How to manage a patient throwing up blood in a primary care setting?

Management of Hematemesis in Primary Care

A patient presenting with hematemesis (throwing up blood) in a primary care office requires immediate assessment of hemodynamic stability and rapid transfer to the emergency department if unstable, as this represents a potentially life-threatening upper gastrointestinal bleed requiring urgent resuscitation and endoscopy. 1

Immediate Assessment in the Office

Assess hemodynamic stability immediately:

• Check vital signs: heart rate, blood pressure, and calculate shock index (heart rate ÷ systolic blood pressure) 2
• Shock index >1 indicates hemodynamic instability requiring immediate hospital transfer 2
• Look for signs of severe bleeding: tachycardia (pulse ≥100 bpm), hypotension (systolic BP ≤100 mmHg), orthostatic changes, or signs of shock 1, 3
• Assess for active bleeding: is the patient actively vomiting blood now? 1

Characterize the bleeding:

• Bright red/bloody hematemesis vs. coffee-grounds emesis: Both have similar severity at presentation (similar rates of hypotension, tachycardia, and anemia), though bloody emesis has modestly higher rates of requiring intervention 4
• Presence of both hematemesis AND melena indicates worse outcomes and higher need for intervention (composite outcome 62.4% vs. 25.6% for isolated hematemesis) 4
• Duration and volume of bleeding 1

Critical red flags requiring immediate ED transfer:

• Shock index >1 2
• Systolic BP <100 mmHg or heart rate >100 bpm 3
• Active ongoing bleeding 1
• Signs of hypovolemia (syncope, altered mental status, severe weakness) 1
• Age >60 years with significant bleeding 3
• Significant comorbidities: liver disease, renal insufficiency, heart disease, malignancy 3
• History of peptic ulcer disease or portal hypertension 2
• Anticoagulant or antiplatelet medication use 1, 3

Disposition Algorithm

For hemodynamically UNSTABLE patients (shock index >1, hypotension, tachycardia, active bleeding):

• Call 911 immediately for emergency transport 1
• While awaiting transport: position patient supine, establish IV access if possible, administer high-flow oxygen 3
• Do NOT delay transport for procedures like nasogastric tube placement 2
• These patients require immediate resuscitation with crystalloids, blood transfusion, and urgent endoscopy within 12-24 hours 1, 3

For hemodynamically STABLE patients with minor bleeding:

• Still requires urgent ED evaluation the same day 1, 5
• Even stable patients can deteriorate rapidly, as 25% of upper GI bleeds rebleed after initial cessation, with 75% of rebleeding occurring within 2 days 5
• Mortality from upper GI bleeding exceeds 10% overall, reaching 30% for variceal bleeding 5, 6

Common Pitfalls to Avoid

Do not assume epistaxis without proper evaluation:

• While epistaxis can cause hematemesis and melena (0.55% incidence), this diagnosis requires careful nasal/nasopharyngeal examination and should only be considered with recent facial trauma, recent epistaxis, or coagulopathy 7
• Do not attribute hematemesis to nosebleed without excluding upper GI source first 7

Do not delay transfer for diagnostic procedures:

• Nasogastric tube placement in the office is not recommended—it delays definitive care and does not change immediate management 2
• Endoscopy is the primary diagnostic procedure and should be performed in hospital within 24 hours (within 12 hours for high-risk patients) 3, 5

Do not underestimate coffee-grounds emesis:

• Coffee-grounds hematemesis has similar severity and outcomes to bloody hematemesis, with comparable rates of hypotension (12% vs. 12%), anemia (27% vs. 25%), and mortality (9.3% vs. 6.6%) 4

Key Management Principles for Hospital Team

Once transferred, the patient will receive:

• Immediate resuscitation: crystalloid fluids targeting blood pressure stabilization and restoration of intravascular volume 1, 3
• Restrictive transfusion strategy: hemoglobin threshold <7 g/dL (target 7-9 g/dL) in patients without cardiovascular disease 1, 3
• Risk stratification: using clinical criteria including age >60, shock, hemoglobin <100 g/L, and comorbidities 1, 3
• Urgent endoscopy: within 24 hours for most patients, within 12 hours for high-risk patients 3
• High-dose IV proton pump inhibitor: 80 mg pantoprazole bolus followed by 8 mg/hour continuous infusion for 72 hours after successful endoscopic therapy 3
• Endoscopic hemostasis: combination therapy (injection plus thermal coagulation) for high-risk stigmata 3

The primary care role is rapid recognition, hemodynamic assessment, and immediate transfer—not definitive management. 1