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نزف هضمي 1


نزف هضمي 1


حالة سريرية

الوصف الكامل Background
A 37 Year old disease with a history of peptic ulcer disease is brought to the emergency room for an alleged episode of heamatomesis. A nasogastric tube lavage reveales cofee ground material. Physical examination reveals pallor, delayed capillary refill without cyanosis.
His vitals:
BP:85\40,
PR: 125
, RR:18\M
, T: 37,7.
WHAT should be the first step in the management of this patient?
A- IV octreotide
B- Surgical intervention
C- Upper GI endoscopy
D- Fluid resussitation
E- IV omeprazole
SINA's picture
by
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Fluid resussitation

the best's picture
the best
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Quote:
D- Fluid resussitation
mbs2380's picture
mbs2380
بعد التخرج


د.

بس ليه cyanotic???

dr.tabban's picture
dr.tabban


Fluid resussitation

اكيد

a.m.a's picture
a.m.a
طبيب مقيم


اففففففففففففففففف

انا قريتها with cyanosis

بس المعالجة المبدأية هي IV fluids.
سؤال: ليه ما عطيناه IV omeprazole كعلاج أولي؟

dr.tabban's picture
dr.tabban

Quote:
بس ليه cyanotic???
Quote:
refill without cyanosis.
a.m.a's picture
a.m.a
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Quote:
بس ليه cyanotic???

مكتوب without cyanosis

the best's picture
the best
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D- Fluid resussitation

برأيي لازم يكون قبل التقييم بالـ endoscopy، ممكن تكون E- IV omeprazole بس شايف الخيار الرابع أزبط.

KMG's picture
KMG
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لانو حيفوت بالصدمة ؟؟؟

mbs2380's picture
mbs2380
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تمام شكرا لكم

Upper GI bleeding is always associated with hematomesis with\out melena.
Assessment of hemodynamic stability and the necessity for fluid resussitation should be the first step in the evaluation of a patient with upper GI bleeding.in this case the pt is paler, has delayed capillary refill, hypotensive and he need resussitation.
C: Endoscopy is the procedure of choice for the diagnosis, treatment and prevention of rebleeding in THE pt . it is easier and costs less and widely available compare 2 surgical interventin (B)
Omeprazole significantly decreases the likelihood of rebleeding.
SINA's picture
SINA
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D- Fluid resussitation

طبعاً

SAMO's picture
SAMO
السنة الخامسة


يعني منعالجه كمريض صدمة ..وبعدين منشوف علاج الافة تبعوا..؟؟

mbs2380's picture
mbs2380
بعد التخرج


yes
first thing to be done is fluid and blood transfusion "the patient is in shock if you noticed"
then you order GI consultation to do EGD and start omeprazole
وذلك بناء على نتائج التنظير.

dr.tabban's picture
dr.tabban


أهم شي بالنزف الهضمي أن ما المهم بالبدء تحديد السبب بل أهم شي الحفاظ على المريض.
كيف بتعرفوا ان المريض
hemodynamically compromised (orthostatic)?

SINA's picture
SINA
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منقيس الضغط وهو متسطح، ومنقيسه وهو جالس. ومنشوف الفرق.

KMG's picture
KMG
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hemodynamic instability is noticed first of all by tachycardia
يعني ممكن المريض حتى ما يكون عندو هبوط توتر لا انتصابي ولا شي، مجرد وجود تسرع القلب الواضح بدون هبوط ضغط هو دليل على بداية تطور صدمة عند المريض.

بعدين بيصير هبوط توتر انتصابي detected by fall in the blood pressure more than 10mmHg when the patient stands up

بعدين الصدمة بتتكامل بهبوط توتر شرياني واضح متل مريضنا هون
then hypoperfusion of other organs occur, especially the kidnies when blood pressure falls below 75 mmHg

dr.tabban's picture
dr.tabban


تمام وعيار الخضاب والهيماتوكريت ليش مشعر في هذه الحالة,,يعني ممكن نعايره ويطلع طبيعي ...طبعاً اول شي وبعدين بيتغير

mbs2380's picture
mbs2380
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شكرا دكتور مهند
بس ممكن بالأرقام كم يتغير النبض وكم يتبدل الضغط بين الجلوس والاستلقاء؟

SINA's picture
SINA
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لازم يقل الضغط أكثر من 20 بين الاستلقاء والجلوس
أو لازم يزيد النبض أكثر من 10

the best's picture
the best
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تمام
THE BEST
طيب هيك حالة اذا ما قالولنا تبدلات الضغط والنبض فينا نقرر أنو المريض Hemodynamic unstable؟

SINA's picture
SINA
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الـ PR: 125، غير محدد تماماً بس لازم ناخذ احتياطنا.

KMG's picture
KMG
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الأدلة على انو المريض unstable بهي الحالة هنن:

A 37 Year old disease with a history of peptic ulcer disease is brought to the emergency room for an alleged episode of heamatomesis. A nasogastric tube lavage reveales cofee ground material. Physical examination reveals pallor, delayed capillary refill without cyanosis.
His vitals:
BP:85\40,
PR: 125
, RR:18\M
, T: 37,7.

dr.tabban's picture
dr.tabban


تمام
لو ما معنا تغيرات قيم النبض والضغط:
انخفاض الضغط الانقباضي عن ال 100 وزيادة النبض عن ال 100 يشير الى ال orthostasis.

SINA's picture
SINA
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[eng]Definetely start with 'Fluid Resuscitation'.... obviously the patient is hemodynamically unstable and if you don't get some fluids in to him fast, his cardiovascular system will crash . And if you wouldn't recognize it you should rethink medicine as a career Shocked So for sure start with IVs and I'd attach him to an oxygen source, nasal cannula? if the NG tube is out.
Now the patient seems to be in bad shape with very low blood pressure, I think the second thing to do is probably surgical intervention to stop the still active bleeding.

let us know how the patient ended up doc Eye-wink

peace
NE

NE2010
بعد التخرج

Quote:
and I'd attach him to an oxygen source, nasal cannula? if the NG tube is out.
Now the patient seems to be in bad shape with very low blood pressure, I think the second thing to do is probably surgical intervention to stop the still active bleeding

Why are you asking for O2?
Surgery is THE LAST thing in the list that the patient needs.
Next to IV fluids is to start PPI IV (omeprazole and prepare patient for upper endoscopy . Octreotide may help somtimes.
Endoscopy after stablizing the patient is very crucial for
1- diagnosis
2- treatment (bleeding control)
3- prognosis

Surgery is left for
Failure of endoscopic treatment ONLY

ABIM's picture
ABIM

Quote:
and I'd attach him to an oxygen source, nasal cannula? if the NG tube is out.
Now the patient seems to be in bad shape with very low blood pressure, I think the second thing to do is probably surgical intervention to stop the still active bleeding

Why are you asking for O2?
Surgery is THE LAST thing in the list that the patient needs.
Next to IV fluids is to start PPI IV (omeprazole and prepare patient for upper endoscopy . Octreotide may help somtimes.
Endoscopy after stablizing the patient is very crucial for
1- diagnosis
2- treatment (bleeding control)
3- prognosis

Surgery is left for
Failure of endoscopic treatment ONLY

ABIM's picture
ABIM
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