Correct pt position for vomiting pt going into shock - PUD hemorrhage

[jonorato]

Currently studying Peptic Ulcer Disease. In discussing priority interventions for a hemorrhage complication where the pt is actively vomiting large amounts of blood and starting to go into shock my prof. said to put the pt. into the trendelenburg position.

My thought was that this would not be the "best" position for the pt based on the ABC's.

Trendelenburg would be contraindicated d/t risk for aspiration. I could see doing a modified trendelenburg (elevate legs only), or side lying/recovery position. I could see putting a pt's HOB down slightly if you were to stay there with suction ready to go. My thought is the priority is to keep that airway patent!

Plus won't the physician be coming in and placing an NGT STAT? are they able to do that when the pt is in trendelenburg?

I don't know, maybe I"m over thinking this...wouldn't be the first time!

Thanks for the responses in advance.

[Esme12, ASN, BSN, RN]

Oh my gosh! I love you for posting that journal article & the added info! I saw the same thing on medscape. I'm such a hound for medscape and additional info. My clinical classmates always laugh and roll their eyes when I start talking about a "journal article I read last night" or "new evidence based practice says". It's a good thing they love the nerd in me so much!

Medscape is my fav resource.

Your instructor is incorrect -- but that does not matter at this point. Once you've respectfully sought clarification and been given an answer, parrot back to him/her exactly what s/he wants to hear.

In the real world, though, that patient would be sitting with the HOB raised to 60-90 degrees in order to minimize the risk of aspiration. The patient would ultimately get an NG but that is much easier said than done, especially if someone is already vomiting. Placing the patient in Trendelenberg, or even raising the feet/legs is not going to do much for this person.

The thing that this patient needs most urgently is two large bore IVs and blood products given via rapid infuser. Zofran (and better yet, phenergan or even Haldol) can help buy some time.

The vomiting is a problem, to be sure, but the patient you describe is exsanguinating and may very well code on you without prompt administration of blood products.

Acute GI bleeds are a big, big deal.

[icuRNmaggie, BSN, RN]

Song in my heart is spot on. IV access is the priority with UGI hemorrhage. Expect an intubation, bedside EGD and central line placement. Initiate the massive transfusion protocol.

An upper GI hemorrhage will brady down quickly. Have atropine ready.

[nurseprnRN, BSN, RN]

PUD doesn't carry the risk for damage when placing an NGT that the usual big bleeds associated with hepatic failure do. I would never sink a tube in somebody with bleeding esophageal varices, because you tear another of those babies and you're in for a world of mess. Call the doc to do it and handle the problems that may occur...and don't let the R1 do it ?

The OP said her case study was about PUD, so not so much of an issue about who sinks the tube there, though the bigger the better because there WILL be clot. All the rest from the above posters applies.

[icuRNmaggie, BSN, RN]

The worst UGI bleeds that I have seen were from DeiuxLafoy arterial malformations in the stomach, cryptogenic liver failure in patients on long term methotrexate, end stage liver failure from hep C, and a pt with a rare familial autosomal liver failure. The hemorrhaging is sudden and massive in these patients.

The varices can be huge and I would never place an NGT in a pt vomiting BRB.

I personally have not seen a massive bleed in a patient with peptic ulcer disease, just the usual coffee ground emesis.

[icuRNmaggie, BSN, RN]

True story : I had a gastric ulcer patient who worked at a racetrack. He was taking horse motrin and washing it down with beer. He was very anemic but not actively bleeding.