A 46-year-old man is brought to the emergency department by the police after being found unresponsive on a nearby park bench. Previously, the patient was brought to the hospital on several occasions due to acute alcohol intoxication. No other history can be obtained. The patient appears disheveled and has a strong smell of alcohol. Temperature is 36.1 C (97 F), blood pressure is 110/76 mm Hg, and pulse is 84/min. Pulse oximetry shows 98% on ambient air. The patient does not follow instructions and withdraws all extremities to painful stimuli. The mucous membranes are dry, and he has several spider angiomata and bilateral gynecomastia. The lungs are clear to auscultation and heart sounds are normal with no murmur. There is moderate abdominal distension with shifting dullness. The liver edge cannot be palpated. While being evaluated in the emergency department, the patient vomits a large amount of bright red blood. Repeat vital signs show that blood pressure is 100/50 mm Hg and pulse is 110/min. Two large-bore peripheral lines are placed and intravenous fluid is administered.
Which of the following is the best next step in management of this patient?

Question

A 46-year-old man is brought to the emergency department by the police after being found unresponsive on a nearby park bench.  Previously, the patient was brought to the hospital on several occasions due to acute alcohol intoxication.  No other history can be obtained.  The patient appears disheveled and has a strong smell of alcohol.  Temperature is 36.1 C (97 F), blood pressure is 110/76 mm Hg, and pulse is 84/min.  Pulse oximetry shows 98% on ambient air.  The patient does not follow instructions and withdraws all extremities to painful stimuli.  The mucous membranes are dry, and he has several spider angiomata and bilateral gynecomastia.  The lungs are clear to auscultation and heart sounds are normal with no murmur.  There is moderate abdominal distension with shifting dullness.  The liver edge cannot be palpated.  While being evaluated in the emergency department, the patient vomits a large amount of bright red blood.  Repeat vital signs show that blood pressure is 100/50 mm Hg and pulse is 110/min.  Two large-bore peripheral lines are placed and intravenous fluid is administered. 
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient has manifestations of chronic liver disease (eg, ascites, spider angiomata, gynecomastia), likely due to alcohol abuse. The large amount of hematemesis is consistent with upper gastrointestinal (GI) bleeding. Given his underlying chronic liver disease, this may be due to bleeding varices. A Mallory-Weiss tear would also be possible, given his apparent recent vomiting. Appropriate stabilization of the patient's condition should be the first step. This patient is at risk of airway compromise due to his unresponsive state (with a low Glasgow Coma Scale score) and large volume of active hematemesis, possibly leading to aspiration. Endotracheal intubation would therefore be the most important first step. Two large-bore intravenous lines should be placed to institute aggressive fluid resuscitation. A blood type and crossmatch should be sent if blood transfusion is deemed necessary. Glasgow Coma Scale After the patient's condition is appropriately stabilized, an immediate upper endoscopy would be appropriate as it is potentially both diagnostic and therapeutic (Choice D). (Choice A) Radiographic imaging is usually not necessary in the evaluation of upper GI bleeding, and a CT scan is typically not helpful as it does not easily visualize the source of bleeding. CT scan can be used in case of suspected retroperitoneal bleed. (Choice B) Given this patient's altered mental status and ascites, diagnostic paracentesis may be needed to assess for possible spontaneous bacterial peritonitis. However, this is less important than initial stabilization/resuscitation and evaluation of upper GI hemorrhage. (Choice E) Although nasogastric tubes are sometimes used to determine whether patients have ongoing bleeding, they should be avoided in patients who have varices or in whom there is a very high concern for varices (eg, alcohol use, cirrhosis). Placement can cause rupture of varices and further hemorrhage. Educational objective: Because of aspiration risk, endotracheal intubation is indicated in unresponsive patients with a large amount of hematemesis. Upper endoscopy should be performed early as it may be both diagnostic and therapeutic. References: Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/12518132)

A 46-Year-Old Man Is Brought to the Emergency Department by the Police