What is the initial management for a patient presenting with hematemesis in the emergency room?

Initial Management of Hematemesis in the Emergency Room

The initial management for a patient presenting with hematemesis in the emergency room should include rapid assessment of hemorrhage severity using an established grading system, followed by immediate bleeding control procedures if the patient presents with hemorrhagic shock and an identified source of bleeding, unless initial resuscitation measures are successful. 1

Initial Assessment and Stabilization

• Assess the extent of bleeding using an established grading system such as the American College of Surgeons Advanced Trauma Life Support (ATLS) classification, which evaluates blood loss based on vital signs, mental status, and clinical presentation 1, 2
• Avoid hyperventilation and excessive positive end-expiratory pressure (PEEP) in severely hypovolemic patients as this can decrease cardiac output and worsen outcomes 1
• Secure large-bore intravenous access (8-Fr central access is ideal in adults) to allow for rapid fluid resuscitation 1
• Administer high FiO2 to ensure adequate oxygenation 1
• Control obvious bleeding points using pressure, tourniquets, or hemostatic dressings 1
• Actively warm the patient and all transfused fluids to prevent hypothermia 1

Diagnostic Workup

• Obtain baseline laboratory studies including complete blood count, prothrombin time (PT), activated partial thromboplastin time (aPTT), and Clauss fibrinogen 1
• Do not rely on single hematocrit measurements as an isolated marker for bleeding 1
• Measure serum lactate and base deficit to estimate and monitor the extent of bleeding and shock 1
• For patients with suspected torso trauma, employ early focused sonography (FAST) for detection of free fluid 1
• Patients with hemodynamic stability and suspected head, chest, or abdominal bleeding following high-energy injuries should undergo further assessment using CT 1
• Consider near-patient testing such as thromboelastography (TEG) or thromboelastometry (ROTEM) if available 1

Resuscitation and Volume Replacement

• Target a systolic blood pressure of 80-100 mmHg until major bleeding has been stopped in patients without brain injury 1
• Initially use crystalloids for fluid resuscitation, with colloids added within prescribed limits for each solution 1
• For massive hemorrhage, administer warmed blood and blood components 1
• In order of availability: O-type blood (quickest), group-specific blood, and cross-matched blood 1

Source Control

• Patients with hemodynamic instability and significant free intraabdominal fluid should undergo urgent surgery 1
• If the source of bleeding is identified and the patient is in hemorrhagic shock, perform an immediate bleeding control procedure unless initial resuscitation measures are successful 1
• For patients with hemodynamic shock and an unidentified source of bleeding, perform immediate further assessment 1
• Consider early endoscopy, which has the highest success rate if performed within the first 36 hours of bleeding onset 3
• For patients with pelvic ring disruption in hemorrhagic shock, perform immediate pelvic ring closure and stabilization 1

Management of Coagulopathy

• Consider antifibrinolytic agents such as tranexamic acid (10-15 mg/kg followed by an infusion of 1-5 mg/kg/h) in bleeding patients 1
• Note that tranexamic acid is FDA-approved for short-term use to reduce hemorrhage in patients with hemophilia 4
• For persistent bleeding, employ a damage control surgical approach in severely injured patients presenting with deep hemorrhagic shock, signs of ongoing bleeding, coagulopathy, hypothermia, or acidosis 1

Ongoing Monitoring and Disposition

• After initial stabilization, admit the patient to a critical care area for monitoring of coagulation, hemoglobin, blood gases, and wound drain assessment 1
• Begin standard venous thromboprophylaxis as soon as bleeding is controlled, as patients rapidly develop a prothrombotic state 1
• Monitor for rebleeding, particularly within the first 48 hours, as 75% of renewed bleeding occurs within two days of the initial hemorrhage 3

Common Pitfalls and Caveats

• Avoid delays between injury and surgical intervention for patients requiring urgent bleeding control 1
• Do not rely solely on blood pressure as an indicator of blood loss, as some patients compensate well despite significant hemorrhage 1
• Avoid vasopressors once control of bleeding is achieved 1
• Remember that mortality rates for hematemesis are generally close to 10%, but can be as high as 30% if secondary to variceal bleeding 3