GI Bleed in the Field
Objective: Treat GI bleeding as a hemorrhage and airway problem — not a PPI problem — and do not be fooled by a “normal” first blood pressure.
Why This Is Hard
Coffee-ground emesis on the carpet looks “old.” Melena looks like tar, not Hollywood bleeding. Variceal patients can exsanguinate into the gut and still talk. This is hypovolemic shock with an airway threat if they are vomiting blood — see shock categories and syncope.
- Hematemesis / coffee-ground / melena / maroon stool — plus liver, NSAID, anticoagulant, alcohol stories
- Airway first if they are vomiting blood
- Shock can present as syncope with a “normal” first BP
- No nitro, no unnecessary anticoagulation stories — this is not ACS candy
Upper vs Lower (Enough for the Truck)
- Upper: hematemesis, coffee-ground, melena. Peptic ulcer, gastritis, varices, Mallory-Weiss. Worse airway and volume threat.
- Lower: hematochezia (red blood from the rectum) can still be a brisk upper bleed. Do not under-triage red stool in a shocky patient.
Street Sequence
- Airway: sitting up if they are vomiting; suction ready; RSI/airway only if they cannot protect and you are authorized — a belly full of blood aspirates.
- Oxygen for hypoxia; two large-bore IVs if you can without delaying transport; keep them warm.
- Recognize shock early: tachycardia, pale, syncope, rising shock index. Compensated bleed still dies in the ED waiting room.
- Destination: hospital that can scope and transfuse. Variceal / known liver failure belongs somewhere with GI/ICU, not a free-standing ER with no blood bank if you have a choice.
- TXA, blood products, octreotide, PPI — only if your system carries them. Mechanical hemorrhage control you can actually do is still “don’t let them aspirate, don’t delay.”
Do Not
- Give nitroglycerin for “chest pain” that started after they dumped a liter of blood.
- Assume a single formed stool on scene rules out a bleed.
- Sit them flat if they are vomiting clots.
Field Pitfalls
- Calling coffee-ground “old” and non-urgent.
- Missing anticoagulant / NSAID / alcohol / prior varices in the history.
Practice
60-second drill
Partner: alcoholic, vomiting bright red, BP 98/70, HR 128, sitting in a recliner. Airway plan, shock label, destination type, and one drug you will not give.
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; protocol still wins
- 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; field win is airway, shock recognition, and the right destination
- AASLD variceal-bleed guidance is likewise hospital-based (vasoactive drugs, tamponade, TIPS). Do not freestyle octreotide or a PPI as the truck’s hemorrhage control.
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.