. Matched. So your emergency and no, no, you can get immediately if you run there and pick it up. You're Greek Specific blood is variable, depending on across much is in the lab on your fresh frozen plasma, and your cryo is actually frozen, so it takes 30 minutes to defraud. To do. Or so again, you need to factor that into your decision making. Um, and in some trust said that my truck Sometimes it has to be delivered by man on a motorbike from a different trust. So that's in the ass to consider that it is not on site. It may take even longer. So lots of logistics behind your major hemorrhage time. Well, I've been talking for a long time, so let's get back to our scenario. So you've you've done excellent job, your Medrol just still miles away, really taking their time. But you have absolutely smashed it. You've got to large cannulas in you sent load of blood This IV fluids run in. You put a major hemorrhage out on, but there's a junior nurse on route to get some elective blood, even though this is a scenario that would never happen because you would never be left alone to deal with this on your own. And this is not to frighten anybody. This is all hypothetical. You will never be left to manage this on your own at any stage. But you did a great job so far less thing about his. Anything else we could be doing, So I'll went through this because I think we've been talking for a long time. But again, we put intervention ends. You given some fluids, you're waiting to some blood products. You go back to a So is my patients still talking to me? Have we lost a airway? While some focusing on getting IV access, do I need to re prioritize? Because remember, your 80 is what's going to cause more. Tyler put constipation to pass away. First the airway, their breathing, the circulation. So this patient has a huge circulation compromise, but we still need to make sure eight and A and B are stable before we continue to see to go back to a he's still talking to you is a bit drowsy, but he's responding. There's no arguments. Need it? He's still on that little bit of oxygen. He's breathing, is stable with a little bit tuckered neck, but no changes. You go back to see your fluid, your fluid to gone through. There's a bit of an increase in the BP. You're gonna give some more fluid. Just always do that, but to come. Other things you can do so you might if appropriate. If the patient is stable enough, you might want to do a PR. See if there's any Melena or have a look. Is already Melena coming out? Because if there's a million or you don't need to do, the pill is a fresh blood that may suggest is not an upper GI. I bleed. It's a bit lower down on Easter. Geez, appropriateness. If they're talking cardiac, you want to make sure it's Sinus. For them, there's never a breath. Me is complicating things. Are they in a half? And actually, that May might make you think, Oh, is that under calculation background to this patient? Unequally. If you have a patient who has history of ischemic heart disease is good to get a new CD to look at the rhythm because these patients may be a risk there. Very hyper, really make off having secondary um, I've so any CG a tachycardia patient is appropriate. If able, I would try and get you on the catheter because this is a response. It a shin attempt. We've got ongoing fluid losses, were trying to replace them. So they need to know, from a kidney point of view how much urine output we get in. Because again, that would be suggestive of successful or, um, no resuscitation. Again, I wouldn't prioritize that over access blood fluids. But if there is someone handy you can put a catheter in, then certainly something to consider. You may want to give some drugs so IV PPI, either as a bolus or an infusion, is recommended by some trusts in more stable patients. There's an argument that, given the PPI, may make it difficult to identify lesions on Odie D. At a later stage, however, some trust say that inmate patients were majorly having having huge hemorrhages, then given IV PPI infusions as a lot of a resuscitation approach is appropriate, so it would be dependent on a trust on then. Remember to have a look at the drug chart. Are they on any high panty, hypertensive speeder blockers that may be giving me a false reading from the observations I'm getting? Are they on any blood thinners there? Anything on the, you know, the on end said steroids that might be causing this job lead. But as I said, you won't be doing all this on your own. There's no way we would after a very rested a major hemorrhage that you would be. They're doing all of this in your E. This is a lot, just hypothetical to reassure you. So the nurse, I'll come Xavier and says, Oh, I've got a bit more background on this patient whose actually admitted this morning with this weird seizure thing they had a home on. Do the doctors have started on this drug called quarters of oxide on this and paper Knicks going through? It looks like he's got a history of alcohol excess liver cirrhosis on it looks like on a G d. There's actually been some visualized varicies, but he's not on any medication. Really, he's got poor compliance. And there's no known drug allergies. Do you think? Oh, that's unusual. Let's have a closer look at this man on Lo and behold, you realize that he is visibly jaundiced. He's got a big distended abdomen. Um, there's