A 68-year-old man is brought to the emergency department complaining of sudden, severe lef… — USMLE Step 2 CK

A $68$ -year-old man is brought to the emergency department complaining of sudden, severe left flank pain that began two hours ago. He also reports a brief episode of lightheadedness just prior to arrival. His medical history is significant for essential hypertension, type 2 diabetes mellitus, and a $40$ -pack-year smoking history. Initially, his temperature is $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), pulse is $98/\text{min}$ , blood pressure is $112/74\text{ mmHg}$ , and respirations are $18/\text{min}$ . Physical examination reveals a palpable, slightly tender, pulsatile mass in the periumbilical region. A focused assessment with sonography for trauma (FAST) demonstrates a $6.5\text{-cm}$ dilation of the infrarenal abdominal aorta and free fluid in the hepatorenal recess. Ten minutes later, the patient becomes progressively lethargic; his repeat blood pressure is $68/42\text{ mmHg}$ , and his pulse is $132/\text{min}$ . Which of the following is the most appropriate next step in the management of this patient?

A
Cross-sectional imaging of the abdomen with intravenous contrast
Proceed directly with operative or endovascular aortic repairAnswer
C
Insertion of a gastric drainage tube and serial clinical observation
D
Administration of rapid-acting intravenous diuretics and noninvasive ventilation
E
Initiation of fluid resuscitation and empiric broad-spectrum antibiotics

Answer

The correct approach is to proceed directly with operative or endovascular aortic repair.

The correct action is immediate operative or endovascular repair. This patient presents with classic signs of a ruptured abdominal aortic aneurysm (AAA), confirmed by the bedside ultrasound showing a

6.5\text{-cm}

dilation and free fluid. Although he was transiently stable upon arrival, his subsequent rapid clinical deterioration (hypotension, tachycardia, and lethargy) indicates ongoing, massive retroperitoneal or intraperitoneal hemorrhage. In this scenario, immediate surgical source control is the only definitive life-saving intervention.

Step-by-Step Solution

Identify the underlying pathology based on initial presentation.

The patient has a known abdominal aortic aneurysm (AAA) measuring 6.5 cm, complicated by a rupture (indicated by severe pain, syncope, and free fluid on ultrasound).

Risk factors (age, smoking) and classic triad components (flank pain, pulsatile mass) establish the anatomical diagnosis.

Assess the patient's hemodynamic status.

The patient has transitioned from being hemodynamically stable to exhibiting profound shock (blood pressure dropping to 68/42 mmHg and heart rate increasing to 132/min) with altered mental status.

Deteriorating vitals dictate a shift in the management algorithm from diagnostic workup to emergent life-saving treatment.

Select the appropriate management pathway for an unstable ruptured AAA.

Immediate transfer to the operating room for surgical or endovascular source control is required.

In hemodynamically unstable patients with a highly suspected or confirmed ruptured AAA, further imaging (like CT angiography) is contraindicated as it wastes critical time.

Key Concept

Hemodynamically unstable patients with a highly suspected or confirmed ruptured abdominal aortic aneurysm require immediate operative or endovascular repair without delaying for further imaging.

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