Paramedics bring a 1.5-year-old boy to the emergency department after his parents found hi… — USMLE Step 2 CK

Paramedics bring a $1.5$ -year-old boy to the emergency department after his parents found him lethargic in his crib. According to the parents, the child developed sudden, intense abdominal pain $12$ hours ago, which was followed by multiple episodes of dark green vomiting. He has not passed stool or gas since the symptoms began. On examination, the child is obtunded. Temperature is $39.2^\circ\text{C}$ ( $102.6^\circ\text{F}$ ), heart rate is $175/\text{min}$ , respiratory rate is $50/\text{min}$ , and blood pressure is $68/38\text{ mm Hg}$ . Auscultation of the lungs reveals bilateral crackles and scattered wheezes, which the paramedics report began after he choked on his vomit during transport. The abdomen is markedly distended, rigid, and diffusely tender with involuntary guarding. Bowel sounds are absent. An upright abdominal radiograph displays prominent, dilated small bowel loops with multiple air-fluid levels and an absence of distal gas. Following initiation of intravenous fluid resuscitation, which of the following is the most appropriate next step in management?

Exploratory laparotomyCevap
B
Nasogastric tube decompression and serial abdominal examinations
C
Computed tomography scan of the abdomen with intravenous contrast
D
Administration of nebulized albuterol and intravenous corticosteroids
E
Administration of intravenous furosemide

Cevap

Exploratory laparotomy is the most appropriate next step because the patient has a complicated small bowel obstruction with peritonitis and septic/hypovolemic shock, requiring immediate surgical source control.

The correct answer is exploratory laparotomy. This patient presents with a classic clinical picture of a complicated small bowel obstruction (e.g., midgut volvulus or necrotic intussusception), evidenced by sudden-onset abdominal pain, bilious (green) emesis, and dilated bowel loops on radiography. Crucially, the patient has progressed to hypovolemic and septic shock (hypotension, severe tachycardia, obtundation) and exhibits peritonitis (rigid, diffusely tender abdomen with guarding). In any pediatric patient with a mechanical obstruction complicated by peritonitis or hemodynamic instability, immediate surgical exploration is required to resect necrotic bowel, restore perfusion, and control the source of sepsis. While airway protection and fluid resuscitation are critical first steps, source control in the operating room is the definitive next step.

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Analyze the clinical presentation and physical examination.

The patient exhibits bilious vomiting, obstipation, and an acute rigid abdomen, which classically indicate a complete small bowel obstruction (likely secondary to volvulus or complicated intussusception).

Identifying the primary source of the pathology dictates the urgency of care.

Assess the patient's hemodynamic and systemic status.

The patient is in shock (obtunded, marked hypotension, severe tachycardia) and shows signs of bowel ischemia/perforation (fever, rigid abdomen, guarding).

Hemodynamic instability paired with peritonitis shifts the management from diagnostic workup or observation to life-saving surgical intervention.

Determine the most appropriate management.

Following initial ABCs and fluid resuscitation, the patient must be taken immediately to the operating room.

An ischemic or perforated bowel will lead to rapid clinical deterioration and death if not physically corrected via exploratory laparotomy.

Anahtar Kavram

Management of complicated pediatric small bowel obstruction

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