© Springer International Publishing AG 2018Chad G. Ball and Elijah Dixon (eds.)Treatment of Ongoing Hemorrhagedoi.org/10.1007/978-3-319-63495-1_21
21. Hemorrhage in the Critical Care Environment: Do We Have to Go Back to the OR?
General Surgery, Trauma and Critical Care, Departments of Surgery and Medicine, Schulich School of Medicine, Western University, London, ON, Canada
Department of Surgery, University of British Columbia, Vancouver, BC, Canada
KeywordsICUCoagulopathyTracheo-innominate fistulaPulmonary artery ruptureTrauma
A morbidly obese 66-year-old female has been admitted to your intensive care unit for 21 days following a neurologic insult. The nurse interrupts your rounds to notify you that the patient has copious amounts of blood pouring out of her tracheostomy and is grossly unstable…
Patients in the intensive care unit (ICU) are by definition complex, are usually very ill, and can be some of the most demanding patients within our practices to manage. They are often in multi-organ failure, hemodynamically unstable, on vasopressors, and/or mechanically ventilated. There may be multiple, often conflicting reasons to account for their tachycardia or hypotension. As such, their physiologic response to bleeding may not be as obvious as one would expect. It will also certainly be more challenging to diagnose.
Having said that, any change in clinical and physiologic status of an ICU patient mandates immediate and thorough evaluation. Bleeding should always be in the differential, and like many things in surgery, we need to rapidly identify or exclude the most serious threats to life.
Look for Surgical Bleeding !!!
Surgical bleeding needs to be identified and treated aggressively with definitive surgery or with some interventional procedure. If you are not a surgeon, call one!
At the bedside, look for obvious bleeding. Check surgical sites, all orifices, and for that matter the bed. Check all tubes (nasogastric tube, chest tubes, urinary catheter, or surgical drains). Evaluate all body cavities for fluid which can be readily done with clinical examination and point of care ultrasound.
Once a bleeding source has been identified, interventions include transfusion of warmed blood products (and possible massive transfusion protocol), correction of coagulopathies, and source control. ICU patients, thankfully, generally have excellent IV access, and although painfully obvious, early surgical consultation is essential.
Once source control has been identified, follow protocols from earlier chapters for surgical control. The more common sources of major bleeding in the ICU include traumatic hemorrhage, postoperative surgical bleeding, gastrointestinal (usually upper), and coagulopathy induced.
There are however a few bleeding situations that are unique to the ICU.
Beware of Hemoptysis with the “Big Yellow Snake”
The pulmonary artery catheter (PAC) was once ubiquitous in ICUs across the globe and is now used very selectively (thankfully!). One of the feared but rare complications associated with its use is pulmonary artery (PA) rupture secondary to either perforation from the PAC tip or, more commonly, from the balloon overdistension. Any hemoptysis or new pleural effusion in a patient with a PAC requires immediate evaluation for a possible PA rupture .