Paramedics arrive at the emergency department with a 72-year-old gentleman who experienced… — USMLE Step 3

Paramedics arrive at the emergency department with a $72$ -year-old gentleman who experienced a sudden syncopal episode at his residence. Upon regaining consciousness in transit, he complained of excruciating, tearing pain radiating from his mid-abdomen to his lower back. His past medical history is significant for hypertension, hyperlipidemia, tobacco use disorder, and a $4.8$ -cm infrarenal abdominal aortic aneurysm identified on ultrasound $18$ months ago. Upon arrival, he is lethargic, pale, and profoundly diaphoretic. Vital signs show a temperature of $36.5^\circ\text{C}$ ( $97.7^\circ\text{F}$ ), heart rate of $138$ /min, respiratory rate of $26$ /min, and blood pressure of $72/42$ mm Hg. Cardiopulmonary auscultation is unremarkable. Abdominal examination reveals a tender, pulsatile midline mass. Both lower extremities are cool with barely palpable dorsalis pedis pulses. Intravenous access is secured with two large-bore catheters, and uncrossmatched blood transfusion is initiated. Which of the following is the most appropriate next step in management?

A
Obtain a computed tomography angiography of the abdomen and pelvis
B
Administer intravenous esmolol to tightly control heart rate and blood pressure
C
Admit to the medical intensive care unit for permissive hypotension and serial hemoglobin monitoring
Expedite transfer to the operating room for immediate surgical exploration and repairCevap
E
Perform a diagnostic peritoneal lavage to confirm the presence of intraperitoneal hemorrhage

Cevap

Expedite transfer to the operating room for immediate surgical exploration and repair.

The correct answer is to expedite transfer to the operating room. This patient presents with the classic triad of a ruptured abdominal aortic aneurysm (AAA): profound hypotension, severe tearing abdominal/back pain, and a pulsatile abdominal mass. Given his known history of an unruptured AAA, the clinical diagnosis is highly evident. In the setting of hemodynamic instability (blood pressure

72/42

mm Hg), any delay in achieving source control of the bleeding is likely to be fatal. Therefore, after initiating resuscitation with uncrossmatched blood products and large-bore intravenous access, immediate transfer to the operating room for definitive surgical repair (either open or endovascular, depending on facility capabilities) is the mandatory next step.

Adım Adım Çözüm

Analyze the patient's presentation and vital signs.

The patient exhibits profound hypotension (

72/42

mm Hg), tachycardia (

138

/min), a pulsatile abdominal mass, and severe back/abdominal pain.

Identifying these clinical signs establishes the classic triad of a ruptured abdominal aortic aneurysm in the setting of hemorrhagic shock.

Correlate the clinical findings with the patient's known medical history.

The history of a known

4.8

-cm abdominal aortic aneurysm confirms the high likelihood of an acute rupture as the primary cause of his hemodynamic collapse.

This establishes the definitive diagnosis clinically, eliminating the need for further diagnostic confirmation.

Determine the optimal setting and procedural intervention for a hemodynamically unstable patient with a ruptured abdominal aortic aneurysm.

Immediate transfer to the operating room for surgical intervention (open or endovascular) is selected.

Any delay for imaging or inappropriate medical stabilization in an unstable patient actively exsanguinating will significantly increase mortality.

Anahtar Kavram

Hemodynamically unstable patients with a known abdominal aortic aneurysm who present with classic signs of rupture (hypotension, pulsatile mass, tearing pain) require immediate surgical intervention without prior confirmatory imaging.

Alternatif Yöntem

In centers with highly integrated vascular teams and readily available hybrid operating rooms, Endovascular Aneurysm Repair (EVAR) may be performed simultaneously upon transfer, but the fundamental decision to proceed immediately to procedural intervention remains exactly the same.

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Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

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Alternatif Yöntem

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