What is the next step in managing an elderly patient with severe abdominal pain, loss of consciousness, and signs of sepsis?

Emergency Management of Elderly Patient with Suspected Perforated Viscus and Septic Shock

The patient requires immediate surgical consultation and exploration due to suspected perforated viscus with signs of peritonitis and septic shock.

Initial Assessment and Stabilization

This 80-year-old male presents with classic signs of peritonitis and septic shock:

• Sudden severe abdominal pain while eating
• Loss of consciousness
• Fever (38.5°C)
• Tachypnea (RR 23/min)
• Tachycardia (pulse 120/min)
• Hypotension (BP 100/70)
• Rigid and tender abdomen

Immediate Actions (First Hour)

1. Establish IV access with two large-bore catheters

   • Begin aggressive fluid resuscitation with crystalloids (20-30 mL/kg) 1
   • Target adequate tissue perfusion as the principal endpoint 1

2. Initiate vasopressor support if fluid-refractory hypotension

   • Norepinephrine is the first-line agent for septic shock 1, 2
   • Administer through a large vein (preferably central line, but antecubital vein if central access not immediately available) 2

3. Start broad-spectrum antibiotics within the first hour 1

   • Ceftriaxone 2g IV plus metronidazole 500mg IV would cover most intra-abdominal pathogens 3
   • Antimicrobials should be given within 1 hour of recognizing sepsis 1

4. Oxygen therapy

   • Apply oxygen to achieve saturation >90% 1
   • Consider semi-recumbent position (30-45° head elevation) if not contraindicated 1

5. Urgent surgical consultation

   • The rigid abdomen with sudden onset severe pain strongly suggests perforated viscus 1
   • Source control through surgery is essential for survival 1

Diagnostic Workup (Concurrent with Resuscitation)

1. Laboratory studies

   • Complete blood count, comprehensive metabolic panel
   • Blood cultures (before antibiotics if possible)
   • Lactate level to assess tissue perfusion
   • Coagulation studies

2. Imaging

   • Upright chest X-ray to look for free air under diaphragm
   • Consider bedside ultrasound if available 1
   • CT scan with contrast if patient stabilizes and surgical intervention is not immediately available

Ongoing Management

1. Continuous monitoring

   • Vital signs, urine output, mental status
   • Consider arterial line for continuous BP monitoring
   • Monitor for signs of adequate tissue perfusion 1:
     • Normal capillary refill time
     • Absence of skin mottling
     • Warm and dry extremities
     • Well-felt peripheral pulses
     • Urine output >0.5 mL/kg/hour

2. Prepare for emergency surgery

   • Operating room notification
   • Consent from family
   • Blood products availability

3. Consider adjunctive therapy

   • Hydrocortisone (up to 300 mg/day) if vasopressor requirements escalate 1

Pitfalls to Avoid

1. Delayed surgical intervention

   • In suspected perforated viscus, surgical delay increases mortality
   • Do not wait for complete diagnostic workup before surgical consultation

2. Inadequate fluid resuscitation

   • Elderly patients often need aggressive initial fluid resuscitation despite concerns about fluid overload
   • Titrate to clinical response rather than fixed protocols 1

3. Delayed antibiotic administration

   • Each hour delay in antibiotic administration increases mortality 1
   • Do not wait for all cultures before starting broad-spectrum antibiotics

4. Overlooking source control

   • Antibiotics alone are insufficient; drainage or debridement of the infection source is critical 1
   • In this case, the rigid abdomen strongly suggests perforated viscus requiring surgical intervention

The clinical presentation of sudden severe abdominal pain during eating, followed by loss of consciousness, with fever, tachycardia, tachypnea, and a rigid abdomen in an elderly patient is highly suggestive of a perforated viscus with resulting peritonitis and septic shock. This is a surgical emergency requiring prompt resuscitation, antibiotics, and definitive surgical management.