A 52-year-old man is brought to the emergency department after experiencing the sudden onset of excruciating, diffuse abdominal pain that began 2 hours ago. He has a history of severe osteoarthritis and takes high doses of naproxen daily. His temperature is 38.3°C (100.9°F), blood pressure is 100/60 mmHg, and pulse is 115/min. On physical examination, he is diaphoretic and lying completely motionless on the stretcher. His abdomen is rigid and board-like, with diffuse rebound tenderness. Arrange the following critical management steps in the most appropriate chronological sequence for this patient.
- 1Establish intravenous access and initiate crystalloid fluid resuscitation
- 2Obtain a portable upright chest radiograph to evaluate for free intraperitoneal air
- 3Administer broad-spectrum intravenous antibiotics and a proton pump inhibitor
- 4Perform an emergent exploratory laparotomy and omental patch repair
Answer
The correct sequence is to first initiate intravenous fluid resuscitation, followed by obtaining a portable upright chest radiograph, then administering intravenous antibiotics and a proton pump inhibitor, and finally performing an emergent exploratory laparotomy.
This patient presents with a classic perforated peptic ulcer, evidenced by the sudden onset of severe abdominal pain, a history of heavy NSAID use, and a rigid, board-like abdomen indicating diffuse peritonitis. The management of such surgical emergencies follows a strict algorithmic approach prioritizing patient stability. First, the patient must be stabilized hemodynamically with intravenous crystalloid fluids to address relative hypovolemia from third-spacing and systemic inflammation. Second, because transporting an unstable patient with peritonitis to a CT scanner is unsafe and time-consuming, a rapid portable upright chest radiograph is obtained to look for free air under the diaphragm, which confirms the diagnosis of a perforated viscus. Third, once the diagnosis is clear, broad-spectrum intravenous antibiotics and a proton pump inhibitor are administered to treat the ongoing bacterial and chemical peritonitis. Finally, the definitive treatment is an emergent exploratory laparotomy to repair the perforation, most commonly utilizing an omental (Graham) patch.
Step-by-Step Solution
Key Concept
The management of a perforated viscus with peritonitis follows a strict chronological sequence: initial hemodynamic resuscitation, rapid diagnostic imaging (upright chest X-ray), administration of preoperative medical adjuncts (antibiotics), and definitive surgical exploration.