Upper GI Bleed Management - An Overly Simplified Algorithm

The basics of managing a patient you have diagnosed with an upper GI bleed.
Upper GI Bleed
AABCCP
Airway, airway, airway (if hemodynamically unstable, resuscitate as much as possible prior to intubation). Make NPO.
Access: two large bore IVs (16 gauge)
Blood: consented and T&S and crossmatch, give blood if unstable or Hgb less than 7 g/dL, +/- massive transfusion
Coagulopathy: reverse if indicated (be very careful in those with cirrhosis, as they are actually in a tenuous state between bleeding and clotting)
Circulation: MAP goal greater than 65, use pressors if needed
PPI: pantoprazole 80 mg IV x1 followed by 40 mg IV BID, drips are not evidence-based!
If cirrhosis:
i) ceftriaxone 1 g IV qD for infection prophylaxis (has a mortality benefit). Why? Patients with cirrhosis have more of a chance for translocation of gut bacteria during acute bleeding, which predisposes to infection.
ii) octreotide 50 mcg bolus followed by 72 hr drip
And, of course, call GI.
If not working, balloon tamponade (often a temporizing measure while awaiting delayed endoscopy)
Sengstaken-Blakemore tube
Minnesota tube
Interventional Procedures
Transjugular intrahepatic portosystemic shunt (TIPS)
Esophageal transection
Gastroesophageal junction devascularization
A special thanks to The ICU Curriculum ( / @theicucurriculum ) for their more in-depth discussion of this topic in the context of shock as well as Tintinalli's Emergency Medicine.
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