What is the immediate treatment for a patient presenting to the Emergency Room (ER) with hematemesis (spitting up blood)?

Immediate Management of Hematemesis in the Emergency Room

For a patient presenting to the ER with hematemesis, immediately secure large-bore IV access, begin fluid resuscitation with crystalloids, assess hemodynamic stability, protect the airway if needed, and prepare for urgent endoscopy within 12-24 hours after stabilization. 1, 2

Initial Resuscitation and Stabilization

Vascular Access and Fluid Management

• Place two large-bore venous cannulae in the anticubital fossae immediately for any patient with hemodynamic compromise 1
• Infuse normal saline to achieve falling pulse rate, rising blood pressure, and adequate urine output (>30 ml/h) 1, 2
• Most patients require 1-2 liters of saline to correct volume losses 1, 2
• If shock persists after 2 liters, plasma expanders are needed as at least 20% of blood volume has been lost 1
• Target central venous pressure of 5-10 cm H₂O in adequately resuscitated patients 1, 2

Airway Protection

• Perform tracheal intubation for active hematemesis, inability to maintain or protect airway, and as needed to provide optimal sedation for endoscopy 1
• Insert a nasogastric tube to protect the airway and decompress the stomach in patients with massive bleeding 1

Blood Transfusion Strategy

• Transfuse packed red blood cells when hemoglobin is <100 g/L (10 g/dL) in acute bleeding 1, 2
• Transfuse immediately when bleeding is extreme, evidenced by active hematemesis with shock 1, 2
• Use O negative blood only in extreme circumstances; rapid cross-matching is usually possible 1
• Group-specific blood can be issued without antibody screening in massive hemorrhage 1

Pharmacologic Therapy

Proton Pump Inhibitors

• Administer intravenous proton pump inhibitors immediately to reduce rebleeding rates, transfusion requirements, and hospital stay 2, 3

Vasoactive Agents (if variceal bleeding suspected)

• Give octreotide 50 mcg IV bolus (can repeat in first hour if ongoing bleeding), followed by continuous infusion of 50 mcg/h for 2-5 days 1
• Somatostatina intravenosa en dosis altas suprime la secreción ácida y reduce el flujo sanguíneo esplácnico 2

Prokinetic Agents

• Consider erythromycin 250 mg IV 30-120 minutes before endoscopy to optimize visualization (check QT interval first) 1

Diagnostic Evaluation

Laboratory Assessment

• Obtain baseline complete blood count, prothrombin time, activated partial thromboplastin time, fibrinogen, and cross-match 1
• Monitor hemoglobin, coagulation parameters, and blood gases serially 1

Risk Stratification

• Patients with pulse >100 bpm, systolic BP <100 mmHg, hemoglobin <100 g/L, age >60 years, or significant comorbidities require intensive monitoring 1
• Presence of bright red blood in nasogastric aspirate is an independent predictor of rebleeding 2

Endoscopic Management

Timing of Endoscopy

• Perform endoscopy within 12-24 hours of presentation after hemodynamic stabilization 1, 3
• Endoscopy should only be done after resuscitation is achieved 1, 2
• In stable patients without high-risk features, endoscopy can be performed on the next available list 1
• Highest success rate occurs when endoscopy is performed within 36 hours of bleeding onset 4

Endoscopic Therapy Options

• Endoscopic therapy should be performed by experienced endoscopists capable of therapeutic procedures 2
• Available techniques include injection therapy (epinephrine), thermal methods, and mechanical clips 2, 3
• Epinephrine injection should always be used in combination with another method to increase hemostasis success 3

Monitoring and Disposition

Intensive Care Setting

• Admit patients with acute severe bleeding to intensive care unit or well-monitored units 1
• Monitor pulse and blood pressure continuously using automated monitors 1
• Insert urinary catheter and measure hourly urine volumes 1

Low-Risk Patient Management

• Patients with mild bleeding, normal vital signs, hemoglobin >100 g/L, age <60 years, and no significant comorbidity can be managed on general medical ward 1
• Hemodynamically stable patients can be safely discharged after 6 hours of observation if they meet all criteria: no orthostatic changes, hemoglobin >10 g/dL, age <60 years, no significant underlying disease, and reliable for follow-up 5

Critical Pitfalls to Avoid

• Never delay resuscitation to perform endoscopy—stabilization always comes first 1, 2
• Do not attempt to normalize blood pressure immediately in massive hemorrhage; restore organ perfusion first 1
• Avoid vasopressors until bleeding is controlled 1
• Three-quarters of rebleeding occurs within 2 days, requiring close monitoring during this period 4
• If no stigmata of recent hemorrhage found at endoscopy, prognosis is excellent and early discharge is appropriate 1