MedEd Portal
Human Patient Simulation
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Title: GI Bleed
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Target Audience: First Year Emergency Medicine Resident
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Learning Objectives:
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Environment:
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Environment
– 10 bed rural Emergency Department
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Manikin Set Up
– Code cart
– Intubation equipment
– Code drugs
– RSI drugs
– O neg blood
Props
– EKG
– Normal CXR
Distractors
– Lower GI bleeding episode and pulseless electrical activity (PEA)
arrest
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Primary
– Recognize and promptly resuscitate a patient with a severe lower
GI bleed
– Recognize potential mediation interactions and significant
consequences thereof
Secondary
– Obtain additional history including medications to aid in
management
– Correct warfarin-induced coagulopathy
Critical Actions Checklist
– IVF resuscitation
– 2 large bore IVs
– Type and Cross with O negative blood readily available
– Consult GI for colonoscopy
– Admit to the ICU
Actors: (All roles may be played by residents participating)
- Resident running the case
- Nurse to place IVs and give medications
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Respiratory tech
Another resident to be the GI or MICU consultant at another hospital (able
to give recommendations)
Case Narrative:
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Chief Complaint: Bloody Stools
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History: 68 year-old male presents with three episodes of bloody diarrhea
since last night. He notes large amounts of bright red blood in the toilet.
He has been feeling very weak, lightheaded, and dizzy, especially when he
stands up. He endorses mild shortness of breath and chest discomfort
along with cough. He has mild dull lower abdominal pain with his
diarrheal episodes.
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Additional history given only if asked: He was just recently treated for
a respiratory infection and has had 3 days of Levofloxacin.
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PMHx: Atrial fibrillation; hypertension; hyperlipidemia; diabetes
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Social Hx: Denies tobacco, alcohol, or illicit drug use. Retired and lives
with wife.
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Meds: Metformin; Warfarin; Lisinopril; Simvastatin; Aspirin;
Levofloxacin
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Surgical Hx: CABG 7 years ago
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Allergies: No known drug allergies.
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ROS: No fevers or vomiting.
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Physical Exam
– BP 99/64, HR 112, RR 22, Temp 36.7, O2sat 93% RA, GCS 15
– HEENT – NCAT, pupils 5mm bilaterally and sluggishly reactive,
– Resp – mild tachypnea; clear breath sounds bilaterally
– CVS – tachycardia; holosystolic murmur
– Abd – soft, non distended; nontender
– Rectal- gross blood, heme positive
– Ext – no gross deformities or ecchymosis
– Neuro – GCS 15; moving all extremities; grossly intact
– Skin –pale, mottled, cool
Instructors Notes:
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Tips to Keep the Scenario Flowing
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During the history, the patient has another massive episode of
bright red lower GI bleeding. His blood pressure drops, and he is
in PEA until he is adequately resuscitated. Have patient start
compressions and ACLS protocol.
Have the resident proceed with intubating after PEA. Also have
the resident explain or demonstrate how to place a nasal gastric
tube.
The resident will need to transfer the patient to a hospital with
access to specialists such as GI. The resident will need to call the
gastroenterologist at the outside facility to alert him that the patient
is being transferred. The resident should also advise discontinuing
the Levofloxacin.
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Tips to Direct Actors
– The director should encourage frequent vital sign rechecks and
mental assessments of the patient
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Scenario Steps
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Optimal Management Path
 The resident should recognize the signs and symptoms of
anemia and dehydration in the patient. Two large bore IVs
should be established with IV fluid boluses going. Labs
should ordered early on including a type and cross and
coagulation panel. O negative blood will be readily
available. The resident should treat the coagulopathy with
Vitamin K and FFP. The resident should consult the GI
service for a speedy colonoscopy and management in this
patient.
Potential Complications Path
 The resident could fail to recognize the coagulopathy needs
to be corrected.
 The resident can fail to identify Levofloxacin as likely
contributor to elevated INR and fail to discontinue it.
Potential Errors Path
 Failure to begin aggressive fluid resuscitation from the
beginning
 Not ordering O negative blood if type and cross takes
significant time to complete
Imaging and Labs
CBC: WBC 13, Hgb 4.3, Hct 13, Plts 178
Chem 10: Na 143, K 3.9, Cl 109, CO3 22, BUN 28, Creat 1. 5, Ca 7.8, Mg
1.8, Phos 3.9
Coags: PT 54, PTT 28, INR 5.6
CXR: unremarkable
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- EKG: Q waves in inferior distribution, unchanged from prior EKG
Debriefing Plan:
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Pilot Testing and Revision:
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Topics to discuss
– In this particular situation, what do you think caused the patient’s
GI bleed?
– What medications should be used with caution in patients taking
Warfarin?
– What are common causes of lower GI bleeds?
Number of Participants – 4
Evaluation form for participants – generic handout
Authors:
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John B. Seymour M.D. University of North Carolina Department of
Emergency Medicine, PGY – 3
Rochelle Chijioke, M.D. University of North Carolina Department of
Emergency Medicine, PGY-2
Kevin Biese M.D. University of North Carolina Department of Emergency
Medicine, Associate Professor and Residency Director
Graham Snyder M.D. Wake Med Health and Hospitals Department of
Emergency Medicine, Assistant Program Director and Simulation Director
Jan Busby-Whitehead M.D. University of North Carolina Division of
Geriatric Medicine/ Institute on Aging, Professor and Chief
Copyright © 2011 The University of North Carolina School of Medicine