haemetemesis teaching

I agree.\n\nIt's best not to give it before endoscopy as long as there is no massive delay in scoping.\n\nTheoretically it can make it more difficult to interpret the endoscopy findings.\n\nIn practice it doesn't make too much difference.\n\nBut we can contact the consultant right now and get his advice.\n\n- - - - -\n\nShall we catheterise her?\n\n[[No catheterise]]\n\n[[Yes catheterise]]

<<fadeoutsound $soundFX2>>\n<<fadeinsound $soundFX3>>\n\nShe fills a vomit bowel with blood while your busy bleeping the reg.\n\n"Doctor do something" shouts nurse Jane.\n\nHer eyes close.\n\nYou commence CPR.\n\nJane calls the crash team.\n\n[[30 min later she is pronounced dead]]

Good.\n\n- - - - -\n\nHow low do the platelets have to be, to give a platelet transfusion?\n\n\n[[<90]]\n\n[[<50]]\n\n[[<45]]

<<stopallsound>>\n<<playsound $soundFX3>>\n\nShe fills a vomit bowel with blood.\n\nBy now she is shut down.\n\nYou can't get IV access.\n\nHer eyes close.\n\nYou commence CPR.\n\nNurse Jane calls the crash team.\n\n[[30 min later she is pronounced dead]]

She fills a vomit bowel with blood.\n\nBy now she is shut down.\n\nYou can't get IV access.\n\nHer eyes close.\n\nYou commence CPR.\n\nNurse Jane calls the crash team.\n\n[[30 min later she is pronounced dead]]

<<fadeoutsound $soundFX1>>\n<<fadeinsound $soundFX2>>\n\nShe fills a vomit bowel with blood while your busy bleeping the reg.\n\n"Doctor do something" shouts nurse Jane.\n\n[[Put two big cannula's in the ACF's|reg1 cannula1a]]\n\n[[Press the crash button|crash1a]]

<<set $soundFX1 = "heartbeat3normalbpmLONG.mp3">>\n<<set $soundFX2 = "heartbeat3fastbpmLONG.mp3">>\n<<set $soundFX3 = "defibrillator2dies.mp3">>\n<<set $soundFX4 = "hospitalNoiseLONGquiet.mp3">>\n\n<<playsound $soundFX4>>\n\nYour the only junior doctor on the ward.\n\nYou have a million jobs to do.\n\nYour reg and consultant have gone off to see the ouliers.\n\nNurse Jane comes to you and asks if you could review Miss Kate.\n\n"She just doesn't look right".\n\n\n\n[[Tell her your busy, and to wait for the reg to come back]]\n\n[[Go and see the patient]]

She fills a vomit bowel with blood while your busy bleeping the reg.\n\n"Doctor do something" shouts Jane.\n\n\n\n[[Get a focused Hx from the patient|focused Hx3]]\n\n[[Put two big cannula's in the ACF's|cannula3]]\n\n[[Press the crash button|crash3]]

<<fadeoutsound $soundFX2>>\n<<fadeinsound $soundFX3>>\n\nShe fills another vomit bowel with blood.\n\nBy now she is shut down.\n\nYou can't get IV access.\n\nHer eyes close.\n\nYou commence CPR.\n\nJane calls the crash team.\n\n[[30 min later she is pronounced dead]]

Her BP is stable now.\n\nSo we should base the transfusion decision on the Hb.\n\nUnless she loses a lot of blood now, in which case we could just transfuse.\n\nIn terms of targets.\n\n8 is a reasonable target in a young healthy person.\n\nIn the elderly or those with comorbidities you can go closer to 10.\n\n- - - - -\n\nShe had a dose of Omeprazole upstairs on the Acute Medical Unit last night.\n\nShall we give another dose now?\n\n[[Yes|YesPPI]]\n\n[[No|NoPPI]]

I agree.\n\nThat way we can measure urine output and determine if we are adequately resucitating or fluid overloading.\n\nShe doesnt look fit enough to be using a commode or the toilet.\n\n- - - - -\n\nThe reg calls the consultant.\n\nThe patient is taken to endosopy.\n\nA large actively bleeding gastric ulcer is detected and zapped with adrenaline and then clipped.

