A fictional 68-year-old presents with large-volume haematemesis, melaena and hypotension. They take warfarin for a mechanical heart valve and appear clammy and confused.
Listen for the assumption.
The haemoglobin is only mildly reduced, so I wondered whether to wait for a repeat result before activating major haemorrhage support.
Why can the first haemoglobin be falsely reassuring in acute blood loss?
It may not yet reflect the volume lost. The clinical picture should drive resuscitation, reversal planning and urgent endoscopy.
Choose an answer below and reveal the reasoning to see consultant feedback at every checkpoint. The full consultant-led synthesis follows after all three decisions.
Go to the first decision ↓The picture develops.
- Persistent hypotension despite initial resuscitation
- INR is markedly elevated
- No known cirrhosis, but the bleeding source is not yet established
Commit before you reveal.
After you select an option, reveal the model reasoning and the consultant’s feedback.
Hear the senior team refine the plan.
The registrar tests the plan, the consultant synthesises the key principle, and the SHO confirms the safer next steps.
I will use Blatchford scoring, but instability already determines the urgency and level of care.
Agreed. Coordinate haemorrhage support, anticoagulant reversal, anaesthetic input and endoscopy, while considering variceal treatment if the history changes the probability.
My handover will give the bleeding and physiological trajectory, access, products, reversal, comorbidities and endoscopy plan.
What must remain explicit.
- Activate local major-haemorrhage support when indicated.
- Discuss urgent reversal in the context of the anticoagulation indication.
- Involve endoscopy and anaesthesia early for an unstable patient.
Where reasoning fails.
- Waiting for haemoglobin to fall
- Over-transfusion without clinical reassessment
- Allowing resuscitation to delay definitive control indefinitely
Severe upper GI bleeding with haematemesis/melaena [extent], physiology [trend], anticoagulation [drug/indication/result], access/products/reversal [details] and endoscopy plan [time/team].
Which information must be communicated simultaneously to the endoscopist, transfusion laboratory and anaesthetist?