UPPER GI BLEED PROTOCOL SCGH ED v2 · UPPER GI BLEED PROTOCOL SCGH ED v2.1
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UPPER GI BLEED PROTOCOL SCGH ED v2.1 <10 ≥13 ≥12 <13 ≥10 <12 <10 ≥12 ≥10 <12 M F Haemaglobin <8 ≥6.5 <6.5 ≤25 ≥10 <10 ≥8 >25 BUN <90 >109 100 109 90 99 Initial Systolic BP Pulse <100 ≥100 Presentation with melaena No Yes Recent syncope No Yes Hepatic disease history No Yes Heart failure history No Yes Score >5 = >50% risk for intervention (or death) MET CRITERIA AIRWAY THREATENED BREATHING 36 < RR< 5 CIRCULATION 140 < HR < 40 SBP < 90 NEUROLOGY GCS FALL > 2 SEIZURE REPEAT / PROLONGED URINE <100ML IN 3 HRS GLASGOW-BLATCHFORD SCORE (severity index for non-variceal bleeds) ANY DELAYS OR PROBLEMS WITH DISPOSITION SHOULD BE URGENTLY ESCALATED TO ED DUTY CONSULTANT (24 HRS) NOTE: IN AN UNSTABLE PATIENT WITH ONGOING BLEEDING, GASTRO’S DECISION NOT TO SCOPE SHOULD NOT BE MISINTERPRETED AS AN ‘INABILITY TO MAKE A PLAN’, RATHER AS AN EVIDENCE BASED RISK BENEFIT ANALYSIS ON PERFOR- MING AN INVASIVE PROCEDURE WITH POOR VISIBILITY, IN AN UNSTABLE PATIENT. GASTRO MUST BE KEPT INFORMED OF THE ONGOING RESPONSE TO RESUSCITATION TO BE ABLE TO MAKE THIS AN INFORMED DECISION. KNOWN PALLIATIVE? * Consider higher value if underlying comorbidities or suggestions of ongoing bleeding † Check Jehovah’s Witness status (some JW may consent to blood products) ‡ Gastroenterology Therapeutic Guidelines 2014 ** Coinsider theatres if anaesthetics involved / airway issues SUSPECTED VARICEAL BLEED? RESUSCITATE PATIENT IN ED 2X LARGE BORE IV ACCESS URGENT FBC (Hb, plt), CLOTTING PROFILE (PT, INR) UE (urea), GROUP AND HOLD† / X-Match† TRANSFUSE*† IF Hb ≤ 70-80 VASOPRESSORS IF INADEQUATE PERFUSION AFTER BLOOD REPLACED IDENTIFY AND CORRECT COAGULOPATHY PANTOPRAZOLE‡ 80mg IV over 30min, 80mg over 10 hours YES ADD TERLIPRESSIN ACETATE 2mg IV STAT‡ (EQUIV 1.7mg IV) CEFTRIAXONE 2g IV INSTABILITY/ MET CRITERIA / HIGH RISK? ONGOING BLEEDING NOT NORMALIZING AFTER RESUSCITATION UNSTABLE EPISODE IN ED (MET CRITERIA) REQUIRING TRANSFUSION LOST ≥30% BLOOD VOLUME COAGULOPATHY OTHER ORGAN FAILURE NO DOCUMENT GLASGOW-BLATCHFORD SCORE IN NOTES NO YES CONSIDER BOUNDARIES OF CARE ADMIT MAU CALL DUTY CONSULTANT (24HRS) URGENT GASTRO REVIEW GASTRO TO REVIEW AND DECIDE ONE OF THE OPTIONS BELOW YES REFER TO MAU ADMIT TO WARD 0800-2200 MAU TO INFORM GASTRO 2200-0800 MAU INFORM GASTRO AT 0800 SCOPE NOT URGENT NO SCOPE TO BE DONE WITHIN 1 WORKING DAY REFER TO ICU (ICU CAN DELEGATE TO HDU IF MORE APPROPRIATE) GASTRO TO DOCUMENT CLEARLY REASON FOR NOT DOING MORE URGENTLY