In emergency medicine, few scenarios are as immediately concerning as arriving on scene to find a patient actively vomiting bright red blood. Upper gastrointestinal (GI) bleeding represents a unique challenge for EMS providers—these patients aren’t trauma victims, yet they’re bleeding like trauma patients. They require both the rapid intervention of trauma care and the thorough assessment of a medical patient.
This guide breaks down the essential principles of managing an upper GI bleed in the prehospital setting, where your actions during those critical first minutes can significantly impact patient outcomes.
Recognizing Upper GI Bleeds
When you suspect an upper GI bleed, look for these four key indicators:
1. Hematemesis (Vomiting Blood)
The appearance of vomited blood provides valuable diagnostic clues:
- Bright red blood: Suggests active, brisk bleeding that requires immediate attention
- Coffee-ground emesis: Indicates blood has been partially digested in the stomach, potentially representing a slower bleed or one that has been going on for longer
- Streaks of bright red blood in later episodes of vomiting only: May indicate a Mallory-Weiss tear (a small, often self-limiting esophageal tear caused by forceful vomiting)
2. Melena (Black, Tarry Stool)
Black, tarry stool indicates digested blood that has transited through the GI tract. This sign suggests an upper GI bleed that’s been ongoing long enough for the blood to be digested. Even in patients who appear stable, melena usually warrants hospital observation and potential endoscopic evaluation.
In contrast, bright red blood in stool typically suggests a lower GI source, though extremely brisk upper GI bleeding can sometimes present this way if blood moves through the GI tract too quickly to be digested.
3. Historical Risk Factors
During your assessment, be alert for these potential contributors, as they can clue into the cause of the GI bleed and help us determine the appropriate treatment:
- History of liver disease or excessive alcohol use
- Risk factor for esophageal varices which are usually the most life threatening form of an upper GI bleed. These are treated with medications like pantoprazole, octreotide, and ceftriaxone in addition to endoscopic intervention such as variceal banding.
- Previous peptic ulcers or chronic NSAID use (like ibuprofen)
- These are risk factors for a bleeding ulcer. These are treated with medications such as pantoprazole in addition to endoscopic intervention such as injecting local medications like epinephrine into the ulcer for vasoconstriction.
- Blood thinner medications
- Risk factor for bleeding from anywhere including the GI tract. This is treated by reversing the coagulopathy created by the blood thinner.
- History of malignancy
- Malignant masses like to bleed. Unless there’s a history of stomach or esophageal cancer, these tend to be lower in the GI tract and slower bleeding.
4. Signs of Hypovolemia
Watch for indications of developing hemorrhagic shock:
- Tachycardia
- Hypotension
- Pale, clammy skin
- Altered mental status
Critical Assessment Questions
Before your patient’s condition deteriorates, gather these five critical pieces of information as soon as possible:
- “What does the vomit look like and how many episodes have you had?”
This helps gauge bleeding severity and blood volume loss. - “Have you had black or tarry stools?”
Confirms an upper GI source and suggests ongoing blood loss. - “Are you on blood thinners?”
Anticoagulants and antiplatelets can worsen bleeding and impact ED treatment strategies. - “Do you drink alcohol, take NSAIDs, or have liver disease or stomach ulcers?”
Alcohol use and liver disease increase the risk of esophageal varices—dilated, fragile blood vessels that can rupture and cause massive bleeding. NSAIDs suggest bleeding ulcers as the likely source. - “Do you have any advance directives, such as a DNR or DNI?”
Important for guiding treatment decisions if the patient deteriorates.
Remember: If your patient shows signs of shock, time is critical. Obtain this information quickly and then focus on rapid intervention and transport.
Airway Management Priorities
Preventing Aspiration
Aspiration represents the most immediate airway threat in GI bleeding. Position your patient appropriately:
- Alert patients: Seated upright with a vomit bag
- Unconscious but breathing patients: Recovery position or semi-Fowler’s position with suction ready
- Actively vomiting patients: Leaning forward or on their side with suction readily available
Medications
Antiemetics may be useful to help prevent further episodes of vomiting.
