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Initial triage and risk
Presentation phenotypes
Uncomplicated dyspepsia without bleeding or peritonitis
Upper gastrointestinal bleeding phenotype
Perforation phenotype
Gastric outlet obstruction phenotype
Immediate instability triggers
SBP < 90 mmHg
HR > 120 beats/min
Altered mental status
Ongoing hematemesis
Peritoneal signs
Early escalation
Resuscitation bay for shock, active hematemesis, peritonitis
Gastroenterology consult for suspected high risk bleeding
Surgery consult for suspected perforation or obstruction
Resuscitation for suspected bleeding ulcer
Hemodynamic support
Two large bore IV lines or intraosseous access if needed
Continuous monitoring and frequent reassessment
Crystalloid only as bridge to blood products in hemorrhagic shock
Blood products strategy
Type and screen with crossmatch
Transfusion threshold hemoglobin < 70 g/L for most stable patients
Transfusion threshold hemoglobin < 80 g/L for active ischemia or significant cardiovascular disease
Massive transfusion protocol for ongoing shock with suspected life threatening hemorrhage
Coagulopathy and antithrombotics
Anticoagulant history and timing of last dose
Reversal pathway per agent when life threatening bleeding
Platelet transfusion for severe thrombocytopenia with active bleeding
Pharmacotherapy bridge to endoscopy
Initiate IV proton pump inhibitor for suspected nonvariceal upper GI bleed
Pantoprazole IV 80 mg bolus then 8 mg/hour infusion
Alternative high dose intermittent pantoprazole IV 40 mg every 12 hours
Antiemetic for ongoing emesis limiting airway protection
NPO status
Perforation and peritonitis pathway
Sepsis and perforation considerations
Broad spectrum antibiotics for suspected perforated viscus
Early source control planning with surgery
Lactate guided resuscitation if shock
Immediate complication avoidance
Avoid oral intake
Nasogastric decompression if severe distension or obstruction phenotype
Initiate IV proton pump inhibitor
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