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Difficulty: MediumInitial Stabilization and Triage

A 54-year-old man with a history of alcohol use disorder and cirrhosis is brought to the emergency department by his daughter after he vomited a large amount of bright red blood at home. In the triage area, he has another massive episode of hematemesis. He appears lethargic and is difficult to arouse. His temperature is 37.1°C (98.8°F), blood pressure is 78/40 mmHg, pulse is 134/min, and respirations are 24/min. Pulse oximetry shows 92% on room air. The patient's skin is cool and clammy. His abdomen is distended with a positive fluid wave.

Which of the following are the most appropriate simultaneous initial steps in the stabilization of this patient? (Select 2 answers)

  1. Endotracheal intubationAnswer
  2. Insertion of two large-bore peripheral intravenous cathetersAnswer
  3. C
    Urgent esophagogastroduodenoscopy
  4. D
    Administration of intravenous propranolol
  5. E
    Computed tomography angiography of the abdomen

Answer

The most appropriate simultaneous initial steps are endotracheal intubation and the insertion of two large-bore peripheral intravenous catheters.
The correct interventions focus on the most immediate, life-threatening aspects of the patient's presentation: loss of airway protection and profound hemorrhagic shock. Endotracheal intubation secures the airway against aspiration of blood in a lethargic patient. Two large-bore peripheral intravenous lines provide the necessary access for rapid, high-volume resuscitation with crystalloids and uncrossmatched blood products, which is critical before moving the patient or attempting endoscopy.

Step-by-Step Solution

1
Assess the patient's airway and breathing status.
The patient has massive ongoing hematemesis and is lethargic (altered mental status), indicating an inability to protect his airway.
Airway compromise is an immediate threat to life in severe upper gastrointestinal bleeding due to the high risk of aspiration.
2
Assess the patient's hemodynamic status.
The patient is in hemorrhagic shock, evidenced by profound hypotension (78/40 mmHg), marked tachycardia (134/min), and cool, clammy skin.
Rapid loss of intravascular volume requires immediate resuscitation to maintain perfusion to vital organs.
3
Determine the necessary initial stabilization interventions.
Airway protection (endotracheal intubation) and securing robust vascular access (two large-bore peripheral IVs) must be performed simultaneously before any diagnostic testing.
These steps address the most immediate life-threatening derangements (ABCs: Airway and Circulation) and lay the foundation for definitive treatment.

Key Concept

In patients with severe upper gastrointestinal bleeding complicated by hemorrhagic shock and altered mental status, initial management must prioritize securing the airway (intubation) and establishing robust intravenous access for rapid volume resuscitation before definitive diagnostic or therapeutic procedures.
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Topics

Initial Stabilization and Triage

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