01Approach to the Critical Patient/attcp75

Triage and immediate priorities

›First minutes

›Airway risk

›Active hematemesis

›Inability to protect airway

›Altered mental status

›Severe agitation

›Breathing

›SpO2 target 92-96%

›Capnography if intubated

›Circulation

›Shock index

›Heart rate divided by SBP

›Shock index > 1 as high-risk marker

›2 large-bore IVs

›Intraosseous access if IV delay

›Cardiac monitor

›Defibrillator readiness for instability

›Escalation triggers

›Massive hematemesis

›Persistent hypotension after 1 L crystalloid

›Lactate rising despite resuscitation

›Ongoing transfusion needs

›Need for intubation

Hemodynamic targets and monitoring

›Resuscitation targets

›MAP >= 65 mmHg

›Higher target if chronic hypertension and end-organ hypoperfusion

›Urine output >= 0.5 mL/kg/hour

›Temperature >= 36.0 C

›Ionized calcium 1.1-1.3 mmol/L during massive transfusion

›ABG or VBG trend for perfusion

›Lactate trend

›Monitoring strategy

›Frequent vitals every 5-15 minutes until stable

›Foley catheter if shock or ongoing resuscitation

›Arterial line if ongoing vasoactive infusion or massive transfusion

Initial stabilization bundle

›Early stabilization bundle

›NPO status

›Antiemetic

›Ondansetron IV 4 mg

›Type and screen

›Type and crossmatch 4-6 units PRBC if unstable

›Transfusion strategy

›Restrictive threshold in most patients

›Hemoglobin threshold 70 g/L for transfusion (Class I)

›Target hemoglobin 70-90 g/L (Class I)

›Higher threshold considerations

›Active ischemia

›Symptomatic anemia

›Significant coronary artery disease

›Coagulopathy strategy

›If warfarin with life-threatening bleed, PCC + vitamin K (Class I)

›If DOAC with life-threatening bleed, specific reversal when available (Class IIa)

›Medication initiation while awaiting endoscopy

›High-dose IV PPI for suspected non-variceal bleed (Class I)

›Octreotide if suspected variceal bleed (Class I)

›Antibiotics if suspected variceal bleed (Class I)

Consults and time goals

›Time-critical coordination

›GI consult for endoscopy planning

›Urgent endoscopy within 24 hours after stabilization (Class I)

›Earlier endoscopy for ongoing bleeding or hemodynamic instability (Class I)

›ICU consult for instability or high-risk features

›Interventional radiology consult for endoscopy failure or inaccessible source (Class IIa)

›Surgery consult for refractory bleeding or perforation concern (Class IIa)

›Anesthesia involvement for airway-protected endoscopy in high aspiration risk

Key concepts

›Core concepts

›Upper GI hemorrhage definition

›Bleeding proximal to ligament of Treitz

›Main etiologies

›Peptic ulcer disease

›Variceal bleeding

›Mallory-Weiss tear

›Erosive esophagitis or gastritis

›Time dependence

›Early stabilization before definitive endoscopic therapy

›Rebleeding risk highest early after presentation

02History/hx56

Presentation pattern and timing

›Symptom profile

›Hematemesis

›Bright red blood

›Coffee-ground emesis

›Melena

›Black tarry stools

›Onset 4-14 hours after bleeding

›Hematochezia

›Possible brisk upper GI bleed

›Shock or orthostasis correlation

›Presyncope or syncope

›Chest pain after retching

›Boerhaave concern if severe and systemic toxicity

Severity and progression clues

›High-risk historical features

›Ongoing hematemesis

›Known cirrhosis or portal hypertension

›Prior variceal bleed

›Anticoagulant use

›Warfarin

›DOAC

›Antiplatelet use

›ASA

›P2Y12 inhibitor

›NSAID use

›Recent GI procedure

›Known peptic ulcer disease

03Physical Exam/exam39

Hemodynamic and perfusion findings

›Shock assessment

›Hypotension

›SBP < 90 mmHg

›MAP < 65 mmHg

›Tachycardia

›Orthostatic vitals

›HR rise >= 30

›SBP drop >= 20 mmHg

›Peripheral perfusion

›Cool extremities

›Delayed capillary refill

›Mental status change

GI-focused exam

›Abdominal findings

›Epigastric tenderness

›Peritonitis signs

›Guarding

›Rebound

›Rigidity

›Distension

›Rectal and stool findings

›Melena

›Hematochezia

›Occult blood context

›Low value in obvious bleeding

Stigmata and alternate source clues

›Chronic liver disease signs

04Differential Diagnosis/ddx27

Life-threatening causes

›Immediate threats

›Variceal hemorrhage (ICD-10 I85.01)

