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Difficulty: HardCardiothoracic and Vascular Surgery

A 72-year-old man is brought to the emergency department via ambulance due to the sudden onset of severe abdominal and back pain that started one hour ago. He also reports severe lightheadedness and nausea. His past medical history is significant for hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), and an open appendectomy 30 years ago. His medications include amlodipine, atorvastatin, and a tiotropium inhaler. On arrival, his temperature is 36.8°C (98.2°F), blood pressure is 74/42 mm Hg, pulse is 128/min and regular, and respirations are 28/min. Oxygen saturation is 94% on room air. Physical examination reveals a diaphoretic and pale patient in acute distress. Cardiopulmonary examination shows tachycardia with no murmurs, and scattered expiratory wheezes bilaterally. The abdomen is distended, diffusely tender to palpation, and a prominent pulsatile mass is appreciated in the epigastrium. Bowel sounds are hypoactive. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Computed tomography angiography of the abdomen and pelvis
  2. B
    Intravenous furosemide and continuous positive airway pressure
  3. Emergent transfer to the operating room for laparotomyAnswer
  4. D
    Nasogastric tube insertion and conservative observation
  5. E
    Intravenous piperacillin-tazobactam and blood cultures

Answer

Emergent transfer to the operating room for laparotomy
The patient presents with the classic triad of a ruptured abdominal aortic aneurysm (AAA): sudden, severe abdominal and back pain, hypotension, and a pulsatile abdominal mass. In a hemodynamically unstable patient with high clinical suspicion for a ruptured AAA, the definitive treatment is immediate hemorrhage control. This requires emergent transfer to the operating room for surgical repair (either open exploratory laparotomy or endovascular aneurysm repair, depending on institutional capabilities and patient anatomy). Attempting to obtain further cross-sectional imaging prior to surgery in an unstable patient is contraindicated due to the high risk of fatal exsanguination during the delay.

Step-by-Step Solution

1
Analyze the patient's hemodynamic status.
The patient is in profound shock, as evidenced by a blood pressure of 74/42 mm Hg, tachycardia (128/min), diaphoresis, and altered peripheral perfusion.
Determining hemodynamic stability is the critical first triage step in any acute emergency, dictating whether imaging can be safely performed or immediate intervention is necessary.
2
Identify the primary source of the pathology based on physical examination findings.
The presence of a prominent, pulsatile epigastric mass in the setting of sudden-onset severe back and abdominal pain points directly to a ruptured abdominal aortic aneurysm (AAA).
The classic triad of a ruptured AAA consists of acute abdominal or back pain, hypotension, and a pulsatile abdominal mass.
3
Determine the appropriate management for an unstable patient with a suspected ruptured AAA.
Immediate surgical intervention (open laparotomy or endovascular repair) without prior cross-sectional imaging.
In hemodynamically unstable patients with a known or highly suspected ruptured AAA, any delay in hemorrhage control (such as transporting the patient to the CT scanner) significantly increases the risk of exsanguination and mortality.

Key Concept

Management of Hemodynamically Unstable Ruptured Abdominal Aortic Aneurysm
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Topics

Cardiothoracic and Vascular Surgery

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