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Question

Difficulty: MediumInitial Stabilization and Triage

A 68-year-old man is brought to the emergency department by paramedics after collapsing in a grocery store. Bystanders report he was complaining of severe, tearing back pain just before losing consciousness. On arrival, he is lethargic and confused but opens his eyes to pain. His past medical history includes hypertension, hyperlipidemia, and a 40-pack-year smoking history. Vital signs are temperature 36.8°C (98.2°F), blood pressure 72/40 mm Hg, heart rate 118/min, respiratory rate 22/min, and oxygen saturation 95% on room air. Physical examination reveals a pale, diaphoretic man with cool extremities. The abdomen is slightly distended, and a prominent pulsatile mass is palpated in the periumbilical region. Femoral pulses are diminished bilaterally. Which of the following are the most appropriate simultaneous initial steps in the stabilization and management of this patient? (Select all that apply)

  1. Insertion of two large-bore peripheral intravenous cathetersAnswer
  2. Emergent bedside abdominal ultrasonographyAnswer
  3. Immediate consultation with vascular surgeryAnswer
  4. D
    Transport to the radiology suite for computed tomography angiography
  5. E
    Administration of intravenous labetalol to reduce aortic shear stress

Answer

The most appropriate simultaneous initial steps are the insertion of two large-bore peripheral intravenous catheters, emergent bedside abdominal ultrasonography, and immediate consultation with vascular surgery.
This patient presents with the classic triad of a ruptured abdominal aortic aneurysm: severe pain (back/abdominal), hypotension indicating hemorrhagic shock, and a pulsatile abdominal mass. When a patient with a suspected ruptured AAA is hemodynamically unstable, the priority is simultaneous resuscitation and definitive surgical preparation. This requires securing immediate large-bore intravenous access for impending massive transfusion, using a fast and non-invasive bedside ultrasound to confirm the presence of the aneurysm and free fluid, and immediately alerting vascular surgery for operative repair. All three actions must occur concurrently in the resuscitation bay.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is hemodynamically unstable (hypotensive, tachycardic) and presenting with signs of severe shock.
Hemodynamic instability dictates that diagnosis and stabilization must occur simultaneously at the bedside.
2
Formulate the most likely diagnosis based on the clinical triad.
The presentation of sudden tearing back pain, profound hypotension, and a pulsatile abdominal mass is classic for a ruptured abdominal aortic aneurysm (AAA).
Recognizing the classic triad immediately narrows the differential and guides the resuscitation priorities.
3
Select the appropriate interventions for a ruptured AAA in an unstable patient.
Secure large-bore IV access for volume and blood products, use bedside ultrasound to confirm the diagnosis, and emergently consult vascular surgery.
These steps address circulation, confirm the catastrophic etiology quickly, and prepare for definitive operative hemorrhage control.

Key Concept

In a hemodynamically unstable patient with a suspected ruptured abdominal aortic aneurysm, management consists of immediate volume resuscitation, bedside ultrasound confirmation, and emergent surgical repair. Transport for definitive imaging (e.g., CT scan) is contraindicated.
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Topics

Initial Stabilization and Triage

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