<<fadeoutsound $soundFX2>>\n<<fadeinsound $soundFX3>>\n\nBy now she is shut down.\n\nYou can't get IV access.\n\nHer eyes close.\n\nYou commence CPR.\n\nJane calls the crash team.\n\n[[30 min later she is pronounced dead]]

<<fadeoutsound $soundFX2>>\n<<fadeinsound $soundFX3>>\n<<unloopsound $soundFX3>>\n\nBy now she is shut down.\n\nYou can't get IV access.\n\nHer eyes close.\n\nYou commence CPR.\n\nJane calls the crash team.\n\n[[30 min later she is pronounced dead]]

<<fadeoutsound $soundFX1>>\n<<fadeinsound $soundFX2>>\n\nBP 87 / 61\n\nHR 98\n\nRR 22\n\nSats 98% air\n\nShe suddenly fills a vomit bowel full of blood.\n\nShe has a pink cannula in her Rt hand.\n\n[[Get a focused Hx from the patient|hxCorrect]]\n\n[[Go and bleep the reg|regCorrect]]\n\n[[Put two big cannula's in the ACF's|Put two big cannula's in the ACF's]]\n\n[[Press the crash button|crashCorrect]]

Good.\n\n- - - - -\n\nShe is not known to have chronic liver disease.\n\nShall we give terlipressin?\n\n[[Yes|terlipressinYES]]\n\n[[No|terlipressinNO]]

<<fadeoutsound $soundFX2>>\n<<fadeinsound $soundFX3>>\n\nShe fills a vomit bowel with blood.\n\nBy now she is shut down.\n\nYou can't get IV access.\n\nHer eyes close.\n\nYou commence CPR.\n\nJane calls the crash team.\n\n[[30 min later she is pronounced dead]]

<<fadeoutsound $soundFX4>>\n<<fadeinsound $soundFX1>>\n\n15 min later you hear screams and shouting.\n\n"Doctor, doctor".\n\nYou rush to the commotion.\n\nThe patient is lying in bed.\n\nBlood dribling from her mouth drentching her gown.\n\nShe has a pink cannula in her Rt hand.\n\nThe nurses look at you.\n\n[[Get a focused Hx from the patient]]\n\n[[Go and bleep the reg]]\n\n[[Put two big cannula's in the ACF's]]\n\n[[Press the crash button]]

<<fadeoutsound $soundFX1>>\n<<fadeinsound $soundFX2>>\n\nHer eyes are open, but she is not answering your questions.\n\n[[Put two big cannula's in the ACF's|cannula3a]]\n\n[[Press the crash button|crash3a]]

You suppose you could.\n\nThey say it's best not to give it before endoscopy as long as there is no massive delay in scoping.\n\nTheoretically it can make it more difficult to interpret the endoscopy findings.\n\nIn practice it doesn't make too much difference.\n\nBut we can contact the consultant right now and get his advice.\n\n- - - - -\n\nShall we catheterise her?\n\n[[No catheterise]]\n\n[[Yes catheterise]]\n\n

<<fadeoutsound $soundFX1>>\n<<fadeinsound $soundFX2>>\n\nYou insert the cannulas.\n\n[[Give 250ml NaCl STAT]]\n\n[[Give 250ml Volplex STAT]]\n\n[[Give 1 Litre NaCl over 30 min|IV 1 litre STAT]]

She keeps saying she feels dizzy, SOB and has epigastric pain.\n\n[[Go bleep the reg|regCorrect2a]]\n\n[[Put in two big cannulas|hx cannul4a]]

"What are you panicking about?" shouts nurse Jane.\n\n"She's not arresting".\n\n"Do something".\n\n[[Get a focused Hx from the patient|hxCorrect3]]\n\n[[Put two big cannula's in the ACF's|cannulaCorrect3]]

