In a patient with a perforated peptic ulcer, peritonitis, and cold, clammy extremities, what is the next immediate management step?

Immediate Management of Perforated Peptic Ulcer with Peritonitis and Shock

The next immediate step is aggressive IV fluid resuscitation and hemodynamic stabilization, which must occur simultaneously with urgent surgical consultation and preparation for exploratory laparotomy—not one before the other. 1

Why Resuscitation Must Come First (But Not Alone)

The presence of cold, clammy peripheries indicates impending or established septic shock from peritonitis. Proceeding directly to the operating room without resuscitation in a patient with signs of septic shock would significantly increase mortality. 1 The World Society of Emergency Surgery (WSES) explicitly states that unstable septic perforated peptic ulcer patients need appropriate and rapid resuscitation (ideally within 1 hour) to reduce mortality, and this must take place simultaneously with surgical consultation, microbiological cultures, and antibiotic administration—not sequentially. 2

The Correct Simultaneous Approach

Your immediate actions should proceed in parallel, not in sequence: 1

• ABC assessment first: Rapid airway, breathing, and circulation evaluation 2
• Begin aggressive IV fluid resuscitation immediately targeting specific physiologic endpoints 2
• Call for urgent surgical consultation at the same time 2, 1
• Administer broad-spectrum antibiotics within the first hour 1
• Obtain blood cultures and other microbiological samples 2
• Prepare for exploratory laparotomy while resuscitating 1

Specific Resuscitation Targets

You must restore these physiological parameters before and during surgery: 2

• Mean arterial pressure (MAP) ≥ 65 mmHg 2, 1
• Urine output ≥ 0.5 mL/kg/h 2, 1
• Lactate normalization 2, 1

Utilize invasive or non-invasive hemodynamic monitoring to optimize fluid and vasopressor therapy and individualize the resuscitation strategy. 2 If the patient remains hypotensive despite adequate fluid resuscitation, vasopressors should be initiated to maintain MAP ≥ 65 mmHg. 2

Why Surgery Cannot Wait (But Also Cannot Proceed Without Resuscitation)

This patient requires exploratory laparotomy for definitive source control—there is no debate about that. 1 However, the critical error would be delaying resuscitation to rush the patient to the operating room. 1 Patients with perforated peptic ulcer and septic shock who undergo surgery without adequate resuscitation have significantly higher mortality rates. 2

The WSES guidelines emphasize that prompt evaluation, early recognition of sepsis, and prevention of further organ failure are critical to reducing mortality. 1 In patients with septic shock from perforated peptic ulcer and signs of severe physiological derangement, a damage control strategy may be required if the patient cannot tolerate definitive repair. 2

Common Pitfall to Avoid

Do not choose between resuscitation OR surgery—both must happen together. The question presents a false dichotomy. In real-world practice, you initiate aggressive IV fluid resuscitation in the emergency department while simultaneously calling the surgical team, administering antibiotics, and preparing the operating room. 1 The patient moves to the OR once initial resuscitation has begun and continues to be resuscitated intraoperatively and postoperatively. 2

When Non-Operative Management is NOT an Option

This patient is absolutely not a candidate for conservative non-operative management. 2 Non-operative management requires: 3

• Hemodynamic stability (this patient has cold, clammy peripheries indicating shock) 3
• Sealed perforation confirmed by water-soluble contrast study 2, 3
• Absence of diffuse peritonitis (this patient has peritonitis) 3

Non-operative management succeeds in only 54-72% of carefully selected patients and should never be attempted in unstable patients with signs of septic shock. 3

Damage Control Surgery Considerations

If during resuscitation the patient demonstrates severe physiological derangement with progressive organ dysfunction, hypotension requiring vasopressors, myocardial depression, and coagulopathy, a damage control approach may be necessary. 2 This involves abbreviated surgery focused on source control (such as simple closure or omental patch), copious irrigation, and temporary abdominal closure, with the patient returning to the ICU for continued resuscitation before definitive repair. 2