Opening statement: This is an immediately life-threatening condition where assessment and resuscitation occur simultaneously. Massive haematemesis is usually related to portal hypertension and oesophageal varices.

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Assessment

History

• onset / duration
• coagulation status (anticoagulants, antiplatelet agents, liver disease)
• any prior treatment

Examination

• A – patency and intubation assessment
• B – Oxygenation, work of breathing, signs of aspiration
• C – HR/BP, perfusion status (CR, turgor, temp etc), urine output, estimation of blood loss
• D – BSL, GCS, Westhaven grade,

Investigations

• Bedside
  • BSL
  • Blood gas (Hb, Lactate, Electrolytes, Ca++)
  • ECG
  • Portable CXR (aspiration)
  • Bedside echo (filling status, cardiac function
• Lab
  • FBC/UEC/LFT/Coag/ROTEM/Ca
  • Crossmatch (for type matched MTP continuation)
• Imaging
  • plan for CT Chest/Abdo/Pelvis (but this will have to wait until intubated)

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Management

Resuscitation

• A – intubate (once haemodynamics supported & MTP transfusing)
  • Anaesthesia, or most experienced operator
  • Standard geometry video laryngoscope (blood on camera = need direct vision option)
  • SALAD (suction assisted laryngoscopy and airway decontamination) technique
  • antiemetic early (metoclopramide AND ondansetron)
• B – preoxygenate with HFNP – less likely to cause aspiration
• C
  • 2x large bore PIVC or rapid large bore central venous sheath
  • Art line essential
  • Massive transfusion protocol
  • push dose vasopressors to temporise
• D – IV dextrose 50% for BSL 6-10
• E – prevent hypothermia
• F – avoid crystalloid
• G – Octreotide, Minnesota tube
• H – TXA 1g stat
• I – Ceftriaxone 1g IV stat

Specific treatment

• Immediate gastroenterology / gen surg involvement
• Minnesota tube – gastric bubble inflated only
• correct coagulopathy
• CT to determine location of lesion –> Endoscopy vs Surgical repair
• Terlipressin / vasopressin
• High dose PPI

Ongoing monitoring

• Hb
• Urine output
• Lactate
• LFTs
• Standard ICU cardiorespiratory monitoring

Supportive treatment

• FASTHUGS
• Vasopressors / inotropes as needed
• Ongoing PPI
• Correct coagulopathy
• Support glucose
• renal replacement therapy may be required
• ongoing terlipressin / vasopressin