Airway

• Suction – Clear blood/vomit to prevent aspiration.
• Airway adjuncts – Oropharyngeal or nasopharyngeal airway if needed.
• Jaw thrust/head tilt-chin lift – If airway obstruction suspected.
• Anaesthetic review – If airway protection is required (e.g., reduced GCS).

Breathing

• High-flow oxygen (15L via non-rebreathe mask) – if sPO2 <94%
• Positioning – Sit patient upright if conscious to aid breathing.
• Monitor oxygen saturations – Adjust oxygen delivery accordingly.

Circulation

• Two large-bore cannulas (14-16G) – Ensure rapid IV access.
• IV fluid resuscitation:
  • 500ml bolus of Hartmann’s/0.9% NaCl (warmed if possible).
• Blood transfusion (if indicated):
  • Massive transfusion protocol – If haemorrhagic shock.
  • Red cell transfusion – If Hb <70 g/L (target 70-100 g/L).
  • Platelets & Fresh Frozen Plasma (FFP) – As per transfusion protocol.
  • As bleeding is severe and the patient is haemodynamically unstable, escalate to Medical Registrar and activate the major haemorrhage protocol.
• Tranexamic acid (TXA) – Consider if major haemorrhage.
• Reversal of anticoagulation:
  • Warfarin: PCC + Vitamin K.
  • DOACs: Idarucizumab (dabigatran), Andexanet alfa (apixaban/rivaroxaban), PCC if unavailable.
  • Discuss with haematology.
• Catheterisation – To monitor urine output (>30ml/hr target).

Disability

• Assess GCS/ACVPU – Escalate if GCS ≤8 (consider airway protection).
• Review drug chart – Stop anticoagulants, NSAIDs, and medications affecting consciousness.

Exposure

• Pharmacological therapy:
  • Terlipressin – For suspected variceal bleeding (Consultant-led decision).
  • Prophylactic antibiotics – For variceal bleeding (e.g., Ciprofloxacin 1g OD for 7 days).
  • Proton Pump Inhibitors (PPIs) – IV PPI post-endoscopy for non-variceal UGIB.
• Keep the patient NBM (nil by mouth) to prepare for endoscopy.
• Endoscopic intervention:
  • Variceal bleeding: Band ligation or sclerotherapy.
    • If variceal bleeding is severe, further measures like a Sengstaken-Blakemore tube or TIPS (Transjugular Intrahepatic Portosystemic Shunt) may be required.
  • Non-variceal bleeding: Adrenaline injection, thermal coagulation, or haemostatic clips.
  • Monitor for rebleeding – Repeat Hb checks and reassess haemodynamic status.

Escalation & Ongoing Management

• Urgent endoscopy – Immediately if unstable; within 24 hours for all UGIB.
• SBAR handover – Escalate to seniors, critical care, and endoscopy team.
• Risk stratification:
  • Glasgow-Blatchford Score (GBS) – Identify low-risk patients for outpatient care.
  • Rockall Score – Assess rebleeding risk and mortality post-endoscopy.
• Follow-up & secondary prophylaxis:
  • PPI therapy – Continue for high-risk peptic ulcer disease.
  • Hepatology input for variceal bleeding – Consider beta-blockers for prophylaxis.