Question Of The Day #58

This cirrhotic patient presents to the Emergency Department with epigastric pain after an episode of hematemesis at home.  His initial vital signs are within normal limits.  While waiting in the Emergency Department, his clinical status changes.  The patient has a large volume of hematemesis with hypotension and tachycardia.  This patient is now in hemorrhagic shock from an upper gastrointestinal bleed and requires immediate volume resuscitation.  The most common cause of upper gastrointestinal bleeding is peptic ulcer disease, but this patient’s cirrhosis history and large volume of hematemesis should raise concern for an esophageal variceal bleed.  IV Pantoprazole (Choice D) is a proton pump inhibitor that helps reduce bleeding in peptic ulcers, but it does not provide benefit in esophageal varices.  Volume repletion is also a more important initial step than giving pantoprazole.  IV Ceftriaxone (Choice C) helps reduce the likelihood of infectious complications in variceal bleed patients.  This has a mortality benefit and is a recommended adjunctive treatment.  However, rapid volume resuscitation is a more important initial step.  IV crystalloid fluids, like normal saline (Choice A), are helpful in patients with hypovolemic shock (i.e., dehydration, vomiting), distributive shock (i.e., sepsis, anaphylaxis), and obstructive shock (i.e., tension pneumothorax, etc.).  Hypovolemic shock due to severe hemorrhage (hemorrhagic shock) requires blood products, not crystalloid fluids which can further dilute blood and cause coagulopathy.  Administration of packed red blood cells (Choice B) is the best next step in management in this case.