Melena on Day Three After Primary PCI in a Patient on Dual Antiplatelet Therapy

What the numbers say. A haemoglobin of 9.1 g/dL in a man scores 6 on the Glasgow-Blatchford score; urea 52 mg/dL (about 8.7 mmol/L) scores 3; pulse of 108 scores 1; melena scores 1 - a total of 11, which is high risk and mandates endoscopy within 24 hours after resuscitation, not later. The shock index is 108/104 = 1.04, above the 0.9 threshold, so he is compensating, not stable. Haemoglobin equilibrates over 12-24 hours, so the true loss is larger than 4.3 g/dL suggests.

0-5 minutes: stay with him, call for help and for the medical registrar and cardiologist; sit him up or lay flat if presyncopal; oxygen only if SpO2 falls below 94%; two large-bore cannulas (16G or wider); send full blood count, coagulation profile, urea and electrolytes, liver function, group and crossmatch two units, and a venous blood gas for lactate.

5-10 minutes: hold enoxaparin and any NSAID; keep him nil by mouth; start an intravenous proton pump inhibitor as prescribed (80 mg bolus then infusion); attach continuous monitoring with 15-minute observations of pulse, blood pressure, respiratory rate, urine output and conscious level. Insert a urinary catheter if output cannot be measured.

10-30 minutes: ensure the cardiology and gastroenterology decisions are made and recorded - the antiplatelet question is theirs, not yours. Prepare for transfer to a monitored bed. Do not give intramuscular injections, do not insert a nasogastric tube without a clear indication, and do not allow a second NSAID dose to be given - remove the drug from the chart and tell the prescriber why.

Transfusion: restrictive threshold of 7 g/dL, but with an active coronary syndrome on day three most units would transfuse at 8 g/dL or with ongoing bleeding, one unit at a time with reassessment.

Clinical reasoning first. The patient has three simultaneous insults to the gastroduodenal mucosa: aspirin (systemic and local cyclo-oxygenase inhibition), ticagrelor (platelet P2Y12 blockade), and a parenteral non-steroidal anti-inflammatory drug that removes prostaglandin-mediated mucosal protection and impairs platelet function further. He is also on enoxaparin and is post-infarct, so both bleeding and thrombosis are live risks. Ketorolac given intramuscularly to a patient on dual antiplatelet therapy is a recognised, largely preventable cause of upper gastrointestinal bleeding and is on most hospital "high-risk drug" lists for this reason.

With the prescriber: speak directly and non-punitively - "he has melena and a haemoglobin drop; the ketorolac was given overnight; I have stopped it; can we agree an alternative and document it?". Paracetamol is the default analgesic in ischaemic heart disease; weak opioids are a second line. Avoid diclofenac, ibuprofen and other NSAIDs entirely.

With the patient: explain that a painkiller given for back pain has probably caused the bleeding, without blaming any individual, and that his cardiac drugs are being reviewed by the cardiologist rather than stopped by the ward team.

With the system: complete the incident report within the shift, stating the drug, dose, route, timing, the patient's antithrombotic therapy and the outcome. The report is for learning, not sanction. Suggest a prescribing prompt in the electronic record for NSAIDs in patients on dual antiplatelet therapy, and a note at the next ward audit. The nurse's own check of the drug chart - recognising that an intramuscular NSAID on day three post-PCI needs a query - is part of the same safety net and should be described that way in the report.

Frame the trade-off explicitly. He has an anterior STEMI treated three days ago - a large myocardial territory and a freshly deployed stent, where stent thrombosis carries a mortality of 20-40% and usually presents as sudden death. Against that, he has a high-risk upper gastrointestinal bleed. Neither stopping all antiplatelet therapy nor continuing both unquestioned is acceptable, and the nurse is not the person who should make the choice.

What is defensible practice:

• Aspirin is usually continued; it is the P2Y12 inhibitor that is most often interrupted after multidisciplinary discussion, and sometimes only temporarily.
• Never stop both agents without a documented cardiology or senior physician decision.
• The decision, the person who made it, the time and the reasoning must appear in the notes.

Escalation when the consultant cannot be reached: the nurse escalates up the chain rather than sideways. Call the on-call medical registrar, then the cardiology registrar, then the intensivist, then the consultant through the hospital switchboard. Record each call with a time stamp. Use the hospital's rapid-response or clinical review call if the patient meets trigger criteria - pulse above 110, systolic below 100 mmHg, or a falling conscious level.

If bleeding becomes catastrophic (haematemesis, systolic below 90 mmHg, lactate rising) and no senior decision is available, withhold nothing on your own authority but escalate to the most senior person reachable and treat resuscitative priorities: large-bore access, blood products, tranexamic acid if prescribed, reversal of anticoagulation in discussion with haematology, and urgent endoscopy. Document the sequence in real time.

Professional protection comes from contemporaneous notes and a demonstrable escalation trail, not from making a unilateral prescribing decision. State the facts, the calls, the advice received and the actions taken.