›SNOMED CT portal hypertension-related esophageal varices with hemorrhage

›Bleeding peptic ulcer (ICD-10 K27.4)

›Posterior duodenal ulcer with GDA bleed concern

›Aortoenteric fistula (ICD-10 K55.21)

›Upper GI malignancy bleed (ICD-10 C16.-)

›Boerhaave syndrome with hematemesis mimic (ICD-10 K22.3)

Common and mimics

›Non-variceal common causes

›Gastric ulcer bleed (ICD-10 K25.4)

›Duodenal ulcer bleed (ICD-10 K26.4)

›Erosive esophagitis (ICD-10 K20.9)

›Gastritis or duodenitis (ICD-10 K29.-)

›Mallory-Weiss tear (ICD-10 K22.6)

›Dieulafoy lesion (ICD-10 K92.2)

›Non-GI mimics

›Swallowed blood from epistaxis (ICD-10 R04.0)

›Hemoptysis misidentified as hematemesis (ICD-10 R04.2)

Clinical differentiators

›Key distinguishing clues

›Coffee-ground emesis

›Slower or stopped upper GI bleed

›Melena without hematemesis

›Possible proximal source with lower rate

›Cirrhosis stigmata

›Variceal probability higher

05Laboratory Tests/lt34

Core labs and immediate interpretation

›Baseline laboratory panel

›Complete blood count for bleeding concern

›Hemoglobin may lag early after acute bleed

›Platelet count for thrombocytopenia risk

›Electrolytes and renal function

›Urea elevation as supportive of upper GI source

›Creatinine for contrast planning

›Liver panel

›Cirrhosis severity context

›Coagulation studies

›INR for warfarin effect and liver dysfunction

›aPTT for heparin effect

›Venous or arterial blood gas

›Lactate for hypoperfusion

›pH for shock severity

Blood bank and transfusion support

›Transfusion preparation tests

›Type and screen

›Repeat if recent transfusion or pregnancy per local policy

›Crossmatch

›4-6 units PRBC in unstable patient

›Massive transfusion panel if ongoing shock

›Triggered MTP activation criteria per institution

Targeted tests for special scenarios

›Etiology and comorbidity tests

›Troponin if chest pain or demand ischemia concern

›Cardiac ischemia precipitated by anemia or hypotension

06Diagnostic Tests/dt72

Scoring Systems

›Risk stratification tools

›Glasgow-Blatchford Score (GBS)

›Components

›Urea

›Hemoglobin

›SBP

›Heart rate

›Melena

›Syncope

›Liver disease

›Heart failure

›Interpretation

›GBS 0-1 as low-risk for outpatient management in selected patients (Class IIa)

