Question

A 62-year-old man presents with an acute onset of bright red vomiting. According to his wife, he ingests excessive amounts of alcohol each day. As you are assessing the patient, you note that his level of consciousness has decreased markedly. His mouth is full of blood, and his skin is pale and moist. You should:

a) Assist his ventilations for 2 to 3 minutes, insert a combitube, suction his airway for up to 15 seconds, start two large-bore IV lines with normal saline, and administer a 1-L fluid bolus.
b) Suction his mouth for up to 20 seconds, insert a nasopharyngeal airway, ventilate him at a rate of 20 breaths/min, consider endotracheal intubation, start a large-bore IV line, and run the IV wide open until signs of improvement are noted.
c) Perform immediate tracheal intubation, insert a nasogastric tube, establish IV or IO access, and administer 10- to 20- mL/kg normal saline or lactated Ringer's boluses to maintain a systolic blood pressure of at least 90 mmHg.
d) Turn him on his side and suction his oropharynx, intubate his trachea if the oral bleeding continues, establish at least one large-bore IV with normal saline, and administer enough fluids to maintain adequate perfusion.

Answer 1

Perform immediate tracheal intubation, insert a nasogastric tube, establish IV or IO access, and administer fluid boluses to maintain blood pressure.

Step-by-step explanation:

Based on the given information, the most appropriate course of action for this patient would be option c) Perform immediate tracheal intubation, insert a nasogastric tube, establish IV or IO access, and administer 10- to 20- mL/kg normal saline or lactated Ringer's boluses to maintain a systolic blood pressure of at least 90 mmHg. The patient is presenting with acute bright red vomiting, decreased consciousness, and signs of shock (pale, moist skin), which suggest severe bleeding in the upper gastrointestinal tract. Tracheal intubation would secure the airway, while nasogastric tube insertion would help drain the stomach of any remaining blood. Establishing IV or IO access and administering fluid boluses would help stabilize the patient's blood pressure and maintain perfusion. It is important to address the underlying cause of the bleeding, which, in this case, is likely related to excessive alcohol intake.