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

Treat this as a sequencing problem in a critically ill patient. The diagnosis of peritonitis is already given, so the task is to choose the safe order of actions for someone who is also in shock, shown by a pulse of 120, a respiratory rate of 30 and a low normal blood pressure with fever and vomiting. A core surgical rule is that an unstable patient must be optimised before any operation, because anaesthetising a septic, fluid-depleted person without prior resuscitation risks sudden cardiovascular collapse on induction. Resuscitation here means oxygen, wide-bore IV access with fluid boluses, early broad-spectrum antibiotics, nasogastric decompression, a urinary catheter to monitor output, and correction of metabolic derangement. Rushing to immediate laparotomy under general anaesthesia (option A) skips this safety step. Diagnostic laparoscopy first (option B) is unnecessary since the diagnosis is clear and delays source control. A drain under local anaesthesia (option C) is a half-measure that fails to address the underlying perforation or source. Once the patient is stable, the definitive procedure for generalised peritonitis is exploratory laparotomy for source control. Hence the next step is to resuscitate and then operate.
\[\boxed{\text{Resuscitate with IV fluids and oxygen, then exploratory laparotomy}}\]