Initial Workup for New Onset Hematemesis

Immediate Assessment and Stabilization

The American College of Gastroenterology recommends assessing severity using vital signs and clinical presentation, such as pulse >100 bpm, systolic BP <100 mmHg, altered mental status, and active hematemesis, to indicate severe bleeding requiring aggressive intervention 2
Measure shock index (heart rate/systolic BP) and pulse pressure to assess hypovolemic shock and transfusion requirements, as recommended by the Critical Care society 3
Secure two large-bore (ideally 8-Fr) IV cannulae in the anticubital fossae for patients with hemodynamic compromise, as suggested by the Gut journal 2
Insert urinary catheter and monitor hourly urine output (target >30 mL/hour), as recommended by the Gut journal 2

Obtain complete blood count, PT, aPTT, and fibrinogen levels immediately, as recommended by the Praxis Medical Insights society 4
Do not rely on single hemoglobin/hematocrit measurements alone as isolated markers for bleeding severity, as they lag behind acute blood loss, according to the Critical Care society 5
Measure serum lactate and base deficit to estimate and monitor the extent of bleeding and tissue hypoperfusion, as recommended by the Critical Care society 5

Initially resuscitate with crystalloids (normal saline or balanced crystalloid) to achieve falling pulse rate, rising BP, and adequate urine output, as recommended by the Gut journal 2
Target systolic BP of 80-100 mmHg (MAP 50-60 mmHg) until major bleeding is controlled in patients without brain injury, according to the Critical Care society 3
Transfuse packed red blood cells when hemoglobin <100 g/L in acute bleeding or when bleeding is extreme with shock, as recommended by the Gut journal 2
For patients with cirrhosis and variceal bleeding, maintain hemoglobin target of 70-90 g/L to avoid exacerbating portal pressure, as suggested by the World Journal of Emergency Surgery 7

Urgent endoscopy is indicated for patients with active hematemesis, hemodynamic instability despite resuscitation, or high-risk features, according to the World Journal of Emergency Surgery 7
Endoscopy should only be performed after adequate resuscitation with stable vital signs when possible, as recommended by the Gut journal 2
Consider endotracheal intubation before endoscopy in severely bleeding patients to prevent pulmonary aspiration, as suggested by the Gut journal 2

Identify patients with liver disease early as they require specific management including restrictive transfusion strategy, according to the World Journal of Emergency Surgery 7
Age >60 years with hemodynamic compromise, pulse >100 bpm, systolic BP <100 mmHg, hemoglobin <100 g/L, and significant comorbid medical diseases are high-risk features requiring intensive monitoring, as recommended by the Gut journal 2

Avoid delays between presentation and endoscopy in unstable patients, but never perform endoscopy before adequate resuscitation, as recommended by the Gut journal 2
Do not rely solely on blood pressure as some patients compensate well despite significant hemorrhage, according to the Praxis Medical Insights society 4
Avoid hyperventilation and excessive PEEP in hypovolemic patients as this worsens cardiac output, as suggested by the Critical Care society 3
Consider central venous pressure monitoring in patients with significant cardiac disease to guide fluid replacement, as recommended by the Gut journal 2