Your patient is Mr. Abrams, a 63 year-old Black male with a history of non-alcoholic liver cirrhosis, esophageal varices, hyperlipidemia, hypertension, type 2 diabetes, osteoarthritis, hypothyroidism, and renal insufficiency. He does not drink alcohol, smoke or use recreational drugs. He is a retired elementary school teacher, married, and has two grown children. 

Mr. Abrams is brought to the emergency department by ambulance. Paramedics tell you he has been complaining of shortness of breath, weakness, and dizziness as well as black, tarry stools for the past three days. He had a syncopal episode when he stood to get out of bed, which is what prompted his wife to call 9-1-1.

Initial vital signs and interventions

Vital Signs: HR 124, BP 92/63, RR 24 with increased WOB, SpO2 86% on RA, Temp 36.9 Celsius

You place an oxymask on Mr. Abrams at 3 L/min and are relieved to see improvement in his vital signs. HR remains elevated at 119, RR is now 22, work of breathing is decreased, and SpO2 is 93%. You place an IV and draw “a rainbow” of labs, meaning you obtain one of each color just in case it’s needed – a tube for coagulation studies, a tube for CBC, and a tube for chemistries. 

In this fictitious hospital, the labs come back very quickly and you make note of the most relevant ones:

Hgb 6.4 g/dL, ALT 350 U/L, AST 505 U/L, Platelets 110K, Prothrombin time (PT) 31 seconds, Bilirubin 7.7mg/dL, Albumin 3.0 g/dL, Creatinine 2.1 mg/dL, BUN 78, K 3.8 mEq/L, Glucose 174 mg/dL, TSH 2.2 mIU/L.

What does the hemoglobin level indicate and what can we anticipate being ordered for Mr. Abrams?

What makes us suspicious the patient is bleeding from the GI tract?

What do the ALT and AST levels indicate?

What does the platelet count indicate and why is it abnormal? 

What does the prothrombin time indicate?

What does the bilirubin indicate?

What does the albumin level indicate?

What does the creatinine level indicate?

What does the elevated BUN indicate?

What is the BUN/Cr ratio and what does this indicate?

What does the potassium level indicate? 

What does the glucose level indicate?

What does the TSH indicate?

What is the difference between a Type & Screen and a Type & Cross?

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Let’s check in on Mr. Abrams

By now Mrs. Abrams has arrived and is able to provide information about the patient’s home medications, which she has brought with her. You inspect the pill bottles and note Mr. Abrams takes metoprolol, hydralazine, levothyroxine, metformin, furosemide, naproxen, and atorvastatin. 

Why does he take metoprolol?

Hypertension

Why does he take hydralazine?

Why does he take levothyroxine?

Why does he take metformin?

Why does he take furosemide?

Now that we know he takes furosemide, what labs will we double check?

Why does he take naproxen?

Why does he take atorvastatin?

Which medication is a red flag?

What do we want to ask his wife about in regards to this medication?

Physical assessment

You perform a full head-to-toe assessment on Mr. Abrams. Significant findings reveal that he is lethargic, and disoriented to time and situation. You reorient the patient, but repeat assessment shows continued confusion. Heart sounds are normal, pulse is weak and fast in the mid 120’s, capillary refill is 3 seconds. Pt is tachypneic, complaining of shortness of breath, and speaking in three to four word sentences. Accessory muscle use is present and lung sounds are normal. Abdomen is moderately distended, with caput medusae present. Pt shows 2+ edema in bilateral lower extremities. Skin signs reveal jaundice and pallor.

Why is Mr. Abrams lethargic? 

Why is Mr. Abrams disoriented?

Why is his pulse weak?

Are we concerned about his capillary refill?

Why is the patient tachypneic, short of breath, and using accessory muscles?

Why is Mr. Abrams’ abdomen distended?

What is caput medusae?

Why does the patient have 2+ pitting edema in the BLE?

How do we assess for jaundice in Mr. Abrams and what does it indicate?

