For the majority of patients presenting with gastrointestinal (GI) bleeding, hematemesis, hematochezia, or melena will be the chief complaint. Occasionally, patients may present with only dizziness, weakness, or syncope. If no obvious cause of shock is present, gastric lavage and a rectal examination should be performed promptly as part of the initial assessment. The severity of blood loss must be assessed quickly so that lifesaving therapeutic interventions can be instituted. Factors that increase the morbidity and mortality are hemodynamic instability, ongoing symptoms, inability to clear bleeding with lavage, age over 60, and other comorbidities.
1This chapter is a revision of the chapter by Alicia Haywood, MD, Tammy Ray, MD, & Timothy G. Price, MD FACEP FAAEM from the 6th edition.
Immediate management of life-threatening bleeding. BUN, blood urea nitrogen; FFP, fresh frozen plasma; PT, prothrombin time; PTT, partial thromboplastin time.
Assess the Rate and Volume of Bleeding
Any patient presenting to the emergency department with ongoing hematemesis or hematochezia is at significant risk of exsanguination, and prompt volume resuscitation must begin at once. Proceed with initial stabilization procedures as described below.
Conduct Initial Assessment
Place the patient in a monitored bed and obtain a full set of vital signs including oxygen saturation. If the initial systolic blood pressure is greater than 100, and the pulse is less than 100 beats/min in the supine position, consider obtaining orthostatic blood pressure and pulse rate measurements.
Recognize Risk Factors for Severe Gastrointestinal Bleeding
Signs, symptoms, or history that may indicate ongoing hemorrhage are as follows:
- Profuse hematemesis or hematochezia
- Hypotension, tachycardia, or signs of shock
- Postural hypotension, tachycardia, or lightheadedness
- Possible aortoenteric fistula (history of abdominal aortic aneurysm repair or palpable pulsating abdominal mass)
- Known or suspected esophageal varices
- Previous history of GI bleeding
- History of diverticulosis
Initial Stabilization Procedures
As with any emergency, always address your patient's ABCs first.
Assess Need for Airway Management
Consider endotracheal intubation for patients with ongoing massive hematemesis or if signs and symptoms of shock are present, If immediate airway control is not needed, provide supplemental oxygen as needed to maintain oxygen saturation at greater than 93%.
Insert two large-bore intravenous catheters (18 gauge or larger) into peripheral veins. If peripheral access cannot be obtained, consider placement of a central venous line.
Begin Fluid Resuscitation
Rapidly bolus either warmed lactated Ringer's or normal saline to restore intravascular volume.
Assess the Need for Immediate Blood Transfusion
For persistent hypotension ...