What should be done for an adult or child with a history of gastrointestinal illness or trauma, presenting with bright red emesis?

Management of Bright Red Emesis (Hematemesis)

Bright red emesis indicates active upper gastrointestinal bleeding requiring immediate resuscitation, hemodynamic stabilization, and urgent endoscopy within 12-24 hours once the patient is stabilized.

Immediate Resuscitation (First 30 Minutes)

• Establish two large-bore peripheral IV cannulae (18-gauge or larger in the anticubital fossae) for rapid volume replacement 1, 2.
• Infuse 1-2 liters of crystalloid (normal saline) immediately to restore hemodynamic stability, targeting a fall in pulse rate, rising blood pressure, and adequate urine output (>30 mL/hour) 1, 2.
• Use a restrictive fluid strategy after initial resuscitation to avoid over-expansion, which can exacerbate portal pressure, impair clot formation, and increase rebleeding risk 2.
• Insert a urinary catheter in severe cases to track hourly urine volumes as a marker of adequate perfusion 1, 2.
• Monitor pulse and blood pressure continuously using automated systems 1.

Blood Product Management

• Transfuse packed red blood cells when hemoglobin is <100 g/L (10 g/dL) in the setting of acute bleeding, as changes in cardiac output occur at this threshold 1.
• Do not transfuse to hemoglobin >9 g/dL unless the patient has active cardiac ischemia, as liberal transfusion increases mortality 2.
• In extreme bleeding with shock, O-negative blood can be given, though rapid cross-matching is usually sufficient 1.
• Plasma expanders are needed if the patient remains shocked after 1-2 liters of saline, indicating at least 20% blood volume loss 1.

Pharmacologic Interventions (Within First Hour)

• Start high-dose IV proton pump inhibitor immediately upon presentation, even before endoscopy 2.
• If variceal bleeding is suspected (history of liver disease), give octreotide 50 mcg IV bolus (can repeat in first hour if ongoing bleeding), followed by continuous infusion at 50 mcg/hour for 2-5 days 2.
• Administer ceftriaxone 1g IV every 24 hours (maximum duration 7 days) in patients with suspected variceal bleeding to reduce infections, rebleeding, and mortality 2.

Risk Stratification and Triage

• Identify high-risk patients requiring intensive monitoring: age >60 years, pulse >100 beats/min, systolic blood pressure <100 mmHg, hemoglobin <100 g/L, and significant comorbidities 1.
• The presence of bright red blood in nasogastric aspirate is an independent predictor of rebleeding and need for emergency endoscopy, though routine nasogastric tube placement is not mandatory 1.
• Admit high-risk patients to an intensive care unit or high-acuity monitored setting for at least the first 24 hours 1, 2.
• Identify patients with significant liver disease early, as they require specific management protocols 1.

Urgent Endoscopy

• Perform endoscopy within 12-24 hours of presentation once circulatory and respiratory stability is achieved 2.
• Never perform endoscopy before achieving hemodynamic stability, as this increases procedural risk 1, 2.
• Endoscopy should be performed by experienced endoscopists trained in therapeutic hemostasis, with appropriately trained support staff available 1.
• In severely bleeding patients, consider endoscopy with an endotracheal tube in place to prevent pulmonary aspiration 1.
• Endoscopy defines the cause of bleeding, establishes prognosis based on stigmata of recent hemorrhage, and allows for therapeutic intervention 1, 2.

Critical Pitfalls to Avoid

• Do not administer excessive crystalloid volumes that cause fluid overload, as this worsens portal hypertension, impairs coagulation, and increases rebleeding risk 2.
• Do not delay endoscopy beyond 24 hours in patients with significant bleeding once stabilized 2.
• Avoid routine correction of coagulation parameters (INR, platelets) unless there is documented bleeding diathesis or ongoing bleeding despite endoscopic therapy 2.
• Keep the patient fasted until hemodynamically stable and endoscopy is completed 1.

Special Considerations

• In patients with significant cardiac disease, measurement of central venous pressure (targeting 5-10 cm H₂O) may clarify decisions concerning intravenous fluid replacement 1.
• Very low-risk young patients who have sustained minor bleeding without hemodynamic compromise may be considered for outpatient management without endoscopy, though this represents a small minority 1, 2.
• Hospitals should have institution-specific protocols with a prespecified chain of notification for multidisciplinary management, including access to gastroenterology and surgery 1.