Upper GI Bleed: Rescue Strategies From Recognition to Stabilization

It's a loud and clear community. This is Will. Welcome to 2026. And I'm excited to tell you about two opportunities that Ross and I are bringing to you guys this year. First, we're launching an email newsletter. If you love our podcast, you love our content. Go to our website, emspodcast.com, and send 'em for the newsletter. We will not spam you. This is stuff that Ross and I are curating personally to try to help you become the best EMS provider that you can be. If you want to take it one step further, Ross and I have launched a class that we're very excited about called the Paramedic Confidence Builder. In this class, we tackle topics that aren't necessarily didactic, paramedic knowledge, but topics like leadership, mental simulation, helping you to build the confidence to become the best provider that you can be. Sometimes these are the hurdles in the way between the knowledge we have in our brain and getting that horsepower onto the ground where it can affect the patient. Information about both of these opportunities can be found again on our website, emspodcast.com. We're building a thriving community of EMTs, paramedics, all kinds of EMS professionals that want to be the best that they can be. So if you're facing challenges and that describes you wanting to improve, come check us out. Otherwise, stay safe, have a great 2026. I want you to imagine arriving at a scene where a patient is actively vomiting perfuse amounts of blood. You walk into a dimly lit apartment and a man in his 50s sits slumped over. Pale is a ghost. A trash can full of bright red vomit is next to him. His wife, panic stricken, turns to you with the look of bewilderment. Her eyes screaming, help him. The clock is ticking in every second counts. What's your next move? This is Loud and Clear, EMS guiding principles. I'm your host, Ross Orbit. I'm a former paramedic, turned emergency physician with a subspecialty fellowship in EMS. Today we're breaking down how to manage a sick upper GI bleed in the field. Because your actions in those first few minutes could mean the difference between life and death. These patients are unique in that they blur the lines between trauma and medical principles. They are not a trauma patient, yet they are still bleeding like a trauma patient. These patients can be so challenging, specifically because they require the speed of trauma treatment, but the thoroughness of a medical patient. As challenging as this can seem, there are principles to managing these patients. And when you understand these principles I'm about to teach you, you'll understand how to tow the line of speedy thoroughness. These principles can be broken down into three stages of this call. First, how to recognize the risk factors and signs of an upper GI bleed. In other words, what is the critical information you need to gather in order to figure out what treatments are going to be necessary. Second is the key airway and circulation interventions that will need your immediate attention. And third is the right way to transport and notify the hospital. Before we get into it, if you haven't heard about our sponsor, the recess tailor, you gotta check them out. Their mission is to design better outcomes. Rather than using a generic bag and attempting to fit whatever we can in whatever random place it happens to fit, you need a bag that is specifically designed with your mission and your equipment in mind. Enter the recess tailor. They work with you to create a one of a kind customized to fit your specific needs bag, such that everything has a place that makes sense and the right tool is suddenly exactly where you need it when you need it. They'll even send you a demo bag to work with and iterate on before you make your final decisions. Reach out to the recess tailor at the recesstailor.com and ask if they may be able to help you design a better bag for your system. Recognizing an upper GI bleed. Four clues that scream GI bleed. These may seem basic, but don't worry, this is just forming the foundation. Once you recognize the GI bleed, once you recognize the following clues and realize this is an upper GI bleed, there are critical steps you're going to need to act fast and take next. So what are the four clues to a GI bleed? Hebotemisus. Well, if the patient is actively vomiting blood in front of you or has bloody vomit in a trash can or toilet bowl on scene, that is an obvious clue they're having a GI bleed. Some less obvious, but still very important things you are going to want to note though, what color is the blood? And was there blood in the first episode of vomiting? What color, large volume bright red blood suggests more active brisk bleeding, whereas coffee ground emesis suggests blood that has been sitting in the stomach for long enough to be partially digested and may represent a slower process. Where a process has been going on for longer. You also want to know if there was blood in the first episode