Esophageal Varices Anyone?

[Kaisu]

Ran on on endstage liver disease pt. with ruptured esophageal varices. As we ran the code it became obvious to me that this man's demise was precipitated by that loathsome "H" hypovolemia. He essentially bled out. The question I have for you is

"Are there prehospital techniques that can help control the bleeding of the ruptured esophageal varices?"

My simple brain says... direct pressure... then leads to How does one apply direct pressure to the esophagus? The only thing I can come up with is combitube.. maybe.

Does anyone have any tips, tricks or ideas on this one. Getting covered in Hep-C blood, doing a surgical crike and throwing everything in the box at this dude, including the the last ditch desperation Sodium Bicarb and working very very hard... never mind the decon of the rig afterwards, leads me to ask what else I could have done.

Edit.. or more precisely.. what could have been done first to correct the H.....

Edited April 17, 2010 by CrapMagnet

[DartmouthDave]

Ran on on endstage liver disease pt. with ruptured esophageal varices. As we ran the code it became obvious to me that this man's demise was precipitated by that loathsome "H" hypovolemia. He essentially bled out. The question I have for you is

"Are there prehospital techniques that can help control the bleeding of the ruptured esophageal varices?"

My simple brain says... direct pressure... then leads to How does one apply direct pressure to the esophagus? The only thing I can come up with is combitube.. maybe.

Does anyone have any tips, tricks or ideas on this one. Getting covered in Hep-C blood, doing a surgical crike and throwing everything in the box at this dude, including the the last ditch desperation Sodium Bicarb and working very very hard... never mind the decon of the rig afterwards, leads me to ask what else I could have done.

Hello,

Tough call for sure. I can not think of any tricks for this fellow. Securing the airway to prevent aspiration of blood and pushing fluids. As for a Combitube I think it wouldn't protect the airway, or tamponade the bleeding. Also, with very forceful emesis I think there could be a risk of esphogeal repture. Dose anybody have any other thoughts on the combitube?

If this fellow made it to the ED there are a few options:

1) Sengstaken-Blakemore Tube can be inserted down the esophagus and inflated. The ballon tamponades the varacies.

Blakemore

2) Panto IV and an infusion

3) Octreotide IV and an infusion to drop portal hypertension

4) Vasopressin (Varices Dose) infusion

5) Blood products (PRBC, FFP, ect..)

6) Endoscopy treatment and surgical interevntions

Even with all this stuff the 4-5 ESRD with bleeds that I have seen never do very well. So, really, I think you tried all that you could have.

Cheers...

[croaker260]

The Combi tube is the LAST thing you want to use, as is any similar device. It will only rip the weakened esophagus wide open. If you read the literature it is specifically contraindicated. Lethal intervention.

I admit these are some of the most dramatic medical calls to go on, there can be blood everywhere! But unfortunately prehospitally,theres not a lot we can do. Fluids, airway control, and tincture of transport. Mortality in these cases of actual rupture can be high

In hospital they will sometimes use a blakemore (sp) tube, which resembles a low pressure foley cath where the bladder runs the entire length of the tube. I have not seen any service carry them prehospitally, though IIRC they arnt much more difficult that an NG tube to place.

Edited April 17, 2010 by croaker260

[Kaisu]

The Combi tube is the LAST thing you want to use, as is any similar device. It will only rip the weakened esophagus wide open. If you read the literature it is specifically contraindicated. Lethal intervention.

I admit these are some of the most dramatic medical calls to go on, there can be blood everywhere! But unfortunately prehospitally,theres not a lot we can do. Fluids, airway control, and tincture of transport. Mortality in these cases of actual rupture can be high

In hospital they will sometimes use a blakemore (sp) tube, which resembles a low pressure foley cath where the bladder runs the entire length of the tube. I have not seen any service carry them prehospitally, though IIRC they arnt much more difficult that an NG tube to place.

See now thats why I post on this site... Thank you for the responses so far.

[DartmouthDave]

Hello,

I was thinking. Vaso for shock mixed 15 units in 250 NS. With a dose between 0.01 and 0.05 units/min.

I know that Vasopressin for varacies is mix much stronger (never used it myself) and administered at a higher dose. Not sure, but I thick the dose is .1 to .5 units/min. Tenfold.

