Management of Hematemesis with Shivering

Immediate Stabilization and Assessment

The American College of Cardiology recommends securing large-bore intravenous access immediately to allow for rapid fluid resuscitation, administering high FiO2 to ensure adequate oxygenation, and targeting systolic blood pressure of 80-100 mmHg until major bleeding has been controlled, with a strength of evidence based on expert opinion and clinical experience 1, 2
Actively warming the patient and all transfused fluids to prevent hypothermia, which can worsen coagulopathy, is recommended by the Critical Care society 1
Obtaining baseline complete blood count, prothrombin time (PT), activated partial thromboplastin time (aPTT), and Clauss fibrinogen, as well as measuring serum lactate and base deficit to estimate and monitor the extent of bleeding and shock, is suggested by the Praxis Medical Insights society 1
The Critical Care society advises against relying on single hemoglobin/hematocrit measurements as isolated markers for bleeding severity, as they may not reflect acute blood loss 1, 2

The European Heart Journal recommends meperidine 12.5-50 mg as the preferred agent due to its potent anti-shivering properties, with a strength of evidence based on moderate-quality randomized controlled trials 3
Alternative agents include magnesium sulfate (2-4 g bolus, then 1 g/h every 2-4 hours) as an adjunct, and ondansetron 4-8 mg every 4-8 hours in a preventative manner, though effects are limited, as suggested by the European Heart Journal 3, 4
Initiating surface counterwarming immediately, and considering acetaminophen as an adjunct, is recommended by the European Heart Journal 4

The Praxis Medical Insights society recommends transfusing packed red blood cells to maintain hemoglobin above 7 g/dL in most patients, with a higher transfusion threshold of 9 g/dL in patients with massive bleeding, significant cardiovascular comorbidities, or when therapeutic interventions may be delayed 1
Administering warmed blood and blood components for massive hemorrhage, and using blood products in order of availability, is suggested by the Praxis Medical Insights society 1

The Praxis Medical Insights society recommends performing urgent endoscopic assessment within 24 hours of presentation after initial stabilization, with a strength of evidence based on expert opinion and clinical experience 1
Implementing appropriate endoscopic hemostatic interventions based on findings, and inserting a nasogastric tube to protect the airway, decompress the stomach, and assess ongoing bleeding, is suggested by the Praxis Medical Insights society 1

The Praxis Medical Insights society recommends considering interventional radiology angiographic embolization techniques when endoscopy is unsuccessful, and surgical intervention may be necessary for massive, life-threatening bleeding 1

The Critical Care society advises against delays between presentation and intervention for patients requiring urgent bleeding control, with a strength of evidence based on high-quality observational studies 1, 2
The Praxis Medical Insights society recommends not relying solely on blood pressure as an indicator of blood loss, as some patients compensate well despite significant hemorrhage 1

Initiating surface counterwarming immediately, particularly warming extremities, is crucial in managing shivering, as recommended by the European Heart Journal 5
Shivering with fever may indicate sepsis requiring prompt evaluation and empiric antibiotics, according to the European Heart Journal 5

Shivering doubles metabolic rate and nearly triples oxygen consumption, triggering bioenergetic failure with demand cerebral ischemia and significant mismatch in energy supply and demand, as reported in the European Heart Journal 6