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Difficulty: HardCardiothoracic and Vascular Surgery

A 68-year-old man is brought to the emergency department by his neighbor after collapsing in his driveway. The patient is awake but lethargic, complaining of agonizing, tearing pain in his left flank that radiates to his groin. His medical history includes hypertension, severe chronic obstructive pulmonary disease (COPD), and atrial fibrillation. He states he ran out of all his medications two weeks ago.

Vital signs are temperature 36.8°C (98.2°F), blood pressure 76/48 mmHg, heart rate 134/min and irregularly irregular, respiratory rate 28/min, and oxygen saturation 92% on room air.

Physical examination reveals a pale, diaphoretic patient who is oriented only to person. Pulmonary auscultation reveals diffuse expiratory wheezes. The abdomen is distended, firm, and diffusely tender with absent bowel sounds. Deep palpation reveals a prominent pulsatile mass in the periumbilical region. A bedside ultrasound demonstrates a 7.2-cm infrarenal aortic aneurysm with a surrounding hypoechoic collection in the retroperitoneum.

Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography angiography of the abdomen and pelvis
  2. B
    Insertion of a nasogastric tube and rapid intravenous fluid resuscitation
  3. Immediate transfer to the operating room for emergent surgical repairAnswer
  4. D
    Administration of intravenous furosemide and ipratropium nebulizers
  5. E
    Deferment of intervention until his next-of-kin can provide informed consent

Answer

Immediate transfer to the operating room for emergent surgical repair
The correct next step is immediate transfer to the operating room. This patient is in hemorrhagic shock secondary to a ruptured abdominal aortic aneurysm, as evidenced by his severe flank pain, hypotension, pulsatile mass, and ultrasound findings of an aneurysm with free retroperitoneal fluid. In any hemodynamically unstable patient with a confirmed ruptured AAA, emergent surgical (open or endovascular) repair is the definitive, life-saving intervention.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and vital signs.
The patient presents with severe flank pain, hypotension (BP 76/48 mmHg), tachycardia, and altered mental status. A pulsatile abdominal mass is palpated.
Identifying the classic triad (abdominal/back pain, hypotension, pulsatile mass) establishes the likelihood of a ruptured abdominal aortic aneurysm (AAA) with hemorrhagic shock.
2
Interpret the bedside imaging results in the context of hemodynamic stability.
The bedside ultrasound confirms a 7.2-cm AAA with retroperitoneal free fluid. The patient remains hemodynamically unstable.
Ultrasound rapidly confirms the diagnosis of AAA rupture without requiring the patient to leave the resuscitation area. In unstable patients, delaying care for advanced imaging (like CT) is strictly contraindicated.
3
Determine the definitive next step in management.
The patient must be transferred immediately to the operating room.
An unstable patient with a confirmed ruptured AAA requires emergent surgical or endovascular repair to achieve source control and prevent fatal exsanguination. Because the patient lacks capacity, the procedure is performed under implied consent.

Key Concept

Hemodynamically unstable patients with a known or ultrasound-confirmed ruptured abdominal aortic aneurysm require immediate operative repair; advanced imaging like CT is contraindicated.
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Topics

Cardiothoracic and Vascular Surgery

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