Gastrointestinal bleeding (suspected)

Any person, 16 years and over, presenting with signs of gastrointestinal bleeding.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort Head elevated if haematemesis Continual visual observation

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning Suction, as required

Breathing

Assessment	Intervention
Respiratory rate and effort Auscultate chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation, as clinically indicated Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93% Patients at risk of hypercapnia, maintain SpO2 at 88–92%

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Pulse rate Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or where clinically relevant e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern
IVC and/or pathology	If clinical signs of hypovolaemia, insert 2 large bore cannulas, if trained If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved Warm fluids should be given, if available Caution should be taken giving large amounts of crystalloids If continued GI losses, active bleeding, and/or continued hypotension: escalate as per local CERS protocol. Consider activating critical blood loss, massive transfusion protocol or code crimson

Disability

Assessment	Intervention
ACVPU	If ACVPU shows reduced level of consciousness, continue to GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature If hypothermic, consider blood warmer and forced air warming devices, e.g. Bair Hugger
Skin inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status – last ate, drank, bowels opened, passed urine or vomited	Commence fluid balance chart, as required
NBM	NBM until medical review
Nausea and/or vomiting	If present, see nausea and/or vomiting section
Gastrointestinal	Commence stool chart

Glucose

Assessment

Intervention

BGL

Measure BGL If BGL less than 4 mmol/L with NO decrease in level of consciousness (Yellow Zone criteria): give 40% glucose gel, up to 15 g, buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 4 mmol/L If BGL less than 4 mmol/L WITH a decrease in level of consciousness (Red Zone criteria) OR the patient is unable to tolerate oral intake: give 40% glucose gel, up to 15 g, buccally in incremental doses, as tolerated, while establishing IV access give 10% glucose 200 mL by IV infusion over 15 minutes, once only if delay in IV access, give glucagon 1 mg IM, once only reassess BGL in 15 minutes If the patient is unconscious or peri-arrest: give 50% glucose 50 mL by slow IV injection, once only. Use with caution as extravasation can cause necrosis if delay in IV access, give glucagon 1 mg IM, once only reassess BGL in 15 minutes

Focused assessment

Complete an abdominal focused assessment.

Consider dehydration focused assessment.

Precautions and notes

• Early escalation may be necessary to consider the need to transfuse with blood product.
• Local massive transfusion protocols should be initiated for life-threatening bleeding.
• Oxygen saturation readings become unreliable in patients with significant blood loss.
• Patients should remain under close observation due to the risk of ongoing acute bleeding and/or rapid deterioration due to hypovolaemic shock.
• Proton pump inhibitors reduce the need for intervention during endoscopy, if given beforehand, as well as reducing the incidence of re-bleeding, but no evidence of change in mortality.

Interventions and diagnostics

Specific treatment

Give pantoprazole 80 mg IV once only.

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Analgesia

Select pain score:

• 1–6 (mild–moderate)
• 7–10 (severe)

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Nausea and/or vomiting

If nausea and/or vomiting is present, give:

• ondansetron 4 mg IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
• or prochlorperazine 12.5 mg IV/IM once only.

Choice of antiemetic should be determined by cause of symptoms.

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Thiamine

If patient is experiencing alcohol withdrawal, or is at high risk of thiamine deficiency (e.g. those who drink large amounts of alcohol or who are severely malnourished), then:

• monitor using alcohol withdrawal scale
• give thiamine 300 mg IV/IM once only

If hypoglycaemic: thiamine should be given before glucose, or as soon as possible. Glucose can further deplete thiamine stores and precipitate Wernicke encephalopathy.

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Radiology

Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.

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Pathology

• FBC, UEC, LFT, coags, group and hold
• If clinically indicated, i.e. urgency, haemodynamic instability or suspected low Hb: VBG

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au