Upper GI Bleeds and Management!

Hello friends,

Today’s POTD will be on upper GI bleeds and what to do when they come. UGIB can seem really terrifying sometimes but hopefully next time you have a patient with an UGIB you remember these next few steps. 

Upper gastrointestinal (GI) bleeding is a potentially life-threatening emergency that requires rapid recognition and intervention. These are patients that tend to end up in our resus bay, can rapidly decompensate, require blood products  and airway protection. 

Step 1. Start with the ABCs! 

• You want to make sure the airway is protected

• Intubating these patients can be very messy and tricky, suction will be your best friend in this scenario! 

• Access is very important especially if you expect having to transfuse these patients 

• Two large-bore IVs are key! If access is an issue or patient is hemodynamically stable secondary to blood loss, you may need to insert a cordis  

Step 2. Once your ABCs are ensured, try to identify the source of bleeding

• Is this a UGIB secondary to varices? Peptic ulcer disease? NSAIDs? Anticoagulation? Does this patient have liver disease and portal HTN? Hx of prior GI bleeds? 

• If you are able to maintain a history or obtain collateral than it can give you some insight as to what is going on 

Step 3. What are we ordering for these patients?

• Well obviously we are obtaining labs, make sure to get a CBC and a type & screen

• What about medications?

• Proton pump inhibitor: 80 mg pantoprazole IV

• Concern about a variceal bleed? Add octreotide (this will reduce splanchnic blood flow)

• Give IV antibiotics, specifically ceftriaxone, in these patients to prevent infections 

Step 4. Who are we calling for these patients?

• GI consult! Sometimes these patients require an emergent or urgent endoscopy 

• ICU! As stated before, these are very sick patients who may quickly decompensate, these patients may also be intubated 

Now, lets say you did all these steps but the patient has taken a turn for the worse and requires intubation while actively vomiting blood? Good news, there is the SALAD technique! 

The SALAD (Suction-Assisted Laryngoscopy and Airway Decontamination) technique is a critical approach for managing airways in patients with significant vomiting or massive upper GI bleeding, it allows you to clear the airway to optimize visualization.

How-to-perform the SALAD Technique: 

    1.    Setup is key: Get a rigid suction (e.g., Yankauer) and connect it to continuous suction. Position the patient appropriately to prevent aspiration (head elevated or reverse Trendelenburg).

    2.    Decontaminate the Airway: Before attempting laryngoscopy, aggressively suction the oropharynx to remove blood, vomitus, or other secretions. Continuously suction while inserting the laryngoscope and during visualization. You are basically inserting the suction into the esophagus so that way you have a better view for intubating. 

    3.    Insert the ET Tube: Once the airway is clear enough for visualization, proceed with intubation

Enjoy this 1 minute video on how the SALAD technique works: https://youtu.be/ZOwNSpDG6vY?si=FG1KMdrDOnXII7Xf 

Resources:

• EMRAP

• UpToDate

• WikiEM

• Core Pendium -Approach to GI Bleed chapter

POTD: Call Back Requests in SCM

Hi everyone,

Today's POTD comes at the request of frazzled tele docs past, present, and future: how to properly request a follow-up call back in SCM. 

By virtue of being a busy urban ER in NYC, we might find ourselves sending patients home with results still pending. The choice to send home a patient with pending results is a discussion between you and your God/attending, but the process of submitting a case for a call back should follow a few general principles.

4 Golden Rules of Call Backs

1) Advise patients that they will receive a call back only if there is a positive finding for results or tests. Emphasize: no news is good news! If they don't receive a call back, it means their test was negative. If the patient is persistent and still wants a call back for negative findings, then make a note of it in the Call Back Reason box. 

2) Specify what it is that you want the call back for in the Call Back Reason box. If you click lab results, instead of writing "lab follow-up", specify the test or value you're focused on. If you click diagnostic test, instead of writing "xray results", include which xray and what you're concerned about. If you click follow-up call, include what clinical symptoms or disease progression you're monitoring. If we don't provide a bit of context, the tele doc has to go chart digging for no reason. See below for what this looks like at the bottom of the ED Disposition Note in SCM, and compare it to what the tele doc sees on their follow-up list.

