Patient: 58M on aspirin + clopidogrel (Plavix), presents with melena ร 2 days, hematemesis in ED. HR 112, BP 88/54, Hgb 6.8.
Immediate resuscitation:
Post-EGD: Ulcer with visible vessel found and clipped. Continue PPI IV drip ร 72h โ then PO PPI BID. Resume aspirin in 3-5 days (cardiovascular benefit > rebleed risk if indicated). Clopidogrel -discuss with cards about timing.
Glasgow-Blatchford Score: Determines need for intervention. Score 0 = safe for outpatient management. This patient scores high โ inpatient + urgent EGD.
Patient: 52M with cirrhosis (Child-Pugh C), presents with hematemesis of bright red blood. HR 128, BP 78/44.
Management:
Key lesson: In variceal bleeds, octreotide + antibiotics + EGD within 12h. Over-transfusing KILLS, target Hgb 7, not 10.
Patient: 75F on apixaban for AFib, presents with painless bright red blood per rectum ร 6 hours. HR 95, BP 110/68, Hgb 8.2.
Management:
Key lesson: Most lower GI bleeds stop spontaneously. Colonoscopy within 24h is diagnostic. Don't forget to restart anticoagulation, stroke risk often outweighs rebleed risk.
| Drug | Dose | Indication | Notes |
|---|---|---|---|
| Pantoprazole (Protonix) | 80 mg IV bolus โ 8 mg/hr ร 72h | Non-variceal UGIB (high-risk) | Raises gastric pH โ stabilizes clot. Start before EGD empirically. Switch to oral after 72h. |
| Octreotide (Sandostatin) | 50 mcg IV bolus โ 50 mcg/hr ร 3โ5 days | Variceal UGIB | โ Splanchnic blood flow โ โ portal pressure. Start as soon as variceal source suspected. Continue 3โ5 days post-banding. |
| Ceftriaxone (Rocephin) | 1 g IV daily ร 7 days | Variceal UGIB (cirrhosis) | Prophylaxis against SBP and bacterial infections. Significantly reduces mortality. Start with octreotide immediately. |
| FFP / Vitamin K | FFP 2โ4 units; Vit K 10 mg IV | Coagulopathy (INR > 1.5โ2) | Reverse anticoagulation before endoscopy if significant coagulopathy. Vit K for warfarin reversal. 4-factor PCC if urgent. |
| PRBCs | Transfuse to Hgb 7โ9 g/dL | Hemodynamically significant bleed | Restrictive transfusion (target Hgb 7) TRIGGER, 2015. Exception: ACS/active cardiac disease -target 8โ9. |
Patient: 52M with alcohol-related cirrhosis (Child-Pugh C), presents with large-volume hematemesis and melena. History of prior variceal bleed 1 year ago, non-compliant with nadolol.
Key findings: HR 128, BP 78/44, Temp 37.8ยฐC, SpO2 94%. Distended abdomen with fluid wave. Hgb 6.2, platelets 62K, INR 1.8, Cr 1.9, lactate 5.1. Glasgow-Blatchford score: 17 (high risk).
Management:
Teaching point: In variceal bleeding, the triad is: restrictive transfusion (Hgb 7), octreotide, and antibiotics. Over-transfusion increases portal pressure and worsens bleeding.
Patient: 71F with Afib on apixaban 5 mg BID and aspirin 81 mg daily (recent drug-eluting stent 3 months ago), presents with coffee-ground emesis and black tarry stools x 2 days.
Key findings: HR 102, BP 108/62, Hgb 7.8 (baseline 12.4), BUN 48, Cr 1.1. Glasgow-Blatchford score: 12. EGD: 1.5 cm duodenal ulcer with visible vessel (Forrest IIa).
Management:
Teaching point: The decision to restart anticoagulation after GI bleed is critical. Delaying beyond 7 days significantly increases thromboembolic events. IV PPI drip is only indicated after endoscopic therapy for high-risk ulcer stigmata.
Patient: 34M with no significant PMH, presents to ED with one episode of coffee-ground emesis after heavy NSAID use for back pain. No hemodynamic instability, no melena.
Key findings: HR 76, BP 128/78, Hgb 14.2. BUN/Cr normal. Glasgow-Blatchford score: 0 (HR < 100, Hgb > 13 in male, BUN < 18.2, SBP > 109, no syncope/melena/liver disease/heart failure).
Management:
Teaching point: Glasgow-Blatchford score of 0 identifies patients who can be safely discharged. It outperforms clinical judgment for identifying low-risk patients who do not need admission or urgent endoscopy.
| Parameter | Frequency | Target / Action |
|---|---|---|
| Vitals | q4h floor, q1โ2h ICU | HR, BP, RR, SpOโ, Temp -notify for significant deviations |
| Labs (BMP, CBC) | Daily AM or as indicated | Trend Cr, Kโบ, WBC, Hgb -adjust treatment based on trajectory |
| Disease-specific markers | Per clinical context | See Overview and Management tabs for condition-specific targets |
| I&Os | Strict if volume-sensitive | UOP โฅ 0.5 mL/kg/hr. Net fluid balance guides diuresis or resuscitation. |
| Telemetry | Continuous if indicated | Arrhythmia detection. Discontinue when no longer indicated (reduces alarm fatigue). |
| Clinical response | Each assessment | Symptom improvement, functional status, appetite, mental status -the exam matters more than labs |