Initial Assessment



If it is established or suspected that a patient has bled acutely from the gastrointestinal tract,pulse and blood pressure are noted and large-bore intravenous lines inserted for the initial infusion of saline or other plasma expanders prior to any further inquiry or examination. Blood is sent for typing and cross-matching, a complete blood count, prothrombin time, and platelet count. The latter two help to rule out a bleeding diathesis, which commonly accompanies bleeding in pa­tients with cirrhosis, and establish a baseline for assessment of coagulation disturbances that may supervene with massive transfusion. Blood sent for electrolytes, BUN, creatinine, and liver func­tion tests at this stage will aid in evaluating renal function, which may become compromised as a result of hypovolemic shock, as well as the pres­ence of liver disease, which would alert the phy­sician to a variceal source of hemorrhage.
Vital signs are the most reliable means for as­sessing the degree of volume loss. An orthostatic fall in blood pressure of greater than 10 mm Hg usually signifies a 20 per cent or greater loss of blood volume. Hypotension is usually accompa­nied by tachycardia, but heart rate alone is un­reliable. When blood loss approaches 40 per cent of blood volume, signs of shock are usually present with pallor, cool extremities, pronounced tachycardia, and hypotension. A small amount of hematemesis or melena is misleading in that it may represent only a small proportion of the blood lost into the gastointestinal tract, while even small losses may seriously compromise an elderly patient or a patient with pre-existing ane­mia or dehydration. The hematocrit is initially unreliable for evaluating acute blood loss, because a fall in hematocrit following acute blood loss re­quires equilibration of the contracted intravas­cular space with the extravascular space, which takes several hours. Thus, soon after even sub­stantial bleeding, the hematocrit may be normal. An initially low hematocrit may suggest pre-ex­isting chronic blood loss, and this mav be con­firmed by the presence of microcytic red cell in­dices.