In a patient with hematemesis, syncope, hypotension, and hemoglobin 8.3 g/dL, what is the immediate next step: intravenous fluid resuscitation or blood transfusion?

Immediate Management of Hematemesis with Syncope and Hypotension

Begin with rapid intravenous fluid resuscitation using 1-2 liters of normal saline through two large-bore IV cannulae, while simultaneously preparing for blood transfusion, which should be administered once initial fluid resuscitation is underway. 1

Initial Resuscitation Priority: IV Fluids First

The immediate priority is restoring circulating blood volume and tissue perfusion through aggressive crystalloid infusion. 1 This patient presents with clear signs of severe hypovolemic shock from acute gastrointestinal bleeding:

• Establish two large-bore venous cannulae (ideally 8-Fr central access or largest peripheral IV) in the anticubital fossae immediately 2, 1
• Infuse normal saline rapidly to restore blood pressure, reduce pulse rate, and ensure adequate urine output (>30 ml/h) 2, 1
• Most patients require 1-2 liters of crystalloid to correct initial volume losses 2, 1

The rationale is straightforward: the primary cause of death in acute hemorrhage is inadequate tissue perfusion, not anemia per se. 1 Crystalloid restores circulating volume immediately, while blood products take time to cross-match and prepare. 2

When to Transfuse Blood

Blood transfusion is indicated when hemoglobin is less than 100 g/L (10 g/dL) in the setting of acute bleeding with hemodynamic compromise. 2, 1 Your patient with Hb 83 g/L (8.3 g/dL) meets this threshold clearly.

However, the sequence matters:

• If shock persists after 1-2 liters of crystalloid, plasma expanders are needed as at least 20% of blood volume has been lost 2, 1
• Blood transfusion should be administered once initial fluid resuscitation is underway, not delayed 1
• In acute bleeding presentations, changes in cardiac output occur at Hb <100 g/L, and mortality is related to severity of anemia in critically ill patients 2

Critical Monitoring During Resuscitation

Insert a urinary catheter and measure hourly urine output (target >30 ml/h) 2, 1

Use automated blood pressure and pulse monitoring continuously 2, 1

Consider central venous pressure monitoring if cardiac disease is present to guide fluid replacement 2, 1

Additional Immediate Actions

Draw baseline labs immediately: complete blood count, PT, aPTT, Clauss fibrinogen, and cross-match 1

Keep the patient fasted until hemodynamically stable 2

Endoscopy should only be performed after adequate resuscitation is achieved 2, 1

Important Clinical Caveats

If Cirrhosis is Suspected (Variceal Bleeding)

Use a restrictive transfusion strategy, transfusing when hemoglobin drops below 7 g/dL, targeting 7-9 g/dL 1

Start vasoactive drugs (terlipressin, somatostatin, or octreotide) immediately 1

Avoid over-resuscitation, as excessive fluids increase portal pressure and worsen variceal bleeding 1

Common Pitfalls to Avoid

Do not delay fluid resuscitation waiting for blood products 1

Do not use vasopressors as first-line therapy in hemorrhagic shock 1

Do not apply trauma hypotensive resuscitation protocols (permissive hypotension) to gastrointestinal bleeding, as adequate perfusion pressure is essential 1

The Answer to Your Question

Both interventions are required, but IV fluid resuscitation must be initiated first and immediately. 1 The patient needs rapid volume expansion with crystalloid (1-2 liters normal saline) to restore blood pressure and tissue perfusion, while simultaneously preparing blood products for transfusion. 2, 1 Blood transfusion follows once initial fluid resuscitation is underway, given the Hb of 83 g/L meets the threshold for transfusion in acute bleeding with shock. 2, 1

If forced to choose only one immediate next step from your options, IV fluid (Option B) takes priority as it can be initiated within seconds, restores circulating volume immediately, and is the foundation upon which all subsequent resuscitation (including blood transfusion) is built. 2, 1