Examkin

Question

Difficulty: MediumCardiothoracic and Vascular Surgery

A 72-year-old man is evaluated in the emergency department for severe, tearing pain in his lower back and abdomen that started suddenly 45 minutes ago. His medical history includes hypertension, tobacco use disorder, and a 5.0-cm abdominal aortic aneurysm (AAA) discovered incidentally on an ultrasound six months prior. On physical examination, he is lethargic, pale, and profusely diaphoretic. His temperature is 36.5°C (97.7°F), blood pressure is 75/45 mmHg, pulse is 132/min, and respiratory rate is 24/min. Abdominal palpation reveals significant distension, diffuse tenderness with involuntary guarding, and a prominent, expansile periumbilical mass. The patient lacks decision-making capacity due to his lethargic state. His son, who holds a legally executed durable power of attorney for healthcare for the patient, urges the medical team to proceed with all necessary life-saving measures. Concurrently, the patient's estranged wife arrives and insists that no surgical interventions be performed. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography angiography of the abdomen and pelvis
  2. B
    Delay intervention to allow the hospital ethics committee to resolve the dispute
  3. C
    Placement of a nasogastric tube, intravenous fluid resuscitation, and serial abdominal examinations
  4. Immediate transfer to the operating room for surgical repairAnswer
  5. E
    Administration of intravenous furosemide and noninvasive positive-pressure ventilation

Answer

Immediate transfer to the operating room for surgical repair
The patient is presenting with the classic triad of a ruptured abdominal aortic aneurysm (AAA): severe tearing pain, a pulsatile abdominal mass, and profound hemodynamic instability (hypotension, tachycardia). In a hemodynamically unstable patient with a known AAA who presents with signs of rupture, the most appropriate next step is immediate transfer to the operating room for emergent surgical repair (open or endovascular). Delaying for advanced imaging is contraindicated because the patient can rapidly exsanguinate. Additionally, because the patient lacks capacity, consent is dictated by his legally appointed healthcare proxy (his son), whose medical authority legally supersedes that of the next-of-kin (his estranged wife). Therefore, no ethics delay is warranted.

Step-by-Step Solution

1
Identify the underlying clinical syndrome.
The patient presents with the classic triad of a ruptured AAA: severe tearing pain, an expansile pulsatile abdominal mass, and profound hypotension.
Recognizing the diagnostic triad in the context of a known 5.0-cm AAA establishes the immediate etiology of his shock as catastrophic hemorrhage.
2
Assess hemodynamic stability to guide diagnostic/therapeutic workflow.
The patient is in class IV hypovolemic shock (BP 75/45 mmHg, HR 132/min, lethargy).
Hemodynamic instability dictates that the patient must not leave the monitored resuscitation area for advanced imaging (e.g., CT scan) and requires immediate intervention.
3
Determine the legal decision-maker to obtain consent.
The patient's son is the legally appointed healthcare proxy via a durable power of attorney.
A designated healthcare proxy overrides default state-mandated next-of-kin hierarchies (such as a spouse). The son's request for life-saving measures provides the necessary legal consent to proceed immediately to the operating room.

Key Concept

Management of hemodynamically unstable ruptured abdominal aortic aneurysm and proxy consent
Rate this question

Topics

Cardiothoracic and Vascular Surgery

More questions from this topic