What is the management for a patient presenting with hematemesis and shivering?

Management of Hematemesis with Shivering

A patient presenting with hematemesis and shivering requires immediate resuscitation with large-bore IV access, fluid administration targeting systolic blood pressure of 80-100 mmHg until bleeding is controlled, urgent endoscopy within 24 hours, and treatment of the shivering with meperidine (12.5-50 mg) which has potent anti-shivering properties while simultaneously addressing the underlying bleeding source. 1, 2

Immediate Stabilization and Assessment

Hemodynamic Resuscitation:

• Secure large-bore intravenous access (ideally 8-Fr central access in adults) immediately to allow for rapid fluid resuscitation 1
• Administer high FiO2 to ensure adequate oxygenation 1
• Target systolic blood pressure of 80-100 mmHg until major bleeding has been controlled 2, 1
• Actively warm the patient and all transfused fluids to prevent hypothermia, which can worsen coagulopathy 1

Critical Laboratory Studies:

• Obtain baseline complete blood count, prothrombin time (PT), activated partial thromboplastin time (aPTT), and Clauss fibrinogen 1
• Measure serum lactate and base deficit to estimate and monitor the extent of bleeding and shock 1
• Do not rely on single hemoglobin/hematocrit measurements as isolated markers for bleeding severity, as they may not reflect acute blood loss 1, 2

Management of Shivering

Pharmacologic Anti-Shivering Therapy:

• Meperidine 12.5-50 mg is the preferred agent due to its potent anti-shivering properties 2
• Be aware that meperidine has an active metabolite associated with neurotoxicity and decreases seizure threshold 2
• Alternative agents include magnesium sulfate (2-4 g bolus, then 1 g/h every 2-4 hours) as an adjunct 2
• Consider ondansetron 4-8 mg every 4-8 hours in a preventative manner, though effects are limited 2

Non-Pharmacologic Measures:

• Initiate surface counterwarming immediately 2
• Consider acetaminophen as an adjunct 2

Blood Product Administration

Transfusion Strategy:

• Transfuse packed red blood cells to maintain hemoglobin above 7 g/dL in most patients 1
• Consider a higher transfusion threshold of 9 g/dL in patients with massive bleeding, significant cardiovascular comorbidities, or when therapeutic interventions may be delayed 1
• For massive hemorrhage, administer warmed blood and blood components 1
• Use blood products in order of availability: O-type blood, group-specific blood, then cross-matched blood 1

Urgent Endoscopic Management

Timing and Approach:

• Perform urgent endoscopic assessment within 24 hours of presentation after initial stabilization 1, 3
• The success rate is highest if endoscopy is performed within the first 36 hours of the onset of bleeding 4
• Insert a nasogastric tube to protect the airway, decompress the stomach, and assess ongoing bleeding 1

Endoscopic Interventions:

• Implement appropriate endoscopic hemostatic interventions based on findings (injection, thermal, or mechanical methods) 1, 3
• Epinephrine injection should always be used in conjunction with another method to increase success of achieving hemostasis 3

Pharmacologic Adjuncts:

• Administer intravenous proton pump inhibitors in the acute setting to decrease the probability of high-risk stigmata seen during endoscopy 3
• Consider pro-kinetic agents 30 minutes to one hour before endoscopy to aid in diagnosis 3

When Endoscopy Fails or Is Unavailable

Alternative Interventions:

• Consider interventional radiology angiographic embolization techniques when endoscopy is unsuccessful 1
• For massive, life-threatening bleeding, surgical intervention may be necessary 1

Critical Pitfalls to Avoid

• Avoid delays between presentation and intervention for patients requiring urgent bleeding control 1, 2
• Do not rely solely on blood pressure as an indicator of blood loss, as some patients compensate well despite significant hemorrhage 1
• Recognize that 65% of hemorrhages subside spontaneously, but 25% bleed recurrently and 75% of renewed bleeding occurs within two days after the initial hemorrhage 4
• Be aware that bloody hematemesis is not necessarily more severe than coffee-grounds emesis, though it is associated with modestly higher rates of hemostatic intervention and rebleeding 5

Disposition

• Admit the patient to a critical care area for monitoring after initial stabilization 1
• Begin standard venous thromboprophylaxis as soon as bleeding is controlled 1
• If the cause of hematemesis cannot be found, aggressive inpatient investigations are required at the first sign of second bleed 4