What is the immediate diagnostic and treatment approach for a patient presenting with hematemesis (vomiting blood)?

Hematemesis: Immediate Diagnostic and Treatment Approach

For a patient presenting with hematemesis, immediately secure two large-bore IV cannulae (18G or larger), begin rapid fluid resuscitation with normal saline, assess hemodynamic stability using shock index (heart rate/systolic BP), and perform urgent upper endoscopy within 24 hours after adequate resuscitation. 1, 2

Immediate Stabilization (First 15 Minutes)

Airway and Breathing

• Administer high FiO2 to ensure adequate oxygenation 3
• Consider endotracheal intubation before endoscopy in patients with massive hematemesis to prevent pulmonary aspiration 4, 1
• Avoid nasogastric tube placement in unsedated patients due to risk of gagging, vomiting, and aerosolization 2

Circulation and Vascular Access

• Establish two large-bore (ideally 8-Fr or 18G) IV cannulae in the antecubital fossae immediately 4, 1, 2
• Insert urinary catheter and monitor hourly urine output (target >30 mL/hour) 4, 1
• Begin rapid fluid resuscitation with normal saline or balanced crystalloid, typically 1-2 liters initially 4, 2

Hemodynamic Targets During Active Bleeding

• Target systolic BP of 80-100 mmHg (MAP 50-60 mmHg) until major bleeding is controlled—avoid aggressive normalization of blood pressure before hemostasis 3, 1
• Maintain mean arterial pressure >65 mmHg while avoiding fluid overload 3, 2
• Do not rely solely on blood pressure as some patients compensate well despite significant hemorrhage 3, 1

Risk Stratification

Severity Assessment

Classify patients based on hemodynamic parameters 4, 1:

Severe bleeding indicators:

• Pulse >100 beats/min 4, 2
• Systolic BP <100 mmHg 4, 2
• Shock index (heart rate/systolic BP) >1 4, 1
• Active hematemesis with altered mental status 1
• Age >60 years with hemodynamic compromise 4, 1

High-risk features requiring intensive monitoring:

• Hemoglobin <100 g/L in acute bleeding 4, 1
• Significant comorbid medical diseases (cardiac, renal, liver disease) 4, 1
• Age >80 years, shock, renal/liver failure, disseminated malignancy 2

Immediate Laboratory Studies (STAT)

Essential Initial Labs

• Complete blood count with hemoglobin and hematocrit 1, 2
• Prothrombin time (PT), activated partial thromboplastin time (aPTT), and Clauss fibrinogen 3, 1
• Type and cross-match for blood products 1, 2
• Serum lactate and base deficit to estimate extent of bleeding and tissue hypoperfusion 1, 2

Critical pitfall: Do not rely on single hemoglobin/hematocrit measurements alone as isolated markers for bleeding severity—they lag behind acute blood loss 3, 1

Blood Product Transfusion

Transfusion Thresholds

• Transfuse packed red blood cells when hemoglobin <100 g/L in acute bleeding or when bleeding is extreme with shock 4, 1, 2
• Maintain hemoglobin target of at least 7 g/dL (70 g/L) during resuscitation phase in most patients 3, 2
• Use higher transfusion threshold of 9 g/dL in patients with massive bleeding, significant cardiovascular comorbidities, or when therapeutic interventions may be delayed 3

Special consideration for cirrhosis: For patients with cirrhosis and suspected variceal bleeding, maintain restrictive hemoglobin target of 70-90 g/L to avoid exacerbating portal pressure 1

Massive Transfusion Protocol

• Administer warmed blood and blood components for massive hemorrhage 3
• Use blood products in order of availability: O negative blood (fastest), group-specific, then cross-matched 4, 3
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 4, 3

Diagnostic Workup

Upper Endoscopy Timing

• Perform urgent upper endoscopy within 24 hours of presentation for most patients after initial stabilization 1, 2, 5
• Endoscopy should only be performed after adequate resuscitation with stable vital signs when possible 4, 1
• Critical pitfall: Never perform endoscopy before adequate resuscitation, but avoid delays in unstable patients once resuscitation is underway 4, 1

Endoscopy Goals

The endoscopy serves three purposes 4:

1. Define the cause of bleeding (varices, ulcer, cancer, Mallory-Weiss tear)
2. Assess prognosis based on endoscopic stigmata of bleeding
3. Administer endoscopic hemostatic therapy (epinephrine injection, cautery, hemoclips, hemospray)

When Upper Endoscopy is Negative or Unavailable

• If patient remains unstable after initial resuscitation with no source identified, consider CT angiography 4
• Up to 15% of patients with severe hematochezia may have an upper GI source 4, 2
• Consider interventional radiology angiographic embolization when endoscopy is unsuccessful 3
• Surgical intervention may be necessary for massive, life-threatening bleeding uncontrolled by endoscopy 3

Pharmacological Management

Acid Suppression

• Initiate high-dose proton pump inhibitor therapy: 80 mg IV bolus followed by 8 mg/hour infusion for 72 hours 2

Suspected Portal Hypertension

• Administer vasoactive drugs (terlipressin or octreotide) if portal hypertension is suspected 2
• Give prophylactic antibiotics if liver disease is suspected 2
• Identify patients with liver disease early as they require specific management protocols 1, 2

Monitoring and Ongoing Assessment

Continuous Monitoring Parameters

• Pulse and blood pressure using automated monitoring 4, 2
• Hourly urine output (target >30 mL/hour) 4, 1
• Skin color, capillary refill, conscious level 4
• Look for obvious blood loss (on clothes, floor, in drains) and indications of internal blood loss 4

Central Venous Monitoring

• Consider central venous pressure monitoring in patients with significant cardiac disease to guide fluid replacement 4, 1
• Target central venous pressure of 5-10 cm H2O in adequately resuscitated patients 4

Common Pitfalls to Avoid

• Delaying resuscitation while waiting for diagnostic tests worsens outcomes 2
• Failing to identify liver disease early leads to inappropriate transfusion strategies and missed variceal bleeding 1, 2
• Hyperventilation and excessive PEEP in hypovolemic patients worsens cardiac output 1
• Delays between presentation and intervention for patients requiring urgent bleeding control 3, 1
• Relying on blood pressure alone as some patients compensate well despite significant hemorrhage 3, 1
• Aggressive normalization of blood pressure before hemostasis can worsen bleeding 3, 1

Natural History

Most hematemesis resolves spontaneously: 88% of patients stop bleeding without intervention, only 6% require therapeutic endoscopic intervention, and operative or interventional radiologic procedures are rarely needed 6. However, 25% of hemorrhages that initially stop will rebleed, with three-quarters of recurrent bleeding occurring within two days 5. Mortality ranges from 6-10% overall but increases to 30% with variceal bleeding 5, 7.