A 47-year-old man with a history of chronic viral hepatitis C infection is brought in by his partner for vomiting blood over the past 2 hours. He is unarousable on physical examination and he has a temperature of 36.8°C, blood pressure of 124/90 mmHg, heart rate of 96 beats per minute, and a respiratory rate of 18 breaths per minute. While being examined, the patient begins to vomit a large amount of blood.
In addition to normal saline administration, which of the following is the best next step in management of this patient?a. Upper GI endoscopy
Endotracheal intubation. The patient in this question is presenting with unrelenting hematemesis, and given his history of chronic hepatitis C infection, the bleeding is likely secondary to esophageal variceal hemorrhage. This patient is hemodynamically unstable and is continuing to vomit blood. In this situation, the ABCs take precedence; since he has an elevated risk of aspiration from a depressed level of consciousness and ongoing hematemesis, the critical next step to perform (in addition to ample fluid administration) is endotracheal intubation to secure his airway (which is already compromised). (A) An upper GI endoscopy is definitely warranted in this case to locate and stop the variceal bleeding; however, this should only be performed after the patient is stabilized. (B) Abdominal CT scan is not indicated with GI bleeding. (D) Octreotide (a somatostatin analog) is an inhibitory hormone that leads to vasoconstriction of portal circulation and therefore would be beneficial in this patient. However, stabilization and securing an airway takes precedence in management.