What is the immediate management for a patient with a gastrointestinal bleed presenting with hematemesis?

Immediate Management of Hematemesis in a Patient with GI Bleed

For a patient who begins vomiting blood immediately upon lying down for CT, abort the imaging, position the patient upright or in left lateral decubitus to prevent aspiration, establish two large-bore IV lines, begin rapid crystalloid resuscitation with 1-2 liters of normal saline, and prepare for urgent upper endoscopy once hemodynamically stable. 1, 2

Immediate Actions (First 5-10 Minutes)

• Stop the CT scan immediately and remove the patient from the scanner to allow for proper positioning and airway management 1
• Position the patient upright (30-45 degrees) or in left lateral decubitus position to minimize aspiration risk during active hematemesis 1, 2
• Establish two large-bore (16-18 gauge) peripheral IV cannulae in the antecubital fossae for rapid volume replacement 3, 1, 2
• Begin rapid infusion of 1-2 liters of crystalloid (normal saline) to restore hemodynamic stability 3, 1, 2

Resuscitation Phase (First 30-60 Minutes)

Hemodynamic Monitoring

• Insert urinary catheter and monitor hourly urine output, targeting >30 mL/hour as a marker of adequate perfusion 3, 1, 2
• Continuously monitor pulse, blood pressure, and oxygen saturation using automated systems 3, 1, 2
• Target mean arterial pressure >65 mmHg during resuscitation while avoiding fluid overload 3, 1

Fluid Management Strategy

• Use a restrictive fluid strategy after initial 1-2 liters, as over-expansion can exacerbate portal pressure (if varices present), impair clot formation, and increase rebleeding risk 3, 1
• If patient remains in shock after 1-2 liters of crystalloid, this indicates at least 20% blood volume loss and plasma expanders or blood products are needed 3, 2

Blood Transfusion Criteria

• Transfuse red blood cells when hemoglobin <100 g/L (10 g/dL) in the setting of acute bleeding with hemodynamic instability 3, 2
• Target hemoglobin of 7-9 g/dL in most patients, as restrictive transfusion strategy improves survival 3, 1
• Use higher threshold (hemoglobin 8-10 g/dL) only in patients with active cardiac ischemia or significant cardiovascular disease 3, 1

Pharmacologic Interventions (Within First Hour)

Vasoactive Therapy

• Start octreotide immediately upon suspicion of upper GI bleeding, even before endoscopy confirms the source 1
• Give 50 mcg IV bolus (can repeat in first hour if ongoing bleeding), followed by continuous infusion at 50 mcg/hour for 2-5 days 1

Acid Suppression

• Administer high-dose IV proton pump inhibitor (e.g., pantoprazole 80 mg IV bolus, then 8 mg/hour infusion) upon presentation 1

Antibiotic Prophylaxis

• Give ceftriaxone 1g IV every 24 hours (maximum duration 7 days) to reduce infections, rebleeding, and mortality in patients with suspected variceal bleeding or cirrhosis 1

Airway Protection Considerations

• Consider endotracheal intubation before endoscopy in patients with massive ongoing hematemesis, altered mental status, or inability to protect their airway 3, 2
• This is a critical decision point: severe bleeding with active vomiting of blood is a high-risk scenario for aspiration 3, 2

Diagnostic Approach

Upper Endoscopy Timing

• Perform upper endoscopy within 12-24 hours once hemodynamic stability is achieved 3, 1, 2
• Never perform endoscopy before achieving adequate resuscitation, as this increases procedural risk and mortality 1, 2
• Keep patient NPO (fasting) until hemodynamically stable and endoscopy can be safely performed 3, 2

Role of CT Angiography

• CT angiography is NOT the first-line test for hematemesis, as this presentation strongly suggests an upper GI source 3
• CTA is reserved for patients with hematochezia (bright red blood per rectum) and hemodynamic instability where the source is unclear 3
• In this case with frank hematemesis, proceed directly to upper endoscopy after stabilization 1, 2

Risk Stratification

High-Risk Features Requiring ICU Admission

• Active hematemesis (as in this patient) 1, 4
• Age >60 years 3, 4
• Hemodynamic instability (shock index >1, defined as heart rate/systolic BP >1) 3, 4
• Significant comorbidities (cardiac disease, liver disease, renal failure) 3, 4
• Hemoglobin <100 g/L 3, 4

Level of Care

• Admit to intensive care unit or high-acuity monitored setting for all patients with acute hematemesis and hemodynamic compromise 1, 2

Critical Pitfalls to Avoid

• Do NOT continue with CT imaging during active hematemesis, as this delays resuscitation, prevents proper positioning, and increases aspiration risk 1, 2
• Do NOT administer excessive crystalloid volumes causing fluid overload, as this worsens portal hypertension (if varices), impairs coagulation, and increases rebleeding 3, 1
• Do NOT delay endoscopy beyond 24 hours once stabilized, as early endoscopy improves outcomes 3, 1, 2
• Do NOT transfuse to hemoglobin >9 g/dL unless patient has active cardiac ischemia, as liberal transfusion increases mortality 3, 1
• Do NOT place nasogastric tube routinely, as it does not reliably aid diagnosis, does not affect outcomes, and causes complications in up to one-third of patients 3

Endoscopic Findings and Prognosis

• Endoscopy defines the cause of bleeding, determines prognosis, and allows therapeutic intervention 3, 2
• High-risk endoscopic stigmata include active arterial bleeding, visible vessel, or adherent clot—these require immediate endoscopic hemostasis 3, 2
• Approximately 75-80% of upper GI bleeding stops spontaneously, but endoscopy is still mandatory for risk stratification and to guide disposition 2

Special Consideration: Positional Hematemesis

The fact that hematemesis began immediately upon lying down suggests either:

• Esophageal varices that became engorged with positional change 3
• Large volume of blood pooled in stomach that refluxed when supine 2
• Mallory-Weiss tear from retching/vomiting during positioning 2

This positional trigger does not change immediate management but reinforces the need for urgent upper endoscopy to identify the source 1, 2