What orders should be placed stat for a patient presenting with hematemesis?

Management of Hematemesis (Bright Red Blood from Mouth)

For a patient presenting with hematemesis (bright red blood from mouth), immediately establish two large-bore IV cannulae (18G or larger) in the antecubital fossae and begin rapid fluid resuscitation with normal saline. 1

Initial Assessment and Resuscitation

• Immediately establish two large-bore IV cannulae (18G or larger) in the antecubital fossae 2, 1
• Begin rapid fluid resuscitation with normal saline, typically 1-2 liters initially 2, 1
• If patient remains hemodynamically unstable after initial fluid resuscitation, administer blood products 2, 1
• Insert urinary catheter and monitor hourly urine output in severe cases 2, 1
• Continuously monitor vital signs (pulse, blood pressure) using automated monitoring 2
• Assess for shock, defined as pulse >100 beats/min and systolic BP <100 mm Hg 2
• Consider central venous pressure monitoring in patients with significant cardiac disease 2

Laboratory and Diagnostic Tests to Order STAT

• Complete blood count (CBC) with hemoglobin and hematocrit 2
• Coagulation profile (PT/INR, PTT) 2
• Type and cross-match for blood products 1
• Comprehensive metabolic panel including liver function tests 2
• Blood urea nitrogen (BUN) and creatinine 2
• Serum lactate to estimate and monitor extent of bleeding and shock 2
• Base deficit to estimate and monitor extent of bleeding and shock 2

Blood Transfusion Criteria

• Transfuse packed red blood cells when hemoglobin is less than 70-100 g/L or with active bleeding and hemodynamic instability 2, 1
• Target hemoglobin level of at least 7 g/dL (4.5 mmol/L) during resuscitation phase 2
• Maintain mean arterial pressure >65 mmHg while avoiding fluid overload 2
• Correct coagulopathy with fresh frozen plasma as needed 2

Endoscopy Timing and Preparation

• Perform upper endoscopy within 24 hours of presentation for most patients 1
• Endoscopy should only be performed after adequate resuscitation has been achieved 2, 1
• Keep patient fasted until hemodynamically stable 2
• For severely bleeding patients, consider endotracheal intubation before endoscopy to prevent pulmonary aspiration 1
• Ensure endoscopy is performed by experienced endoscopists capable of therapeutic interventions 1

Risk Stratification

• Classify severity based on age, vital signs, hemoglobin level, and presence of significant comorbidities 2
• Consider using the Rockall scoring system to assess risk of rebleeding and death 2
• High-risk features include: age >80 years, shock, renal/liver failure, disseminated malignancy, and active bleeding on endoscopy 2

Pharmacological Management

• Start high-dose proton pump inhibitor therapy (80 mg IV bolus followed by 8 mg/hour infusion for 72 hours) 2
• Consider vasoactive drugs (terlipressin or octreotide) if portal hypertension is suspected 2
• Administer prophylactic antibiotics if liver disease is suspected 2
• Consider tranexamic acid in cases of severe bleeding 2

Special Considerations

• Identify patients with liver disease early as they require specific management protocols 2
• In very low-risk young patients with minor bleeding and no hemodynamic compromise, discharge without endoscopy may be reasonable 2, 3
• For patients with hypoglycemia, use D5NS (5% dextrose in normal saline) for maintenance fluids 1
• Monitor for rebleeding with continuous observation of pulse, blood pressure, and urine output 2

Common Pitfalls to Avoid

• Delaying resuscitation while waiting for diagnostic tests 2
• Using single hematocrit measurements as an isolated marker for bleeding severity 2
• Overhydration with IV fluids, which can exacerbate bleeding 4
• Delaying endoscopy beyond 24 hours in high-risk patients 5
• Using H2-receptor antagonists instead of proton pump inhibitors (PPIs have superior acid suppression) 2
• Failing to identify the source of bleeding, as up to 15% of severe lower GI bleeding may have an upper GI source 2

Remember that most upper GI bleeding (88%) stops spontaneously, but early intervention is crucial for those with continued bleeding or high-risk features 3.