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Your patient is Mr. Abrams, a 63 year-old Black male with a history of non-alcoholic liver cirrhosis, esophageal varices, hyperlipidemia, hypertension, type 2 diabetes, osteoarthritis, hypothyroidism, and renal insufficiency. He does not drink alcohol, smoke or use recreational drugs. He is a retired elementary school teacher, married, and has two grown children.
Mr. Abrams is brought to the emergency department by ambulance. Paramedics tell you he has been complaining of shortness of breath, weakness, and dizziness as well as black, tarry stools for the past three days. He had a syncopal episode when he stood to get out of bed, which is what prompted his wife to call 9-1-1.
Initial vital signs and interventions
Vital Signs: HR 124, BP 92/63, RR 24 with increased WOB, SpO2 86% on RA, Temp 36.9 Celsius
You place an oxymask on Mr. Abrams at 3 L/min and are relieved to see improvement in his vital signs. HR remains elevated at 119, RR is now 22, work of breathing is decreased, and SpO2 is 93%. You place an IV and draw “a rainbow” of labs, meaning you obtain one of each color just in case it’s needed – a tube for coagulation studies, a tube for CBC, and a tube for chemistries.
In this fictitious hospital, the labs come back very quickly and you make note of the most relevant ones:
Hgb 6.4 g/dL, ALT 350 U/L, AST 505 U/L, Platelets 110K, Prothrombin time (PT) 31 seconds, Bilirubin 7.7mg/dL, Albumin 3.0 g/dL, Creatinine 2.1 mg/dL, BUN 78, K 3.8 mEq/L, Glucose 174 mg/dL, TSH 2.2 mIU/L.
What does the hemoglobin level indicate and what can we anticipate being ordered for Mr. Abrams?
The hemoglobin is low because the patient is bleeding from the GI tract. We can anticipate the MD ordering a Type & Cross along with a blood transfusion.
What makes us suspicious the patient is bleeding from the GI tract?
The presence of dark, tarry stools indicate an upper GI bleed is currently occurring or has occurred recently.
What do the ALT and AST levels indicate?
ALT and AST are elevated in liver disease, which is expected for this patient.
What does the platelet count indicate and why is it abnormal?
Low platelets indicate the patient is at risk for bleeding. Platelets are low in liver disease due to sequestration in the spleen and reduced thrombopoiesis in the bone marrow.
What does the prothrombin time indicate?
Increased clotting times and higher risk of bleeding, which is common in patients with liver disease due to the liver not making adequate clotting factors.
What does the bilirubin indicate?
Bilirubin is elevated in liver disease.
What does the albumin level indicate?
Albumin is produced by the liver, so levels are decreased in chronic liver disease. Without sufficient plasma proteins, the patient is at risk for edema and fluid accumulation in the abdomen due to third-spacing. When fluid accumulates in the abdomen this is called ascites.
What does the creatinine level indicate?
The elevated creatinine level is associated with the patient’s renal insufficiency. Some medications can cause creatinine to become elevated, and others may need to be dose-adjusted if they are heavily reliant upon the kidneys for excretion. He is also at risk for decreased urine output, so we’ll watch I/Os very closely!
What does the elevated BUN indicate?
While the BUN may be elevated due to his chronic renal insufficiency, take a look at his BUN/Cr ratio.
What is the BUN/Cr ratio and what does this indicate?
Mr. Abrams’ BUN/Cr ratio is 37.14. In a patient with a GI bleed, a BUN/Cr ratio equal to or above 36 is indicative of an upper GI bleed, whereas lower ratios are associated with lower GI bleeds. The reason the BUN increases is that blood is full of proteins which are absorbed in the GI tract. When the bleed is in the upper GI tract, there is time for adequate absorption of these proteins. Recall that BUN (blood urea nitrogen) reflects the end product of protein breakdown. So, more protein absorption and breakdown leads to an increase in urea, which causes the BUN to be elevated. Voila! Upper GI bleed!
What does the potassium level indicate?
The potassium level is WDL, but we are watching it closely because chronic renal insufficiency can cause hyperkalemia, and hyperkalemia can cause dangerous cardiac arrhythmias.
What does the glucose level indicate?
