Upper Gastrointestinal Haemorrhage
76 General Medical Emergencies
(i) Add GTN 200 mg to 500 mL of 5% dextrose, i.e. 400 g/mL,
using a glass bottle and low-absorption polyethylene infusion set.
(ii) Infuse initially at 1 mL/h, maintaining the systolic BP above
100 mmHg. Progressively increase to ≥20 mL/h, avoiding
hypotension.
5 Commence mask continuous positive airways pressure (CPAP) respiratory
support:
(i) Use a dedicated, high-flow fresh gas circuit, tight-fitting mask
and variable resistor valve, starting at 5–10 cmH 2 O.
(ii) A trained nurse must remain in attendance at all times, as some
patients will not tolerate the mask.
(iii) Never simply use wall oxygen with a black anaesthetic mask and
head harness, as this will asphyxiate the patient due to inadequate
fresh gas flow.
6 Morphine 0.5–2.5 mg i.v. with an antiemetic such as metoclopramide 10 mg
i.v. is rarely helpful, and it may further obtund the patient particularly if the
patient is tired or has COPD.
7 Admit the patient under the medical team.Acute upper airway obstruction
See page 13.UPPER GASTROINTESTINAL HAEMORRHAGE
DIAGNOSIS
1 Causes of upper gastrointestinal haemorrhage include:
(i) Peptic ulceration (over 40% of cases):
(a) duodenal ulcer (DU)
(b) gastric ulcer (GU) less common.
(ii) Gastric erosions or gastritis:
(a) post-alcohol
(b) drug-induced (salicylates, non-steroidal anti-inflammatory
drugs [NSAIDs], steroids).
(iii) Reflux oesophagitis.
(iv) Bleeding oesophageal or gastric varices associated with portal
hypertension (due to cirrhosis, often alcoholic).
(v) Mallory–Weiss tear (oesophageal tear following vomiting or
retching).