3) Do not give a call back for urine culture or STI results. The process of call backs is that the next day's tele doc gets a list of call back requests from the last 24 hours. Urine culture and STI results will inevitably not be available within 24 hours of the patient being seen, so to include next-day call back requests for these results is meaningless. However, the results of urine culture and STI testing are sent out on a regular basis to future tele docs (see below), and any positive results will automatically get a call back when they result. The only exception is that if you have high concern for STI test results, you can include it as a call back so that the tele doc can keep an eye on it.

4) Verify phone numbers! You can find a patient's phone number printed on the Discharge 123 forms below the signatures on the Patient Signature Form. It is the very first sheet in the Discharge 123 packet, and then is repeated again after the instructions and results. When you're discharging a patient, be sure to confirm the number is correct. If the number is incorrect, or especially if there is no number at all, write in the call back box the correct number.

Follow these 4 simple rules for call back requests and every tele doc will sigh in relief.

Happy calling,

Kelsey

POTD: Suture Choices

Hi everyone,

For today's POTD, I want to review the suture choices we have available when performing laceration repairs in the ED. Much of our training for laceration repairs is on-the-job, informal practice and learning, but I want to offer a more systematic approach. 

So, when you're getting all your equipment together for your laceration repair, what suture are you grabbing? And why? And whose "gut" are plain gut and chromic gut sutures coming from? We will go over questions to consider when making your choice, your suture options (with particular focus on what we have stocked at MMC), and some clinical examples for when you might choose each.

3 Questions to Consider When Choosing Your Suture

1) Tensile strength: How much tension is across the wound? A primary purpose of laceration repairs is to decrease tension across the wound. Remember everting edges? That's all in an attempt to give the wound a little extra skin to work with in case the tension does pull the edges apart as it heals. Whether to evert or not is controversial these days (definitely don't invert, though). But when it comes to sutures, the primary principle remains: choose the smallest size suture that can best fight the tension you're up against.

2) Site of laceration: Where on the body are you repairing? If it's going inside the body, aim for absorbable. If it's at the skin, you have more options.

3) Follow-up: What is the likelihood this patient can return for follow-up suture removal? For pediatric patients who have already gone through the trauma of getting stitches and whose parents have already had to somehow coordinate a single ED visit while a gaggle of other responsibilities awaits them at home, or patients with poor access to healthcare at baseline, consider sparing them a second ED visit for suture removal and trial absorbable sutures when possible.

Your Suture Options

Materials

There are two big buckets of suture materials: absorbable and non-absorbable. Within each of those buckets you have two main sub-types: braided/multifilament and monofilament. Braided essentially means that there are multiple strands woven together, and monofilament means a single strand. The more the strands means the tighter the knot... but also the more surface area for inflammation and infection. I've stuck to just remembering the brand names of the sutures, but you might come across the generic names; use whatever works for you. For the absorbable sutures, note that there is often a discrepancy between when the suture loses its strength and when the suture actually absorbs/falls off.

1) Absorbable: braided/multifilament, monofilament

a. Braided/multifilament: vicryl, vicryl rapide

i. Vicryl: buried, loses strength 21d

ii. Vicryl rapide: irradiated to speed up resorption, buried or used in skin, loses strength 10d

b. Monofilament: fast absorbing gut, plain gut, chromic gut

i. Fast absorbing gut: used in skin, great for face ("F"ast for "F"ace), loses strength 7d

ii. Plain gut: used in skin, loses strength 8-9d

iii. Chromic gut: coated in chromium to slow down resorption, used in skin, great for hands or oral lacs, loses strength 10-21d

**Fun fact: gut is short for "catgut" sutures. Cat lovers, don't be afraid; our suture materials aren't actually coming from cats' guts. But they are coming from cow, pig, and sometimes horse intestines, all of which are known to be highly collagenous, elastic, and strong.**

