In the face of hemodynamic instability aggressive fluid resus

citation is started with initial evaluation. If patient demonstrates tachycardia or orthostatic changes, infuse 20 mL/kg of normal saline or Ringer lactate solution (or compatible blood when available) and reassess.

2. Verify that substance is actually blood using guaiac test. In patients with significant bleeding, perform gastric lavage to rule out upper GI bleeding. Infants have rapid gastric emptying time, so upper GI bleeding can present as blood in the diaper. A negative aspirate does not rule out upper tract bleeding; up to 10% of patients with duodenal ulcers can have a negative gastric aspirate.

3. Obtain samples for laboratory analysis based on clinical presentation. In a healthy infant with a few streaks of blood, stool culture and observation is acceptable. If suspicious of significant GI bleeding, immediately obtain type and cross-match, CBC, PT, and PTT.

4. If suspicious of an obstructive lesion, order flat and upright abdominal films. Proceed as needed to additional imaging studies and surgical consultation.

5. Patients who have undergone significant volume loss with vital sign changes should undergo endoscopy as soon as bleeding is controlled. Avoid use of contrast if endoscopy is planned because it may obscure mucosal lesions.

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