Prehospital Management of Upper GI Bleeds: A Guide for EMTs and Paramedics

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.