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Upper gastrointestinal bleeding is one of the most common life-threatening emergencies encountered in the emergency department. In the US, acute GI hemorrhage accounts for approximately 300,000 hospitalizations annually, with overall in-hospital mortality rates of up to 10%, and substantially higher in patients with underlying hepatic disease. Cirrhosis markedly increases the risk and severity of GI hemorrhage due to portal hypertension, esophageal and gastric varices, and coagulopathy. Variceal bleeding carries a six-week mortality rate exceeding 20%, even with aggressive management.

Rapid restoration of intravascular volume is essential when these patients arrive in hemorrhagic shock, yet vascular access is often difficult in hypovolemic patients and those with conditions like cirrhosis who may have peripheral edema and prior vascular compromise. In such cases, intraosseous (IO) access offers a reliable and rapidly deployable alternative. The following case from Memorial Regional Hospital illustrates how LifeFlow enabled timely resuscitation through IO access in a critically ill patient with GI hemorrhage, allowing rapid stabilization and transfer to definitive intervention.

Case Presentation

A 79-year-old male with a history of cirrhosis presented to the ED at Memorial Regional Hospital with active GI bleeding. He arrived with evidence of severe hemorrhagic shock, including diaphoresis and pallor, blood pressure was in the 70/50s with a heart rate in the 120s, yielding a shock index of 1.7. No peripheral IV could be established, so an intraosseous (IO) line was placed to provide emergent vascular access.

Management

The care team initiated massive transfusion protocol (MTP) using LifeFlow through the IO line. Over the course of approximately one hour, four units of packed red blood cells (350 mL each, totaling 1,400 mL) and one liter of normal saline were delivered via LifeFlow. Blood products were warmed using a QinFlow Warrior used in-line with LifeFlow. Norepinephrine was also initiated to support blood pressure given the depth of the patient’s hemodynamic compromise.

Following administration of the first unit of blood the patient’s blood pressure improved to approximately 100/70 mmHg and his heart rate decreased from the 120s to 110. With hemodynamic stabilization achieved, the patient was transferred to interventional radiology for embolization to address the source of hemorrhage.

Discussion

Patients with cirrhosis and GI hemorrhage present a difficult challenge for emergency clinicians. These patients are predisposed to rapid hemodynamic decompensation due to underlying coagulopathy, portal hypertension, and reduced physiologic reserve.  LifeFlow enabled the care team to administer four units of blood and one liter of normal saline within approximately one hour through the patient’s only available vascular access, achieving meaningful hemodynamic improvement while awaiting transfer to definitive care. The immediate stabilization and subsequent titration of additional blood to maintain stability would have been difficult or impossible to attain through other available techniques.

Leo Santibanez, RN described LifeFlow as “simple to set up and effective in rapid transfusion,” noting that it ensured each unit of blood was administered within less than five minutes. He reported that the speed of resuscitation with LifeFlow “likely saved the patient from arresting and stabilized him enough to make it to IR.” The patient’s immediate improvement in hemodynamics following the first unit of blood underscores the critical role that speed of delivery plays in hemorrhagic shock.

Following IR embolization, the patient’s family elected for hospice care the following day, reflecting the gravity of his underlying disease. Nevertheless, the ability to rapidly reverse hemorrhagic shock with LifeFlow allowed the care team to pursue definitive intervention and afforded the patient and his family time to make an informed decision.