So.....when the patient coded Vasopressin could, in theory, fix two problems. That is if you had it. Just a random thought.

Weak theory. Am I off base here?

Cheers....

[HERBIE1]

Hello,

I was thinking. Vaso for shock mixed 15 units in 250 NS. With a dose between 0.01 and 0.05 units/min.

I know that Vasopressin for varacies is mix much stronger (never used it myself) and administered at a higher dose. Not sure, but I thick the dose is .1 to .5 units/min. Tenfold.

So.....when the patient coded Vasopressin could, in theory, fix two problems. That is if you had it. Just a random thought.

Weak theory. Am I off base here?

Cheers....

If they are hypotensive from hypovolemia, then a pressor is of little value- there is nothing in the tank.

Largest IV's you can obtain, fluids under pressure- squeezing manually, BP cuff, or fancy pressure bag. Airway, CONSTANT SUCTION- in my experience, just use the suction tubing straight into the oral cavity- even the largest tonsilar catheter quickly gets clogged with all the blood clots and is useless.

These are horrible calls- generally the back of the rig looks like a horror movie- blood everywhere. You simply cannot keep up with the emesis.

[flight-lp]

You can also use non-selective beta blockers to decrease the overall cardiac output and splanchnic blood flow. We use IV Inderal in severe cases, along with a nitrate to keep the pressures down. We get Sandostatin from the sending facilities and will occasionally keep a spare dose or two on our CCT units. We also carry the SB tubes on these units for uncontrolled hemorrhages. These folks are definately a handful, gettting them tubed is a priority, trach / cric 'em if you cant pass the ETT or ventilate them due to blood obstructing the airway.

Vasopressin is an alternative, however bear in mind that while the V1 receptor will increase venous BP through increased SVR, this can cause potential for cardiac ischemia. Risk vs. benefit has to be heavily weighed.

[chbare]

If they are hypotensive from hypovolemia, then a pressor is of little value- there is nothing in the tank.

As touched on by Flight, the goal with utilising vasopressin is hemorrhage control by constriction of arterioles. Vasopressin is actually very effective at initial hemorrhage control, but re-bleeding can occur quite frequently.

Take care,

chbare.

[DartmouthDave]

Hello,

Interesting. Inderal IV. I have never seen it used for varices. I am going to look that up. Always like to pick up something new. One never knows when it will come in handy.

Could IV Metoprolol be used as well? If for example Inderal was not available?

Sorry, I wasn't too clear with my Vaso post. There is a Vaso Shock dose and a Vaso Varices dose. At the high end of the Varices dose the patient will get 30 units an hour or so.

Now, in a code secondary to a bleed push Vaso 40 units IV. In theory, it may help with ROSC and the bleed. For most ALS units (not a CCT team) this may be the only possible drug that could be helpful. Basically, what was clarified by previous posters.

I have seen three SB tubes. I have never put one in. In theory, they slide in like an OG. The one thing I have always wonder is how!! They are much more flacid than an oralgastric tube. How do you keep it from curling up. Just wondering.

Second question. Securing the SB tube. They need a little tension to keep the gastric ballon in place. The three times I have seen a SB tube the patient was tubed. Two had the SB secured to the ET tube. One, to a hockey helment. Now, how would you secure a SB tube to a patient that isn`t intubated........just wondering!

Cheers

Edited April 18, 2010 by DartmouthDave

[chbare]

I think nonselective beta blockers are recommended, Inderal happens to be the "parent" of this class of beta blockers. With that, I am not sure any pharmacological therapy really reduces mortality. I think there may be limited evidence that the newer vasopressin analogues may impact mortality.

SB tubes have rather fallen out of favour in recent years. The last one I saw was secured to a football helmet. Honestly, there are many risks to placing a SB and not much in the way of benefit IMHO. I day say endoscopic techniques are the standard and have pretty much replaced SB tubes. Especially since somebody well educated in SB tubes should be the one placing the tube. If this is the case, the patient is most likely where they need to be. While I may galvanise people into hating me, I would absolutely recommend nasogastric intubation.

I do find it ironic that in the same discussion we are talking about the harm a combitube can cause, yet discussing SB tube use as a therapy. Anybody who has seen a SB tube should understand the irony of that dichotomy.

Take care,

chbare.