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Difficulty: MediumSurgical and Procedural Interventions

Emergency medical services bring a 62-year-old gentleman to the trauma bay after he collapsed at home. His wife reports that he has been complaining of severe, unremitting abdominal pain for the past 48 hours. His past medical history includes long-standing osteoarthritis, for which he takes high-dose naproxen daily. On presentation, his temperature is 39.1°C (102.4°F), blood pressure is 82/50 mm Hg, pulse is 128/min, and respirations are 24/min. Physical examination reveals a distended, diffusely tender abdomen with rigid, board-like guarding and rebound tenderness. Bowel sounds are absent. An upright chest radiograph reveals free air under the right hemidiaphragm. Which of the following interventions are indicated immediately in this patient's management? (Select all that apply)

  1. Transfer to the operating room for emergent exploratory laparotomyAnswer
  2. Administration of intravenous crystalloids and broad-spectrum antibioticsAnswer
  3. C
    Computed tomography scan of the abdomen and pelvis with intravenous contrast
  4. D
    Upper gastrointestinal endoscopy to identify and clip the bleeding source
  5. E
    Placement of a nasogastric tube and admission to the medical intensive care unit for observation

Answer

The correct interventions are the administration of intravenous crystalloids and broad-spectrum antibiotics, alongside immediate transfer to the operating room for an emergent exploratory laparotomy.
This patient presents with signs of septic shock and a rigid, acute abdomen. The presence of free air under the diaphragm on an upright chest radiograph confirms a hollow viscus perforation, highly likely to be a peptic ulcer given his heavy NSAID use. The standard of care for a perforated hollow viscus with peritonitis and hemodynamic instability requires concurrent life-saving measures: immediate medical resuscitation with intravenous fluids and broad-spectrum antibiotics to address the septic shock, and rapid transfer to the operating room for an exploratory laparotomy to achieve surgical source control.

Step-by-Step Solution

1
Interpret the clinical presentation and vital signs.
The patient has hypotension, tachycardia, and fever, indicating septic shock, accompanied by a rigid abdomen (peritonitis).
Recognizing the severity of the patient's instability dictates the urgency of intervention.
2
Correlate history with imaging findings.
Chronic NSAID use combined with free air under the diaphragm confirms a perforated hollow viscus, most likely a peptic ulcer.
Free intraperitoneal air in a patient without recent surgery represents a surgical emergency requiring source control.
3
Determine the appropriate sequencing of procedural interventions.
Simultaneous medical stabilization (fluids, antibiotics) and surgical exploration (laparotomy) are required.
Delays for further diagnostic testing in a hemodynamically unstable patient with an established acute abdomen increase mortality.

Key Concept

Management of a perforated hollow viscus with septic shock requires simultaneous medical resuscitation and emergent surgical exploration.
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Topics

Surgical and Procedural Interventions

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