How should a patient with chest pain and hematemesis be managed?

Management of a 20-Year-Old with Chest Pain and Hematemesis

This patient requires immediate resuscitation with intravenous fluid replacement, urgent upper endoscopy within 24 hours to identify and treat the bleeding source, and simultaneous cardiac evaluation with 12-lead ECG to exclude acute coronary syndrome, as the combination of chest pain and hematemesis suggests either upper gastrointestinal bleeding with cardiovascular compromise or a life-threatening condition requiring dual-track assessment. 1, 2

Immediate Resuscitation and Stabilization

Hemodynamic Assessment and Fluid Resuscitation

• Establish two large-bore intravenous cannulae in the anticubital fossae immediately for patients with hematemesis and potential hemodynamic compromise 1
• Measure vital signs including heart rate, blood pressure in both arms, respiratory rate, and oxygen saturation to assess both bleeding severity and exclude aortic dissection 1, 2
• Infuse normal saline to achieve falling pulse rate, rising blood pressure, and adequate urine output (>30 ml/h); 1-2 liters typically corrects volume losses in most patients 1
• Transfuse red blood cell concentrate when hemoglobin is <100 g/L in acute bleeding or when bleeding is extreme with active hematemesis and shock 1
• Insert urinary catheter and measure hourly urine volumes in patients with significant bleeding 1

Risk Stratification for Bleeding Severity

The Rockall scoring system identifies high-risk features that predict mortality and rebleeding 1:

• Age >60 years increases mortality risk significantly (though this patient is 20 years old, reducing this specific risk) 1
• Tachycardia (pulse >100/min) and hypotension (systolic BP <100 mmHg) define shock and predict poor outcomes 1
• Heart rate ≥100/min carries an odds ratio of 3.67 for severe bleeding 3
• Systolic blood pressure ≤115 mmHg carries an odds ratio of 3.45 for severe bleeding 3
• Syncope increases risk of severe bleeding (OR 2.82) 3

Cardiac Evaluation (Dual-Track Approach)

Immediate ECG and Cardiac Assessment

• Obtain 12-lead ECG within 10 minutes of presentation to identify STEMI, ST-segment depression, T-wave changes, or new conduction abnormalities 1, 2
• Draw blood immediately for high-sensitivity cardiac troponin as the preferred biomarker for myocardial injury 2
• Establish continuous cardiac monitoring with emergency resuscitation equipment and defibrillator readily available 2
• Consider aspirin 160-325 mg if acute coronary syndrome is suspected and there are no contraindications from active bleeding 1

Critical Pitfall to Avoid

Do not assume chest pain is simply referred pain from esophageal bleeding—young patients can have acute coronary syndrome, aortic dissection, or pulmonary embolism, and the combination of symptoms mandates parallel evaluation 1

Diagnostic Endoscopy

Timing and Preparation

• Perform upper endoscopy within 24 hours after adequate resuscitation in most patients with hematemesis 1
• Endoscopy should only be performed when resuscitation has been achieved and blood pressure is stable 1
• In severely bleeding patients with active hematemesis, consider endoscopy with endotracheal intubation in place to prevent pulmonary aspiration 1
• Fast the patient until hemodynamically stable before endoscopy 1

Urgent vs. Semi-Elective Endoscopy

• Patients with ongoing hemodynamic instability despite adequate resuscitation require emergency "out of hours" endoscopy 1
• Patients with mild to moderate bleeding who stabilize can undergo semi-elective endoscopy on the next morning list 1
• Endoscopy must be performed by experienced endoscopists capable of therapeutic interventions including hemostasis 1

Specific Bleeding Source Considerations

Upper GI Bleeding Management

• Active bleeding from peptic ulcer in a shocked patient carries an 80% risk of continued bleeding or death 1
• Endoscopic hemostasis therapy (mechanical, thermal, injection, or combination) should be provided for high-risk stigmata including active bleeding, non-bleeding visible vessel, or adherent clot 4
• Fresh frozen plasma may be considered if coagulopathy is present 1

Esophageal Varices (if identified)

• Endoscopic variceal sclerotherapy is recommended for control of active variceal bleeding 5
• Balloon tamponade and intravenous vasopressin serve as adjuncts if sclerotherapy is unsuccessful 5

Monitoring and Serial Assessment

Laboratory Monitoring

• Single hematocrit measurements should not be used as an isolated marker for bleeding 1
• Repeat troponin measurements at 3,6, and 9-12 hours after symptom onset to detect delayed rise indicating myocardial injury 2
• Measure serum lactate and base deficit to estimate and monitor extent of bleeding and shock 1
• Perform serial ECGs every 2-4 hours to detect evolving ischemic changes 2

Clinical Monitoring

• Continuous multi-lead ST-segment monitoring to detect silent ischemia 2
• Assess for signs of rebleeding: recurrent hematemesis, hemodynamic deterioration, or falling hemoglobin 1, 3

Disposition and Admission

Admission Criteria

• Admit to monitored bed (coronary care unit or intensive care unit) if high-risk features present: ongoing chest pain, elevated troponin, hemodynamic instability, active bleeding, or shock 1, 2
• Patients with severe bleeding (transfusion ≥2 units, hematocrit decrease ≥20%, or continued bleeding within 24 hours) require intensive monitoring 3
• Consider admission to high dependency unit for elderly patients with multiple comorbidities and serious hemorrhage 1

Low-Risk Discharge Criteria (Not Applicable to This Patient)

Young healthy patients with minor bleeding, no hemodynamic compromise, and negative cardiac workup could potentially be discharged after 9-12 hours with negative serial troponins, stable ECG, and no recurrent symptoms 2—however, this 20-year-old with both chest pain AND hematemesis requires admission for dual-track evaluation 1, 2

Additional Diagnostic Considerations

Imaging Studies

• Chest X-ray to evaluate for pneumothorax, mediastinal widening (aortic dissection), pulmonary edema, or aspiration 1, 2
• Echocardiography to assess cardiac function, pericardial effusion, and wall motion abnormalities if cardiac etiology suspected 2, 6
• CT angiography if aortic dissection cannot be excluded clinically 1, 2

Aortic Dissection Exclusion

The ADD (Aortic Dissection Detection) score should be calculated 1:

• High-risk conditions: connective tissue disease, family history, known aortic disease
• High-risk pain features: abrupt onset, severe intensity, ripping/tearing quality
• High-risk examination: pulse deficit, blood pressure differential >20 mmHg, focal neurologic deficit
• Score ≥1 indicates high probability requiring immediate aortic imaging 1