This case is written by Dr. Cheryl ffrench. Dr. ffrench is an emergency physician in Winnipeg and has also served as the Emergency Department’s Medical Director of Simulation since 2011. She has developed four separate simulation curricula for EM including a joint trauma simulation program with General Surgery.

Why it Matters

Massive upper GI bleeds are very challenging to manage. This case takes learners through all of the reasons that upper GI bleeds can be so difficult. In particular, it highlights the following key aspects of management:

Recognizing the need for early blood transfusion in a hypotensive, bleeding patient and anticipating the need for massive transfusion.

Anticipating and appropriately planning the need for controlling the airway while understanding that a bloody airway is a difficult airway.

Inserting a Sengstaken-Blakemore tube, which is a rarely performed procedure in the ED.

Clinical Vignette

You are working in a tertiary care centre emergency department with full consultant services. A patient is brought into the ED with active hematemesis. He complains of general chest discomfort and nausea. He insists that he is “fine” and just “needs a beer”. He is triaged to the resuscitation area.

Case Summary

A 58-year-old male known for alcoholism presents to the emergency department with an active, massive upper GI bleed due to esophageal varices. The patient deteriorates into hypovolemic shock requiring medical management, massive transfusion, intubation for airway protection, and insertion of a Blakemore tube.

Download the case here: Massive UGIB

ECG for case is found here:

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

CXR for case is found here:

(CXR source: http://radiopaedia.org/images/220869)

Post-intubation CXR for case is found here:

(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)

Blakemore tube x-ray found here:

(Image source: http://images.radiopaedia.org/images/585576/652c659aa92ffac9625a44acfa7b9a_big_gallery.jpg)