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Difficulty: MediumCardiothoracic and Vascular Surgery

A 67-year-old woman is brought to the emergency department by her daughter due to a sudden onset of excruciating lower back and abdominal pain that began 45 minutes ago. She reports feeling profoundly dizzy and nearly fainted before arrival. Her past medical history is significant for a 4.84.8 cm abdominal aortic aneurysm diagnosed two years ago, chronic obstructive pulmonary disease, and essential hypertension. Her temperature is 36.5∘C36.5^\circ\mathrm{C} (97.7∘F97.7^\circ\mathrm{F}), blood pressure is 74/4274/42 mm Hg, heart rate is 128128/min, and respiratory rate is 2626/min. On physical examination, she is diaphoretic and pale. Cardiopulmonary examination reveals regular tachycardia and prolonged expiratory wheezing. The abdomen is distended and diffusely tender, with a prominent, tender, pulsatile mass palpated in the epigastrium. Femoral pulses are weak bilaterally. 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
    Nasogastric tube insertion and upright abdominal radiography
  4. D
    Intravenous furosemide and noninvasive positive-pressure ventilation
  5. E
    Intravenous broad-spectrum antibiotics and blood cultures

Answer

Immediate transfer to the operating room for surgical repair
The correct answer is immediate transfer to the operating room for surgical repair. This patient is presenting with hemorrhagic shock secondary to a ruptured abdominal aortic aneurysm (AAA). The classic presentation of a ruptured AAA includes sudden onset of severe abdominal, flank, or back pain, profound hypotension, and a palpable pulsatile abdominal mass. When a patient is hemodynamically unstable and has either a known history of an AAA or classic clinical findings indicating rupture, diagnostic imaging is contraindicated. The patient must be taken immediately to the operating room for emergent open surgical or endovascular repair. Time is the most critical factor for survival.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and recognize the primary clinical triad.
The patient is in profound shock (blood pressure 74/4274/42 mm Hg) and presents with the classic triad of sudden severe back/abdominal pain, hypotension, and a pulsatile abdominal mass.
Identifying hemodynamic instability is the critical branch point in managing a suspected vascular rupture.
2
Synthesize the clinical findings with the patient's past medical history.
The patient has a known 4.84.8 cm abdominal aortic aneurysm, confirming that her acute presentation is due to a ruptured aneurysm.
A known history of an aneurysm combined with signs of hemorrhagic shock provides a definitive clinical diagnosis.
3
Determine the safest and most appropriate intervention based on stability.
The patient must bypass diagnostic imaging and be transported immediately to the operating room for open or endovascular repair.
In hemodynamically unstable patients with a known or highly suspected ruptured aneurysm, imaging (like a CT scan) wastes critical time and significantly increases mortality.

Key Concept

Hemodynamically unstable patients presenting with classic clinical signs of a ruptured abdominal aortic aneurysm require emergent surgical repair without prior diagnostic imaging.
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Topics

Cardiothoracic and Vascular Surgery

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