CASE: 43-year-old male presents to the ER with chief complaint of vomiting blood and epigastric (upper stomach) pain. Approximately 1 hour prior to presenting to the ER, he finished dinner with his family of 5; became nauseated and sweaty; and vomited his meal mixed with a large amount of dark red blood. His wife states that it seemed "like a gallon!" Pertinent past history included weekly ibuprofen use for chronic knee pain and alcohol use consisting of beer only on the weekends when he is not working. He injured his knee due to playing frequently with his children. On exam, he is afebrile (no fever); has blood pressure of 82/44; heart rate of 122; respiratory rate of 28; and oxygen saturation of 96% when breathing room air. The patient appears pale, sweaty, and has some mild tenderness to palpation over his upper abdominal area.
Immediately, the patient is placed on nasal cannula oxygen with continuous pulse oximetry and telemetry. This allows him to breath pure oxygen through his nose while the doctor can monitor the oxygen level in his blood and his heart rate and rhythm on a screen similar to a small flat screen TV. Two 18 gauge peripheral IVs are placed and O negative blood is ordered, stat, from the laboratory to be given through the rapid transfusion warming unit. Pantoprazole and octreotide boluses and drips are ordered. Pantoprazole is a medicine given through an IV that reduces acid in the stomach. Octreotide is a medicine also given through an IV that reduces pressure in the veins of the esophagus.
Seth Womack, MD, FAAEM is a Board Certified Emergency Medicine Physician in active clinical practice at a level 1 trauma center. He is licensed in Louisiana, Wisconsin, and Texas. Dr. Womack's undergraduate degree is in biomedical engineering. In addition to his busy clinical practice, Dr. Womack serves as an emergency medicine expert witness. He can be contacted at Seth Womack, MD FAAEM; 16623-C FM 2493, PMB #408; Tyler, TX 75703; Womack@ERmdexpert.com; (414) 218-4310 (Cell). http://www.ERmdexpert.com
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