iEM Image Feed: Viscus perforation

A 35 years old previously healthy gentleman presented to the Emergency Department with a sudden-onset severe and diffuse abdominal pain which started an hour ago. Chest X-ray was ordered; what do you see?

Abdominal pain is one of the commonest ED presentations. Like acute MI, AAA rupture, or DKA, viscus perforation should be in our worst-case scenario list. The image shows free air under the diaphragm.

The expected hints for this type of patient are a history of peptic/duodenal ulcer disease, severe abdominal pain that patients do not want to move, and a rigid and very tender abdomen, which any palpation gives much pain to the patient. 

We need to remember that this situation is a surgical emergency. There are some steps that we need to do immediately for this patient.

1. Proper history and examination
2. Attaching to monitor and following vital signs and intervene if necessary to normalize them
3. Opening 2 large-bore IV lines and fluid resuscitation as needed
4. IV pain medication
5. IV antibiotics
6. Stopping oral ingestion and placing NG tube
7. Contact surgery
8. Sending basic biochemistry lab, coagulation profile, blood type and cross, CBC, which will be asked by surgery soon. 
9. Arranging transfer to the OR