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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

  • Identify risk factors associated with stress ulcer formation and determine which critically ill patients should receive pharmacologic prophylaxis.

  • Recommend appropriate pharmacologic alternatives, including agent, route of administration, and dose for the prevention of stress-induced ulcers.

  • Identify and implement monitoring parameters for the recommended stress ulcer prophylaxis regimens.

  • Discuss the pharmacologic approaches to the management of stress ulcer–induced bleeding.

PATIENT PRESENTATION

Chief Complaint

No complaint—patient is unresponsive.

HPI

Penny Robinson is a 26-year-old woman who presents to the ED with traumatic injuries following a motor vehicle accident (MVA). She was the restrained driver of a car who was hit on the driver’s side by a tractor-trailer that ran a red light. When EMS arrived in the field, the patient was unresponsive with labored breathing. She was given fentanyl 50 mcg, succinylcholine 40 mg, midazolam 5 mg, and was intubated prior to transfer to the hospital. The EMS report indicates that the intubation was very difficult. The extraction time from the vehicle to the ED was 25 minutes.

PMH (Provided by Patient’s Mother)

PE × 1 about 2 months ago

IBS-C × 10 years

S/P cholecystectomy 8 years ago

Contact dermatitis from recent poison ivy exposure

FH

Both mother and father are still alive and in “good health.”

SH

Patient is a graduate student at a local university. She smoked cigarettes 1 ppd × 6 years until she was hospitalized for a PE and has since quit. She does not drink alcohol or use illicit drugs.

ROS

Patient is unresponsive after an MVA.

Meds

Lubiprostone 24 mcg PO Q 12 H

Apixaban 10 mg PO BID

Prednisone 40 mg daily

Allergies

No known drug allergies

Review of Systems

Unable to be provided

Physical Examination

Gen

Young, unresponsive woman; no obvious bleeding on exam

VS

BP 96/64, P 106, RR 24, T 37.3°C; Wt 112 lb (51 kg), Ht 5′11″ (180 cm)

Skin

Warm, dry; small lacerations across forehead and chest; ecchymoses present on both legs and arms

Neck/Lymph Nodes

Supple, no palpable areas of deformity or masses

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