The elevated glucose is associated with type 2 diabetes. Note that in advanced liver failure patients often become hypoglycemic due to impaired gluconeogenesis. However, Mr. Abrams does not appear to have that particular complication at this time.
What does the TSH indicate?
The normal TSH level indicates the patient is on the proper dose of levothyroxine for his hypothyroidism.
What is the difference between a Type & Screen and a Type & Cross?
There are three components here, ABO blood typing, screening and crossmatching. Blood typing is done to determine the patient’s blood type such as A-positive or B-negative. If the MD thinks the patient might need blood at some point, then a Type & Screen is ordered. This test determines the patient’s ABO blood type and screens for the presence of antibodies against red blood cell antigens. A type & screen does not reserve units of blood for the patient because they don’t necessarily need blood right now.
A type and cross adds an additional step, which is the crossmatch. In this step the recipient’s blood is crossmatched against potential donor blood. The patient will either have blood ordered for transfusion at this time, or an order will be placed to hold a certain number of crossmatched units for planned transfusion (such as during surgery).
Let’s check in on Mr. Abrams
By now Mrs. Abrams has arrived and is able to provide information about the patient’s home medications, which she has brought with her. You inspect the pill bottles and note Mr. Abrams takes metoprolol, hydralazine, levothyroxine, metformin, furosemide, naproxen, and atorvastatin.
Why does he take metoprolol?
Why does he take hydralazine?
Why does he take levothyroxine?
Why does he take metformin?
Why does he take furosemide?
To reduce edema and ascites associated with chronic liver disease
Now that we know he takes furosemide, what labs will we double check?
Creatinine and potassium…remember, furosemide is a loop diuretic that causes potassium losses! It also can cause creatinine to increase.
Why does he take naproxen?
Why does he take atorvastatin?
Which medication is a red flag?
The naproxen is a red flag because of its association with GI bleeding. Not only can it cause peptic ulcers to form and bleed, studies show it can also contribute to the bleeding of esophageal varices. Since esophageal varices develop in patients with liver disease due to portal hypertension, and Mr. Abrams has low platelets and an elevated prothrombin time, we are very concerned about his use of this medication.
What do we want to ask his wife about in regards to this medication?
We want to ask his wife how much naproxen he takes. She tells you he takes it multiple times daily, so now we are now really, really, really concerned!
Physical assessment
You perform a full head-to-toe assessment on Mr. Abrams. Significant findings reveal that he is lethargic, and disoriented to time and situation. You reorient the patient, but repeat assessment shows continued confusion. Heart sounds are normal, pulse is weak and fast in the mid 120’s, capillary refill is 3 seconds. Pt is tachypneic, complaining of shortness of breath, and speaking in three to four word sentences. Accessory muscle use is present and lung sounds are normal. Abdomen is moderately distended, with caput medusae present. Pt shows 2+ edema in bilateral lower extremities. Skin signs reveal jaundice and pallor.
Why is Mr. Abrams lethargic?
Anemia secondary to GI bleed.
Why is Mr. Abrams disoriented?
One reason for confusion or disorientation is that he lost consciousness at home and woke up in the ambulance. This would be disorienting to anyone! However, hypoxia causes confusion, which is definitely a concern for this patient.
Low circulating blood volume reduces preload, which reduces cardiac stretch. Reduced cardiac stretch leads to reduced cardiac output and a weak pulse.
Are we concerned about his capillary refill?
This is right at the edge of delayed capillary refill. Any further blood loss is going to affect this even more, so yes, we are concerned.
Why is the patient tachypneic, short of breath, and using accessory muscles?
Low hemoglobin means less oxygen is being delivered to the tissues, so Mr. Abrams is hypoxic. As a compensatory mechanism, his respiratory rate and work of breathing has increased. This also causes him to feel shortness of breath.
Why is Mr. Abrams’ abdomen distended?
Patients with chronic liver disease have increased portal hypertension and low circulating plasma proteins, so fluid is easily lost into the abdomen due to third-spacing (a condition called ascites). Increased vascular pressure can also cause an enlarged spleen, and the liver is likely enlarged as well. Both of these enlarged organs can contribute to abdominal enlargement. Note that when ascites is significant, it also causes shortness of breath, so we want to watch Mr. Abrams closely for increased abdominal distention and associated respiratory compromise.