of vomit. If the patient has had multiple episodes of vomiting without blood and in subsequent later episodes, they notice some bright red streaks, this is indicative of a Mallory Weist hair. A Mallory Weist hair is a small tear in the esophagus that occurs from the violent, wretching process experienced during earlier episodes of vomiting. This is usually self-limited, usually small volume and usually not life threatening. Second clue, melanop, black or tarry stools. This indicates digested blood. Black and tarry stools suggest an upper GI bleed that has been going on for a little bit as it has had time to transit the GI tract and be digested into this black foul, smelling sticky substance. This is concerning for an upper GI source of the bleed and even if the patient is otherwise well appearing and stable with normal vitals, this still usually requires at a minimum an overnight observation in the hospital to closely monitor their hemoglobin with cereal labs and then a discussion with GI about whether or not they would like to scope them as an inpatient or schedule them as an outpatient. In contrast to melanop, bright red blood per rectum in the stool usually suggests a lower GI source. Lower GI bleeds are usually less concerning although rarely can be brisk enough to be life threatening. It is also worth noting that in the setting of active perfused bloody vomit and large volume bright red bloody stools, this can actually represent a brisk upper GI bleed that just traveled through the GI tract so quickly that it did not have the time to be digested into the black tary substance. These patients are probably going to be obvious and really sick. Three, historical clues. Any history of liver disease or excessive alcohol used to suggest possibly undiagnosed liver disease, any history of peptic ulcers or chronic or excessive insides use such as ibuprofen, which can cause bleeding ulcers? Are they on any blood dinners or any history of malignancy? These are all historical clues that put patients at risk for GI bleeds. Finally, the fourth clue, any signs or symptoms of hypovolemia. So a fast heart rate, low blood pressure, pale skin, confusion, these signs are concerning for developing hemorrhagic shock. Now before your patient develops hemorrhagic shock and suddenly becomes unresponsive, ideally you will have assessed the critical information necessary to help you guide your interventions and hospital handoff. Is a good thing to test yourself on for any patient? Ask yourself, what are the five most important questions I want to know right now in case this person goes unconscious? But for a GI bleed, what these are, are what does the vomit look like and how many episodes of bloody vomit have you had? Why? Because the appearance and timing of the bloody vomit can help clue us into how brisk or severe it may be. In addition, the amount can help us understand how much blood they may have already lost. Two, have you had black or tarry's tools? Again, because this suggests an upper GI source of their bleeding, which is generally more concerning and may suggest that they have had ongoing blood loss for longer than realized. Three, are you on blood thinners? Antiquagolins like warfarin or the doax, and anti-platelets like aspirin or clopidogrel can worsen bleeding and impact our reversal strategies in the ED. Four, do you drink alcohol or take NSAID such as ibuprofen? Or do you have known liver disease or stomach ulcers? And if they have known liver disease, have they ever had an endoscopy or an upper GI scope that has demonstrated esophageal varices? Why? Because alcohol use or known liver disease increases the risk of esophageal varices. Varicial bleeding is usually the most concerning cause of an upper GI bleed. Esophageal varices occur in the setting of cirrhosis. In cirrhosis IE liver failure, the liver becomes scarred, making it more difficult for venous blood to pass through the portal vein of the liver on its way to the IVC. This elevation in portal venous pressure leads to a back pressure of veins that immediately feed into this system. Many of those veins live in the esophagus. This back pressure leads to a ballooning and dilation of these esophageal veins creating esophageal varices. These dilated esophageal varices are brittle and can rupture and begin bleeding. And because of the increased back pressure on these esophageal varices, that bleeding can be brisk and profuse. Now, NSAIDs such as ibuprofen, For Vintai Princesses. chronically suggests bleeding ulcers as the source of bleeding. Still important to recognize and treat and can lead to severe life-threatening bleeding, but usually less so than esophageal varices. Finally your last question, any advanced directives such as a DNR or DNI? Realize that if the patient is showing signs of shock, i.e. a weak pulse, altered level of consciousness, severe hypotension. Time is not on your side. We need to get the critical information just discussed and then move quickly towards the hospital. These