What is the most appropriate next step in managing a patient with hypotension, tachycardia, and melena, with lab results showing anemia (low Hemoglobin (Hb) level) and normal platelet count?

Immediate Management of Hemorrhagic Shock from Upper GI Bleeding

Administer normal saline immediately as the first-line intervention for this patient presenting with hemorrhagic shock from upper GI bleeding, followed by blood transfusion once available. 1

Clinical Presentation Analysis

This patient demonstrates clear signs of hemorrhagic shock requiring urgent intervention:

• Hemodynamic instability: Blood pressure 90/60 mmHg with compensatory tachycardia (HR 120/min) indicates significant volume depletion 1
• Poor tissue perfusion: Cold extremities and faint peripheral pulses suggest inadequate end-organ perfusion 1
• Active bleeding: Melena with maroon-colored stool indicates upper GI bleeding, likely NSAID-induced peptic ulcer disease given 5-day ibuprofen use 1
• Anemia: Hemoglobin 8.7 g/L represents significant blood loss requiring intervention 1

Immediate Resuscitation Algorithm

Step 1: Crystalloid Resuscitation (First Priority)

Administer a 500 mL normal saline bolus immediately through large-bore IV access. 1 The European trauma guidelines and European Society of Cardiology both recommend crystalloids as the initial treatment for hemorrhagic shock, with normal saline being the preferred choice. 1 This addresses the immediate life-threatening hypovolemia before blood products become available.

Step 2: Blood Transfusion (Second Priority)

Transfuse 2-3 units of packed red blood cells once available, targeting hemoglobin 7-9 g/dL. 1, 2 The Critical Care society indicates RBC transfusion is indicated when hemoglobin is below 9 g/dL in the setting of active bleeding with hemodynamic instability. 1 Each unit should increase hemoglobin by approximately 1.5 g/dL. 2

Step 3: Ongoing Management

• Target systolic blood pressure 80-100 mmHg until bleeding is controlled (permissive hypotension approach) 1
• Discontinue NSAIDs immediately 1
• Initiate proton pump inhibitor therapy for presumed peptic ulcer disease 1
• Arrange urgent upper endoscopy to identify and treat the bleeding source 1
• Monitor with serial hemoglobin checks and vital signs for rebleeding 1

Why Not the Other Options?

Colloid solutions (Option B) and albumin (Option D) are not recommended as first-line therapy. The evidence consistently supports crystalloids over colloids for initial hemorrhagic shock resuscitation. 1 Colloids offer no mortality benefit and are more expensive.

Blood transfusion alone (Option C) without initial crystalloid resuscitation is inappropriate because:

• Blood products take time to prepare, cross-match, and administer 1
• Immediate volume expansion with crystalloids is life-saving and should not be delayed 1
• The sequential approach (crystalloids first, then blood) is the standard of care 1

Critical Pitfalls to Avoid

• Do not delay crystalloid administration while waiting for blood products—this patient needs immediate volume resuscitation 1
• Avoid aggressive fluid resuscitation beyond initial stabilization as this can worsen bleeding before endoscopic control 3
• Do not target normal blood pressure initially—permissive hypotension (SBP 80-100 mmHg) is appropriate until bleeding is controlled 1
• Transfuse single units sequentially rather than multiple units simultaneously, reassessing after each unit 2

Monitoring Parameters

• Continuous cardiac monitoring given the critically low hemoglobin and hemodynamic instability 2
• Hourly urine output targeting >30 mL/h 2
• Serial hemoglobin checks until stable above 7-8 g/dL 2
• Watch for transfusion reactions or volume overload during blood product administration 2