What is the management approach for a patient with hematemesis?

Management of Hematemesis

Immediately secure the airway in patients with decreased consciousness or ongoing massive hematemesis, establish large-bore IV access, and begin resuscitation with warmed blood products rather than crystalloids while simultaneously controlling obvious bleeding sources. 1

Immediate Resuscitation (First 15 Minutes)

Airway and Breathing

• Secure the airway immediately using rapid sequence intubation in any patient with decreased level of consciousness or massive ongoing hematemesis to prevent aspiration 1, 2
• Administer high-flow oxygen (high FiO2) to all patients 3, 1
• Insert a nasogastric tube in patients with massive hematemesis to protect the airway and decompress the stomach 3

Circulation and Vascular Access

• Establish large-bore IV access immediately—ideally 8-Fr central venous catheter in adults 3, 1
• If central access fails, proceed to intraosseous or surgical venous access 3, 1
• Apply direct pressure, tourniquets, or hemostatic dressings to any obvious external bleeding points 3

Initial Laboratory Assessment

• Draw baseline blood work immediately: full blood count, PT, aPTT, Clauss fibrinogen (not derived fibrinogen), and cross-match 3, 1
• Consider near-patient viscoelastic testing (TEG or ROTEM) if available for real-time coagulation assessment 3, 1

Fluid Resuscitation Strategy

Blood Product Administration

• Resuscitate with warmed blood products, not crystalloids, in patients with massive haemorrhage 3, 1
• Blood availability follows this hierarchy: Group O (fastest) → group-specific → cross-matched 3, 1
• Group-specific blood can be issued without performing an antibody screen because patients have minimal circulating antibodies 3
• O negative blood should only be used if blood is needed immediately 3
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 3, 1

Transfusion Targets

• Transfuse packed red blood cells to maintain hemoglobin above 7 g/dL in stable patients 3
• Use a threshold of 9 g/dL in patients with massive bleeding, significant cardiovascular comorbidities, or possible delay in therapeutic interventions 3

Coagulation Management

Tranexamic Acid

• Administer tranexamic acid 1g IV over 10 minutes as soon as possible if the patient is bleeding or at risk of significant bleeding 1
• Follow with 1g infusion over 8 hours 1
• Must be given within 3 hours of bleeding onset for maximum benefit 1

Fibrinogen Replacement

• For fibrinogen <1 g/L: administer fibrinogen concentrate 3-4g or cryoprecipitate (15-20 single donor units) 1, 2
• Target fibrinogen level >1.5 g/L in massive haemorrhage 1
• A fibrinogen <1 g/L represents established haemostatic failure and predicts microvascular bleeding 3

Fresh Frozen Plasma

• For PT/aPTT >1.5 times normal: administer fresh frozen plasma at minimum 15 mL/kg 3, 1
• Early infusion of FFP (15 mL/kg) should be used to prevent coagulopathy if a senior clinician anticipates massive haemorrhage 3
• Established coagulopathy requires more than 15 mL/kg of FFP to correct 3

Platelet Transfusion

• Maintain platelet count >50 × 10⁹/L (>75 × 10⁹/L in massive haemorrhage, >100 × 10⁹/L if traumatic brain injury present) 3, 1

Calcium Monitoring

• Monitor and correct ionised calcium to normal range during massive transfusion 1

Blood Pressure Management

Permissive Hypotension Phase

• Restore organ perfusion but do not aggressively normalize blood pressure until bleeding is controlled 3, 1
• If the patient is conscious, talking, and has a palpable peripheral pulse, blood pressure is adequate 3
• Avoid vasopressors during the active bleeding phase 1

Post-Control Phase

• Once bleeding is controlled, aggressively normalize blood pressure, acid-base status, and temperature 1

Diagnostic Approach

Endoscopy Timing

• Perform endoscopy within 36 hours of bleeding onset for highest diagnostic success rate 4
• In hemodynamically stable patients, endoscopy within 6 hours of admission is recommended 3
• Gastroscopy should be performed first to rule out upper gastrointestinal bleeding 3

Imaging Considerations

• Consider contrast-enhanced CT before colonoscopy if lower gastrointestinal source is suspected—this increases detection rate for vascular lesions (35.7% vs 20.6%) 3
• CT angiography is more sensitive than conventional angiography, identifying bleeding at rates of 0.3 mL/min vs 0.5 mL/min 3

Definitive Hemostasis

Endoscopic Intervention

• Endoscopic hemostatic interventions can reduce hematemesis mortality 4
• For variceal bleeding: endoscopic band ligation is the definitive therapy 5
• For gastric varices: cyanoacrylate injection may be required 5

Angioembolization

• Super-selective angiographic embolization achieves immediate hemostasis in 40-100% of cases with 15% rebleeding rate 3
• Requires active bleeding at rates >0.5 mL/min to localize bleeding site 3
• Risk of bowel ischemia is 1-4% 3

Post-Resuscitation Care

Monitoring

• Admit to critical care unit for continued monitoring after bleeding control 1
• Monitor coagulation parameters, hemoglobin, blood gases, and assess for rebleeding 1
• Three-quarters of all renewed bleeding occurs within two days after initial hemorrhage 4

Thromboprophylaxis

• Initiate venous thromboprophylaxis as soon as bleeding is controlled—patients rapidly develop a prothrombotic state following massive haemorrhage 3, 1
• Standard venous thromboprophylaxis should be commenced as soon as possible after haemostasis has been secured 3

Risk Stratification for Disposition

Safe Discharge Criteria (Hemodynamically Stable Patients)

Patients with hematemesis can be safely discharged after 6 hours of observation if they meet ALL of the following criteria 6:

• Lack orthostatic vital sign changes 6
• Lack significant underlying disease 6
• Hemoglobin concentration >10 g/dL 6
• Age <60 years 6
• Reliable and compliant patient 6

High-Risk Features Requiring Admission

• Coffee-grounds emesis with concurrent melena has worse outcomes (composite endpoint 59.1%) compared to isolated coffee-grounds emesis (27.1%) 7
• Bloody emesis with concurrent melena has composite endpoint of 62.4% vs 25.6% for isolated bloody emesis 7
• Child-Pugh class C liver disease carries 53.4% risk of complications 5

Common Pitfalls

• Do not use derived fibrinogen values—insist on Clauss fibrinogen for accurate assessment 2
• Do not assume bloody hematemesis is more severe than coffee-grounds emesis—they have similar severity at presentation (pulse ≥100 bpm: 35% vs 37%; mortality: 6.6% vs 9.3%) 7
• Do not delay endoscopy beyond 36 hours—diagnostic yield decreases significantly 4
• Do not forget to administer octreotide (50 mcg bolus then 25 mcg/hour for 24 hours) and intravenous ceftriaxone (1 g/hour) in suspected variceal bleeding 5