What is the immediate course of action for a 9-year-old child presenting with hematemesis (vomiting blood)?

Immediate Management of Hematemesis in a 9-Year-Old Child

Immediately assess hemodynamic stability and initiate resuscitation while simultaneously investigating for life-threatening causes, particularly severe thrombocytopenia, which requires urgent platelet count measurement and potential emergency intervention. 1

Initial Stabilization and Assessment

Hemodynamic Resuscitation

• Establish intravenous access and administer crystalloid boluses of 20 mL/kg if the child shows signs of shock or hemodynamic instability 2
• Avoid excessive crystalloid administration during active hemorrhage; prioritize blood products once available 2
• Monitor for hypothermia and electrolyte imbalances during rapid fluid administration, as children are particularly vulnerable 2

Urgent Laboratory Evaluation

• Obtain complete blood count with platelet count immediately to rule out thrombocytopenia as a life-threatening cause 1
• Check coagulation studies (PT/INR, aPTT) 2
• Type and crossmatch blood products 2
• Consider additional testing based on clinical context: chemistry profile, direct antiglobulin test if hemolysis suspected 2

Risk Stratification Based on Platelet Count

Critical Thrombocytopenia (Platelet Count <20,000/mm³)

If platelet count is <20,000 with mucous membrane bleeding (hematemesis qualifies), hospitalize immediately and initiate emergency treatment 2, 1, 3:

• Administer platelet transfusions at 10-20 mL/kg 2
• Give high-dose parenteral methylprednisolone 30 mg/kg daily for 3 days 2, 1, 3
• Administer intravenous immunoglobulin (IVIg) 0.8-1 g/kg as a single dose, which raises platelet counts in >80% of children more rapidly than corticosteroids alone 2, 3
• These interventions can be used alone or in combination; combination therapy is preferred for life-threatening bleeding 2, 1

Moderate Thrombocytopenia (Platelet Count 20,000-30,000/mm³)

• Hospitalize if symptomatic bleeding is present 2
• Consider observation if asymptomatic, though hematemesis indicates symptoms are present 2, 3

Normal or Mildly Reduced Platelet Count

Proceed with evaluation for gastrointestinal causes of bleeding.

Gastrointestinal Evaluation

Endoscopy Timing and Indications

• Upper GI endoscopy is the primary investigative procedure and should be performed within 36 hours of bleeding onset for highest diagnostic yield 4
• Endoscopy has a 75% overall diagnostic yield in children with hematemesis, with higher yield (91%) in children under 12 years 5
• In a 9-year-old, the most common causes are gastritis (44%) and esophagitis (36%), with peptic ulcer disease and varices being less common (7% and 4% respectively) 5

Common Pitfalls to Avoid

• Failing to check platelet count in any bleeding child—coagulopathy must be excluded immediately 1
• Delaying endoscopy beyond 36 hours reduces diagnostic accuracy 4
• Using adult dosing for medications or blood products; always calculate weight-based dosing in children 2, 6

Blood Product Administration (If Needed)

Transfusion Thresholds and Dosing

• Transfuse RBCs at 10 mL/kg, which increases hemoglobin by approximately 20 g/L 2, 6
• Fresh frozen plasma: 10-15 mL/kg if coagulopathy present 2, 6
• Cryoprecipitate: 5-10 mL/kg if fibrinogen deficiency identified 2, 6
• Prescribe blood products by volume, not units, in children 2, 6

Massive Hemorrhage Protocol

• If bleeding exceeds 20 mL/kg of blood products in 1 hour, activate massive transfusion protocol with 1:1:1 ratio of packed RBCs, plasma, and platelets 1
• Consider tranexamic acid 15 mg/kg loading dose followed by 2 mg/kg/hour infusion for trauma-related bleeding 2, 6

Disposition

Hospitalization Criteria

• Any child with severe, life-threatening bleeding requires hospitalization regardless of platelet count 2, 3
• Platelet count <20,000 with mucous membrane bleeding (hematemesis) mandates hospitalization 2, 3
• Active hematemesis with hemodynamic compromise requires intensive care monitoring 2

Observation May Be Appropriate If:

• Bleeding has completely stopped
• Hemodynamics are stable
• Platelet count is >30,000 (if thrombocytopenia was the concern)
• No evidence of ongoing blood loss
• Reliable follow-up is ensured 2, 3

However, given that hematemesis represents visible upper GI bleeding, most 9-year-olds presenting with this symptom will require hospitalization for endoscopic evaluation and monitoring 4, 5.