›Higher scores associated with need for intervention and mortality

›AIMS65

›Components

›Albumin < 30 g/L

›INR > 1.5

›Altered mental status

›SBP <= 90 mmHg

›Age >= 65

›Interpretation

›Higher score associated with inpatient mortality and ICU need

›Rockall score

›Pre-endoscopy components

›Age category

›Shock category

07Disposition/dispo37

Level of care decisions

›Admission criteria

›Any hemodynamic instability

›Active bleeding signs

›Ongoing hematemesis

›Ongoing melena with instability

›Need for transfusion

›Anticoagulation reversal requirement

›Suspected variceal bleed

›Significant comorbidities

›CAD

›CKD

›Cirrhosis

›High-risk scores

›AIMS65 >= 2

›High GBS with intervention expectation

›ICU or step-down criteria

›Persistent hypotension after resuscitation

›Recurrent bleeding after initial stabilization

›Intubation requirement

›Ongoing vasoactive infusion

›MTP activation

Discharge pathway for low-risk patients

›Outpatient management criteria

›Hemodynamically stable

›No ongoing bleeding

›Hemoglobin stable on repeat measurement

›Low-risk score

08Treatment/t83

Resuscitation and blood products

›Volume and blood product strategy

›Crystalloid

›Balanced crystalloid boluses in hypotension

›Avoid over-resuscitation in cirrhosis with variceal bleed

›PRBC transfusion

›Hemoglobin threshold 70 g/L in most patients (Class I)

›Target hemoglobin 70-90 g/L (Class I)

›Platelets

›If platelet count < 50 x10^9/L with active bleeding, transfuse (Class IIa)

›FFP

›Reserved for massive transfusion or specific factor deficiency (Class IIb)

›Fibrinogen replacement

›If fibrinogen < 1.5-2.0 g/L during massive transfusion, cryoprecipitate or fibrinogen concentrate (Class IIa)

›Calcium replacement during MTP

›Calcium chloride IV 1 g after every 4 units PRBC or per ionized calcium target

Non-variceal bleeding pharmacotherapy

›Acid suppression

›Pantoprazole IV

›Initiate 80 mg bolus (Class I)

›Follow with 8 mg/hour infusion for 72 hours after high-risk endoscopic stigmata (Class I)

›Alternative regimen 40 mg IV q12h after endoscopic therapy in select cases (Class IIb)

›Oral PPI transition when stable and tolerating PO

›High-dose oral PPI for 14 days after high-risk ulcer therapy (Class I)

›Antifibrinolytics

›Tranexamic acid

›Not recommended for routine GI bleeding due to lack of benefit and potential harm signal (Class III)

Variceal bleeding bundle

›Splanchnic vasoconstrictor therapy

›Octreotide

›Initiate 50 micrograms IV bolus (Class I)

›Follow with 50 micrograms/hour infusion (Class I)

›Duration 2-5 days based on endoscopic control and rebleeding risk (Class I)

›Terlipressin

›Alternative where available (Class I)

›Dose per local formulary

›Antibiotic prophylaxis in cirrhosis with GI bleed

›Ceftriaxone IV 1 g daily for up to 7 days (Class I)

›Higher risk settings

›Advanced cirrhosis

›Prior quinolone exposure

›Endoscopic therapy

›Variceal band ligation (Class I)

›Sclerotherapy if banding not feasible (Class IIa)

›Rescue therapies for refractory variceal bleeding

›Balloon tamponade as bridge to definitive therapy (Class IIa)

›Airway protection required before placement (Class I)

›Time limit strategy

›Maximum 24 hours preferred

›Self-expanding esophageal metal stent as alternative bridge (Class IIa)

›Early TIPS in selected high-risk patients (Class IIa)

›Ongoing bleeding despite endoscopic + pharmacologic therapy

›Severe portal hypertension and high rebleeding risk

Anticoagulation and antiplatelet management

›Warfarin reversal for life-threatening bleed

›4-factor PCC

›50 units/kg IV based on INR and product guidance (Class I)

›Vitamin K

›10 mg IV (Class I)

›DOAC reversal for life-threatening bleed

›Andexanet alfa for factor Xa inhibitors where available (Class IIa)

›Idarucizumab for dabigatran (Class I)

›4-factor PCC when specific antidote unavailable (Class IIb)

›Antiplatelet strategy

›ASA continuation in secondary prevention once hemostasis achieved (Class IIa)

›P2Y12 management individualized with cardiology if recent stent (Class I)

Airway and procedural considerations

›Airway protection strategy

›Intubation triggers

›Active massive hematemesis

›Altered mental status

›Severe hypoxemia

›Planned balloon tamponade

›RSI considerations

›Hemodynamic optimization before induction

›Post-intubation hypotension mitigation plan

›Endoscopy preparation

›Erythromycin prokinetic before endoscopy

›250 mg IV 30-90 minutes before EGD to improve visualization (Class IIa)

