What is the immediate management for a patient presenting with hematemesis?

Immediate Management of Hematemesis

For a patient presenting with hematemesis, immediately secure large-bore intravenous access (ideally 8-Fr central line), administer high-flow oxygen, initiate fluid resuscitation targeting systolic blood pressure of 80-100 mmHg until bleeding is controlled, actively warm the patient and all fluids, obtain baseline labs including coagulation studies, and arrange urgent endoscopy within 24 hours after initial stabilization. 1, 2, 3

Initial Resuscitation and Stabilization

Airway and Breathing

• Administer high FiO2 to ensure adequate oxygenation in all patients with hematemesis 1, 2
• Avoid hyperventilation and excessive positive end-expiratory pressure (PEEP) in severely hypovolemic patients, as this decreases cardiac output and worsens outcomes 1, 2
• Insert nasogastric tube to protect the airway, decompress the stomach, and assess ongoing bleeding 4

Circulation and Vascular Access

• Secure the largest bore IV access possible, with 8-Fr central venous access being ideal in adults 1, 2
• If peripheral or central access fails, consider intra-osseous or surgical venous access 1
• Rapid clinical assessment is critical: If the patient is conscious, talking, and has a palpable peripheral pulse, blood pressure is likely adequate 1

Hemodynamic Targets

• Target systolic blood pressure of 80-100 mmHg until major bleeding has been controlled in patients without brain injury 1, 4, 2
• Do not rely solely on blood pressure as an indicator of blood loss—some patients compensate well despite significant hemorrhage 1, 4, 2

Fluid Resuscitation Strategy

• Initially use crystalloids for fluid resuscitation 1, 2
• For massive hemorrhage, immediately administer warmed blood and blood components rather than continuing crystalloid resuscitation 1, 4
• Blood product availability hierarchy: O-type blood (fastest), followed by group-specific blood, then cross-matched blood 1, 4, 2

Temperature Management

• Actively warm the patient and all transfused fluids to prevent hypothermia, which worsens coagulopathy 1, 4, 2

Laboratory and Diagnostic Assessment

Essential Baseline Labs

• Obtain complete blood count (CBC), prothrombin time (PT), activated partial thromboplastin time (aPTT), and Clauss fibrinogen for cross-match 1, 4, 2
• Measure serum lactate and base deficit to estimate and monitor the extent of bleeding and shock 1, 4, 2
• Do not rely on single hematocrit measurements as isolated markers for bleeding severity—they may not reflect acute blood loss 1, 4, 2

Advanced Coagulation Monitoring

• If available, perform near-patient testing such as thromboelastography (TEG) or thromboelastometry (ROTEM) 1, 2

Imaging Studies

• For hemodynamically stable patients, perform urgent endoscopy within 24 hours after initial stabilization 4, 2, 3
• Endoscopy is most successful when performed within the first 36 hours of bleeding onset 5
• For suspected torso trauma, employ early focused abdominal sonography (FAST) for detection of free fluid 1, 2

Blood Product Administration

Transfusion Thresholds

• Transfuse packed red blood cells to maintain hemoglobin above 7 g/dL in most patients 4
• Use a higher transfusion threshold of 9 g/dL in patients with massive bleeding, significant cardiovascular comorbidities, or when therapeutic interventions may be delayed 4

Pharmacologic Hemostasis

• Administer intravenous proton pump inhibitors in the acute setting to decrease the probability of high-risk stigmata during endoscopy 3
• Consider tranexamic acid 10-15 mg/kg followed by infusion of 1-5 mg/kg/h in patients with significant bleeding 1, 4, 2
• Prokinetic agents can be given 30-60 minutes before endoscopy to aid in diagnosis 3

Source Control and Definitive Management

Endoscopic Intervention

• Perform urgent endoscopic assessment within 24 hours of presentation after initial stabilization 4, 2, 3
• Implement appropriate endoscopic hemostatic interventions based on findings (injection, thermal, or mechanical methods) 3
• If using epinephrine injection, always combine with another method to increase success of achieving hemostasis 3

When Endoscopy Fails

• Consider interventional radiology angiographic embolization when endoscopy is unsuccessful 4
• Surgical intervention may be necessary for massive, life-threatening bleeding 4
• For patients with ongoing hemodynamic instability despite initial measures, perform immediate bleeding control procedures 1, 2

Damage Control Approach

• Employ damage control surgery in severely injured patients presenting with deep hemorrhagic shock, signs of ongoing bleeding, coagulopathy, hypothermia, acidosis, or need for time-consuming procedures 1, 2

Ongoing Monitoring and Disposition

Critical Care Admission

• Admit to critical care area for monitoring of coagulation, hemoglobin, blood gases, and wound drain assessment 1
• Monitor physiology continuously: skin color, heart rate, blood pressure, capillary refill, conscious level 1

Thromboprophylaxis

• Begin standard venous thromboprophylaxis as soon as bleeding is controlled, as patients rapidly develop a prothrombotic state 1, 2

Critical Pitfalls to Avoid

• Avoid delays between presentation and intervention for patients requiring urgent bleeding control 1, 4, 2
• Do not use vasopressors once control of bleeding is achieved 1
• Never rely on derived fibrinogen levels—they are misleading and should not be used 1
• Recognize that 65% of hemorrhages subside spontaneously, but 25% rebleed (usually within 2 days) and 10% have persistent bleeding 5
• Mortality rates approach 10% overall but can reach 30% in variceal bleeding 5