a shift in dollars when you examine is tense on D's Got openly be, um, I otherwise again from a GI says point of use a little bit confused. But otherwise GI said Jesus, about 14 on his a febrile. And here you're finding it's a big tents, abdomen jaundiced sclera. He's got music. Put Medusa's I go elated abnormal veins on Spider Needle on his abdomen. So you think I wanted the saying else going on her. So if you think back to our causes of opportunities, said Main things of peptic ulcer disease or potentially variceal bleeds on this patient, given that he looks like he might be in decompensated liver failure with previous varicies on a G, I think variceal bleeding would be inappropriate differential. SUNY's patients tell a person is an option for management, which essentially causes vasoconstriction to stop read, um, again, you Certainly it would not be appropriate to prescribe this without seeing your school. Remember, this is a potent basic constrictor. So in some patients with again ischemic cardio disease, it may not be appropriate to give them. So it's a risk benefit balance on this would be a senior or specially supervision that would be given, but is good to have that in the back of your mind. There is variceal bleeding. The differential. Is it something I could suggest as, UM, intervention we could give you on in these patients Antibiotics, which I think someone said earlier, would certainly be appropriate if you've got a variceal bleeds. There's been rupture off a mucosal membrane on Venus membrane, then they're high risk of getting infections. So in my trust has fitness the first line, but it would be very border trust. So this is way thinking about your etiology. It's may slightly change your management, but again, this is much further down the line on regardless of the etiology, you're 80 approach and resuscitation and management is to the Prempro. We nearly done a promise so intensive, definitive management. The main things are is the priority to sustain stabilized for the next steps are going to be Where is the believes and how can you stop it? So your C is may suggest we need to go for another GD if they're convinced this is an upper GI bleed Flector six ct on Jay's, Maybe alternative. So if Odette is negative, is there something lower down? They confined? Um, vendor with Molina, I think up until the hepatic flexure you could still get Melena from GI bleeds from mouth down. So it may be much lower down than the odor decommitted on in patients who are not suitable for GD. Sometimes CT angiograms can be used. Your urgency could be diagnostic and therapeutic on be more dramatic methods off management can be a pin place if they can't blades or put Drumlin's of the ulcers they can do, um, what they call them. But they can like eight. The Paris is on okay d as well. But if that's not appropriate with those different causes, these more dramatic methods can be used, which we're going to now. But it's good to be aware off, um, because they may be used. A tertiary sent us on very quickly. I don't want to bore you too much with this But since school's you might be familiar with and you may be asked for in opera job, very patients, particularly is who are coming to any have ambulated in who wrote to be stable your blood for school. You did before your endoscopy and essentially quantifies patients. He would require treatment and intervention on there for required mission. So your patients Syria, hemoglobin, BP is all okay. They got no other concerning features. They may be able to go home and have outpatient management in their scoring highly. Then they may to have inpatient review on inpatient intervention on. But the endoscopy department may ask her back to school to try and prioritize patients who need intervention that day on then sometimes you may see the Rachael School rock or school used afterwards once they've had the intervention. Done on this, essentially is a school that helps try to identify patients who are high risk of bleeding or have a higher risk of mortality. Um, even after the GI, he might have, you know, further investigations are interventions done, so just scores to be aware of. You don't need to know these off my heart. If you ask for them. You can go into Medcap and use them, but it's good to understand why they used. So that is at the end of May, talking about you more done if you played it this fall. Eso remember, the main thing you need to do is reassess. To reassess, to recess. Whenever you put in intervention in place, you must go back and start again and make sure nothing else has changed. My main take home messages with Upper GI Bleed on any other scenario is called for help. Really? You'll never be criticized for calling for help, really. But you don't get yourself too far down the line where things are getting about off hand on down. You're you know you're going to help on go out adults, so call for help her early do you. 80 assessment and make sure you have completed or treated a before you may want to be treated me before you're going to see the main things in your on your patients is to first you resuscitate and stabilize before you're going on To think about interventions, be familiar with the trust major hemorrhage protocol on from that you're peri arresting cardiac arrest critical, Major. You know he's gonna turn up when he put the