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Difficulty: HardInitial Stabilization and Triage

A 64-year-old man is brought to the emergency department by paramedics after his wife found him lethargic and confused at home. She reports that he had been complaining of progressive, severe upper abdominal pain and nausea over the past three days. His past medical history is significant for osteoarthritis, for which he takes high-dose ibuprofen daily, and hypertension. On physical examination, the patient is obtunded and profusely diaphoretic. Temperature is 39.4°C (102.9°F), blood pressure is 72/40 mmHg, pulse is 132/min, and respirations are 28/min. Pulse oximetry is 93% on room air. Cardiopulmonary examination reveals tachycardia with distant heart sounds and rapid, shallow breathing. Abdominal examination demonstrates a rigid, board-like abdomen with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent. Which of the following is the most appropriate initial step in the management of this patient?

  1. Administer intravenous crystalloid fluids and broad-spectrum antibioticsAnswer
  2. B
    Obtain an upright plain radiograph of the chest and abdomen
  3. C
    Consult general surgery for an emergent exploratory laparotomy
  4. D
    Obtain a computed tomography scan of the abdomen and pelvis
  5. E
    Initiate a continuous intravenous infusion of norepinephrine

Answer

The correct answer is to administer intravenous crystalloid fluids and broad-spectrum antibiotics.
The correct answer is to administer intravenous crystalloid fluids and broad-spectrum antibiotics. This patient is presenting with a rigid abdomen, fever, and profound hypotension (blood pressure 72/40 mmHg), which is highly indicative of septic shock secondary to peritonitis, likely from a perforated peptic ulcer given his chronic nonsteroidal anti-inflammatory drug use. In any hemodynamically unstable patient, the immediate priority is the stabilization of airway, breathing, and circulation. According to sepsis resuscitation protocols, the most critical initial step is the rapid administration of an intravenous crystalloid fluid bolus (e.g., 30 mL/kg) and empiric broad-spectrum antibiotics to restore end-organ perfusion and control the source of infection.

Step-by-Step Solution

1
Identify the clinical syndrome from the patient's presentation.
The patient presents with a rigid abdomen, fever, tachycardia, profound hypotension, and altered mental status, which is highly suggestive of peritonitis and septic shock secondary to a perforated viscus (likely a peptic ulcer given his chronic NSAID use).
Accurate recognition of the shock state drives the immediate prioritization of treatment over diagnostics.
2
Determine the priority of care for a hemodynamically unstable patient.
In any patient presenting with hemodynamic instability (blood pressure 72/40 mmHg), initial stabilization of airway, breathing, and circulation always takes precedence.
Definitive diagnostic testing or subspecialty consultation cannot be safely performed on an unresuscitated, unstable patient.
3
Select the best initial intervention.
The immediate administration of intravenous crystalloid fluids and empiric broad-spectrum antibiotics is selected.
This is the critical first step in the resuscitation of septic shock to restore end-organ perfusion and begin treating the underlying infection.

Key Concept

In patients presenting with severe hemodynamic instability (e.g., septic shock from an acute abdomen), immediate resuscitation with intravenous fluids and antibiotics must be prioritized over diagnostic imaging and subspecialty consultation.
Estimated Time:1m 30s
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Topics

Initial Stabilization and Triage

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