A 45-year-old male construction worker arrives at the emergency department triage desk complaining of an abrupt onset of excruciating epigastric pain that began 2 hours ago. The pain has now spread throughout his entire abdomen. He appears acutely ill, diaphoretic, and lies completely still on the gurney. Vital signs show a temperature of 38.2°C (100.8°F), blood pressure of 100/60 mm Hg, heart rate of 115/min, and respiratory rate of 22/min. Physical examination demonstrates a rigid, board-like abdomen with severe, diffuse rebound tenderness and involuntary guarding. Arrange the following steps in the most appropriate chronological sequence for the initial evaluation and management of this patient.
- 1Establish intravenous access and begin aggressive crystalloid fluid resuscitation.
- 2Perform an upright chest radiograph to identify subdiaphragmatic free air.
- 3Administer preoperative broad-spectrum intravenous antibiotics and proton pump inhibitors.
- 4Proceed with an emergency exploratory laparotomy and omental patch repair.
Cevap
The correct sequence is to first establish intravenous access for fluid resuscitation, followed by performing an upright chest radiograph to confirm the diagnosis. Next, administer preoperative broad-spectrum antibiotics and proton pump inhibitors, and finally proceed with an emergency exploratory laparotomy.
The correct chronological sequence aligns with the fundamental principles of trauma and acute care surgery: first prioritize physiological stability (resuscitation), second obtain a rapid diagnosis (imaging), third provide preoperative medical optimization (antibiotics), and finally perform definitive intervention (surgery).
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Anahtar Kavram
Initial evaluation and sequential management of a suspected perforated viscus.