2) Non-absorbable: braided/multifilament, monofilament

a. Braided/multifilament: silk

i. Silk: used in skin, great for securing chest tubes/drains, must be removed

b. Monofilament: ethilon, prolene

i. Ethilon aka Nylon: used in skin, black in color, must be removed, OUR GO-TO SUTURE

ii. Prolene: used in skin, blue in color, great for black hair/beards, must be removed

Sizes

For thin sutures (which is most of what we stock in the ED), the smaller the number, the bigger the physical size. These range from 1-0 (pronounced "one-oh") to 12-0 (pronounced "twelve-oh). 1-0 is the biggest, and 12-0 is the smallest. We will mainly use size 2-0 to size 6-0.

For thick sutures, it is the opposite; the smaller the number, the smaller the physical size. These range from 0-10 (no "-oh" afterwards). 0 is the smallest, and 10 is the biggest. We have size 0 silk in the ED, but the other sizes are mostly for the surgeons.

Needle Types

Straight or curved is the main distinction to know. Straight you can use with your hands to secure drains/tubes. Otherwise we are using curved with our needle drivers. (Pro tip: I once saw Dr. Masoudi make a curved needle out of a straight needle by physically bending it with a needle driver himself and it was extremely cool).

Removal

The importance of removing sutures isn't just for appearance purposes; it's to decrease the risk of an inflammatory reaction to the foreign body currently embedded in the skin. So the quicker we can get them out, the better. When giving return instructions to our patients, take into account the size and location of the suture. A good rule of thumb is the average suture removal length is 7d, but that shortens to around 5d closer to the face and extends to around 10-14d further towards the extremities. Suture Man is always a helpful resource, too.

Examples for Suture Choices at MMC

Uncomplicated laceration in an adult patient? Non-absorbable monofilament, ethilon or prolene, size 6-0 for face and size 3-0/4-0/5-0 everywhere else

Face laceration in a pediatric patient? Absorbable monofilament, fast absorbing gut, size 5-0

Trunk/extremities laceration in a pediatric patient? Absorbable braided or monofilament, vicryl rapide or plain gut, size 4-0 or 5-0

Deep laceration >3cm that requires buried sutures? Absorbable braided, vicryl, size 4-0

Oral laceration? Absorbable monofilament, chromic gut, size 3-0 or 4-0

Laceration within or around hair? Non-absorbable monofilament, prolene, size 3-0 to 6-0

Figure 8 suture for brisk/arterial bleeding? Non-absorbable monofilament, ethilon, size 2-0 is our biggest

Chest tube securing? Non-absorbable braided, silk (straight needle), size 0

For practice, try to find each of these suture types below on our trauma metal shelving unit in resus room 51...

I highly recommend downloading the Suture app (https://www.suture.app/) on your phone to use on shift, which is an interactive tool that will tell you the appropriate suture material, size, and removal time depending on the location and tension of the wound. 

And, of course, we can't forget about skin glue (dermabond), steri strips, and the handy-dandy stapler. I am a die-hard fan of these quick, easy adjuncts for wounds that are low in tension and in an appropriate location for repair.

Happy suturing,

Kelsey

Resources:

1) https://canadiem.org/nice-threads-guide-suture-choice-ed/

2) https://www.ncbi.nlm.nih.gov/books/NBK539891/

3) https://www.emdocs.net/wounds-and-lacerations-in-the-ed-management-pearls-and-pitfalls-for-emergency-physicians/

4) https://coreem.net/core/suture-materials/

5) https://home.hippoed.com/blog/skin-deep-selecting-suture-material-for-the-skin-surface

6) https://www.aliem.com/pv-laceration-repair-and-sutures/

7) https://lacerationrepair.com/wound-blog/eversion/#:~:text=As%20it%20turns%20out%2C%20eversion,creating%20an%20optimal%20healing%20environment.

8) https://www.forbes.com/sites/quora/2018/09/26/what-is-catgut-really-made-from/