Suction Techniques
Effective suctioning is essential but often under-practiced:
- Use the largest Yankauer or DuCanto catheter available
- Set suction to maximum power
- Keep the suction device within easy reach at the head of the stretcher
- Practice suctioning regularly, including while performing other procedures
Intubation Considerations
Consider intubation for patients who:
- Have altered mental status and cannot protect their airway
- Are actively vomiting massive amounts with aspiration risk
Remember that GI bleed patients present particularly challenging airways due to:
- Hemodynamic instability from blood loss
- Impaired oxygenation from vomit or aspiration
- Increased aspiration risk when paralyzed
For these high-risk airways:
- Preoxygenate aggressively with nasal cannula (allows suction access to the oropharynx)
- Consider a ramped position to improve glottic view and reduce aspiration risk
- Lead with suction before placing the laryngoscope
- Have backup airway plans ready
- Brief your team on the approach and back up plans before starting
Circulatory Support & Vascular Access
Establishing Access
Secure vascular access early:
- Place two large-bore IVs (18G or larger)
- Use forearm or antecubital sites when possible
- Consider intraosseous (IO) access without hesitation, even in an awake patient, if IV attempts fail and the patient is critically unstable
Fluid Resuscitation Strategy
Balance fluid administration carefully:
- For stable patients: Minimize fluids to avoid worsening bleeding
- For hypotensive patients: Give judicious NS or LR boluses without aggressive fluid overload
- Blood product administration: Follow your local protocols, typically for systolic BP < 90 mmHg
The “Permissive Hypotension” Approach
Current evidence supports a restrictive fluid and blood product strategy in GI bleeding. Research has shown that a more conservative approach (transfusing only when hemoglobin falls below 7 g/dL) results in:
- Less rebleeding
- Lower mortality
- Reduced portal venous pressure (especially important in variceal bleeding)
Your resuscitation goal is not a normal blood pressure but rather:
- Mean arterial pressure (MAP) > 65 mmHg, or
- Systolic BP > 90 mmHg
Transfusion Strategies for Acute Upper Gastrointestinal Bleeding. Published in the New England Journal of Medicine, 2013, by Villanueva et al
Medication Considerations
Tranexamic Acid (TXA)
Despite its theoretical benefits, the evidence doesn’t currently support TXA use in GI bleeding. The large HALT-IT trial found that TXA did not reduce mortality from upper GI bleeding but did increase venous thromboembolic events.
Hemorrhage Alleviation with Tranexamic acid – Intestinal bleeding Trial (HALT-IT) Published in the Lancet, 2020, by Ker et al
Hospital-based Medications
While not typically administered prehospitally, be aware of these medications that may be given upon hospital arrival:
- Octreotide: Used for suspected variceal bleeding to reduce portal blood flow
- Antibiotics (ceftriaxone): Given to patients with liver disease to prevent spontaneous bacterial peritonitis
- Proton pump inhibitors: Reduce stomach acid production, particularly helpful for ulcer-related bleeding
- Antiemetics: Metoclopramide is preferred as it also increases GI motility and theoretically will help move blood contents through the stomach into the small intestine. But if all you have on the ambulance is ondansetron, use it.
- Anticoagulation reversal agents if the patient is on a blood thinner: May include fresh frozen plasma or specific reversal agents
Transport & Hospital Notification
Destination Selection
Transport to an endoscopy-capable facility. Consider aeromedical transport for unstable patients with prolonged ground transport times.
Effective Hospital Notification
Provide these key details in your early notification:
- Patient risk factors (alcohol use, liver disease, NSAIDs, blood thinners)
- Bleeding characteristics (amount, frequency, duration)
- Mental status and vital signs
- Airway status
- Vascular access obtained and interventions initiated
This information allows the receiving team to prepare appropriately for your arrival and continue seamless care.
Ongoing Assessment
Monitor these patients closely throughout transport:
- Check vital signs every 5 minutes if unstable
- Continuously reassess airway patency
- Watch for mental status changes as an early indicator of shock
Key Principles for Success
Upper GI bleeds require balancing the urgency of trauma care with the thoroughness of a medical assessment. Success depends on:
- Recognition: Quickly identify the signs of upper GI bleeding and gather the critical information
- Stabilization: Focus on airway protection and appropriate circulatory support
- Transport: Move rapidly to definitive care while providing ongoing monitoring
- Communication: Notify the receiving facility early with comprehensive information
By mastering these principles, you’ll be well-equipped to manage these challenging patients and potentially save lives in what can rapidly become life-threatening emergencies.
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This educational content is intended for EMT and paramedic continuing education. It is not meant to be exhaustive or comprehensive nor is it meant to be a replacement for your medical direction. Always follow your local protocols and medical direction when managing patients with suspected upper GI bleeding.