patients are bleeding in a hemorrhagic shock. Treat this like a trauma and move fast, but just like a medical patient, the history is key to determining the appropriate treatment algorithm moving forward. So the way to find this balance of speed and thoroughness is by understanding exactly what the critical information is that we need to know before we leave. Try to mentally simulate and practice these questions so that they come to you quickly without having to use much cognitive load trying to remember them in the moment. Because once we figure out the answer to these questions, we need to start focusing on the next stage of the call. Treatment and stabilization. This starts with airway management. The biggest threat? Aspiration. Positioning is everything here. Keep the airway open and prevent choking. Are they awake in alert? Sit them upright with a vomit bag in their hands. Are they unconscious but breathing? Either still upright or in a semi-fellars position or on their side in the recovery position. Either way, with a suction device at the ready. Are they actively vomiting? Lean them forward or put them on their side and suction as needed. Succeed here is key. This is a skill that you likely don't practice, but you should. Not only is it important to clear the airway so that air can get in and out, it's also important to help prevent aspiration. It's like vacuuming a spill before it has the chance to set in. Just like a liquid spill can soak into a carpet and cause a stain, vomiting if not cleared can seep into the lungs and cause inflammation and infection, making it more difficult to oxygenate. Always have suction nearby when you're managing an airway. Which means this is one of those pieces of equipment that you need to check at the beginning of every shift. If you wait to find out it doesn't work in the middle of this call, you're screwed. On this call, you're going to have that suction turned up full blast. You're going to have the largest yank hour de can't do catheter you have on there. And I like to kink the catheter tubing so it stays on but isn't making that loud obnoxious noise. And then I stuff it underneath the mattress at the head of the bed so it's mere centimeters from my fingertips and the patient's mouth when I need it. Packing isn't rocket science but it is a fine motor skill that can go out the window when you're in the heat of the moment if you have it practiced it. So take time to practice using the suction in a multitude of ways. Practice using it by itself. Practice with a laryngeoscope in your hand. Practice with an OPA in your hand. And lead with the suction on every intubation you do. If you want to learn more about this, go listen to our Salad Airway episode where we talk in more detail about intubating a contaminated airway leading with suction. Now when it comes to intubation, if they have altered mental status and can't protect their airway, you're going to need to consider securing the airway. Or if they are actively vomiting massive amounts and at risk of aspirating, this patient may need intubated in order to secure the airway and help facilitate other time sensitive interventions that need to happen. If you have RSI in your system, realize this is a really risky scary airway. Not only may this be a physiologically difficult airway because of the hemorrhagic shock leading to hypotension and anacidosis, but also because the vomit or aspiration may not be allowing them to oxygenate properly and may get in your way as you attempt to visualize the cords. Now we've talked about the physiologically difficult airway in depth via a four part series in the past, so I encourage you to go back and review those episodes. But what I will say here is realize the minute you paralyze them, you remove that gag reflex and increase their risk of aspiration. The gastroesophageal sphincter may also relax leading to everything that is left in the stomach to start trying to make its way out. Ultimately, you may decide you just have to take the airway, but be prepared. Be prepared as much pre-action as possible before intubating. I like to place these patients on a nasal cannula from a giggle. This allows you to pre-action but unlike a non-rebrither, it keeps their oral farings unobstructed from an exit for the vomit or your suction if you need it. If you decide you're going to need to intubate, crank that nasal cannula all the way open. And if you need, supplement with some positive pressure with a BVM. Yes, a BVM may lead to some insufflation of the stomach, so be prepared with the suction which is the theme of this episode. But ultimately, a lack of oxygen will kill them faster than an aspiration. So if you need the positive pressure of the BVM, don't hesitate to use it. A BVM will be preferred over something like CPAP because of the vomiting aspiration risk. When you go to intubate, I would ideally have this patient in a somewhat ramped position. Not only can this help improve your glotic view, but can also help with oxygenation and reduce the likelihood of aspiration when you relax that GE junction with your paralytics. As you proceed, keep the nasal cannula on with oxygen cranked. Succeed before you even put the laryngeoscope blade in and then keep leading with your suction as you slowly advance your blade. Finally, be prepared. This is a physiologically difficult airway in addition to an anatomically difficult airway. Be prepared for the patient to become hypotensive or code during the procedure and have your team and tools and medication by your side to respond appropriately if it happens. Discuss this and the plan for what to do with your team before you proceed. Make sure you have backup plans for if you can't intubate. Yes, an ET tube is preferred to secure the airway from aspiration, but a super glotic airway is still pretty good and better than not oxygenating the patient and the patient coding. Remember, hypoxia and acidosis are more deadly and will kill the patient faster than an aspiration. Managing the airway is important, but this next point is nearly as important also requires fast action and attention. These patients are hemorrhaging, so we need to provide circulatory support and get IV access. Get vascular access early. Ideally, your partner is doing this immediately after they obtain a set of vitals while you're obtaining that critical information we talked about in stage 1. Or while you're managing the airway, if that becomes emergently necessary first. You're going to want not just one, but two large bore IVs, 18 gauge or bigger as proximal as possible, so forearm or ac preferred. If you can't get IV access, consider an IO. This can always be intimidating on an awake patient, but if they are sick, e.g. Hypotensive with signs of shock, we've got to start addressing that and we need access to do it. A really sick patient who you can't get IV access on, awake or not, needs an IO. Once you have access, what do you do about fluid resuscitation? If the blood pressure is stable, you want to minimize fluids to avoid possible worsening of the bleeding. Similar to a trauma patient, we want to allow for permissive hypotension here. We want to prevent worsening of the back pressure or dilution of the clotting factors. If they're hypotensive, yes, you're going to give some normal saline or lactated ringers bullets, but avoid aggressive fluid overloading, especially in varicial bleeds. We'll talk about why in just a sec. Do you carry blood? If you do, your threshold at which to initiate transfusion of blood products will be based on your local protocols, but it is likely going to be similar to your trauma patients. Your trigger to initiate blood is likely to be hypotension with a systolic blood pressure less than 90. In a hemorrhaging patient with a systolic less than 90 and you have blood, you may start with a fluid blus and if still hypotensive, give the blood or you may just start with the blood. These two different strategies have not been studied to my knowledge and in my opinion, I skip the fluids and I give blood as fluids don't make a lot of physiologic sense here. What the counter argument to this is, blood is not a benign intervention and transfusion reactions although rare can end and of themselves be life threatening. And furthermore, blood is a precious limited resource and some of these patients may respond to a fluid blus and never need the blood product. So I don't think we know the right answer here and I really encourage you to ask your medical director which strategy they prefer. Now, let's talk about why you don't want to give blood products if the systolic blood pressure is above 90. But again, blood is a precious limited resource like I just mentioned so we need to be thoughtful about its use. Second and more importantly, too much blood can actually worsen outcomes in these patients. A study published in the New England Journal of Medicine in 2013 by The Little Wave at All entitled transfusion strategies for acute upper gastrointestinal bleeding found that patients randomized to a restrictive transfusion strategy meaning they only transfused if the hemoglobin was less than 7 as compared to a liberal strategy where they transfused if the hemoglobin was less than 9 show that those in the restrictive arm that waited until less than 7 required less blood had less re-bleeding rates had lower mortality. They also looked at the portal venous pressures five days after admission and showed lower pressures in the restrictive strategy. Remember how it's the backup of that portal venous pressure that can lead to severe brisk bleeding from esophageal varices? So this study, although not specifically looking at blood pressures, does demonstrate that too much blood can actually be harmful for these patients. So even if you carry blood, I argue we should still allow permissive hypotension and only transfuse if the systolic blood pressure is less than 90. The goal is not a normal blood pressure, the goal is merely a mean arterial pressure greater than 65 or a systolic greater than 90. Airway and circulatory management are going to be your guiding framework and focus of treatment on these calls. So what about medications in the pre-usputal setting? What about TXA? Some EMS protocols allow for TXA in GI bleeds, but the evidence for trans-exemic acid in GI bleeds has been mostly theoretical and based on observational studies or small trial. There was actually a recent very large study entitled the hemorrhage alleviation with TXA intestinal bleeding trial or the halted trial. This was published in the Lancet in 2020 by Kerr et al. This was a huge multi-center trial that included more than 12,000 patients and they found that TXA did not reduce the mortality when compared to placebo but did have an increase in venous thrombo and balic events. So TXA didn't save lives in GI bleeding but it did put them at risk with increased rates of blood clots. But this time I would not give TXA to my upper GI bleeding patients. Now when you get to the ED, we do have some other medications we're going to consider. If it's varicene bleeding or if it's suspected with the history of liver disease and alcohol use, we will give a medication called octriotide. Octriotide decreases the inflow of blood to the portal system by constricting the splint nick arterials and thus significantly reduces the intravaric seal pressures. Now when studied, octriotide hasn't been shown to decrease mortality in GI bleeding but it has shown to decrease the amount of blood products needed which again is a precious limited resource. Octriotide is given as a bulless followed by a 48 hour infusion. We will also give an antibiotic called septriaxone if there's a history of liver disease. This antibiotic has actually been shown to improve mortality in bleeding from esophageal varicies. The theory for why this is is that these patients are at risk for getting a severe intraabdominal infection called spontaneous bacterial peritonitis. Septriaxone treats this infection and may be prevented from occurring when these patients are hospitalized and critically ill with an acute upper GI bleed. Also, if there is any history of anticoagulation, we may give fresh rosin plasma or a specific reversal agent if they're on a doach and the hospital stocks that reversal agent. If the patient is on an anti-platelet medication such as aspirin or clopidogrel, whether or not to give a transfusion of platelets is controversial but maybe considered on a case by case basis. Finally, we will usually give a proton pump inhibitor such as pantopresolt. This decreases acid production in the stomach and should theoretically help, especially if the upper GI bleed is secondary to a stomach ulcer. Before we get to the final piece of the puzzle, the last thing I will say with regards to treatment is to monitor these patients closely. What to monitor? Vital signs every 5 minutes of unstable. Are they maintaining their airway and their mental status? Realize that mental status changes can be an early indicator of shock. The final piece of this call is the transport and hospital notification. Like we said, we want to treat this similar two-way trauma. And that if they are sick, we need to move fast and get them to definitive management. This means we need to get them to an endoscopy capable facility. Which honestly is likely to be most facilities outside of your rural critical access hospitals. If you are going to have a prolonged transport time, consider air medical transport if there are any signs of instability or shock. Notify the hospital early about these patients so that they can prepare for your arrival and their resuscitation to ensue. Important information that you want to relay is the critical information we discussed in the beginning. Any history of alcohol abuse, liver disease, chronic ed-set use or blood thinners. How many episodes of vomiting over how long? What is their current mental status in last set of vitals? How is their airway and what access do you have and are you giving fluids or blood? If you relay all of this information in your pre-ausible notification, then the recess team at the hospital will know exactly what to set up and what their next steps are going to be upon your arrival. So in conclusion, upper GI bleeds are a time-sensitive emergency. You need to recognize, stabilize and move fast and notify the receiving facility. Recognize the signs and gather the critical information. Stabilize with a focus on airway and circulatory support. Support ASAP to definitive care and notify the receiving facility early with all of the critical information so that they know how to set up for your arrival. Before you go, comment below what's the most challenging GI bleeds case you've encountered in the field. And if you found this useful, like, subscribe and hit the bell to be notified every time we put out more EMS training content. And if you liked this episode, I know you're going to like our interview on the ideal trauma call with Dave Edwards, so go check that out next.