Place 2 large bore IVs (or sheath introducer/rapid infusion catheter) and monitor airway status
Crystalloid IVF can be used for initial resuscitation but should be limited due to the dilutional anemia and coagulopathy that can result (i.e. IV fluid use in non-compressible hemorrhage)
Pantoprazole or esomeprazole 80mg x 1; then 8mg/hr
Intermittent dosing of pantoprazole, esomeprazole, or omeprazole 40 mg IV BID not inferior to continuous infusion dosing
Reduces the rate of re-bleeding and need for surgery if there is an ulcer, but does not reduce morbidity or mortality
There is a mortality benefit in Asian patients
Intermittent dosing of pantoprazole, esomeprazole, or omeprazole 40 mg IV BID not inferior to continuous infusion dosing
Reduces the rate of re-bleeding and need for surgery if there is an ulcer, but does not reduce morbidity or mortality
There is a mortality benefit in Asian patients
For short-term prophylaxis against SBP and bacteremia
Ceftriaxone 1gm daily x 7 days (first line)
OR ciprofloxacin IV or PO 500mg BID x7 days
Indicated for:
Patients with cirrhosis or history of ETOH abuse (regardless of whether bleeding is variceal or not)
Prior to endoscopy or as soon as possible after endoscopy
Patients with cirrhosis or history of ETOH abuse (regardless of whether bleeding is variceal or not)
Prior to endoscopy or as soon as possible after endoscopy
Consider octreotide (50 mcg IV bolus, then 50 mcg/hr continuous, maintained at 2-5 days in patients with concern for variceal bleeding)
Consider vasopressin
0.4 unit bolus, then infuse at 0.4 - 1 unit/min
Give with IV nitroglycerin at 10 - 50 mcg/min to bolster portal hypotension and reduce vasopressin systemic effects
Associated with many vasoconstrictive complications to include peripheral necrosis, dysrhythmias, myocardial ischemia 
Terlipressin (analog of vasopressin, available outside U.S.)
Alternative to vasopressin with mortality benefit
Given as 2mg IV q4 hrs, then decrease to 1mg IV q4 hrs until bleeding stops
tranexamic acid (TXA) initially thought to help, NNT = 30, no one harmed; but HALT-IT trial RCT found it did not reduce death from GI bleeding
0.4 unit bolus, then infuse at 0.4 - 1 unit/min
Give with IV nitroglycerin at 10 - 50 mcg/min to bolster portal hypotension and reduce vasopressin systemic effects
Associated with many vasoconstrictive complications to include peripheral necrosis, dysrhythmias, myocardial ischemia 
Terlipressin (analog of vasopressin, available outside U.S.)
Alternative to vasopressin with mortality benefit
Given as 2mg IV q4 hrs, then decrease to 1mg IV q4 hrs until bleeding stops
Alternative to vasopressin with mortality benefit
Given as 2mg IV q4 hrs, then decrease to 1mg IV q4 hrs until bleeding stops
Indications:
Hemoglobin <7 g/dl
In hemodynamically stable patients, the  goal transfusion threshold should be 7 g/dl; NICE guidelines recommend avoidance of<unk> er-transfusion
Continued active bleeding
Failure to improve perfusion and vital signs after infusion of 2L NS
Known varicele bleeding
In hemodynamically stable patients, the  goal transfusion threshold should be 7 g/dl; NICE guidelines recommend avoidance of<unk> er-transfusion
Consider initiating massive transfusion protocol
Prothrombin complex concentrates
Cryoprecipitate to raise fibrinogen (goal >120mg/dL)
Platelets (goal >50-100k/μL)
FFP can be used to correct anticoagulated patients, but is not indicated in cirrhotics with variceal bleeding
Monitor for hypocalcemia
For life-threatening hemorrhage if endoscopy is not available
Adverse reactions are frequent:
Mucosal ulceration<unk> /gastric rupture
Tracheal compression (consider intubation prior to balloon insertion)
Mucosal ulceration<unk> /gastric rupture
Tracheal compression (consider intubation prior to balloon insertion)
Should be performed at the discretion of the gastroenterologist; within 12 hrs for variceal bleeding
Early endoscopy does not necessarily improve clinical outcomes
Consider erythromycin 3mg/kg IV<unk> er 20-30min, 30-90min prior to endoscopy
Achieves endoscopy conditions equal to lavage
Achieves endoscopy conditions equal to lavage
Protection of airway from massive aspiration, especially prior to endoscopy; does not protect against pneumonia or cardiopulmonary<unk> ents
Have bed-side push-dose pressors on hand
NGT (salem sump to remove stomach contents)
Varices not contraindication to NGT
Consider metoclopramide 10mg IV
Increases tone of lower<unk>  sphincter
Good pre-Oxygenation critical
Chest and HOB elevation to 45 degrees - consider intubating from 45 degrees to prevent gastric contents coming up
RSI - consider halving sedation dosages for lost blood volume
Etomidate or ketamine for sedation
Succinylcholine and vecuronium increases LES tone
Intubation with strong chance for first pass
Slow and gentle BVM breaths at 10 breaths/min if first pass fails
Trendelenberg if vomiting, keeping emesis out of lungs (have many suctions available before this happens)
Meconium aspirator may be hooked up to ETT for large bore suction
Antibiotics not needed in early phase of aspiration
Chemical pneumonitis in first 24 hours, not bacterial pneumonia
Early antibiotics may predispose patient to resistant bacterial superinfection
SIRS-like response often occurs from aspiration, but otherwise not sepsis if there is no other concerning source or suspicion
May require pressors and fluids
Consider withholding early antibiotics, but doing the rest of the sepsis treatments
Varices not contraindication to NGT
Consider metoclopramide 10mg IV
Increases tone of lower<unk>  sphincter
Increases tone of lower<unk>  sphincter
Etomidate or ketamine for sedation
Succinylcholine and vecuronium increases LES tone
Chemical pneumonitis in first 24 hours, not bacterial pneumonia
Early antibiotics may predispose patient to resistant bacterial superinfection
May require pressors and fluids
Consider withholding early antibiotics, but doing the rest of the sepsis treatments
Esophageal varices
Peptic ulcer disease 
Mallory-Weiss tear
Gastritis/esophagitis
Esophageal candidiasis
Gastric/esophageal varices
Achalasia
Esophagitis