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Difficulty: MediumSurgical and Procedural Interventions

A 72-year-old man is brought to the emergency department due to the sudden onset of severe, tearing abdominal and back pain that began 30 minutes ago. He has a history of hypertension, hyperlipidemia, and a 5.5-cm abdominal aortic aneurysm (AAA) that has been monitored with annual ultrasounds. His current medications include lisinopril and atorvastatin. On arrival, he is lethargic, pale, and diaphoretic. His temperature is 37.0°C (98.6°F), blood pressure is 72/42 mmHg, heart rate is 128/min, and respiratory rate is 24/min. Physical examination reveals a tender, pulsatile periumbilical mass. Femoral pulses are weak bilaterally. Two large-bore intravenous lines are established. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate transfer to the operating room for surgical repairAnswer
  2. B
    CT angiography of the abdomen and pelvis
  3. C
    Intravenous esmolol infusion
  4. D
    Bedside abdominal ultrasonography
  5. E
    Aggressive fluid resuscitation to a systolic blood pressure > 120 mmHg

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 presents with the classic triad of a ruptured abdominal aortic aneurysm (AAA): sudden-onset severe tearing abdominal and back pain, a pulsatile abdominal mass, and profound hypotension. Given that this patient already has a known 5.5-cm AAA, the clinical diagnosis is highly reliable. In hemodynamically unstable patients with a ruptured AAA, survival depends on minimizing the time to proximal aortic control. The patient should be immediately transported to the operating room for emergent open surgical repair or endovascular aneurysm repair (EVAR), depending on the facility's capabilities. Delaying surgery for any reason, including diagnostic imaging or extensive medical stabilization, dramatically increases mortality.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and clinical presentation.
The patient is in profound hemorrhagic shock (blood pressure 72/42 mmHg, heart rate 128/min) with a tender, pulsatile abdominal mass.
Hemodynamic instability dictates the urgency of intervention and determines whether a patient can safely undergo diagnostic imaging.
2
Synthesize the presentation with the patient's medical history.
The combination of severe back/abdominal pain, shock, and a pulsatile mass in a patient with a known 5.5-cm AAA establishes a clinical diagnosis of a ruptured AAA.
Recognizing the classic triad of a ruptured AAA allows for rapid decision-making without the need for confirmatory testing.
3
Determine the most appropriate management pathway for an unstable patient with a ruptured AAA.
The patient requires immediate surgical hemostasis (open or endovascular repair).
Any delay in achieving proximal aortic control in the operating room significantly increases the risk of mortality in a ruptured AAA.

Key Concept

Hemodynamically unstable patients with a known abdominal aortic aneurysm and clinical signs of rupture require immediate surgical repair without prior confirmatory imaging.
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Topics

Surgical and Procedural Interventions

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