How to manage a patient with hematemesis and shivering?

Management of Hematemesis with Shivering

Immediately secure two large-bore IV lines, begin resuscitation targeting systolic BP 80-100 mmHg, actively warm the patient to prevent hypothermia-induced coagulopathy, and treat shivering with meperidine 12.5-50 mg while arranging urgent endoscopy within 24 hours. 1

Immediate Stabilization

Secure vascular access and begin resuscitation:

• Establish two large-bore (ideally 8-Fr) IV cannulae in the anticubital fossae immediately 2
• Administer high FiO2 to ensure adequate oxygenation 1
• Target systolic blood pressure of 80-100 mmHg (MAP 50-60 mmHg) until major bleeding is controlled—avoid aggressive fluid resuscitation that may worsen bleeding 1, 2
• Insert urinary catheter and monitor hourly urine output (target >30 mL/hour) 2

Critical pitfall: Do not rely solely on blood pressure or single hemoglobin measurements as indicators of bleeding severity, as patients may compensate well despite significant hemorrhage and hemoglobin lags behind acute blood loss 1, 2

Address Shivering Immediately

The shivering in this patient likely represents either infection/sepsis or hypothermia from blood loss and shock. 3

Pharmacologic management of shivering:

• Meperidine 12.5-50 mg is the preferred first-line agent due to its potent anti-shivering properties—it both lowers the shivering threshold and suppresses shivering 1
• Add magnesium sulfate (2-4 g bolus, then 1 g/h every 2-4 hours) as an adjunct 1
• Consider acetaminophen as an additional adjunct 1
• Ondansetron 4-8 mg every 4-8 hours can be used preventatively, though effects are limited 1

Non-pharmacologic measures:

• Initiate surface counterwarming immediately, particularly warming extremities (ears, palms, soles) 4, 1
• Actively warm all transfused fluids to prevent hypothermia, which worsens coagulopathy 1

Important consideration: Shivering with fever (≥38.0°C) may indicate sepsis requiring prompt evaluation and empiric antibiotics, as infection is common in critically ill patients 4, 3

Laboratory Assessment

Obtain immediately:

• Complete blood count, PT, aPTT, and Clauss fibrinogen 1, 2
• Serum lactate and base deficit to estimate extent of bleeding and tissue hypoperfusion 1, 2
• Measure shock index (heart rate/systolic BP) to assess hypovolemic shock and transfusion requirements 2

Blood Product Administration

Transfusion strategy:

• Transfuse packed red blood cells to maintain hemoglobin above 7 g/dL in most patients 1
• Use a higher transfusion threshold of 9 g/dL (90 g/L) in patients with massive bleeding, significant cardiovascular comorbidities, or when therapeutic interventions may be delayed 1
• Administer warmed blood and blood components for massive hemorrhage 1

Exception: For patients with cirrhosis and variceal bleeding, maintain hemoglobin target of 7-9 g/dL (70-90 g/L) to avoid exacerbating portal pressure 2

Urgent Endoscopic Management

Timing and approach:

• Perform urgent endoscopic assessment within 24 hours of presentation after initial stabilization 1
• Endoscopy should only be performed after adequate resuscitation with stable vital signs when possible 2
• Consider endotracheal intubation before endoscopy in severely bleeding patients to prevent pulmonary aspiration 2
• Insert nasogastric tube to protect airway, decompress stomach, and assess ongoing bleeding 1
• Implement appropriate endoscopic hemostatic interventions based on findings 1, 5

Critical pitfall: Avoid delays between presentation and intervention for patients requiring urgent bleeding control, but never perform endoscopy before adequate resuscitation 1, 2

When Endoscopy Fails

Escalation pathway:

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

Risk Stratification

High-risk features requiring intensive monitoring:

• Age >60 years with hemodynamic compromise 2
• Pulse >100 bpm, systolic BP <100 mmHg 2
• Hemoglobin <100 g/L 2
• Significant comorbid medical diseases 2
• Active hematemesis or hemodynamic instability despite resuscitation 2

Metabolic Consequences of Untreated Shivering

Shivering doubles metabolic rate and nearly triples oxygen consumption, which can trigger bioenergetic failure with demand cerebral ischemia and significant mismatch in energy supply and demand 4, 3. In a patient already compromised by hemorrhagic shock, this metabolic toll can worsen tissue hypoperfusion and outcomes, making aggressive shivering management essential 4.