ALTERED MET CRITERIA / TARGETS CRITERIA TO ESCALATE TO URGENT SCOPE EXPECTED TIME OF SCOPE SCOPE TO BE DONE IN ICU REFER TO ICU (ICU CAN DELEGATE TO HDU IF MORE APPROPRIATE) GASTRO TO DOCUMENT CLEARLY INDICATION FOR IMMEDIATE SCOPE EXPECTED TIME OF URGENT SCOPE CONSIDER MINNESOTA TUBE IN ICU OR REFER TO INTERVENTIONAL RADIOLOGY / SURGERY SCOPE LIKELY TO BE DONE WITHIN 2HRS (DAY) OR SCOPE TEAM HAS BEEN CALLED IN (NIGHT) SCOPE TO BE DONE IN ENDOSCOPY SUITE OR THEATRES KEEP IN ED UNTIL ENDOSCOPY SUITE OR THEATRES READY ** SCOPE TO BE DONE >1 WORKING DAY REFER TO MAU ADMIT TO WARD GASTRO TO DOCUMENT CLEARLY REASON FOR NOT DOING MORE URGENTLY ALTERED MET CRITERIA / TARGETS CRITERIA TO ESCALATE TO URGENT SCOPE EXPECTED TIME OF SCOPE / REASON FOR NOT SCOPING / BLUE FORM DISPOSITION TO BE DETERMINED BASED ON GASTRO REG / GASTRO CONS URGENCY OF SCAN 6 points 1 point 3 points 6 points 0 point 1 point 0 points 6 points 3 points 2 point 4 points 3 points 1 point 2 points 0 points 1 point 0 points 1 point 0 points 1 point 0 points 1 point 0 points 1 point 0 points 0 points Author: Updated by: Clinical reviewer: Approved by: Approval date: Drs Bendall / Baker / Jeffrey Dr T Ercleve Dr T Ercleve Dr P Allely 18/10/2017 RMO / CONS / CONS CONS CONS ED / ICU / GASTRO ED ED Dr J Armstrong 18/10/2017 18/10/2019 Approved by: Approval date: Next review date Role Name Position Service Sponser / owner Drugs and Therapeutics Committee
Transcript of UPPER GI BLEED PROTOCOL SCGH ED v2 · UPPER GI BLEED PROTOCOL SCGH ED v2.1
UPPER GI BLEED PROTOCOL SCGH ED v2.1 <10 ≥13≥12 <13≥10 <12
<10 ≥12 ≥10 <12
M
F
Haemaglobin
<8 ≥6.5 <6.5≤25 ≥10 <10 ≥8>25BUN
<90 >109100 10990 99
Initial Systolic BP
Pulse
<100≥100
Presentation with melaena
NoYes
Recent syncope
No Yes
Hepatic disease history
No Yes
Heart failure history
No Yes
Score >5 = >50% risk for intervention (or death)
MET CRITERIAAIRWAY THREATENEDBREATHING 36 < RR< 5CIRCULATION 140 < HR < 40 SBP < 90NEUROLOGY GCS FALL > 2 SEIZURE REPEAT / PROLONGEDURINE <100ML IN 3 HRS
GLASGOW-BLATCHFORD SCORE(severity index for non-variceal bleeds)
ANY DELAYS OR PROBLEMS WITHDISPOSITION SHOULD BEURGENTLY ESCALATED TO
ED DUTY CONSULTANT (24 HRS)
NOTE: IN AN UNSTABLE PATIENT WITH ONGOING BLEEDING,GASTRO’S DECISION NOT TO SCOPE SHOULD NOT BE
MISINTERPRETED AS AN ‘INABILITY TO MAKE A PLAN’, RATHERAS AN EVIDENCE BASED RISK BENEFIT ANALYSIS ON PERFOR-MING AN INVASIVE PROCEDURE WITH POOR VISIBILITY, IN AN
UNSTABLE PATIENT. GASTRO MUST BE KEPT INFORMED OF THEONGOING RESPONSE TO RESUSCITATION TO BE ABLE TO MAKE
THIS AN INFORMED DECISION.
