John has been experiencing blood-stained ETT aspirates, blood-stained secretions from nasogastric aspiration and blood oozing from around the nasopharyngeal airway. Provide two rationales for this bleeding and consider nursing actions and their effects
What will be an ideal response?
Suggested response: Rationales include: 1) Bleeding might be associated with a traumatic intubation. It is not uncommon to have some localised bleeding following intubation in an emergency, which may present itself as coffee ground aspirates on NG aspiration, some blood-stained drainage from the nose or mouth after the procedure (i.e. for a short time only) and perhaps some initial bloodstained secretions from the ETT. This should be closely monitored, but would be expected to be limited to the initial 1–2 hours following intubation and for the first 1–2 suctions or NG aspirations only. It would be important to consider sending blood for coagulation profile to rule out the second and more serious cause of coagulopathy associated with evolving sepsis. 2) Coagulopathy is associated with evolving septic shock. Coagulation studies should be undertaken and, if abnormal, will guide treatment. Nursing actions include observing and assessing all vascular insertion sites, ensuring minimal movement of all invasive lines and devices such as ETT. Need also to monitor urine, all bodily orifices and regular neurological assessment to rapidly note any spontaneous bleeding, both overt and occult. Avoid unnecessary procedures that might cause bleeding, such as routine ETT suction, insertion of lines, tubes, rectal temperture probes and likewise do not remove any invasive lines such as arterial lines etc without treating the coagulopathy with drugs such as tranexamic acid, blood clotting factors such as fresh frozen plasma. Serial measurement of coagulation profile is important prior to undertaking these procedures and after administration of coagulation factors.
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