Examkin

Soru

Zorluk: ZorInitial Stabilization and Triage

A 62-year-old woman is brought to the emergency department by her daughter after vomiting a large volume of bright red blood at home. The patient has a history of alcohol use disorder and was diagnosed with decompensated liver cirrhosis six months ago. Upon arrival, the patient is lethargic, opening her eyes only to painful stimuli, and producing incomprehensible sounds. She withdraws her extremities from painful stimuli. Vital signs include a temperature of 36.4°C (97.5°F), blood pressure of 68/38 mm Hg, pulse of 142/min, and respiratory rate of 28/min. Pulse oximetry shows an oxygen saturation of 91% on room air. Physical examination reveals cool, clammy skin, scleral icterus, and a distended abdomen with a positive fluid wave. Which of the following are the most appropriate simultaneous initial steps in the management of this patient? (Select two)

  1. Endotracheal intubationCevap
  2. Establishment of bilateral large-bore peripheral intravenous accessCevap
  3. C
    Urgent esophagogastroduodenoscopy
  4. D
    Computed tomography angiography of the abdomen
  5. E
    Placement of a balloon tamponade device

Cevap

The most appropriate simultaneous initial steps are endotracheal intubation and the establishment of bilateral large-bore peripheral intravenous access.
The correct options reflect the foundational principles of initial resuscitation: Airway and Circulation. This patient is experiencing a massive upper gastrointestinal hemorrhage likely secondary to esophageal variceal rupture, resulting in decompensated hypovolemic shock (hypotension, marked tachycardia, poor peripheral perfusion) and altered mental status. Her Glasgow Coma Scale score is calculated at 8 (eye opening to pain = 2, incomprehensible sounds = 2, withdrawal to pain = 4). A GCS of 8 or less, especially in the setting of active hematemesis, is an absolute indication for immediate endotracheal intubation to secure the airway and prevent fatal aspiration of blood. Simultaneously, circulation must be addressed by placing bilateral large-bore peripheral intravenous catheters (18-gauge or larger) to allow for rapid, massive volume resuscitation with blood products. Both steps must be ordered and performed concurrently to stabilize the patient.

Adım Adım Çözüm

1
Assess the patient's airway and neurological status.
The patient has a Glasgow Coma Scale score of 8 (eyes 2, verbal 2, motor 4) and active hematemesis.
Patients with a GCS of 8 or less or those actively vomiting without intact airway reflexes require immediate definitive airway protection to prevent fatal aspiration.
2
Assess the patient's hemodynamic status (circulation).
The patient exhibits signs of profound decompensated hemorrhagic shock, including marked hypotension (68/38 mm Hg) and severe tachycardia (142/min).
Immediate large-bore peripheral venous access must be established simultaneously with airway management to facilitate rapid volume resuscitation with uncrossmatched blood and fluids.
3
Prioritize stabilization over definitive diagnosis or secondary procedural treatments.
Endoscopy and other interventions are deferred until ABCs (Airway, Breathing, Circulation) are fully secured.
Prematurely advancing to diagnostic testing or specialized procedures in a critically unstable patient dramatically increases the risk of mortality and peri-procedural cardiac arrest.

Anahtar Kavram

In patients presenting with severe hemorrhagic shock and altered mental status, securing the airway (intubation) and restoring circulation (large-bore IV access for rapid resuscitation) must occur simultaneously before advancing to any definitive diagnostic or therapeutic procedures.
Bu soruyu puanla

Konular

Initial Stabilization and Triage

Bu konudan daha fazla soru