 Welcome back to emergency medicine video on perforated viscose. In this section, we will discuss diagnosis and treatment. The cornerstone for the diagnosis of perforated viscose lies in diagnostic imaging. We will discuss both x-ray and CT. First, let's discuss x-ray. In patients with a viscous perforation, the air from the GI tract now leaks into the peritoneum, also known as free air. This free air is what we look for on x-rays. In an upright patient, this free air will rise in the top part of the peritoneum, in this case just underneath the diaphragm. On an x-ray, it will look like this. What about if the patient is unable to sit up and they can only lie on their side or in a lateral decubitus position? In this case, the free air does not rise up to the diaphragm. It will rise up towards the top part of the body, on the side. On an x-ray, the free air will be between the liver edge and the chest wall if the patient is lying on their left side. In addition to free air, x-ray may also give us other clues as to the cause of the perforated viscous. In this case, we are able also to see dilated bowel loops from a bowel obstruction. However, there are two main limitations of x-ray. One, if there is not a lot of free air or if the patient is unable to sit up for a long time, the free air just has not had the time to track up to be underneath the diaphragm to be visible on an x-ray yet. The second limitation of x-ray is that even if we see free air, all we know is that there is a perforated viscous. It is a very quick way to confirm diagnosis, but it does not tell us where the perforation is. To further help us diagnose where the perforation is, a CT scan is usually ordered. A CT scan is more sensitive and specific for picking up free air. It is also helpful in telling us where the perforation is most of the time. Also, a CT scan is helpful in ruling out other diagnosis. It is a great test for those three reasons. However, CT also have its limitations. With CT, the patient will need to either have IV or both IV and oral contrast. Those might be contraindicated in patients with renal pathology and also takes time to administer. Also, to be able to go to CT, the patient also need to be stable enough to leave the emergency department to go to the radiology suite. Recently, bedside ultrasound has been increasingly used to diagnose free air in the abdomen. As this technique becomes more developed and used, it might supplement x-ray as the first modalities to diagnose perforated viscous. What about for lab tests? There are no specific tests for perforated viscous. Since the patient often would be quite sick and might need to go for an operation, you would want some baseline blood work. Tests like CBC, lights, creatinine, LFTs, lactate, coagulation studies, and perhaps blood should be ordered before. Let's go into treatment. In terms of treatment for perforated viscous, there are three main goals. As with all emergency patient, resuscitation is the first goal. The second goal is to treat the infection, since all the gut flora will now be spread inside the peritoneum. Thirdly, is a definitive surgical repair. First, resuscitation. As we discussed before, patients can quickly become septic after a viscous perforation. Aggressive volume resuscitation should be used if the patient's vital signs are unstable. In general, you will start with 1 to 2 liters of crystalloids. More fluids might be given depending on the patient's clinical status. If fluids alone are not enough to bring back the patient's hemodynamic status, then vasopressors might be considered. Second, antibiotics. We want to use antibiotics that cover the gut flora. We want to use those that cover gram-positive, gram-negative, and anaerobes. Examples include a tertiary cephalosporin, plus either metronidazole or a clinomycin. However, in general, if you have antibiotics that cover these three categories, that should be adequate. Lastly, surgical repair. The general surgery team should be consulted as soon as perforation is highly suspected. In some case, they should know as soon as free air is being picked up, either by x-ray or bedside ultrasound. Most patients will need repair in the operating room. How do we put this together? In a patient with a suspicion of perforated viscous, you want to start with an upright chest x-ray. If you see free air on the upright chest x-ray, your diagnosis is made. You want to consult surgery at this point and organize a CT to find out exactly where the perforation is, if the patient is stable. What if the upright chest x-ray is normal? That depends on what the patient looks like. If the patient is stable, you can organize a CT scan. You may also decide to treat the patient with antibiotics at this point, and you can wait for the results of the CT scan. What about if the patient is unstable? You want to resuscitate the patient, start antibiotics, and consult general surgery early. If the patient becomes stable after your resuscitation, you may choose to organize a CT scan in conjunction with the general surgery team. In summary, in this section, we talk about the diagnosis and treatment for perforated viscous. Thank you for watching.