<<fadeoutsound $soundFX2>>\n<<fadeinsound $soundFX1>>\n\nYou've sent off the bloods including FBC.\n\nAnd request 4 units of blood.\n\nThe reg arrives on the ward.\n\n"She's really hypotensive. 250ml boluses are not going to do much. Give a litre over 30 min"\n\n- - - - -\n\n"What's your target BP?"\n\n[[>90]]\n\n[[>100]]\n\n[[>120]]

<<stopallsound>>\n<<playsound $soundFX2>>\n\n"What are you dong?" shouts nurse Jane.\n\n"Were already here!"\n\n"Do something."\n\n[[Put two big cannula's in the ACF's|cannula1a]]\n\n[[Bleep the reg|reg1a]]

<<fadeoutsound $soundFX1>>\n<<fadeinsound $soundFX2>>\n\n"What are you dong?" shouts nurse Jane.\n\n"Were already here!"\n\n"Do something."\n\n[[Put two big cannula's in the ACF's|cannula3a]]\n\n[[Get a focused Hx from the patient|focused Hx 3a]]

15 min later Jane returns to you.\n\n"She really doesn't look right. I think you should review her".\n\n\n[[Tell her your coming straigtaway to get her off your back and continue your jobs]]\n\n[[Go and see the patient]]\n\n[[Tell her your still busy, and to wait for the reg]]

Maybe.\n\nI think 8 or 9 is a reasonable target in a young healthy person.\n\nIn the elderly or those with comorbidities you can go closer to 10.\n\n- - - - -\n\nShe had a dose of Omeprazole upstairs on the Acute Medical Unit last night.\n\nShall we give another dose now?\n\n[[Yes|YesPPI]]\n\n[[No|NoPPI]]

Mis Kate

15 min later you hear screams and shouting.\n\n"Doctor, doctor".\n\nYou rush to the commotion.\n\nThe patient is lying in bed.\n\nBlood dribling from her mouth drentching her gown.\n\nShe has a pink cannula in her Rt hand.\n\nThe nurses look at you.\n\n[[Get a focused Hx from the patient]]\n\n[[Go and bleep the reg]]\n\n[[Put two big cannula's in the ACF's]]\n\n[[Press the crash button]]

<<fadeoutsound $soundFX1>>\n<<fadeinsound $soundFX2>>\n\nYou go and bleep the reg.\n\nHe doesn't answer.\n\nWhen you return she fills another vomit bowel with blood.\n\n[[Get a focused Hx from the patient|hxCorrect3]]\n\n[[Put two big cannula's in the ACF's|cannulaCorrect3]]\n\n[[Press the crash button|crashCorrect3]]

I agree.\n\nShould only use it for varicieal bleeds to treat hypotension.\n\n- - - - -\n\nHer last Hb was 9.3\n\nAre you going to transfuse her blood regardless of the result of the blood you took, or have you got a target Hb?\n\n[[regardless, just transfuse as she has active bleeding]]\n\n[[8]]\n\n[[9]]\n\n[[10]]

Nearly.\n\nThe cut off's <50.\n\n- - - - -\n\nShe is not known to have chronic liver disease.\n\nShall we give terlipressin?\n\n[[Yes|terlipressinYES]]\n\n[[No|terlipressinNO]]

I think we should aim a little lower.\n\n8 or 9 would be a better target in a young healthy person.\n\nIn the elderly or those with comorbidities you can go closer to 10.\n\n- - - - -\n\nShe had a dose of Omeprazole upstairs on the Acute Medical Unit last night.\n\nShall we give another dose now?\n\n[[Yes|YesPPI]]\n\n[[No|NoPPI]]

<<fadeoutsound $soundFX1>>\n<<fadeinsound $soundFX2>>\n\n"What are you panicking about?" shouts Jane.\n\n"She's not arresting".\n\n"Do something".\n\n[[Get a focused Hx from the patient|hxCorrect4]]\n\n[[Go and bleep the reg|regCorrect4]]\n\n[[Put two big cannula's in the ACF's|Put two big cannula's in the ACF's]]

She's not really responding.\n\n\n[[Put two big cannula's in the ACF's|cannulaCorrect3]]