cardiac arrest. The peri rest out on if and out. Always ask whether your f ones f twos s h o Z registrars people always happy to help you on do something is easy to ask if you don't know the answer Don't sit there Worried about things are some some help so that you learned for next time these my resource is I haven't played them out very well, but that's why I used to fifties presentation on. But if you have any questions, do you let me know? And thank you for listening. I'm participated. Okay, so we've just got a couple questions I have come through so far. Um, one question is any thoughts on trying examined acid and it's used in these settings. Yeah, So I think try examine acid again in a major hemorrhage is a pro pro again, with any medications that you give, you need to weigh up the risks and the benefits. So, given the tranexamic is gonna put him into more profound body aches State in a major hemorrhage, I think completely appropriate because you have an active bleed in front of you, but it is a hypothetical risk of clot. Um, in some patients, they may be higher risk given trying stomach acid. Um, I think again as an f one, you would not be, um, necessarily expected to give trying exam IQ. Um, I think by the time you're getting to that point, you should have given fluids and give you blood products before that and get an access. And by the time it's that's done, um, you have help next to you already, but certainly don't think about. I think trying to make is certainly appropriate in any big bleeds. But with any drug just way up the pros and cons on think about any contraindications for that patient that make make you think maybe no. Um, but yes, in a big major hemorrhage, trying zonnic would be a breakthrough. There's another question about the role of just generally quit and then a little bit of blockages in upper cardiogenic leaders. Well, um, so for to the role of in terms of having this two aspects that so being aware that patient is on beetle blockers is helpful in terms of is that drug mask in their their symptoms. So, for example, even in any sick patients say if you get your call to see a patient who has a temperature, they might have a bit of a low BP. But the heart rate is 80 70 80. You think? Oh, that's okay. They're not They're not meeting the sepsis guidelines. Um, if they're beat of blocks, they're gonna have the natural response to having, um, sepsis. Infection. Hemorrhage is going to be blunted by the result pillow or the whatever be to block their own. So it's just important to very mind Has this patient taking to be two blocker and, um, I getting forced reading the heart rate? Because if the drug is stopping them, having a natural response If you know the tachycardia is a way to maintain that BP And if the beauty blockers are stopping that response, then it's just something to very mind in terms of Beatle blockers of it in the context of up a job lead propantel Oh is used as a barrier seals. Sorry. Paris's in terms off that profit bleed prophylaxis a bleed in, um so there is a role in terms of the prevention. But in terms of the acute, be on while patient, you wouldn't give any be two boxes. Patient his lead. Um, because the tachycardia is the main thing that's maintaining that BP. Does that answer the question, or is there something I'm missing? No. Just roll. We're waiting to hear back from the person on. There's just a couple more questions. One is about spontaneous back to your baseline, which I think will cover in another webinar. But there's also one disregarding like when we would use FFP versus crime precipitate versus platelets in the source. Yes, it's a different question. So again, it's not something I'm huge a competent on either was having to read for this presentation. So my understanding is that your FFP is clotting. Factors on your cryoprecipitates is primarily fibrinog in. So I think, for patients, these are for patients. Your warfarin eyes with high iron ours. You might get some clotting factors as well. Try and reverse the Was it 10 9 70 which ah inhibited in a pot and cascade with warfarin. Where is your crime city is more fibrogen on, I think within the cryo. It's a smaller volume and more concentrated. So both of them are derivatives. The past for on both have rolls within a major hemorrhage. Out or bleeding patients is dependent on what you're what in chose you on. To be honest, I probably I I certainly wouldn't be prescribing FFP or cryo without having advice and hematologist because it's so It's one of those things that I'm certainly not confident on if I'm honest. So my understand is that cryo is Piper any gym predominantly on that FFP is clotting factors both the plasma derivatives on down in major hemorrhages You're losing No, only pee McGlade been packed Red cells you lose in past summer, you're losing platelets. So in major damages you just replaced hemoglobin. You know, I think you still have quite a lot of these if you don't replace the bottom factors. So the reason that we give not just red paps pat red cells, we give patients if the pain is so low that we give clotting factors is that you need to replace the whole package This whole basically. But that's kind of the extent of what my understanding is without doing something. Told you a vision so I can certainly ask around. 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