KNOWN PALLIATIVE?
* Consider higher value if underlying comorbidities or suggestions of ongoing bleeding
† Check Jehovah’s Witness status (some JW may consent to blood products)
‡ Gastroenterology Therapeutic Guidelines 2014
** Coinsider theatres if anaesthetics involved / airway issues
SUSPECTED VARICEAL BLEED?
RESUSCITATE PATIENT IN ED2X LARGE BORE IV ACCESSURGENT FBC (Hb, plt), CLOTTING PROFILE (PT, INR) UE (urea), GROUP AND HOLD† / X-Match†TRANSFUSE*† IF Hb ≤ 70-80VASOPRESSORS IF INADEQUATE PERFUSION AFTER BLOOD REPLACEDIDENTIFY AND CORRECT COAGULOPATHYPANTOPRAZOLE‡ 80mg IV over 30min, 80mg over 10 hours
YES
ADD TERLIPRESSIN ACETATE 2mg IV STAT‡ (EQUIV 1.7mg IV)CEFTRIAXONE 2g IV
INSTABILITY/ MET CRITERIA / HIGH RISK?
ONGOING BLEEDINGNOT NORMALIZING AFTER RESUSCITATIONUNSTABLE EPISODE IN ED (MET CRITERIA)REQUIRING TRANSFUSIONLOST ≥30% BLOOD VOLUMECOAGULOPATHYOTHER ORGAN FAILURE
NO
DOCUMENT GLASGOW-BLATCHFORDSCORE IN NOTES
YES
NO
YES
CONSIDER BOUNDARIES OF CAREADMIT MAU
YES
CALL DUTY CONSULTANT (24HRS)URGENT GASTRO REVIEWGASTRO TO REVIEW AND DECIDE ONE OF THE OPTIONS BELOW
YES
REFER TO MAUADMIT TO WARD0800-2200 MAU TO INFORM GASTRO2200-0800 MAU INFORM GASTRO AT 0800
SCOPE NOT URGENT
NO
SCOPE TO BE DONEWITHIN 1 WORKING DAY
REFER TO ICU (ICU CAN DELEGATE TO HDUIF MORE APPROPRIATE)GASTRO TO DOCUMENT CLEARLY
REASON FOR NOT DOING MORE URGENTLYALTERED MET CRITERIA / TARGETSCRITERIA TO ESCALATE TO URGENT SCOPEEXPECTED TIME OF SCOPE
SCOPE TO BE DONE IN ICUREFER TO ICU (ICU CAN DELEGATE TO HDUIF MORE APPROPRIATE)GASTRO TO DOCUMENT CLEARLY INDICATION FOR IMMEDIATE SCOPE EXPECTED TIME OF URGENT SCOPECONSIDER MINNESOTA TUBE IN ICU ORREFER TO INTERVENTIONAL RADIOLOGY / SURGERY
SCOPE LIKELY TO BE DONE WITHIN 2HRS (DAY)OR SCOPE TEAM HAS BEEN CALLED IN (NIGHT)
SCOPE TO BE DONE IN ENDOSCOPY SUITE ORTHEATRES
KEEP IN ED UNTIL ENDOSCOPY SUITE ORTHEATRES READY **
SCOPE TO BE DONE>1 WORKING DAY
REFER TO MAUADMIT TO WARDGASTRO TO DOCUMENT CLEARLY
REASON FOR NOT DOING MORE URGENTLYALTERED MET CRITERIA / TARGETSCRITERIA TO ESCALATE TO URGENT SCOPEEXPECTED TIME OF SCOPE / REASON FOR
NOT SCOPING / BLUE FORM
DISPOSITION TO BE DETERMINED BASED ON GASTRO REG / GASTRO CONS URGENCY OF SCAN
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