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Difficulty: HardSurgical and Procedural Interventions

Emergency medical services bring a 72-year-old male to the emergency department with sudden-onset, agonizing abdominal pain that started 4 hours ago. His past medical history is significant for nonvalvular atrial fibrillation, for which he takes apixaban, as well as hypertension and osteoarthritis. On arrival, his temperature is 38.4°C (101.1°F), blood pressure is 88/50 mm Hg, pulse is 124/min, and respiratory rate is 22/min. He appears diaphoretic and is lying completely still on the gurney. Abdominal examination reveals a rigid, board-like abdomen with severe diffuse tenderness, rebound tenderness, guarding, and absent bowel sounds. An upright chest radiograph demonstrates a crescent of radiolucency beneath the right hemidiaphragm. Laboratory results reveal a leukocyte count of 17,500/mm³ and a hemoglobin of 13.2 g/dL. Which of the following interventions are indicated in the immediate management of this patient? (Select all that apply)

  1. Immediate exploratory laparotomyAnswer
  2. Administration of prothrombin complex concentrateAnswer
  3. Initiation of intravenous broad-spectrum antimicrobial therapyAnswer
  4. D
    Computed tomography of the abdomen and pelvis with contrast
  5. E
    Upper gastrointestinal endoscopy
  6. F
    Preoperative dobutamine stress echocardiography

Answer

The correct interventions are immediate exploratory laparotomy, administration of prothrombin complex concentrate, and initiation of intravenous broad-spectrum antimicrobial therapy.
This patient presents in septic shock with a rigid abdomen and radiographic evidence of pneumoperitoneum, indicating a perforated hollow viscus (such as a peptic ulcer). The definitive management is immediate surgical source control via an exploratory laparotomy. Concurrently, medical stabilization must occur. Because the patient is taking apixaban (a direct oral anticoagulant), he requires emergent reversal with prothrombin complex concentrate (PCC) or andexanet alfa to prevent fatal intraoperative bleeding. Additionally, the spillage of enteric contents necessitates the immediate initiation of broad-spectrum intravenous antibiotics to treat intra-abdominal sepsis.

Step-by-Step Solution

1
Diagnose the acute surgical abdomen based on clinical and radiographic findings.
The patient has a rigid abdomen, hypotension, tachycardia, and subdiaphragmatic free air on chest radiograph, confirming a perforated hollow viscus.
Identifying the etiology of shock and peritonitis dictates the need for emergent source control.
2
Determine the necessary preparatory steps for emergency surgery in a patient on anticoagulation.
The patient is taking apixaban and must receive rapid reversal with prothrombin complex concentrate (or andexanet alfa) prior to incision.
Operating on a fully anticoagulated patient carries a prohibitive risk of catastrophic, uncontrollable hemorrhage.
3
Initiate medical management for intra-abdominal sepsis.
Broad-spectrum intravenous antibiotics are ordered alongside aggressive fluid resuscitation.
Gastrointestinal contents in the peritoneal cavity cause severe infection; early antibiotics significantly reduce morbidity and mortality.

Key Concept

Patients with a perforated hollow viscus and hemodynamic instability require simultaneous resuscitation, broad-spectrum antibiotics, rapid reversal of any concurrent anticoagulation, and emergent exploratory laparotomy.
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Topics

Surgical and Procedural Interventions

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