During an afternoon shift at an outpatient clinic, staff hear a loud thud from a restroom … — USMLE Step 3

During an afternoon shift at an outpatient clinic, staff hear a loud thud from a restroom and discover a $74$ -year-old man collapsed on the floor. He is immediately transported via advanced life support to the adjacent hospital's resuscitation bay. Upon arrival, the patient is diaphoretic, lethargic, and complains of excruciating, tearing pain radiating to his lower back. Vital signs reveal a blood pressure of $65/40$ mm Hg, a heart rate of $128$ /min, and a respiratory rate of $24$ /min. Physical examination demonstrates a prominent, expansile pulsation in the epigastrium. An immediate bedside focused assessment with sonography for trauma (FAST) reveals a $7.5$ cm dilation of the infrarenal aorta surrounded by hypoechoic free fluid. Which of the following are appropriate immediate steps in the procedural and clinical management of this patient? Select all that apply.

Immediate transport to the operative suite for urgent open or endovascular aortic repairCevap
Restriction of fluid resuscitation to maintain a target systolic blood pressure between $80$ and $90$ mm HgCevap
C
Administration of intravenous esmolol to rapidly reduce aortic shear stress
D
Transfer to the radiology suite for computed tomography angiography to guide operative planning
E
Delaying operative transfer until type-specific, fully cross-matched packed red blood cells arrive from the blood bank

Cevap

The appropriate immediate steps are immediate transport to the operative suite for urgent aortic repair and the restriction of fluid resuscitation to maintain a target systolic blood pressure between

80

and

90

mm Hg.

The correct interventions recognize that a ruptured abdominal aortic aneurysm in a hemodynamically unstable patient mandates immediate surgical control alongside damage-control resuscitation. Immediate transport to the operating room is required because definitive hemostasis is the only effective treatment. Concurrently, implementing permissive hypotension (targeting a systolic blood pressure of

80

90

mm Hg) is essential. Aggressive fluid resuscitation before surgical control is achieved can increase hydrostatic pressure, dislodge the fragile retroperitoneal clot, and exacerbate bleeding.

Adım Adım Çözüm

Analyze the patient's clinical presentation and vital signs.

The patient has profound hypotension (

65/40

mm Hg), tachycardia, and tearing back pain with an expansile abdominal mass, indicating hemorrhagic shock.

Identifying the severity of shock dictates the urgency of procedural interventions and limits the time available for diagnostic workup.

Evaluate the bedside diagnostic findings.

Bedside ultrasonography demonstrates a

7.5

cm infrarenal aortic dilation with free fluid.

This confirms the diagnosis of a ruptured abdominal aortic aneurysm (AAA), making further diagnostic testing unnecessary.

Determine the indicated surgical interventions.

The patient requires immediate transfer to the operating room for emergency open or endovascular aortic repair.

In hemodynamically unstable patients with a known ruptured AAA, definitive surgical hemostasis is the only life-saving intervention.

Identify the necessary perioperative hemodynamic management.

Implement permissive hypotension, targeting a systolic blood pressure of

80

90

mm Hg.

Aggressive fluid resuscitation to a 'normal' blood pressure can pop the protective retroperitoneal clot, exacerbating the hemorrhage.

Anahtar Kavram

Management of Hemodynamically Unstable Ruptured Abdominal Aortic Aneurysm

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Konular

Bu konudan daha fazla soru