Treatment of major haemorrhage

• Fluid resuscitation with colloid and blood with blood products as appropriate to correct any coagulopathy. Maintain haemoglobin between 7-10g/dl and have adequate cross-matched blood available should further large haemorrhages occur.

• If possible, discontinue any on-going anticoagulation, e.g. heparin.

• Urgent diagnostic fibreoptic endoscopy. Local injection of epinephrine or a sclerosant into (or thermal sealing of) a bleeding peptic ulcer base may halt further bleeding. Likewise, banding or sclerosant injection may arrest bleeding varices.

• If oesophageal varices are known or highly suspected, consider vasopressin or terlipressin ± a Sengstaken-type tube for severe haemorrhage, either as a bridge to endoscopy or if banding/injection is unsuccessful. Remember that sources of bleeding other than varices may be present, e.g. peptic ulcer.

• For peptic ulceration and generalised inflammation commence an H2 antagonist or proton pump inhibitor. Give intravenously to ensure effect. Enteral antacid may also be beneficial.

• Surgery is rarely necessary but should be considered if bleeding continues, e.g. >6-10 unit transfusion requirement. Inform a surgeon promptly of any patient with major bleeding.

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