154.A 24-year-old man is brought to the ED after being shot once in the
abdomen. On arrival, his BP is 100/60 mm Hg, HR is 115 beats per minute,
and RR is 22 breaths per minute. His airway is patent and you hear breath
sounds bilaterally. On abdominal examination, you note a single bullet
entry wound approximately 1 cm to the right of the umbilicus. During the
log roll, you see a single bullet exit wound approximately 3 cm to the right
of the lumbar spine. His GCS score is 15. The patient’s BP is now 85/65 mm Hg
and HR is 125 beats per minute after 2 L of fluid. Which of the following
is the most appropriate next step in management?
a. Probe the entry wound to see if it violates the peritoneum
b. Perform a FAST examination
c. Perform a DPL
d. Take the patient directly to the CT scanner
e. Take the patient directly to the OR
155.A 55-year-old woman presents to the ED stating that her nose has
been bleeding profusely for the last 3 hours. After 25 minutes of bilateral
pressure on her nasal septum, there is still profuse bleeding. You place ante-
rior nasal packing bilaterally but bleeding still persists. The patient is start-
ing to get anxious. Her BP is 110/70 mm Hg, HR is 80 beats per minute, RR
is 18 breaths per minute, and oxygen saturation is 98%. Laboratory results
reveal a white blood cell (WBC) count of 9000, hematocrit (HCT) 34%,
platelets of 225,000, and international normalized ratio (INR) 1.1. Under
direct visualization, you note the bleeding originating from the posterior
aspect of her septum. Which of the following is the most appropriate
management?
a. Place posterior nasal packing, start antibiotics, and admit the patient to a mon-
itored hospital bed.
b. Place the patient supine and wait for spontaneous resolution of the bleeding.
c. Keep pressure on her nasal septum and administer fresh frozen plasma and
platelets.
d. Place posterior nasal packing, and discharge the patient home with follow-up
in 24 hours.
e. Apply silver nitrate to the nasal mucosa until the bleeding stops.
142 Emergency Medicine