A 72-year-old male is brought to the emergency department by ambulance due to sudden-onset, severe abdominal pain that radiates to his back. His past medical history is significant for hypertension, hyperlipidemia, and a known 5.5-cm abdominal aortic aneurysm. Upon arrival, he appears pale and diaphoretic. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 75/40 mmHg, heart rate of 128/min, and respiratory rate of 22/min. Physical examination reveals an expansile, pulsatile abdominal mass. Peripheral pulses are weak but symmetric bilaterally. Two large-bore intravenous lines are placed, and fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?
- Immediate transfer to the operating roomCevap
- BComputed tomography angiography of the abdomen and pelvis
- CBedside echocardiography and administration of intravenous diuretics
- DAdministration of broad-spectrum intravenous antibiotics
- ENasogastric tube insertion and conservative management
Cevap
Immediate transfer to the operating room
The correct answer is immediate transfer to the operating room. This patient presents with the classic triad of a ruptured abdominal aortic aneurysm (AAA): acute severe abdominal or back pain, a pulsatile abdominal mass, and hypotension. Because the patient has a known history of a 5.5-cm AAA and is currently hemodynamically unstable (blood pressure 75/40 mmHg), the diagnosis is presumed to be a ruptured AAA. For hemodynamically unstable patients with a known AAA and signs of rupture, emergent surgical repair (either open exploratory laparotomy or endovascular repair, depending on institutional protocols and rapid anatomy assessment in the OR) is required immediately. Delaying surgery for any diagnostic imaging is contraindicated as it significantly increases mortality.
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Hemodynamically unstable patients with a high clinical suspicion for ruptured abdominal aortic aneurysm require immediate surgical intervention without prior imaging.