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Zorluk: OrtaCardiothoracic and Vascular Surgery

An 81-year-old male with a history of hypertension and a 50-pack-year smoking history is brought to the emergency department after a syncopal episode at home. Upon arrival, he reports sudden, severe, and constant abdominal and left flank pain. His current medications include lisinopril and hydrochlorothiazide. His temperature is 36.8°C (98.2°F), blood pressure is 82/45 mm Hg, pulse is 118/min, and respiratory rate is 22/min. He appears pale, diaphoretic, and lethargic. Physical examination reveals a distended abdomen with a palpable, pulsatile mass located above the umbilicus. A bedside focused assessment with sonography for trauma (FAST) demonstrates a 7.5-cm dilation of the infrarenal aorta with an adjacent anechoic fluid collection in the retroperitoneum. Two large-bore peripheral intravenous lines are placed, and fluid resuscitation is initiated.

Which of the following is the most appropriate next step in management?

  1. Immediate transfer to the operating room for surgical repairCevap
  2. B
    Computed tomography angiography of the abdomen and pelvis
  3. C
    Intravenous administration of labetalol
  4. D
    Insertion of a nasogastric tube and serial abdominal examinations
  5. E
    Intravenous administration of piperacillin-tazobactam

Cevap

Immediate transfer to the operating room for surgical repair
The correct approach for a patient presenting with the classic triad of a ruptured abdominal aortic aneurysm (AAA)—severe abdominal/flank pain, pulsatile mass, and hypotension—is immediate definitive intervention. Bedside ultrasound has already confirmed a 7.5-cm infrarenal AAA with free retroperitoneal fluid, definitively establishing the diagnosis of a rupture. Because the patient is in hemorrhagic shock, any delay for advanced imaging is contraindicated. The patient must be transferred emergently to the operating room for open surgical or endovascular repair to obtain source control of the bleeding.

Adım Adım Çözüm

1
Identify the patient's primary condition and hemodynamic status.
The patient has a ruptured 7.5-cm abdominal aortic aneurysm (AAA) with profound hypotension (82/45 mm Hg) and tachycardia.
Recognizing the triad of abdominal/flank pain, pulsatile abdominal mass, and hypotension is crucial for diagnosing a ruptured AAA and determining the acuity of the situation.
2
Determine the appropriate management algorithm based on hemodynamic stability.
Because the patient is hemodynamically unstable and the diagnosis is already confirmed by bedside ultrasound, he must proceed directly to definitive repair.
Unstable patients with a known source of active hemorrhage cannot safely undergo cross-sectional imaging and require immediate surgical source control.

Anahtar Kavram

Hemodynamically unstable patients with a ruptured abdominal aortic aneurysm (diagnosed clinically or via bedside ultrasound) require emergent surgical repair (open or endovascular) without further imaging.
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Cardiothoracic and Vascular Surgery

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