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
- 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
— LMA (e.g. proseal)
— meconium aspirator (can attach to ETT tube and suction as you go)
— aspiration pneumonitis does not need antibiotics— bronchodilators and lung protective ventilation may help
— SIRS response may require ongoing fluid resuscitation +/- pressures
References and Links
- 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
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.