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Zorluk: OrtaCardiothoracic and Vascular Surgery

A 72-year-old man is brought to the emergency department via ambulance after a witnessed syncopal episode at his home. Upon arrival, he is awake but lethargic and complains of severe, tearing abdominal and lower back pain that began abruptly one hour ago. His medical history is significant for hypertension, hyperlipidemia, and a 5.2 cm abdominal aortic aneurysm that has been managed conservatively. His temperature is 36.8°C (98.2°F), blood pressure is 78/42 mm Hg, heart rate is 122/min, and respiratory rate is 22/min. Oxygen saturation is 95% on room air. Physical examination reveals pale, cool, and diaphoretic skin. The abdomen is distended and tender to deep palpation, with a prominent pulsatile mass palpated in the periumbilical region. Intravenous access is established and fluid resuscitation is initiated. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate surgical explorationCevap
  2. B
    Computed tomography angiography of the abdomen
  3. C
    Insertion of a nasogastric tube and abdominal radiography
  4. D
    Intravenous furosemide and noninvasive positive pressure ventilation
  5. E
    Intravenous broad-spectrum antibiotics and blood cultures

Cevap

The correct answer is immediate surgical exploration.
The most appropriate next step in management is immediate surgical exploration. This patient's presentation of sudden-onset, severe tearing back and abdominal pain, a pulsatile abdominal mass, and profound hypotension constitutes the classic triad of a ruptured abdominal aortic aneurysm (AAA). Because he is hemodynamically unstable, he must be taken immediately to the operating room for emergency open or endovascular repair. Any delay for further diagnostic testing significantly increases mortality.

Adım Adım Çözüm

1
Analyze the patient's vital signs and physical examination findings.
The patient has marked hypotension (78/42 mm Hg), tachycardia (122/min), and a distended abdomen with a palpable pulsatile mass.
To determine the patient's hemodynamic status and identify the likely source of shock.
2
Synthesize the clinical presentation with the patient's past medical history.
A history of a 5.2 cm abdominal aortic aneurysm combined with sudden-onset severe back pain, syncope, and hemorrhagic shock strongly suggests a ruptured AAA.
To establish a primary working diagnosis.
3
Apply the management algorithm for a suspected ruptured AAA based on hemodynamic stability.
Because the patient is hemodynamically unstable, the algorithm dictates proceeding directly to the operating room for surgical exploration rather than obtaining confirmatory imaging.
To select the most appropriate immediate life-saving intervention and avoid fatal delays.

Anahtar Kavram

Hemodynamically unstable patients presenting with signs of a ruptured abdominal aortic aneurysm (AAA) require immediate surgical exploration or endovascular repair without prior confirmatory imaging.
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Cardiothoracic and Vascular Surgery

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