In an elderly patient with fresh rectal bleeding, known hypertension and colorectal polyp, presenting with tachycardia, pallor, blood pressure 160/96, and no hemoglobin result, what is the most appropriate initial management?

Initial Management: IV Fluid and Blood Product Resuscitation

The most appropriate initial management is B: IV fluid and blood products. This elderly patient presents with signs of severe hemorrhagic shock (tachycardia 120 bpm, pallor) requiring immediate hemodynamic resuscitation before any diagnostic procedures. 1, 2

Why Resuscitation Takes Priority

The first priority in management is to correct fluid losses and restore blood pressure before any diagnostic evaluation. 1 This patient meets criteria for severe bleeding based on:

• Age >60 years 1
• Heart rate >100 bpm (120 in this case) 1
• Clinical signs of shock (pallor, tachycardia) 1, 3
• Paradoxical hypertension (160/96) likely represents compensatory vasoconstriction in the setting of volume depletion 2

Immediate Resuscitation Protocol

Vascular Access and Fluid Therapy

• Establish two large-bore peripheral IV lines immediately in the anticubital fossae 1, 2, 4
• Infuse 1-2 liters of crystalloid solution (normal saline or balanced crystalloids) rapidly to correct intravascular volume depletion 1, 2
• Target mean arterial pressure >65 mmHg during resuscitation 2, 3
• Monitor urine output ≥30 mL/hour via urinary catheter as an indicator of adequate perfusion 1, 2

Blood Product Transfusion

• Transfuse packed red blood cells to maintain hemoglobin >10 g/dL in this elderly patient with hypertension (cardiovascular risk factor) 2, 3
• Blood typing and cross-matching should be performed immediately to enable rapid transfusion 4, 3
• In extreme bleeding with shock, O-negative blood can be given, though rapid cross-matching is usually sufficient 1

Why NOT CT or Urgent Colonoscopy First

CT Angiography (Option A) is Inappropriate Initially

• CT must be deferred until hemodynamic stabilization is achieved; performing it in an unstable patient markedly increases risk of cardiovascular collapse, aspiration, and mortality 2
• CT angiography can only localize bleeding when the rate exceeds 0.5 mL/min and requires the patient to be stable 2

Urgent Colonoscopy (Option C) is Dangerous Before Stabilization

• Colonoscopy must be postponed until the patient achieves hemodynamic stability 2, 4
• Performing colonoscopy in an unstable patient markedly increases the risk of aspiration, cardiovascular events, and mortality 2
• The patient should be fasted until hemodynamically stable, then endoscopy undertaken 1
• Colonoscopy should be performed within 24 hours after adequate resuscitation and bowel preparation 2, 4, 3

Hemodynamic Stabilization Targets Before Proceeding

Resuscitation is adequate when ALL of the following are achieved: 2

• Heart rate <100 bpm
• Systolic blood pressure >100 mmHg
• Mean arterial pressure >65 mmHg
• Hemoglobin ≥10 g/dL (in elderly with cardiovascular comorbidities)
• Urine output ≥30 mL/hour

Common Pitfalls to Avoid

• Never delay resuscitation to perform diagnostic procedures—stabilization always takes priority over diagnosis 4, 3
• Avoid fluid overload during resuscitation, which can exacerbate bleeding 2, 3
• Do not assume a lower GI source in severe bleeding; approximately 15% of patients with hematochezia have an upper GI source 2, 4

After Stabilization

Once hemodynamic targets are met, colonoscopy within 24 hours with adequate bowel preparation is the gold-standard diagnostic modality 2, 4 Given this patient's known colorectal polyp history, the bleeding source may be identified and treated endoscopically. 4