What to do if there's a small amount of blood in vomit, specifically hematemesis?

Management of Small Amount of Blood in Vomit (Hematemesis)

Immediately establish two large-bore IV cannulae (18G or larger) and begin rapid fluid resuscitation with 1-2 liters of normal saline, even for small amounts of hematemesis, as this represents upper gastrointestinal bleeding that requires urgent assessment and stabilization. 1

Immediate Resuscitation and Stabilization

• Secure IV access with two large-bore cannulae (18G or larger) in the antecubital fossae and initiate rapid crystalloid infusion 1
• Monitor vital signs continuously using automated monitoring, specifically assessing for shock (pulse >100 beats/min, systolic BP <100 mm Hg) 1
• Assess hemodynamic stability by checking postural pulse changes (≥30 beats/min from lying to standing) or severe postural dizziness, which indicate significant volume depletion from blood loss 2
• Administer isotonic fluids orally, nasogastrically, subcutaneously, or intravenously for volume depletion 2

Critical Laboratory Tests to Order STAT

• Complete blood count (CBC) with hemoglobin and hematocrit 1
• Coagulation profile (PT/INR, PTT) to identify bleeding disorders 1, 3
• Type and cross-match for blood products 1
• Serum lactate and base deficit to estimate extent of bleeding and shock 1

Blood Transfusion Thresholds

• Transfuse packed red blood cells when hemoglobin falls below 70-100 g/L or with active bleeding and hemodynamic instability 1
• Target hemoglobin of at least 7 g/dL (4.5 mmol/L) during resuscitation 1
• Maintain mean arterial pressure >65 mmHg while avoiding fluid overload 1

Pharmacological Management

• Start high-dose proton pump inhibitor therapy immediately: 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours 1
• Consider vasoactive drugs (terlipressin or octreotide) if portal hypertension or liver disease is suspected 1, 3
• Administer prophylactic antibiotics if liver disease is present 1

Endoscopy Timing

• Perform upper endoscopy within 24 hours of presentation after adequate resuscitation 1, 4
• Keep patient fasted until hemodynamically stable and endoscopy can be safely performed 1
• Consider urgent endoscopy (within hours) if the patient remains hemodynamically unstable despite initial resuscitation 3

Risk Stratification

• Use the Rockall scoring system to assess risk of rebleeding and mortality 1
• High-risk features include: age >80 years, shock, renal/liver failure, disseminated malignancy, and active bleeding on endoscopy 1

Diagnostic Confirmation

• Visual inspection and photographic documentation of vomitus helps confirm the presence of blood 3
• Esophagogastroduodenoscopy (EGD) is the gold standard for diagnosis, allowing direct visualization and therapeutic intervention 3
• CT angiography can identify active bleeding sites if endoscopy is delayed or unavailable 3

Critical Pitfalls to Avoid

• Never delay resuscitation while waiting for diagnostic tests, as this worsens outcomes 1
• Do not rely on single hematocrit measurements as isolated markers of bleeding severity 1
• Always consider upper GI sources even if bleeding seems minor, as up to 15% of severe lower GI bleeding originates from upper sources 1
• Avoid nasogastric tube placement in unsedated patients due to risk of gagging, vomiting, and aerosolization 3
• Do not use epinephrine injection alone for endoscopic hemostasis; always combine with thermal or mechanical methods 4

Ongoing Monitoring

• Continuously observe pulse, blood pressure, and urine output to detect rebleeding 1
• Rebleeding is defined as: fresh hematemesis/melaena with shock, CVP drop >5 mmHg, or hemoglobin reduction >20 g/L over 24 hours 2
• Most rebleeding occurs within 48 hours of initial hemorrhage 5