Unconscious Patient, Haematemasis & Melaena

Unconsciousness and GI bleeding, two presentations seen on most shifts in the ED and potentially both caused by alcohol. However there are also a wide range of other causes for both.

CMP 6 – Unconcious Patient

EM Curriculum: (click to view)

Background

A reduced level of consciousness may be a result of metabolic or neurological disturbance and it is important to be able to identify which. Prior to this you must recognise those patients who are at risk due to their level of consciousness. You need to be able to use standardised assessment tools that can be communicated to other teams as necessary.

GI bleeding can vary in aetiology, and also in severity. It is important to identify the patients that need aggressive management and be able to escalate their care. It is also worth being able to identify those patients that could go home. Variceal bleeds may represent only around 10% of upper GI bleeds but up to 30% of variceal bleeds are fatal [1]. There are scoring systems that can be used to risk assess and predict mortality of GI bleeds and you should be aware of these and use them to aid your management.

References:

  1. Sharara AI, Rockey DC. Gastroesophageal variceal hemorrhage. N Engl J Med. 2001;345:669–681.


Learning Outcomes from completing the tasks

  • Revise the history and the role of the Glasgow Coma Score including it's limitations.

  • List the causes of an upper GI bleed and be able to construct a management plan.

  • Be able to apply the Rockall score to a case example.

  • Recall the causes of a lower GI bleed and know when a surgical opinion is required.

Learning Outcome from face-to-face teaching

  • Know the potential causes of unconsciousness in a patient and be able to construct a plan to identify the diagnosis.

  • Be able to identify patients who are at risk due to their level of consciousness.

  • Consider the role of PPI's and H.pylori eradication in patients with GI bleeds.

  • Review the choice of fluid and access in resuscitation of a patient with a GI bleed.

    • To consider the flow rates of IV cannulas and central lines.

    • Be able to correctly "prescribe" blood products and discuss the role of consent forms prior to transfusion in the ED.


Tasks

Complete the following before the face-to-face teaching session:

Task 1: Glasgow Coma Scale

Duration: 45 mins

An article exploring the history of the Glasgow Coma Score, the positive and negatives of its use as well as a break down of the components. The videos include a bit more about the history of the GCS from one of the authors of the original paper. They also show some worked examples of assessing GCS.

Task 2 – Upper and Lower GI Bleeding

Part I: Upper GI Bleeds

Duration: 45 mins

This module covers both variceal and non-variceal bleeding in adults, it gives a good synopsis of the evidence based treatments for these conditions. Although for an enlightening review of the evidence regarding PPIs and upper GI bleeding check out the SMART EM  podcast in the additional resources section below.

Part II: Lower GI Bleeds

Duration: 45 mins

This module covers the causes and management of lower GI bleeds including identifying those that need early surgical review.

Task 3: Sengstaken Placement

Duration: 12 mins

Watch this video guide to the use and placement of a Stengstaken-Blakemore Tube, and once you are familiar with the device it is worth finding out where they are kept in your department.

 Image: EMCrit.org

Image: EMCrit.org

Task 4: Causes of Unconciousness

Duration: 6 mins

Reduced conscious level is a common finding in the ED. With a wide variety of causes a required treatments a systematic approach can make ascertaining that cause a lot easier.

This vodcast will give you framework to follow for such patients.


#EM3 Content:

Lightning Learning:

SimBlog:


Case Discussions

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

Read the description for each of these cases and calculate the GCS. Try to do it from memory rather than looking up the breakdown, this can easily come in part B of MCEM.
A 59 year old man is brought into the assessment bay, he is vomiting fresh red blood and has a brought a bowl full of it. You notice he looks a little jaundiced.

Additional Resources

Have a look at the following additional resources relevant to this topic:

BMJ Quiz:

This question taken from an FRCS revision bank gives a short description of a patient and tasks you with calculating the GCS. (requires BMA membership)

BMJ Case Report – An Unconscious Patient:

A case to read through and then four questions to answer, (requires BMA membership).

HALT-IT:

A trial looking at the role of tranexamic acid in GI bleeds. LRI is participating in this trial so watch this space!

e-UHL:

This eLearning module on upper GI bleeding has been written by two of the senior gastroenterology trainees in Leicester and can be accessed through an eUHL account.

DNUK:

There are two upper GI eLearning modules:

  1. Variceal Bleeds

  2. Non-Variceal Bleeds

Glasgow-Blatchford Score:

A screening tool to assess the likelihood that a patient with an acute upper gastrointestinal bleeding (UGIB) will need to have medical intervention such as a blood transfusion or endoscopic intervention.

Rockall Score:

A scoring system to identify patients at risk of adverse outcome following acute upper gastrointestinal bleeding.

MCEM Courses:

Bromley Case of the Week of a variceal bleed.

SIGN:

The SIGN guidelines for upper and lower GI bleeds.


Course Feedback

Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form: