GI Bleed in the Field

Why this matters

Coffee-ground vomit can look old. Black stool looks like tar, not dramatic bleeding. Varices, swollen veins from liver disease, can bleed into the gut while the patient still talks. This is shock from lost blood. It is also an airway threat if they are vomiting blood. See shock categories and syncope. Do not treat it as a stomach-acid problem on scene.

Upper versus lower bleeding

• Upper bleeding includes vomiting blood, coffee-ground vomit, and black tarry stool. Causes include an ulcer, gastritis, varices, and a Mallory-Weiss tear. That tear comes from forceful vomiting. The airway threat and the blood-loss threat are worse with upper bleeding.
• Red blood from the rectum can still be a fast upper bleed. Do not send red stool to a lower priority when the patient looks like they are in shock.

Clinical sequence

1. Protect the airway first. Sit them up if they are vomiting. Have suction ready. Use an advanced airway only if they cannot protect the airway and you are authorized. A stomach full of blood is easy to inhale.
2. Give oxygen when the sat is low. Start two large-bore IVs if you can do it without delaying transport. Keep them warm.
3. Recognize shock early. A fast heart rate, pale skin, and fainting matter. The body can hide blood loss at first. The patient can still die from the bleed later. Do not clear them on one blood pressure.
4. Go to a hospital that can scope and transfuse. Known liver failure or varices belong where gastroenterology and an ICU are available. Do not choose a freestanding emergency room with no blood bank if you have a choice.
5. Do not copy a trauma tranexamic-acid card onto a gastrointestinal bleed. HALT-IT found that tranexamic acid did not reduce death from gastrointestinal bleeding. It increased clots and seizures. Octreotide and acid-suppressing drugs are hospital treatments. They are not field bleeding control unless a written gastrointestinal protocol says otherwise.

Do Not

• Do not give nitroglycerin for chest pain that started after a large bleed.
• Do not give a trauma dose of tranexamic acid for varices or an ulcer just because you carry the vial.
• Do not assume one formed stool on scene rules out bleeding.
• Do not lay them flat if they are vomiting clots.

Common errors

• Calling coffee-ground vomit old and non-urgent.
• Missing blood thinners, NSAID pain medicine, alcohol, or prior varices in the history.

Practice

Related: Shock Categories, TXA, Damage-Control Resuscitation.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

• NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; your protocol still decides care
• 2025 ACC/AHA/ACEP/NAEMSP/SCAI ACS Guideline — nitrates are not for hypotensive ACS; GI bleed with demand ischemia is still a hemorrhage problem first
• ACG 2021 Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding — resuscitation, endoscopy, and source control are hospital pathways; the field job is airway protection, shock recognition, and the right destination
• HALT-IT (Roberts et al., Lancet 2020) — TXA did not reduce death in GI bleeding and increased venous thromboembolism and seizures; do not treat GI bleed as CRASH-2 trauma
• AASLD variceal-bleed guidance is hospital-based (vasoactive drugs, tamponade, TIPS). Do not use octreotide or a PPI as hemorrhage control in the ambulance unless a written GI protocol says so.