Caput medusae is associated with portal hypertension and is due to the shunting of blood through umbilical veins, which become engorged and visible on the surface.
Why does the patient have 2+ pitting edema in the BLE?
Mr. Abrams has low serum albumin and therefore, low circulating plasma proteins. This means oncotic pressure is decreased and fluid is able to leak into the interstitial space (third-spacing).
How do we assess for jaundice in Mr. Abrams and what does it indicate?
In individuals with dark or yellow-toned skin, the best place to observe for jaundice is the sclera. Note that if a patient with darker skin has callouses on the palms or soles of their feet, these can appear yellow without jaundice being present. You can also observe for a yellow discoloration of the oral mucosa by looking at the hard palate. Jaundice indicates there is a buildup of bilirubin in the blood.
How do we assess for pallor in Mr. Abrams?
Assessing for pallor in individuals with darker skin tones can be difficult. The mucus membranes of very dark skinned individuals tend to appear ashen or gray while the color is more yellowish-brown in those with brown skin tones. You can also observe the palmar surface which may appear paler than usual. Note that fluorescent lighting can give the skin a bluish tint, so use a halogen lamp or natural light.
Now, back to Mr. Abrams
While you are calling the MD to let her know that Mr. Abrams’ labs have resulted, you hear a scream coming from his bay. You rush in to see Mrs. Abrams shouting, “He’s bleeding, he’s bleeding!” as Mr. Abrams vomits bright red blood.
Thankfully, Dr. Jones has also heard the commotion and is rushing to the bedside. She orders an emergent blood transfusion and calls for a central line kit while you suction the oropharynx and maintain Mr. Abrams in a side-lying position. The central line is inserted and secured just as the four units of unmatched O-negative blood are delivered to his bay. Dr. Jones has ordered a stat chest X-ray and the technician has also just shown up. At this time you notice cyanotic skin signs and the monitor reveals a HR of 132, BP 76/43, RR 28, SpO2 72% on 3L oxymask.
What is the significance of Mr. Abrams vomiting bright red blood?
The blood is bright red because it is fresh, meaning the bleeding is actively occurring. The fact that he is vomiting the blood tells us this is an upper GI bleed, possibly from esophageal varices or a bleeding ulcer.
Why did the blood bank send up O-negative blood?
O-negative blood is the “universal donor” blood and can be administered in emergency situations without a type and screen or type and crossmatch.
What’s going on with his blood pressure?
Mr. Abrams’ blood pressure has dropped significantly due to loss of circulating volume.
Does Mr. Abrams need volume or does he need vasopressors like norepinephrine to improve his blood pressure?
Mr. Abrams needs volume! The blood transfusions will help and he’ll also likely get fluids at the same time. We need to increase circulating volume quickly to avoid circulatory collapse, especially since it appears he is actively hemorrhaging!
Why did Dr. Jones insert a central venous catheter?
A central venous catheter allows for the rapid infusion of blood and fluid. Plus, with a blood pressure in the 70s, getting a peripheral IV is going to be incredibly difficult.
How do you assess for cyanosis in Mr. Abrams, who has dark skin?
In dark skinned individuals, cyanosis is most likely to be noticed as a gray or whitish tint around the mouth or a bluish or gray discoloration of the conjunctiva.
How would you assess for cyanosis in Mr. Abrams if he had yellow skin tones?
In individuals with yellow skin tones, cyanosis presents as a grayish-greenish skin color.
Why did Dr. Jones order a stat chest X-ray?
A chest X-ray is used to verify position of the central venous catheter prior to its use.
What’s going on with his vital signs? What concerns you and what are you going to do about it?
The significant drop in SpO2 is very concerning. A good plan would be to escalate oxygen delivery to a non-rebreather at 100% FiO2. Depending on how he responds, this may be sufficient, or the patient may need intubation and mechanical ventilation.
What’s next for Mr. Abrams?
