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Difficulty: MediumCardiothoracic and Vascular Surgery

An emergency response team delivers a 69-year-old male to the trauma center following a syncopal episode at his residence. The patient's spouse reports that he complained of sudden, agonizing pain in his left flank radiating to his groin moments before collapsing. His medical records indicate a history of coronary artery disease and a 40-pack-year smoking history. On evaluation, he is lethargic, and his skin is cool, clammy, and mottled. His blood pressure is currently 74/42 mm Hg, heart rate is 128/min, and respiratory rate is 24/min. Palpation of the abdomen reveals a tender, prominently pulsatile central mass. Peripheral pulses in the lower extremities are diminished bilaterally. Two large-bore intravenous lines are placed. 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 administration of labetalol to reduce aortic shear stress
  3. Immediate transfer to the operating room for surgical explorationAnswer
  4. D
    Admission to the intensive care unit for permissive hypotension and observation
  5. E
    Administration of broad-spectrum antibiotics and acquisition of blood cultures

Answer

Immediate transfer to the operating room for surgical exploration
The correct action is immediate transfer to the operating room for surgical exploration. This patient presents with the classic triad of a ruptured abdominal aortic aneurysm (AAA): sudden onset of severe abdominal or flank pain, severe hypotension indicative of shock, and a pulsatile abdominal mass. In the setting of hemodynamic instability (blood pressure of 74/42 mm Hg, tachycardia, poor peripheral perfusion), any delay in definitive surgical control is associated with extremely high mortality. Therefore, advanced imaging such as a CT scan must be bypassed, and the patient must be taken directly to the operating room for emergent open or endovascular repair to achieve hemorrhage control.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and history.
The patient has sudden flank pain, syncope, severe hypotension, tachycardia, and a tender, pulsatile abdominal mass.
To establish the primary differential diagnosis, which strongly points to a ruptured abdominal aortic aneurysm (AAA).
2
Evaluate the patient's hemodynamic status.
Blood pressure is 74/42 mm Hg with clinical signs of profound shock (lethargy, cool and clammy skin, tachycardia).
To determine if the patient is stable enough to undergo advanced diagnostic imaging or if they require emergent intervention.
3
Select the most appropriate management path.
Proceed directly to the operating room for surgical or endovascular repair.
In a hemodynamically unstable patient with classic signs of a ruptured AAA, imaging will delay life-saving surgery and increase mortality. Emergent source control is strictly required.

Key Concept

Hemodynamically unstable patients with classic clinical signs of a ruptured abdominal aortic aneurysm (AAA) require immediate surgical intervention without prior advanced imaging (e.g., CT scan).
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Topics

Cardiothoracic and Vascular Surgery

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