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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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.