›Activate massive transfusion pathway per local protocol dependent if severe shock
Resuscitation and transfusion
›Hemodynamic support
›Balanced transfusion strategy if massive bleeding per local protocol dependent
›Packed RBC transfusion threshold
›Hemoglobin less than 70 g/L in most patients
›Higher threshold in active cardiac ischemia or severe comorbidity individualized
›Platelet transfusion considerations
›Severe thrombocytopenia with active bleeding
›Planned endoscopic therapy threshold per local protocol dependent
Acid suppression and hemostatic pharmacotherapy
›Medication therapy
›PPI IV bolus then infusion or intermittent high dose per local protocol dependent
›Pantoprazole IV 80 mg once
›Then 8 mg per hour infusion
›Alternative pantoprazole IV 40 mg every 12 hours
›If suspected variceal bleeding then vasoactive therapy
›Octreotide IV 50 mcg bolus
›Then 50 mcg per hour infusion
›If suspected variceal bleeding then antibiotics
›Ceftriaxone IV 1 g daily
›Duration typically up to 7 days per GI plan
Anticoagulation and antiplatelet reversal
›Reversal strategy
›Warfarin associated bleeding
›Vitamin K IV 10 mg
›PCC dosing per product and INR local protocol dependent
›Dabigatran associated bleeding
›Idarucizumab IV 5 g
›Factor Xa inhibitor associated bleeding
›PCC local protocol dependent
›Andexanet alfa availability local protocol dependent
›Heparin associated bleeding
›Protamine dosing per heparin timing
Diagnostic sequencing
›Testing flow
›Labs and type and screen early
›ECG if symptoms or high risk
›Endoscopy planning after stabilization
›CTA consideration if ongoing bleed and endoscopy delayed or nondiagnostic
Consultation
›Specialist involvement
›Gastroenterology early for endoscopy planning
›ICU for shock or high risk scores
›Surgery and vascular surgery if aortoenteric fistula concern
Reassessment loop
›Repeat checks
›Recheck vitals every 15 to 30 minutes during active resuscitation
›Repeat abdominal exam for peritonitis evolution
›Monitor for ongoing bleeding output
›Repeat hemoglobin trend based on stability
17Disposition/dispo25
ICU criteria
›ICU level care indicators
›Ongoing hemodynamic instability
›Need for vasopressors
›Ongoing massive transfusion requirement
›High risk variceal bleed with active hemorrhage
Inpatient admission criteria
›Admission indicators
›Transfusion requirement
›Active bleeding within ED course
›Significant comorbidity
›Anticoagulation with reversal needs
›Moderate to high risk scores
Observation pathway
›Observation candidates local protocol dependent
›Stable vitals after ED course
›No ongoing bleeding observed
›Hemoglobin stable on repeat check
Discharge criteria
›Safe discharge requirements
›Low risk score pathway local protocol dependent
›No ongoing bleeding
›Stable vital signs
›Reliable follow up within 24 to 72 hours
›Clear return precautions understood
Transfer criteria
›Transfer triggers
›No endoscopy capability
›Ongoing bleeding requiring intervention
›Suspected aortoenteric fistula requiring vascular surgery
18Discharge Instructions/di9
Copy discharge instructions
›Patient instructions
›You have signs of bleeding in your stomach or upper intestine that can cause black stools
›Return to the emergency department right away if you vomit blood or have black stools again
›Return right away for fainting, severe weakness, chest pain, trouble breathing, or confusion
›Avoid NSAIDs such as ibuprofen or naproxen unless a clinician tells you otherwise
›Take your acid reducing medicine exactly as prescribed
›Avoid alcohol until you are cleared by your clinician
›Follow up within 24 to 72 hours as arranged for further testing and possible endoscopy
›If you take blood thinners do not restart them unless you were told to do so
19References/r7
Guidelines and decision tools
›Key references
›American College of Gastroenterology guideline for upper gastrointestinal and ulcer bleeding 2021
›Baveno consensus guidance on portal hypertension and variceal bleeding latest update local protocol dependent
›European Society of Gastrointestinal Endoscopy guideline non variceal upper GI hemorrhage 2021 update
›Glasgow Blatchford Score derivation and validation studies
›AIMS65 derivation and validation studies
›Rockall score derivation and validation studies
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.