How do we assess for pallor in Mr. Abrams?

Now, back to Mr. Abrams

While you are calling the MD to let her know that Mr. Abrams’ labs have resulted, you hear a scream coming from his bay. You rush in to see Mrs. Abrams shouting, “He’s bleeding, he’s bleeding!” as Mr. Abrams vomits bright red blood.

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Thankfully, Dr. Jones has also heard the commotion and is rushing to the bedside. She orders an emergent blood transfusion and calls for a central line kit while you suction the oropharynx and maintain Mr. Abrams in a side-lying position. The central line is inserted and secured just as the four units of unmatched O-negative blood are delivered to his bay. Dr. Jones has ordered a stat chest X-ray and the technician has also just shown up. At this time you notice cyanotic skin signs and the monitor reveals a HR of 132, BP 76/43, RR 28, SpO2 72% on 3L oxymask. 

What is the significance of Mr. Abrams vomiting bright red blood?

Why did the blood bank send up O-negative blood?

What’s going on with his blood pressure?

Does Mr. Abrams need volume or does he need vasopressors like norepinephrine to improve his blood pressure?

Why did Dr. Jones insert a central venous catheter?

How do you assess for cyanosis in Mr. Abrams, who has dark skin? 

How would you assess for cyanosis in Mr. Abrams if he had yellow skin tones?

Why did Dr. Jones order a stat chest X-ray?

What’s going on with his vital signs? What concerns you and what are you going to do about it?

What’s next for Mr. Abrams?

Luckily Mr. Abrams maintains an adequate oxygen saturation level on the non-rebreather (whew!) and Dr. Jones calls the gastroenterologist on-call to tell him Mr. Abrams needs a STAT EGD (upper endoscopy). The GI specialist orders a pantoprazole infusion and octreotide infusion to be started immediately and tells Dr. Jones the team can be there in 60 minutes. 

Though the transfusion and fluids have improved Mr. Abrams’ blood pressure, it still has not risen above 88 systolic and Dr. Jones knows patients can bleed out quickly. She calls for an intubation tray and a Blakemore tube. Mr. Abrams is intubated and then Dr. Jones places the Blakemore tube. Once the nasogastric tube is set to intermittent LWS, you see initial drainage of blood and what looks like coffee grounds, but after a minute, it appears to slow down. Good job! We’ve just bought Mr. Abrams some time. 

What is the purpose of pantoprazole in GI bleeds?

What is the purpose of octreotide for Mr. Abrams?

Why was Mr. Abrams intubated? He seemed to be doing okay with the non-rebreather.

What is the purpose of a Blakemore tube?

Why did Dr. Jones consult the gastroenterologist?

What’s up with the coffee ground substance from the NG tube?

Help is here to save the day!

At this point, Mr. Abrams is in the hands of the endoscopy team who have elected to perform this life-saving procedure at the bedside in the ER. As the primary nurse, you monitor Mr. Abrams’ vital signs and, since he is intubated, you manage sedation through a continuous infusion of propofol and fentanyl. The procedure takes approximately one hour and you realize as the team finishes up that Mr. Abrams has been lying in the supine position for quite some time. Before transferring him to the ICU, you perform a skin assessment to look for early signs of pressure injury and thankfully don’t find any. You transport Mr. Abrams to the ICU for close monitoring and are happy to see much improved vital signs: HR 84, BP 110/71, RR 18, SpO2 98% on 40% FiO2. You anticipate Mr. Abrams being extubated in the ICU once the propofol wears off and being transferred to the Med Surg floor tomorrow. Good job!

Why are propofol and fentanyl often used together?

How do you assess for stage 1 pressure injury in a patient with dark skin like Mr. Abrams?

A happy ending

Mr. Abrams is extubated later that day and shows no signs of further bleeding or hemodynamic compromise. He is provided education about avoiding NSAIDs and taught to recognize the signs of GI bleeding. He is discharged home after a three day hospital stay. Good job working with Mr. Abrams!

_____________________________________

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