A 52-year-old man with a history of peptic ulcer disease presents to the emergency department with acute onset severe epigastric pain and rigid abdomen. Upright chest X-ray shows pneumoperitoneum. His vital signs are: BP 90/60 mmHg, HR 120/min, RR 28/min, Temperature 38.2°C. What is the most appropriate immediate next step in management?

Explanation

## Clinical Context This is a classic presentation of perforated peptic ulcer with peritonitis — hemodynamically unstable (hypotensive, tachycardic, tachypneic) with imaging confirmation (pneumoperitoneum on upright CXR). ## Why Immediate Resuscitation + Surgical Consultation is Correct **Key Point:** In a haemodynamically unstable patient with confirmed perforation, the priority is **resuscitation and operative intervention**, not further imaging. **High-Yield:** The management sequence for perforated viscus is: 1. Aggressive fluid resuscitation (IV access, crystalloids) 2. Nasogastric decompression (reduces gastric distension and aspiration risk) 3. Broad-spectrum antibiotics (cover gram-negative, gram-positive, and anaerobes) 4. Immediate surgical consultation 5. Proceed to OR without delay **Clinical Pearl:** Pneumoperitoneum on imaging is diagnostic — no further imaging delays definitive treatment. The patient is already in septic shock (hypotension, tachycardia, fever); every minute counts. ## Rationale for This Sequence - **NG tube:** Decompresses stomach, reduces risk of aspiration during induction, improves surgical access - **IV fluids + antibiotics:** Stabilize the patient for anaesthesia; prevent progression to multi-organ failure - **Surgical consultation:** Ensures OR readiness and team briefing - **No delay for CT:** The diagnosis is confirmed clinically and radiologically; CT adds no actionable information in an unstable patient [cite:Harrison 21e Ch 287]