ED management of acute upper GI bleeding pathway

This pathway is for all patients presenting with a history of fresh blood haematemesis or melaena. This does not include food vomit with streaks of blood. All GI bleeding patients including those with a history of dark coloured or “coffee ground” vomit must be discussed with a senior before admission/discharge.

ED management of acute upper GI bleeding pathway form

Stable and not witnessed large volume haematemesis

Actions

Can be managed in stream 2
Large bore IV access
Bloods: FBC, U & E
Risk assessment using Blatchford score
Blatchford score 0 or 1; Bloods NAD, no malaena, go to exclusion criteria
Blatchford score greater than 1; exclusion criteria not met or other reason; admit AMU

Glasgow Blatchford score

Shocked and witnessed large volume haematemesis

Actions

Manage in resuscitation room
Seek Senior clinician support
Large bore access x2
FBC/U&E/Coag; Cross match 6 units or initiate massive haemorrhage protocol as appropriate
Discuss with Med Registrar to organise timely endoscopy etc.
If actively bleeding and platelet count lower than 50 consider platelet transfusion
If actively bleeding and INR or APPT or PT greater than 1.5 times normal; consider FFP
If actively bleeding and on warfarin: prothrombin complex concentrate

If ulcer inflammation with witnessed significant GI bleed - give loading dose IV esomeprazole 80mg

If variceal bleeding

give antibiotics
give terlipressin

Low risk UGIB for OP management

Blatchford score 0/1, bloods NAD, no melaena, no exclusion criteria

Request Outpatient OGD via paper request and deliver to Endoscopy unit FAO Michelle Fraser and "ED Urgent OP Bleed”.
Provide Outpatient OGD advice sheet via intranet
Stop NSAIDs
Give safety netting advice “if further bleeding, malaena or syncope then return to ED”
Write “OPD endoscopy” on the follow up section on the back of ED notes

Admission

Do not wait for blood results if patient’s destination is available and safe transfer. UGIB patients are usually for medical team but if signs of peritonism then surgical Team.

Exclusion criteria for Outpatient Management

Other reason for admission
On Warfarin
History of varices
Age over 70 years
Lives alone
No telephone