Massive GI bleed scenario
candidate brief
You have been asked to re-review a patient who has been waiting in ambulance handover as he now looks more unwell.
20% clin reasoning, 80% resuscitation skills
actor brief
You are Mark, a 55yo who called an ambulance as you were vomiting blood. You have had GI bleeds in the past but this is the first time that you have vomited blood.
PMH: alcoholic liver disease, COPD, angina
DHx: spironolactone, lactulose, thiamine, braltus, salbutamol PRN, GTN PRN
Functional baseline - lives alone but functionally housebound apart from very short walks
examiner brief
65yo with known varices has vomited a large amount of blood. Initially looked ok, but has since had another big vomit and now looks grey and clammy.
Initial obs:
SpO2 96% on air, RR 24
HR 110, BP 90/60
GCS 15
Tender upper abdo
VBG- pH 7.21, lac 4, Hb 65
- Washes hands, introduces self
- confirms patient identity
- takes pertinent history
- 2x Wide bore cannulae, asks for group+save and crossmatch e.g. 4 units
- 500ml crystalloid
- Gives terlipressin
- Recognise massive haemorrhage
- Activate massive haemorrhage protocol
- Allocates roles
- e.g. drugs, checking blood products
- Transfuses blood when available → 'flying squad'/emergency O negative blood
- Transfuses in 1:1:1 ratio Red cells/FFP/platelets
- Allows for permissive hypotension
- Considers correcting calcium and potassium e.g. on repeat VBGs
- Arranges emergency OGD
- Hands over to specialty - critical care, gastro
- Leads team well
- Global mark from examiner