›NG tube

›Not routine for diagnosis (Class IIb)

›Consider for decompression before endoscopy in select cases (Class IIb)

Definitive non-endoscopic hemostasis

›Interventional radiology options

›Transcatheter arterial embolization for persistent or recurrent non-variceal bleeding after endoscopy (Class IIa)

›Embolization target selection guided by CTA and endoscopic findings

›Surgical options

›Surgery for refractory bleeding or perforation (Class IIa)

›Surgery for aortoenteric fistula (Class I)

09Special Populations/sp36

Pregnancy

›Pregnancy considerations

›Differential expansion

›Hyperemesis gravidarum with Mallory-Weiss tear

›Preeclampsia-related hepatic disease overlap symptoms

›Imaging

›Endoscopy acceptable when indicated with obstetric coordination (Class IIa)

›CT angiography only if benefits outweigh fetal radiation risk (Class IIa)

›Medications

›PPI acceptable when clinically indicated

›Octreotide use individualized with maternal benefit priority in variceal hemorrhage

›Rh status

›Rh immunoglobulin not indicated for GI bleeding alone

Geriatric

›Older adult considerations

›Higher risk of atypical presentation

›Minimal tachycardia due to beta-blockers

›Confusion as primary sign of shock

›Comorbidity impact

›Lower physiologic reserve

›CAD demand ischemia risk

›Transfusion thresholds individualized

›Symptom-driven strategy in significant CAD (Class IIa)

›Medication risk

›Higher delirium risk with sedatives for endoscopy

Pediatrics

›Pediatric considerations

›Etiology differences

10Background/b38

Epidemiology

›Epidemiology snapshot

›Common causes

›Peptic ulcer disease as leading cause in many settings

›Varices in patients with portal hypertension

›Risk factors prevalence patterns

›NSAID exposure common in ulcer bleeds

›Cirrhosis increases risk of variceal bleeding

›Outcomes associations

›Mortality higher with shock at presentation

›Mortality higher with comorbidities and advanced age

Pathophysiology

›Mechanisms

›Peptic ulcer bleeding

›Arterial erosion

›Forrest classification correlates with rebleeding risk

›Variceal bleeding

›Portal hypertension

›Variceal wall tension and rupture risk

›Mallory-Weiss tear

›Mucosal laceration after forceful retching

›Erosive disease

›Superficial mucosal bleeding

Therapeutic Considerations

›Rationale of key therapies

›Restrictive transfusion

›Lower portal pressures and rebleeding risk in cirrhosis

›Lower transfusion-related complications

11Patient Discharge Instructions/pdi23

copy discharge instructions

›Discharge instructions

›Diagnosis explanation

›Bleeding from upper digestive tract

›Medications

›PPI as prescribed

›Avoid NSAIDs

›Avoid alcohol until cleared if liver disease risk

›Diet

›Start with clear fluids then advance as tolerated

›Follow-up

›Primary care within 1-3 days

›GI follow-up for endoscopy plan if arranged

›H pylori testing plan if ulcer suspected

›Return immediately for

›Vomiting blood

›Black tarry stools

›Bright red blood in stool

›Fainting or near-fainting

›Chest pain

›Severe abdominal pain

›Shortness of breath

›New confusion

›Inability to keep fluids down

12References/r12

Clinical guidelines and evidence sources

›Evidence sources

›ACG clinical guideline for upper gastrointestinal and ulcer bleeding

›AASLD guidance for variceal hemorrhage and portal hypertensive bleeding

›Baveno consensus statements for portal hypertension management

›Major trials supporting restrictive transfusion in UGIB (Class I evidence)

›HALT-IT trial results informing TXA non-use in GI bleeding (Class III)

Coding and terminology

›Coding references

›ICD-10 K92.2 gastrointestinal hemorrhage, unspecified

›ICD-10 K25.4 gastric ulcer with hemorrhage

›ICD-10 K26.4 duodenal ulcer with hemorrhage

›ICD-10 I85.01 esophageal varices with bleeding

›SNOMED CT upper gastrointestinal hemorrhage concept mapping for problem list standardization

Evidence & Review

Evidence & Review