Intubation of the GI bleeder
OVERVIEW
Massive GI hemorrhage presents multiple challenges during intubation:
- haemorrhage obscures view of vocal cords
- high risk of aspiration
- risk of haemorrhagic shock and haemodynamic instability
- risk to staff from contact with body fluids
RSI MODIFICATIONS
- wear PPE including goggles, mask, gown and gloves
- empty the stomach
— place an NGT, this does not decrease the esophageal sphincter opening pressure
— consider delayed sequence intubation if this is not tolerated
— varices are not a contra-indication
— administer prokinetics (e.g. metoclopramide 10mg IV, erythromycin 250mg IV) - perform intubation with the patient in head up 45 degrees position (Semi-Fowler position)
— optimal position for intubation success
— may decrease aspiration risk - ensure adequate preoxygenation and apneic oxygenation
— use high flow nasal prongs if available— avoid NIV in the actively vomiting patient
— consider delayed sequence intubation
— use gentle BVM to maintain oxygenation as required (e.g. 6-10 breaths/min) - Use appropriate intubation medications
— use a haemodynamically stable dose of induction agent (e.g. ketamine 1-2 mg/kg IV)
— use paralytics (e.g. rocuronium 1.2mg/kg IV); these do not drop lower esophageal sphincter tone - Use optimal equipment
— video laryngoscopes may be obscured by blood and vomit
— use 2 suction set-ups, assistants either side can hold in the corners of the patient’s mouth
— bougie
— LMA (e.g. proseal)
— meconium aspirator (can attach to ETT tube and suction as you go) - Aspiration
— aspiration pneumonitis does not need antibiotics— bronchodilators and lung protective ventilation may help
— SIRS response may require ongoing fluid resuscitation +/- pressures
References and Links
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
- EMCrit Podcast 5 – Intubating the Critical GI Bleeder
- EMCRIT — A novel set-up to allow suctioning during direct endotracheal and fiberoptic intubation
- EMUpdates — Airway Control in the Massive Oral Bleed Patient
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