She fills a vomit bowel with blood while your busy bleeping the reg.\n\n"Doctor do something" shouts Jane.\n\n[[Put two big cannula's in the ACF's|bleepreg2 cannula2a]]\n\n[[Get a focused Hx from the patient|focused Hx 2a]]

No. We don't need it to be that high.\n\n100 sytolic is good enough.\n\n- - - - -\n\nHow low do the platelets have to be, to give a platelet transfusion?\n\n\n[[<90]]\n\n[[<50]]\n\n[[<45]]

"What are you panicking about?" shouts nurse Jane.\n\n"She's not arresting".\n\n"Do something".\n\n\n[[Go bleep the reg|regCorrect2a]]\n\n[[Put in two big cannulas|hx cannula2a]]

"What are you panicking about?" shouts nurse Jane.\n\n"She's not arresting".\n\n"Do something".\n\n\n[[Put two big cannula's|reg cannula]]

<<fadeoutsound $soundFX2>>\n<<fadeinsound $soundFX3>>\n\nHer eyes are open, but she is not answering your questions.\n\nShe fills another vomit bowel with blood.\n\n"Doctor do something" shouts Jane.\n\nHer eyes close.\n\nYou commence CPR.\n\nJane calls the crash team.\n\n[[30 min later she is pronounced dead]]

<<fadeoutsound $soundFX1>>\n<<fadeinsound $soundFX2>>\n\nShe keeps saying she feels dizzy, SOB and has epigastric pain.\n\n[[Press the crash button|crashcorrect2]]\n\n[[Go bleep the reg|regCorrect2]]\n\n[[Put in two big cannulas|hx cannula]]

No.\n\nIf the platelets <50 then we give a tranfsusion.\n\n- - - - -\n\nShe is not known to have chronic liver disease.\n\nShall we give terlipressin?\n\n[[Yes|terlipressinYES]]\n\n[[No|terlipressinNO]]

I disagree.\n\nWe should only use it for varicieal bleeds to treat hypotension.\n\n- - - - -\n\nHer last Hb was 9.3\n\nAre you going to transfuse her blood regardless of the result of the blood you took, or have you got a target Hb?\n\n[[regardless, just transfuse as she has active bleeding]]\n\n[[8]]\n\n[[9]]\n\n[[10]]

<<fadeoutsound $soundFX2>>\n<<fadeinsound $soundFX1>>\n\nRepeat BP 109/69\n\nYou've sent off the bloods including FBC.\n\nAnd request 4 units of blood.\n\nThe reg arrives on the ward.\n\n- - - - -\n\n"Your giving IV fluids. What's your target BP?"\n\n[[>90]]\n\n[[>100]]\n\n[[>120]]

<<fadeoutsound $soundFX1>>\n<<fadeinsound $soundFX2>>\n\nShe fills another vomit bowel with blood.\n\nBy now she is shut down.\n\nYou can't get IV access.\n\nHer eyes close.\n\nYou commence CPR.\n\nNurse Jane calls the crash team.\n\n[[30 min later she is pronounced dead]]

No. That's too low.\n\nAim for >100.\n\n- - - - -\n\nHow low do the platelets have to be, to give a platelet transfusion?\n\n[[<90]]\n\n[[<50]]\n\n[[<45]]

While your busy bleeping the reg, she vomits another bowel full of blood.\n\n[[Put two big cannula's|reg cannula]]\n\n[[Press the crash button|crashcorrect2a]]

<<fadeoutsound $soundFX4>>\n<<fadeinsound $soundFX1>>\n\nYou draw the curtains round.\n\nJane is standing next to you.\n\nMiss Kate is a 27y lady who was admitted on the Acute Medical Unit with haematemesis last night.\n\nHer Hb was 9.8 and they gave 40mg IV omeprazoe. \n\nPMH = nil.\n\nSH = no alcohol.\n\nShe looks ok.\n\nShe feels a little dizzy but is otherwise well.\n\nObs from 45min ago:\n\nBP 116 / 71\n\nHR 73\n\nRR 18\n\nSats 98% air\n\nNothing on examination except same slight tenderness in the epigastrium.\n\n[[Reassure nurse that nil acute and continue your jobs]]\n\n[[Ask for a repeat set of obs]]