Luckily Mr. Abrams maintains an adequate oxygen saturation level on the non-rebreather (whew!) and Dr. Jones calls the gastroenterologist on-call to tell him Mr. Abrams needs a STAT EGD (upper endoscopy). The GI specialist orders a pantoprazole infusion and octreotide infusion to be started immediately and tells Dr. Jones the team can be there in 60 minutes.
Though the transfusion and fluids have improved Mr. Abrams’ blood pressure, it still has not risen above 88 systolic and Dr. Jones knows patients can bleed out quickly. She calls for an intubation tray and a Blakemore tube. Mr. Abrams is intubated and then Dr. Jones places the Blakemore tube. Once the nasogastric tube is set to intermittent LWS, you see initial drainage of blood and what looks like coffee grounds, but after a minute, it appears to slow down. Good job! We’ve just bought Mr. Abrams some time.
What is the purpose of pantoprazole in GI bleeds?
Pantoprazole is used in upper GI bleeds to reduce gastric acid and minimize its detrimental effects on platelet aggregation, thereby reducing bleeding.
What is the purpose of octreotide for Mr. Abrams?
Octreotide inhibits vasodilatory hormones, which reduces blood flow in the GI tract along with portal and variceal pressures. Because we suspect Mr. Abrams is bleeding from esophageal varices, this medication may be beneficial.
Why was Mr. Abrams intubated? He seemed to be doing okay with the non-rebreather.
Mr. Abrams was intubated for airway protection.
What is the purpose of a Blakemore tube?
Though not as common as they once were thanks to the use of endoscopic procedures, a Sengstaken-Blakemore tube is a nasogastric tube with two inflatable balloons. Once inflated, the gastric tube in the stomach helps reduce blood flow to the esophageal varices, which can help reduce bleeding. If needed, the other balloon, which is located along the length of the tubing, is inflated to provide gentle steady pressure that helps tamponade bleeding esophageal varices. The tube also has an opening at the bottom for drainage of gastric contents.
Why did Dr. Jones consult the gastroenterologist?
With bleeding, the most important intervention is to make it stop. The Blakemore tube is only a temporary measure and should not be inflated for more than six hours. An esophagogastroduodenoscopy (EGD) enables the gastroenterologist to locate and stop the bleeding through various techniques such as clipping, band ligation, and injection of localized epinephrine.
What’s up with the coffee ground substance from the NG tube?
When blood sits in the stomach it coagulates, giving it a coffee-ground appearance. Sometimes patients will vomit this substance (coffee-ground emesis), so if you see this…think GI bleed!
Help is here to save the day!
At this point, Mr. Abrams is in the hands of the endoscopy team who have elected to perform this life-saving procedure at the bedside in the ER. As the primary nurse, you monitor Mr. Abrams’ vital signs and, since he is intubated, you manage sedation through a continuous infusion of propofol and fentanyl. The procedure takes approximately one hour and you realize as the team finishes up that Mr. Abrams has been lying in the supine position for quite some time. Before transferring him to the ICU, you perform a skin assessment to look for early signs of pressure injury and thankfully don’t find any. You transport Mr. Abrams to the ICU for close monitoring and are happy to see much improved vital signs: HR 84, BP 110/71, RR 18, SpO2 98% on 40% FiO2. You anticipate Mr. Abrams being extubated in the ICU once the propofol wears off and being transferred to the Med Surg floor tomorrow. Good job!
Why are propofol and fentanyl often used together?
Propofol provides sedation, but does not provide any pain control. Fentanyl provides pain control and some sedation. Together, the patient is sedated and pain is managed.
How do you assess for stage 1 pressure injury in a patient with dark skin like Mr. Abrams?
In a patient with lighter skin, you assess for a stage 1 pressure injury by checking for non-blanching erythema. Because darker skin may not show blanching even when healthy, checking for non-blanching erythema will not be beneficial. In fact, erythema may not even be noticeable. Check the area for variations in skin color and note it may be warmer or cooler than surrounding tissue, firmer than surrounding tissue, have noticeable edema or bogginess, or be painful.
A happy ending
Mr. Abrams is extubated later that day and shows no signs of further bleeding or hemodynamic compromise. He is provided education about avoiding NSAIDs and taught to recognize the signs of GI bleeding. He is discharged home after a three day hospital stay. Good job working with Mr. Abrams!
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