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EMSWORLD.com | OCTOBER 2015 37 a device sufficient to maintain a saturation of at least 94%. In patients who are unstable and may decompensate, it is advisable to attempt to achieve an oxygen saturation of 100% in an effort to create and maintain an oxygen reserve in the blood; this will lengthen the time to hypoxia should the patient's condition deteriorate. Patients with active hematemesis will require aggressive airway suctioning and possibly intubation. Patients with hepatic encephalopathy and SBP may have an altered level of con- sciousness that requires airway control. Any patient with gurgling or snoring respira- tions should have their airway suctioned and a BLS airway adjunct inserted. If the airway cannot be kept open with BLS air- way adjuncts, consider a more secure supra - glottic airway (King airway, LMA, etc.) or endotracheal tube. If they're used in your service following advanced airway place- ment, naso- or orogastric tubes should be carefully considered because of the poten- tial for disrupting varices. Circulation Patients presenting with hypotension should be placed supine to maintain ade- quate cerebral blood f low. Obtain large- bore peripheral IV access (14- or 16-gauge angiocath in the antecubital). Administer fluid volume utilizing an isotonic crystalloid solution such as normal saline to maintain a mean arterial pressure above 60 mmHg. Patients with hypotension secondary to SBP are experiencing severe sepsis and should be managed, from a fluid volume replacement perspective, as any patient with severe sepsis. The optimal volume of fluid that should be administered in patients with SBP and hypotension is unknown. It is prudent to administer rapidly infused 250–500-mL boluses of an isotonic crys- talloid solution. Evaluate peripheral tissue perfusion, mental status, blood pressure and the presence of pulmonary edema after each bolus to determine the effectiveness of treat- ment. It is conceivable that a patient in shock would receive 1–2 liters or more of fluid in the prehospital setting. Consider vasopres- sors such as norepinephrine in the treatment of SBP and shock refractory to fluids. Patients with variceal hemorrhage are very similar to trauma patients when consid- ering fluid volume resuscitation. As in any patient with hypovolemic shock secondary to an uncontrollable internal hemorrhage, fluid volume resuscitation should be conser- vative, or at least not overzealous, to avoid fluid volume overload and worsening hemor- rhage. In patients with massive hemorrhag- ing from variceal bleeding, lost blood volume is ideally replaced with a blood transfusion and clotting factors as necessary. Article references available at EMSWorld.com/12113585. For More Information Circle 28 on Reader Service Card