What are the initial steps in managing a patient with hematemesis?

Initial Management of Hematemesis

Immediately secure the airway with rapid sequence intubation in any patient with decreased consciousness or massive ongoing hematemesis to prevent aspiration, establish large-bore IV access (ideally 8-Fr central line), and resuscitate with warmed blood products rather than crystalloids. 1

Immediate Airway and Breathing Management

• Intubate immediately using rapid sequence intubation if the patient has decreased level of consciousness or massive ongoing hematemesis—aspiration is the primary immediate threat to life 1
• Administer high-flow oxygen (high FiO2) to all patients with hematemesis 2, 1
• Insert a nasogastric tube in patients with massive hematemesis to decompress the stomach and protect the airway 1

Vascular Access and Initial Assessment

• Establish large-bore IV access immediately—the ideal is an 8-Fr central venous catheter in adults 2, 1
• If peripheral access fails, consider intra-osseous access or surgical venous access 2
• Draw baseline blood work immediately: complete blood count, PT, aPTT, Clauss fibrinogen (not derived fibrinogen), and cross-match 2, 1
• Consider near-patient coagulation testing with thromboelastography (TEG) or thromboelastometry (ROTEM) if available 2

Fluid Resuscitation Strategy

• Resuscitate with warmed blood products, not crystalloids, in patients with massive hemorrhage 1, 3
• Blood availability follows this hierarchy: Group O blood (fastest) → group-specific → cross-matched 1
• Transfuse packed red blood cells to maintain hemoglobin above 7 g/dL in stable patients 1
• Use a higher threshold of 9 g/dL in patients with massive bleeding, significant cardiovascular comorbidities, or possible delay in therapeutic interventions 1
• Actively warm the patient and all transfused fluids 2

Coagulation Management

• Administer tranexamic acid 1g IV over 10 minutes as soon as possible if the patient is bleeding or at risk of significant bleeding—this must be given within 3 hours of bleeding onset for maximum mortality benefit 1, 3
• For fibrinogen <1 g/L: administer fibrinogen concentrate 3-4g or cryoprecipitate (15-20 single donor units) 1
• Target fibrinogen level >1.5 g/L in massive hemorrhage 1
• Maintain platelet count above 75 × 10⁹/L, as levels <50 × 10⁹/L are strongly associated with microvascular bleeding 3

Blood Pressure Management

• Restore organ perfusion but do not aggressively normalize blood pressure until bleeding is controlled—a normal blood pressure is not necessary at this stage 2, 1
• Once bleeding is controlled, aggressively normalize blood pressure, acid-base status, and temperature 1, 3
• Avoid vasopressors during active bleeding 3

Critical History Elements to Obtain

While resuscitation is ongoing, obtain a brief focused history to identify high-risk bleeding sources:

• History of trauma (blunt or penetrating) 2
• Obstetric patient 2
• Major recent surgery (neurosurgery, spinal, cardiac, liver surgery) 2
• Underlying medical conditions affecting coagulation 2
• Recent infection or septicemia—particularly staphylococcus aureus, which can cause mycotic aneurysms with aortoesophageal fistula 4
• Presence of concurrent melena with hematemesis—this combination significantly worsens outcomes compared to isolated hematemesis (composite adverse outcomes 62.4% vs. 25.6% for bloody hematemesis) 5

Physical Examination Priorities

• Look for obvious external bleeding points and control with pressure, tourniquets, or hemostatic dressings 2
• Assess injury patterns and look for blood loss on clothes, floor, or in drains 2
• Look for signs of internal blood loss 2
• Assess physiology: skin color, heart rate, blood pressure, capillary refill, conscious level 2
• If the patient is conscious, talking, and has a palpable peripheral pulse, blood pressure is adequate 2

Important caveat: Some patients compensate well despite significant blood loss—do not be falsely reassured by initially normal vital signs 2

Diagnostic Approach After Stabilization

• In hemodynamically stable patients, perform endoscopy within 6 hours of admission—success rate is highest if performed within the first 36 hours of bleeding onset 1, 6
• Consider contrast-enhanced CT before endoscopy if lower gastrointestinal source is suspected 1

Definitive Hemostasis

• Super-selective angiographic embolization achieves immediate hemostasis in 40-100% of cases with 15% rebleeding rate, though it requires active bleeding at rates >0.5 mL/min to localize the bleeding site 1
• Alert the surgical team early about potential need for operative intervention and cell salvage autotransfusion 2

Post-Resuscitation Care

• Admit to critical care unit for continued monitoring after bleeding control 1
• Monitor coagulation parameters, hemoglobin, blood gases, and assess for rebleeding 1
• Initiate venous thromboprophylaxis as soon as bleeding is controlled—patients rapidly develop a prothrombotic state following massive hemorrhage 1

Common Pitfalls

• Do not use derived fibrinogen values—insist on Clauss fibrinogen for accurate assessment 2
• Do not assume bloody hematemesis is more severe than coffee-grounds emesis—research shows they have similar severity at presentation (pulse ≥100 bpm: 35% vs. 37%; mortality: 6.6% vs. 9.3%), though bloody emesis has modestly higher rates of hemostatic intervention due to higher frequency of varices 5
• Do not delay massive transfusion protocol activation while waiting for laboratory results in obvious massive hemorrhage 2