<<fadeoutsound $soundFX1>>\n<<fadeinsound $soundFX2>>\n\n"What are you dong?" shouts nurse Jane.\n\n"Were already here!"\n\n"Do something."\n\n[[Get a focused Hx from the patient|focused Hx 2]]\n\n[[Go and bleep the reg|bleepreg2]]\n\n[[Put two big cannula's in the ACF's|cannula2]]

<<fadeoutsound $soundFX2>>\n<<fadeinsound $soundFX3>>\n<<unloopsound $soundFX3>>\n\nWhile your busy bleeping the reg, she vomits another bowel full of blood and stops breathing.\n\nYou commence CPR.\n\nJane calls the crash team.\n\n[[30 min later she is pronounced dead]]

Her eyes are open, but she is not answering your questions.\n\n[[Bleep the reg|reg2a]]\n\n[[Put two big cannula's in the ACF's|cannula2a]]

The nurse takes a few minutes to set up the infusion pump to give 250ml.\n\nShe is still severely hypotensive.\n\nBP 83 / 55\n\n\n[[Give another 250ml bolus]]\n\n[[Give 1 litre over 30 min|IV 1 litre STAT]]

You go and bleep the reg.\n\nHe doesn't answer.\n\nWhen you return she fills another vomit bowel with blood.\n\n[[Put in two big cannulas|hx cannul4a]]

<<fadeoutsound $soundFX2>>\n<<fadeinsound $soundFX3>>\nHer eyes are open, but she is not answering your questions.\n\nShe fills another vomit bowel with blood.\n\n"Doctor do something" shouts Jane.\n\nHer eyes close.\n\nYou commence CPR.\n\nJane calls the crash team.\n\n[[30 min later she is pronounced dead]]

<<fadeoutsound $soundFX2>>\n<<fadeinsound $soundFX3>>\n\n"What are you dong?" shouts nurse Jane.\n\n"Were already here!"\n\n"Do something."\n\nHer eyes close.\n\nYou commence CPR.\n\nJane calls the crash team.\n\n[[30 min later she is pronounced dead]]

<<unloopsound $soundFX3 >>\n\nYour called to the consultants office.\n\nHe shows you the medical notes with Nurse Jane's documentation.\n\nThe consultant also asks if your indemnity cover is up to date.\n\nYou never forget the patients name for the rest of your life.\n\nMiss Kate turns out to be your biggest 'Mis take'.

Her eyes are open, but she is not answering your questions.\n\n[[Go and bleep the reg|reg1]]\n\n[[Put two big cannula's in the ACF's|cannula1]]\n\n[[Press the crash button|crash1]]

<<fadeoutsound $soundFX2>>\n<<fadeinsound $soundFX3>>\n\n"What are you dong?" shouts Jane.\n\n"Were already here!"\n\n"Do something."\n\nHer eyes close.\n\nYou commence CPR.\n\nJane calls the crash team.\n\n[[30 min later she is pronounced dead]]

I think we should catheterise.\n\nThat way we can measure urine output and determine if we are adequately resucitating or fluid overloading.\n\nShe doesnt look fit enough to be using a commode or the toilet.\n\n- - - - -\n\nThe reg calls the consultant.\n\nThe patient is taken to endosopy.\n\nA large actively bleeding gastric ulcer is detected and zapped with adrenaline and then clipped.

<<fadeoutsound $soundFX2>>\n<<fadeinsound $soundFX3>>\n\nShe fills a vomit bowel with blood while your busy bleeping the reg.\n\n"Doctor do something" shouts Jane.\n\nHer eyes close.\n\nYou commence CPR.\n\nJane calls the crash team.\n\n[[30 min later she is pronounced dead]]

Yes 8 is a reasonable target in a young healthy person.\n\nIn the elderly or those with comorbidities you can go closer to 10.\n\n- - - - -\n\nShe had a dose of Omeprazole upstairs on the Acute Medical Unit last night.\n\nShall we give another dose now?\n\n[[Yes|YesPPI]]\n\n[[No|NoPPI]]