A 71-year-old man is brought to the emergency department via ambulance due to sudden-onset… — USMLE Step 3

A $71$ -year-old man is brought to the emergency department via ambulance due to sudden-onset, severe abdominal and lower back pain accompanied by a brief episode of syncope at home. His medical history is significant for hypertension, hyperlipidemia, and a $5.2\text{-cm}$ infrarenal abdominal aortic aneurysm that has been managed conservatively. Upon arrival, he is diaphoretic and confused. Vital signs are temperature $36.8^\circ\text{C}$ ( $98.2^\circ\text{F}$ ), blood pressure $68/42\text{ mmHg}$ , pulse $135\text{/min}$ , and respirations $22\text{/min}$ . Physical examination reveals a distended abdomen with an exquisitely tender, pulsatile midline mass. Intravenous access is rapidly established with two large-bore peripheral catheters. Which of the following are the most appropriate immediate steps in the management of this patient? (Select all that apply)

Immediate transfer to the operating room for surgical explorationAnswer
Activation of the institution's massive transfusion protocolAnswer
C
Computed tomography angiography of the abdomen and pelvis
D
Intravenous administration of esmolol
E
Admission to the surgical intensive care unit for invasive hemodynamic optimization

Answer

The most appropriate immediate steps are immediate transfer to the operating room for surgical exploration and activation of the institution's massive transfusion protocol.

The correct sequence of actions focuses on immediate survival. The patient is presenting with a ruptured abdominal aortic aneurysm (AAA), evidenced by the classic triad of sudden severe abdominal/back pain, a pulsatile abdominal mass, and profound hypotension. In the setting of hemodynamic instability and a known AAA, the diagnosis is made clinically. The priority is immediate transfer to the operating room for definitive surgical hemorrhage control (either open surgical repair or endovascular aneurysm repair, depending on institutional protocol). Concurrently, the patient is in severe hemorrhagic shock and requires volume expansion. To avoid dilutional coagulopathy and dislodging any fragile hemostatic clots (permissive hypotension), resuscitation should be executed via a massive transfusion protocol (balanced ratios of packed red blood cells, fresh frozen plasma, and platelets) rather than large-volume crystalloids.

Step-by-Step Solution

Identify the primary clinical problem based on the patient's presentation.

The patient has the classic triad of a ruptured abdominal aortic aneurysm (AAA): severe abdominal/back pain, a pulsatile abdominal mass, and profound hypotension.

Recognizing this triad in a patient with a known AAA confirms the diagnosis of rupture without the need for further diagnostic studies.

Determine the patient's hemodynamic status.

The patient is in Class IV hemorrhagic shock (blood pressure

68/42\text{ mmHg}

, pulse

135\text{/min}

, confusion, diaphoresis).

Hemodynamic instability dictates whether the patient can undergo further imaging or requires immediate definitive intervention.

Select the appropriate procedural and medical interventions for an unstable ruptured AAA.

The patient requires immediate operative intervention for hemorrhage control and balanced resuscitation with blood products (massive transfusion protocol).

Any delay for imaging or inappropriate medical stabilization in the setting of uncontrolled arterial hemorrhage will likely be fatal.

Key Concept

Hemodynamically unstable patients with a classic presentation of a ruptured abdominal aortic aneurysm require immediate surgical exploration and balanced blood product resuscitation; preoperative imaging is contraindicated.

Estimated Time:1m 30s

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