A rapid response is called for a 67-year-old male inpatient recovering from an emergent op… — USMLE Step 2 CK

A rapid response is called for a 67-year-old male inpatient recovering from an emergent open sigmoid colectomy performed 5 days ago for perforated diverticulitis. He has a history of severe chronic obstructive pulmonary disease and obesity (BMI $41 \text{ kg/m}^2$ ). His vital signs are temperature $37.2^\circ\text{C}$ ( $99.0^\circ\text{F}$ ), blood pressure $145/85 \text{ mmHg}$ , heart rate $110/\text{min}$ , and respiratory rate $22/\text{min}$ . The nursing staff reports that while the patient was having a violent coughing fit, his abdominal binder became saturated with copious amounts of a pink, salmon-colored fluid. Upon removal of the binder and surgical dressings, it is immediately apparent that the midline abdominal incision has dehisced and multiple loops of small intestine are protruding outside the abdominal cavity onto the skin.

Arrange the following steps for the definitive management of this patient's surgical complication in the most appropriate chronological order.

1Cover the protruding viscera with sterile, saline-moistened dressings
2Establish intravenous access and administer fluid resuscitation and broad-spectrum antibiotics
3Transport the patient emergently to the operating room
4Perform an exploratory laparotomy to assess bowel viability and irrigate the abdomen
5Reapproximate the abdominal fascia or place a temporary abdominal closure device

Cevap

The correct chronological management of wound evisceration begins with immediately covering the protruding viscera with sterile, saline-moistened dressings. Next, intravenous access is established to provide fluid resuscitation and broad-spectrum antibiotics. The patient is then emergently transported to the operating room, where an exploratory laparotomy is performed to assess bowel viability and irrigate the abdominal cavity. Finally, the abdominal fascia is reapproximated, or a temporary abdominal closure device is placed if primary closure is not feasible.

Wound evisceration is a life-threatening surgical emergency where intra-abdominal contents protrude through a full-thickness defect in the abdominal wall. The chronological approach prioritizes immediate organ protection, followed by physiologic stabilization, and finally definitive operative repair. First, the exposed viscera must be covered with sterile, saline-moistened dressings to prevent desiccation and necrosis. Manual reduction at the bedside is strictly contraindicated. Second, the patient is resuscitated with intravenous fluids and given broad-spectrum antibiotics to mitigate the risk of peritonitis and sepsis. Third, the patient is emergently transported to the operating room. Fourth, an exploratory laparotomy is performed to assess the viability of the eviscerated bowel and to thoroughly irrigate the abdominal cavity. Finally, the abdominal fascia is closed. If significant bowel edema makes primary fascial closure impossible without causing abdominal compartment syndrome, a temporary abdominal closure technique is employed.

Adım Adım Çözüm

Identify the complication as a surgical emergency (wound evisceration).

The presence of protruding bowel loops confirms wound evisceration.

Salmon-colored drainage followed by visible viscera is the classic presentation of this life-threatening postoperative complication.

Prioritize immediate bedside organ protection.

Cover the viscera with sterile, saline-moistened dressings.

The exposed bowel is extremely vulnerable to desiccation, ischemia, and necrosis if left unprotected in room air.

Initiate preoperative systemic stabilization.

Administer intravenous fluids and broad-spectrum antibiotics.

Evisceration leads to significant fluid loss and exposes the sterile peritoneal cavity to pathogens, necessitating immediate resuscitation and prophylaxis.

Determine the optimal environment for definitive care.

Transport the patient emergently to the operating room.

Bedside reduction is strictly contraindicated; definitive surgical repair must occur in a sterile operating suite.

Execute the surgical repair sequence.

Perform laparotomy and washout, followed by appropriate fascial closure.

The bowel must be thoroughly inspected for injury and the abdomen irrigated before closing the abdominal wall securely.

Anahtar Kavram

Wound evisceration is a surgical emergency characterized by the protrusion of intra-abdominal organs through a disrupted fascial closure. Management involves immediately covering the exposed viscera with sterile, saline-soaked dressings, avoiding bedside reduction, providing IV fluids and antibiotics, and urgently transporting the patient to the operating room for definitive surgical repair.

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