GI Bedside Emergencies

Source: ICU FAQ.org

84: What if my patient pulls his NG tube?
85: Pulls his NG tube just far out enough to aspirate tube feeds?
86: Vomits?
87: Vomits tube feeds?
88: Vomits and aspirates?
89: Vomits “coffee grounds”?
90: Bright red blood?
91: What if he starts passing melanotic stool, or BRBPR?
92: What if my patient starts having severe abdominal pain?
93: What if he’s pregnant?
94: What does appendicitis look like?
95: What does a bowel infarct look like?
96: What if my patient has lost bowel sounds, has a K of 6.7 and a pH of 7.10?


GI

84: What if my patient pulls his NG tube?

I’d probably pull mine, too. Please make sure I’m getting enough Haldol. Make that fentanyl.
Have I mentioned the DNR tattoo that I’m going to get? I wonder if the shops in New Hampshire have the radio-opaque tattoo dye that shows up on a chest film: “I am a DNR! My attorney’s phone number is…”. I can just see the scene at the light box.

85: Pulls his NG tube just far out enough to aspirate tube feeds?

Bad. Every now and then you’ll walk into a room and say, "Well, this patient is a very short little guy - that NG tube looks way out to me." This is why you want to check the position of the NG tube at the beginning of every shift. In fact, you should keep in mind that you need to check the position of everything at the beginning of every shift (and during the shift!) – last night I noticed that my patient’s central line looked like it had taken a yank; not mentioned during report. There was a blood return from all three ports, but the only thing to do was to get a film – it was okay, but who knew?

Question for the group: when do you think you should add methylene blue to the patient’s tube feeds?

86: Vomits?

Did he aspirate? Why is he vomiting? Inferior ischemia? Too much tequila before he went down in the airport bar? Did I enter the room? (Why does that happen so much?)

87: Vomits tube feeds?

Did he aspirate? What was the residual last time you checked? Sometimes the end of an NG tube will tuck up into a corner of the stomach – if my patient hasn’t got much in the way of bowel sounds and hasn’t had much aspirate in a day, I sometimes pull the tube back a bit or advance it a bit. Sometimes you find a 600cc surprise this way.

Sometimes an NGT will get too far in. You might see a patient losing really enormous amounts of NG drainage, maybe 5 liters a day – the tube may have made it’s way into the duodenum. The drainage is usually lighter and clearer than your usual gastric output, and there’s really too much of it – if you think that the tube is too far in, you may find that if you pull it back while leaving it to low suction, the drainage may suddenly change color to a nice gastric green. It’ll change anyhow, once the tip comes back into the stomach.

88: Vomits and aspirates?

Did he aspirate? Guess so! You were keeping the head of the bed at 45ยบ, right? Checking aspirates, right? Has she stooled lately? Sometimes it just happens, as do many things, no matter how careful or how perfect your care is. Watch the person carefully – almost by definition they’re going to have a new pneumonia to deal with. Does she need blind suctioning? Reglan? Intubation?

89: Vomits "coffee grounds"?

Did she aspirate? The classic upper GI bleed scenario. Check a crit, watch her pressure, saline lavage through an NG tube The team definitely inserts this one, esophageal varices can pop if they get poked by an NG tube going down, but how do you know ahead of time? History of previous bleeds? Cirrhosis? Is the patient getting something to block acid secretion?

90: Bright red blood?

"BRB": a little worse than coffee grounds. This person is probably going to need an endoscopy – should he be intubated for airway protection before they do it? Can the patient consent for transfusion? If no one is available for consent, they team can sign the consent themselves, indicating that they couldn’t reach any "significant others", and that the situation was emergent.

91: What if he starts passing melanotic stool, or BRBPR?

Same idea, different place. Depending on the severity of the bleed, the patient can be transfused and watched, not transfused and watched, colonoscopized (how exactly do they expect a patient in the midst of an acute abdominal process to drink all that go-lytely, exactly?), or maybe even operated on. Make sure that you’re in close communication with the blood bank, and have supplies set up ahead of time. We sometimes "call for the cooler" – which will have all available units of say, A-negative FFP that are due to expire in the next six hours – something like that.

92: What if my patient starts having severe abdominal pain?

This usually happens to me in the car. I need to stay out of Starbucks. Sometimes this can be a whole lot of nothing – other times, some deadly process. Assess carefully, document carefully, drag the resource nurse and the team into the room, follow up. Abdominal CT scan? RUQ ultrasound (what would that be looking for?) Does surgery need a heads-up about the patient?

93: What if he’s pregnant?

This almost happened to me in a car. I never got as far as ultrasound though.

94: What does appendicitis look like?

Hurts! I understand that it can show up anywhere in the abdomen. Where is McBurney’s Point? –two exits past Dennisport on the Cape, right? I know a good place for lobster rolls.

Jayne: “This whole part is stupid.” (Just for the record.)

95: What does a bowel infarct look like?

This is something that we actually do see at times, unlike appendicitis, although all sorts of things are always possible. It’s important to remember that hypotension can produce really serious effects in all kinds of places, especially if your patient is a vasculopath to start out with. A patient with high blood pressure at home may have kidneys that go into ATN after just an hour or two of hypotension. (They may have blood pressure like that because their renal arteries are stenosed, and the kidneys are cranking out angiotensin and all, trying to perfuse themselves.) Those renals may be stenosed just like their coronary ones are, and maybe like their carotids, and maybe their mesenteric…)

No bowel sounds, that’s for sure. And what do you think their chemistries might be doing?

96: What if my patient has lost bowel sounds, has a K of 6.7 and a pH of 7.10?

See, you already knew! Dead tissue of any size in the body is going to release all the intracellular K it has, and all the poorly perfused/ dead/ almost dead tissue involved is going to go into anaerobic respiration before it dies, producing a big lactic acidosis. These people have lactate levels upwards of 10 – your basic humongous metabolic acidosis. Other things being equal, what will their ABGs look like? (A lactate of ten is high enough to make us old nurses cringe. Saw somebody in the 20’s last week, but for different reasons. Your basic Real Bad Sign.)

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