A patient presents with haematemesis and melaena and is hypotensive and tachycardic. What is the correct immediate priority?

Answer: B. Simultaneous assessment and resuscitation with IV access and crossmatch

Resuscitation comes first

In acute upper GI bleeding, the immediate priority is simultaneous assessment and resuscitation - haemodynamic stabilisation takes precedence over diagnosis.

Immediate steps in an unstable patient

• Assess haemodynamics: pulse, BP, urine output, pallor.
• IV cannulae (large bore); send FBC, LFT, renal function, group and crossmatch.
• Crystalloid infusion, then blood components as needed.
• Airway protection (intubation/ventilation) if required.

Goals of resuscitation

• Maintain ECF volume and tissue oxygenation: Hb 9-10 g/dL, SpO2 > 94%, urine output 1 mL/kg/hr, CVP 5-8 (8-12 if ventilated).

Key principle

• More lives are lost to inadequate resuscitation than to lack of facilities - fears about heart failure or saline should not delay adequate fluid resuscitation.
• Endoscopy follows after resuscitation (it is diagnostic and therapeutic; ~50% of bleeds stop spontaneously).