Question

A young sewage worker is brought to hospital with a history of exhaustion, abdominal pain, vomiting, fever and shock. His heart rate is 120/min, respiratory rate is 30/min and blood pressure is 100/70 mmHg. His clinical features are suggestive of peritonitis. What is the next step of management?

• A. Immediately take the patient for laparotomy under general anaesthesia
• B. Take the patient for diagnostic laparoscopy and then exploratory laparotomy
• C. Insert an abdominal drain under local anaesthesia and then proceed to exploratory laparotomy
• D. Resuscitate the patient with IV fluids and oxygen, then shift the patient for exploratory laparotomy

Hint:

Never anaesthetise a shocked septic patient before optimising them; stabilise first, then operate.

Answer 1

The Correct Option is D

Step 1: Identify the clinical picture. The patient has peritonitis with features of shock (tachycardia 120/min, tachypnoea 30/min, borderline-low/narrow-pulse-pressure blood pressure, fever, vomiting). This is a surgical emergency, but the patient is haemodynamically unstable.
Step 2: Apply the principle of resuscitation before definitive surgery. In a shocked patient, taking him straight to theatre under general anaesthesia is dangerous, because induction of anaesthesia in a hypovolaemic, septic patient can precipitate cardiovascular collapse.
Step 3: The correct sequence is to first stabilise the patient: secure the airway, give high-flow oxygen, establish IV access and give IV fluid resuscitation, start broad-spectrum antibiotics, insert a nasogastric tube and urinary catheter, and correct electrolytes. Only after adequate resuscitation should he be shifted for definitive surgery.
Step 4: The definitive treatment of generalised peritonitis is exploratory laparotomy to identify and control the source. So once resuscitated, he goes for exploratory laparotomy.
Step 5: Options A, B and C either rush an unstable patient to surgery or perform inadequate procedures (an abdominal drain alone does not treat the source). The correct first step is resuscitate, then operate.
Answer: D (Resuscitate with IV fluids and oxygen, then shift for exploratory laparotomy).