280.A 50-year-old man is brought to the ED by ambulance with significant
hematemesis. In the ambulance, paramedics placed two large-bore IVs and
began infusing normal saline. In the ED, his HR is 127 beats per minute,
BP is 79/45 mm Hg, temperature is 97.9°F, RR is 24 breaths per minute,
and oxygen saturation is 96%. On physical examination, his abdomen is
nontender, but you note spider angiomata, palmar erythema, and gyneco-
mastia. Laboratory results reveal WBC 9000/μL, hematocrit 28%, platelets
40/μL, aspartate transaminase (AST) 675 U/L, alanine transaminase (ALT)
325 U/L, alkaline phosphatase 95 U/L, total bilirubin 14.4 mg/dL, conjugated
bilirubin 12.9 mg/dL, sodium 135 mEq/L, potassium 3.5 mEq/L, chloride
110 mEq/L, bicarbonate 26 mEq/L, blood urea nitrogen (BUN) 20 mg/dL,
creatinine 1.1 mg/dL, and glucose 150 mg/dL. Which of the following is the
most likely diagnosis?
a. Perforated gastric ulcer
b. Diverticulosis
c. Splenic laceration
d. Esophageal varices
e. Ruptured AAA
281.A 55-year-old man is brought to the ED by his family. They state that
he has been vomiting large amounts of bright red blood. The patient is an
alcoholic with cirrhotic liver disease and a history of portal hypertension
and esophageal varices. His vitals on arrival are HR 110 beats per minute,
BP 80/55 mm Hg, RR 22 breaths per minute, and temperature 99°F. The
patient appears pale and is in moderate distress. Which of the following is
aninappropriateoption in the initialmanagement of a hypotensive patient
with a history of known esophageal varices presenting with hematemesis?
a. Sengstaken-Blakemore tube placement
b. Two large-bore IV lines and volume repletion with crystalloid solutions
c. Nasogastric (NG) lavage
d. IV octreotide
e. Gastrointestinal (GI) consult
300 Emergency Medicine