A 55-year-old woman is transported to the triage area by her husband after being found lethargic at home. She has a known history of decompensated cirrhosis due to chronic alcohol use. Over the past several hours, she has vomited large quantities of bright red blood. On arrival, she is somnolent, groans to painful stimuli, and continues to have episodes of active hematemesis. Vital signs show a blood pressure of 75/40 mmHg, a pulse of 135/min, and respirations of 26/min. Pulse oximetry displays 91% on room air. Which of the following is the most appropriate initial step in the management of this patient?
- Endotracheal intubationAnswer
- BEsophagogastroduodenoscopy
- CIntravenous octreotide administration
- DComputed tomography angiography of the abdomen
- EImmediate transfer to the intensive care unit
Answer
The most appropriate initial step is to perform endotracheal intubation.
The correct answer emphasizes the fundamental principle of trauma and critical care resuscitation: 'Airway first.' This patient is presenting with hemorrhagic shock and active hematemesis in the setting of severe hepatic dysfunction. Her altered mental status (lethargic, responding only to pain) means she has lost her protective airway reflexes. The ongoing vomiting of blood places her at an extremely high risk for aspiration, which can rapidly lead to fatal asphyxiation or severe aspiration pneumonitis. Therefore, securing a definitive airway with endotracheal intubation is the single most urgent priority, superseding diagnostic procedures, pharmacologic interventions, or disposition planning.
Step-by-Step Solution
Key Concept
In patients with massive upper gastrointestinal bleeding and altered mental status, securing the airway via endotracheal intubation is the immediate priority to prevent aspiration and ensure adequate ventilation prior to resuscitation and endoscopic intervention.