An emergency medical services team brings a 68-year-old male to the trauma bay following a… — USMLE Step 2 CK

An emergency medical services team brings a $68$ -year-old male to the trauma bay following an episode of syncope at home. His wife reports that he complained of sudden, excruciating pain in his left flank and lower abdomen just before collapsing. His past medical history is significant for chronic obstructive pulmonary disease, hypertension, and a $45$ -pack-year smoking habit. On arrival, he is lethargic, pale, and diaphoretic. Vital signs include a temperature of $36.8^\circ\text{C}$ ( $98.2^\circ\text{F}$ ), blood pressure of $72/45\text{ mm Hg}$ , heart rate of $128/\text{min}$ , and respiratory rate of $26/\text{min}$ . Palpation of the abdomen reveals significant distention and a tender, pulsatile mass just above the umbilicus. A point-of-care ultrasound performed immediately demonstrates a $6.8\text{ cm}$ infrarenal aortic dilation with surrounding retroperitoneal free fluid. Which of the following is the most appropriate next step in management?

Emergent transfer to the operating room for vascular repairAnswer
B
Computed tomography angiography of the abdomen and pelvis
C
Insertion of a nasogastric tube and implementation of bowel rest
D
Administration of intravenous furosemide and noninvasive positive pressure ventilation
E
Administration of continuous nebulized albuterol and intravenous corticosteroids

Answer

The most appropriate next step is emergent transfer to the operating room for vascular repair.

This patient presents with the classic triad of a ruptured abdominal aortic aneurysm (AAA): severe flank or abdominal pain, hypotension, and a pulsatile abdominal mass. His presentation of hypovolemic shock (blood pressure

72/45\text{ mm Hg}

, tachycardia, lethargy) combined with bedside ultrasound confirmation of a

6.8\text{ cm}

AAA with retroperitoneal fluid demands immediate life-saving intervention. Hemodynamically unstable patients with a ruptured AAA must be transferred emergently to the operating room for either open surgical repair or endovascular aneurysm repair (EVAR). Any delay, including obtaining advanced imaging, significantly increases mortality.

Step-by-Step Solution

Analyze the patient's vital signs and physical presentation.

The patient is in severe hypovolemic shock (

72/45\text{ mm Hg}

128/\text{min}

, lethargy, diaphoresis).

To determine hemodynamic stability, which dictates the urgency and safety of diagnostic modalities.

Synthesize the clinical triad and ultrasound findings.

Sudden flank pain, hypotension, and a pulsatile mass confirmed by ultrasound as a

6.8\text{ cm}

AAA with free fluid indicates a ruptured AAA.

To establish the primary diagnosis responsible for the patient's shock.

Select the appropriate management based on stability and diagnosis.

Immediate transfer to the operating room for surgical or endovascular repair.

A ruptured AAA in an unstable patient is a surgical emergency requiring immediate hemorrhage control; delaying for CT imaging is contraindicated.

Key Concept

Management of a ruptured abdominal aortic aneurysm in a hemodynamically unstable patient

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