Location: Ward Patient: Manikin (With Voice – Can give history) Condition: Bleeding oesophageal varices with haemodynamic instability. 67 year old male, on day two of admission for alcoho l withdrawal and investigation of deranged liver function tests, has an episode of hematemesis on the ward. Team are the medical emergency response team called to assess. Initial Observations: RR 20, Sp02 96% RA, HR 110 (Sinus), BP 85/60, Temp 37.4 GCS: 1 5 Appearance: Pale, hospital gown with blood stained front. Past Medical: “ Alcoholic (5 - 10 cans cider/day), Smoker 20/day.” “Sees consultant every few months for a hard liver and some fluid on belly” “Seizures before, most recent 4 months ago” “Gallbladder removed aged 28” Medications: Spironolactone 25mg BD, Bisoprolol 2.5mg, Thiamine 100mg OD. Allergies: NKDA Upper GI Bleed S cenario Dr Tiarnán Byrne Dr James Condren This work is licensed under a Creative Commons Attribution - NonCommercial - ShareAlike 4.0 International L icense Participants: Medical Students (Clinical Years). Team of 5. Competition: SimWars 2019, Cork Round: Semi - Finals Learning Objectives • Identification of the deteriorating patient. • Diagnosis of upper gastrointestinal bleed (UGIB). • Risk factors and causes of UGIB. • General principles for management of UGIB. • Management of bleeding oesophageal varices. • Indications for blood transfusion. • Teamwork and communication. • Seeking specialist help early. • Progression of Scenario Upper GI Bleed Recognition of UGIB Intial Resuscitation & Work - Up Haemodynmically Instability Persists Need for Blood Products & ICU Recognised Transfer for Urgent Endoscopy Failure to Recognise & Treat UGIB Blood Pressure Falls Asystolic Arrest Scenario Ends Exam Results Cardiac: HS I+II normal, nil added. Tachycardic. Respiratory: Airway clear. Air entry normal bilaterally. Gastrointestinal: Palpable liver edge 5cm below costal margin. Abdomen slightly distended (fluid) but non - tender. Bowel sounds positive. DRE normal , no blood. Neuro: No focal neurology. ECG: Sinus Tachycardia VBG: With Appropriate Resuscitation Time 00:00 00:02 00:04 00:06 00:08 10:00 Condition Alert Verbal Verbal Verbal Verbal Verbal Pulse 110 (Sinus) 118 115 110 110 100 BP 92/62 84/60 8 6/52 90 /54 87/60 87 /55 Sp02 98 % RA 96% 96% 96% 96% 96% RR 22 24 24 24 24 24 Without Appropriate Resuscitation Time 00:00 00:02 00:04 00:06 00:08 10:00 Condition Alert Verbal Pain Unresponsive Pulse 11 0 (Sinus) 118 124 142 BP 92/62 80/56 76/ 56 70/ 50 Arrest Arrest Sp02 96% RA 9 6% 90% 82% RR 22 24 30 30 Source: Wikipedia . Creative Commons Licence https://en.wikipedia.org/wiki/Chest_radiograph#/media/File:Normal_posteroanterior_(PA)_chest_radiograph_(X - ray).jpg