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Difficulty: MediumCardiothoracic and Vascular Surgery

An emergency medical services team transports a 71-year-old man to the acute care bay after he suddenly collapsed at a grocery store. Prior to collapsing, he complained of severe, tearing pain in his lower back and abdomen. His past medical history includes hypertension, hyperlipidemia, and a 45-pack-year smoking history. Upon arrival, he is lethargic but arousable. His temperature is 36.5°C (97.7°F), blood pressure is 74/42 mm Hg, pulse is 128/min, and respirations are 24/min. The patient's skin is pale, cold, and clammy. Physical examination of the abdomen reveals a prominent, expansile, pulsatile mass measuring approximately 7 cm in width. The abdomen is otherwise soft without peritoneal signs. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography angiography of the abdomen
  2. B
    Intravenous administration of esmolol
  3. Immediate surgical explorationAnswer
  4. D
    Bedside abdominal ultrasonography
  5. E
    Large-volume crystalloid resuscitation and intensive care admission

Answer

Immediate surgical exploration
This patient presents with the classic triad of a ruptured abdominal aortic aneurysm (AAA): severe abdominal and back pain, hemodynamic instability (hypotension, tachycardia), and a palpable, expansile pulsatile abdominal mass. The most appropriate next step in management for a hemodynamically unstable patient with a clinically obvious ruptured AAA is immediate surgical exploration (either open repair or endovascular aneurysm repair). Any delay to obtain imaging or perform further diagnostic testing in a patient with an undeniable pulsatile mass and shock drastically increases mortality.

Step-by-Step Solution

1
Identify the primary pathophysiologic state.
The patient is in profound hemorrhagic shock, indicated by hypotension (74/42 mm Hg), tachycardia (128/min), and poor peripheral perfusion (pale, cold, clammy skin).
Vital signs dictate the immediate urgency and safety parameters for further diagnostic testing.
2
Correlate the shock state with the physical examination findings.
The patient has sudden lower back and abdominal pain combined with a 7 cm expansile, pulsatile abdominal mass.
This classic triad (pain, hypotension, pulsatile mass) in an older male smoker is highly specific for a ruptured abdominal aortic aneurysm (AAA).
3
Determine the algorithmic next step for a ruptured AAA.
Proceed directly to the operating room for immediate surgical exploration (open or endovascular repair).
In a hemodynamically unstable patient with a clinically evident ruptured AAA, any delay for imaging significantly increases mortality.

Key Concept

Hemodynamically unstable patients presenting with the classic triad of a ruptured abdominal aortic aneurysm (abdominal/back pain, hypotension, and a definitive pulsatile mass) require immediate surgical exploration without prior imaging.
Estimated Time:1m 30s
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Topics

Cardiothoracic and Vascular Surgery

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