Download GI Bleed Case - 39.5 KB

MedEd Portal/ POGOe
Human Patient Simulation
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Title: Gastrointestinal Bleeding
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Target Audience: First Year Emergency Medicine Resident
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Learning Objectives:
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Environment:
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Environment
– 10 bed rural Emergency Department
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Manikin Set Up
– Code cart
– Intubation equipment
– Code drugs
– Rapid Sequence Intubation (RSI) drugs
– O negative blood
Props
– Electrocardiogram (EKG)
– Normal Chest X-ray (CXR)
Distractors
– Lower GI bleeding episode and Pulseless Electrical Activity (PEA)
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Primary
– Recognize and promptly resuscitate a patient with a severe lower
GI bleed
Secondary
– Obtain additional history including medications to aid in
management
– Correct warfarin-induced coagulopathy
Critical Actions Checklist
– Intravenous Fluid (IVF) resuscitation
– 2 large bore IVs
– Type and Cross with O negative blood readily available
– Nasogastric NGT
– Consult gastrointestinal (GI) for colonoscopy
– Admit to the Intensive Care Unit (ICU)
Actors: (All roles may be played by residents participating)
- Resident running the case
- Nurse to place IVs and give medications
- Respiratory tech
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Another resident to be the GI or MICU consultant at another hospital (able
to give recommendations)
Case Narrative:
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Chief Complaint: Bloody Stools
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History: 68 year-old male presents with three episodes of bloody diarrhea
since last night. He notes large amounts of bright red blood in the toilet.
He has been feeling very weak, lightheaded, and dizzy, especially when he
stands up. He endorses mild shortness of breath and chest discomfort
along with cough. He has mild dull lower abdominal pain with his
diarrheal episodes.
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Additional history given only if asked: He was just recently treated for
a respiratory infection and has had 3 days of Levaquin.
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Past Medical History (Hx): Atrial fibrillation; hypertension;
hyperlipidemia; diabetes
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Social Hx: Denies tobacco, alcohol, or illicit drug use. Retired and lives
with wife.
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Meds: Metformin; Coumadin; Lisinopril; Simvastatin; Aspirin; Levaquin
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Surgical Hx: Coronary Artery Bypass (CABG) 7 years ago
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Allergies: No known drug allergies.
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Review of Systems: No fevers or vomiting.
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Physical Exam
– Blood Pressure 99/64, Heart Rate 112, Respiratory Rate 22,
Temperature 36.7, Oxygen saturation 93% on room air, Glasgow
coma scale 15
– Head eyes ears nose and throat – normocephalic and atraumatic,
pupils 5mm bilaterally and sluggishly reactive,
– Respiratory – mild tachypnea; clear breath sounds bilaterally
– Cardiovascular – tachycardia; holosystolic murmur
– Abdominal – soft, non distended; nontender
– Rectal- gross blood, heme positive
– Extremity – no gross deformities or ecchymosis
– Neurological – GCS 15; moving all extremities; grossly intact
– Skin –pale, mottled, cool
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Instructors Notes:
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Tips to Keep the Scenario Flowing
– During the history, the patient has another massive episode of
bright red lower GI bleeding. His blood pressure drops, and he is
in PEA until he is adequately resuscitated. Have patient start
compressions and Advanced Cardiac Life Support (ACLS)
protocol.
– Have the resident proceed with intubating after PEA. Also have
the resident explain or demonstrate how to place an NG tube.
– The resident will need to transfer the patient to a hospital with
access to specialists such as GI. The resident will need to call the
gastroenterologist at the outside facility to alert him that the patient
is being transferred.
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Tips to Direct Actors
– The director should encourage frequent vital sign rechecks and
mental assessments of the patient
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Scenario Steps
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Optimal Management Path
 The resident should recognize the signs and symptoms of
anemia and dehydration in the patient. Two large bore IVs
should be established with IV fluid boluses going. Labs
should ordered early on including a type and cross and
coags. O negative blood be readily available. The resident
should treat the coagulopathy with Vitamin K and fresh
frozen plasma (FFP). The resident should consult the GI
service for a speedy colonoscopy and management in this
patient.
Potential Complications Path
 The resident could fail to recognize that the coagualopathy
needs to be corrected.
Potential Errors Path
 Failure to begin aggressive fluid resuscitation from the
beginning
 Not having O negative blood readily available to give
patient
Imaging and Labs
CBC: WBC 13, Hgb 4.3, Hct 13, Plts 178
Chem 10: Na 143, K 3.9, Cl 109, CO3 22, BUN 28, Creat 1. 5, Ca 7.8, Mg
1.8, Phos 3.9
Coags: PT 54, PTT 28, INR 5.6
CXR: unremarkable
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Debriefing Plan:
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Topics to discuss
– In this particular situation, what do you think caused the patient’s
GI bleed?
– What medications should be used with caution in patients taking
Coumadin?
– What are common causes of lower GI bleeds?
Pilot Testing and Revision:
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EKG: sinus tachycardia
Number of Participants – 4
Evaluation form for participants – generic handout
Authors:
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John B. Seymour, MD. University of North Carolina Department of
Emergency Medicine.
Rochelle Chijioke, MD. University of North Carolina Department of
Emergency Medicine.
Amar Patel, MS. Director of the Center for Innovative Learning at
WakeMed Health & Hospitals.
Graham Snyder, MD. Assistant Professor and Medical Director of
the Center for Innovative Learning at WakeMed Health & Hospitals
Kevin Biese. MD, MAT. University of North Carolina Department of
Emergency Medicine, Assistant Professor and Residency Director
Jan Busby-Whitehead, MD. University of North Carolina Professor &
Chief, Division of Geriatric Medicine; Director, Center for Aging and
Health.