or patients with symptoms concerning for

coronary ischemia. Silent ischemia can occur as a result of

decreased oxygen delivery related to blood loss.

PROCEDURES

Nasogastric aspiration should be performed on patients

suspected of having an upper GI bleed. Aspirate appearing

like gross blood or "coffee grounds" is evidence of an upper

GI source. The stomach may then be lavaged with 200-300 mL

saline to see if the aspirate clears. Note that false negatives

may occur with bleeding distal to the pylorus, and false

positives may occur from nasal trauma. NG aspiration is

an especially uncomfortable and anxiety-provoking procedure for the patient, and the use of topical anesthetic is

advised. Although NG aspiration in GI bleeding is routinely performed, it will only yield a useful diagnostic

result in a minority of cases.

MEDICAL DECISION MAKING

The exact location of GI bleeding is usually not determined

in the initial ED evaluation. Examination of any emesis,

stool, or NG aspirate may help to determine the general

location of the hemorrhage and direct further diagnostic

and treatment strategies (Figure 30-1).

TREATMENT

Patients with active GI bleeding should be placed on a cardiac monitor with supplemental oxygen. Large peripheral

IV catheters should be inserted in unstable patients. If these

Suspected Gl

bleeding

Hematemesis/

positive NG

aspirate

No

Hematochezia/

negative NG

aspirate

No

Melena

Yes

Yes

Yes

CHAPTER 30

U pper Gl

bleeding

Probable

lower Gl

bleeding

Probable

upper Gl

bleeding

Figure 30-1 . Gl bleeding diagnostic algorithm.

Gl, gastrointestinal; NG, nasogastric.

lines cannot be inserted, a large-bore (SF) central line should

be placed to maximize vohune resuscitation. N fluid bolus

of 1-2 L of normal saline should be administered. If the

patient remains unstable after the fluid bolus, administration of packed red blood cells (RBCs) is indicated. Uncrossmatched type 0 blood is ordered for patients with unstable

vital signs and significant blood loss. If a coagulopathy is

suspected, fresh-frozen plasma is also ordered.

For upper GI bleeding, histarnine-2 antagonists are fre ­