Haematemesis is the single most common opening scenario in the IMT clinical station, and it rewards structure over knowledge. The panel wants to hear you resuscitate before you diagnose, use a named risk score, and know which patients need endoscopy tonight rather than tomorrow.

How should you approach a patient vomiting fresh blood?

Say out loud that this is an emergency and that you would assess A–E while resuscitating, not after. The marks are in doing two things at once and saying so.

  • Airway — at risk if there is a large-volume bleed or reduced consciousness; call for anaesthetic help early
  • Breathing — respiratory rate, saturations, oxygen
  • Circulation — two large-bore cannulae, bloods including crossmatch, clotting and lactate, and a fluid challenge guided by response
  • Disability — conscious level, and consider encephalopathy if there is chronic liver disease
  • Exposure — melaena on PR examination, stigmata of chronic liver disease

Name the early haemoglobin trap before you are asked: immediately after acute blood loss, haemoglobin and haematocrit are normal because red cells and plasma are lost in the same ratio. The value only falls once interstitial fluid redistributes, over roughly the following 8–12 hours, so a normal haemoglobin does not reassure you.

Which risk score should you use, and when?

NICE CG141 asks for two different scores at two different moments, and candidates routinely conflate them.

  • Glasgow-Blatchford score at first assessment — it is pre-endoscopic and decides whether the patient needs admission at all
  • Full Rockall score after endoscopy — it estimates mortality and rebleeding risk once you know the lesion

NICE recommends considering early discharge for patients with a pre-endoscopy Blatchford score of 0. Say the number rather than "a low score" — it is the sentence that marks you out from a candidate who only knows the scores exist.

When does the patient need endoscopy?

Immediately after resuscitation for unstable patients with severe acute bleeding, and within 24 hours of admission for everyone else admitted with acute upper GI bleeding.

What are the transfusion and drug decisions?

Transfuse to a restrictive threshold rather than a target haemoglobin — over-transfusion worsens outcomes in this group, including in variceal bleeding, where it raises portal pressure. Do not offer proton pump inhibitors before endoscopy to patients with suspected non-variceal bleeding; PPIs come after endoscopic diagnosis of non-variceal bleeding with stigmata of recent haemorrhage.

Suspected variceal bleeding

  • Terlipressin at presentation, continued until haemostasis or for up to five days
  • Prophylactic antibiotics at presentation — this reduces mortality, not just infection
  • Band ligation for oesophageal varices; consider TIPS if bleeding is not controlled

How do you hand this over in one minute?

The handover mark is separate from the clinical mark and is lost by rambling. Use SBAR, lead with the ask, and give numbers: who the patient is, what they have bled, what you have done, what their observations are now, and precisely what you want the receiving team to do and by when.