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Difficulty: MediumCardiothoracic and Vascular Surgery

A 72-year-old man is brought to the emergency department after experiencing a sudden onset of severe, tearing pain in his lower back and left flank. His wife states that he briefly lost consciousness at home. His medical history includes hypertension, hyperlipidemia, type 2 diabetes mellitus, and a 45-pack-year smoking history. He does not take any anticoagulant medications. On arrival, he is lethargic, pale, and diaphoretic. Vital signs are temperature 36.8°C (98.2°F), blood pressure 75/40 mmHg, heart rate 128/min, and respiratory rate 24/min. Physical examination reveals cold extremities with weak distal pulses. Abdominal examination demonstrates a tender, pulsatile mass in the periumbilical region. A bedside ultrasound confirms the presence of an infrarenal abdominal aortic dilation measuring 7.2 cm with an adjacent retroperitoneal hypoechoic fluid collection. Which of the following is the most appropriate next step in management?

  1. Immediate transfer to the operating room for surgical repairAnswer
  2. B
    Computed tomography angiography of the abdomen and pelvis
  3. C
    Initiation of intravenous esmolol and nitroprusside
  4. D
    12-lead electrocardiogram and measurement of cardiac troponin
  5. E
    Admission to the intensive care unit for aggressive fluid resuscitation

Answer

The most appropriate next step is immediate transfer to the operating room for surgical repair.
This patient presents with the classic triad of a ruptured abdominal aortic aneurysm (AAA): severe back/flank pain, hypotension indicating hemorrhagic shock, and a pulsatile abdominal mass. The diagnosis is confirmed by bedside ultrasound showing a large aneurysm with retroperitoneal fluid. In a hemodynamically unstable patient with a known ruptured AAA, the absolute priority is immediate hemorrhage control. The correct action is emergent transfer to the operating room for either open surgical repair or endovascular aneurysm repair (EVAR), depending on the patient's anatomy and the facility's capabilities. Delaying surgery for any reason significantly increases mortality.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and vital signs.
The patient is an elderly male smoker presenting with sudden severe back/flank pain, syncope, and profound hypotension (BP 75/40 mmHg) with tachycardia (128/min).
Identifying the classic triad of a ruptured abdominal aortic aneurysm (AAA): severe pain, hypotension/shock, and a pulsatile abdominal mass.
2
Interpret the bedside imaging findings.
Bedside ultrasound shows a 7.2 cm AAA with an adjacent hypoechoic collection.
The fluid collection adjacent to a large aneurysm in a hypotensive patient confirms retroperitoneal hemorrhage from a ruptured AAA.
3
Determine the management pathway based on hemodynamic stability.
Because the patient is hemodynamically unstable, diagnostic testing that requires moving the patient (like a CT scan) is contraindicated.
Unstable patients with a known ruptured AAA require emergent source control of the hemorrhage.
4
Select the definitive treatment.
Immediate transfer to the operating room for emergent open surgical or endovascular repair.
Definitive hemorrhage control is the only way to prevent fatal exsanguination.

Key Concept

Hemodynamically unstable patients with a ruptured abdominal aortic aneurysm (confirmed by bedside ultrasound) require immediate transfer to the operating room for emergent surgical repair, bypassing further imaging such as CT angiography.
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Topics

Cardiothoracic and Vascular Surgery

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