Question Of The Day #33

question of the day
qod33
AAA CT scan possible rupture

Which of the following is the most appropriate next step in management for this patient’s condition?

This elderly male patient presents to the emergency department with abdominal pain. Compared to younger patients, abdominal pain in an elderly patient has a higher likelihood of being due to a surgical emergency or from a diagnosis that carries a higher mortality. Elderly patients may have more nonspecific associated symptoms that may make it difficult to confirm a dangerous diagnosis without advanced imaging. Additionally, elderly patients do not always have a fever or elevated white blood cells during an abdominal infection. The differential diagnosis of abdominal pain in an elderly patient should be broad and encompass conditions related to many body systems.

The syncopal event and signs of shock should raise concern for a more serious etiology of the patient’s symptoms. The CT image provided shows a dilated aorta filled with contrast dye and a large surrounding intra-luminal thrombus. An infrarenal abdominal aorta measuring over 3cm is considered aneurysmal. This patient’s abdominal aorta measures approximately 7cm from outer wall to outer wall using the scale provided on the right-hand side of the image. The green measurement line in the image below shows the size of the aorta from outer wall to outer wall (includes thrombus).

The diagnosis for this patient is a ruptured abdominal aortic aneurysm (AAA). This condition carries a high mortality and is often lethal without prompt surgical intervention (Choice A). Administration of blood products is helpful if there are signs of hemorrhagic shock as in this patient. Antibiotics, like IV Vancomycin and Piperacillin-Tazobactam (Choice B), are not helpful in the management of this diagnosis. Endotracheal intubation (Choice C) is needed prior to operative intervention, but Emergency department management should focus on volume resuscitation and close communication with the surgical team for operative repair. IV Heparin (Choice D) may be beneficial in acute mesenteric ischemia from an embolic etiology (i.e. Atrial fibrillation), but anticoagulation would worsen this patient’s hemorrhagic shock.

AAAs can present to the Emergency department without any symptoms and be discovered incidentally on imaging or on physical exam as a pulsatile abdominal mass. Other presentations include severe back pain (the abdominal aorta is retroperitoneal) and circulatory shock. Rupture of a AAA can be large and result in rapid decompensation and death, or bleeding can be contained in the retroperitoneal space with transiently stable vital signs. Risk factors for AAA formation are male sex, tobacco use, hypertension, increased patient age, Marfans syndrome, or Ehlers-Danlos syndrome. The diagnosis of AAA is clinical and includes the use of bedside aortic ultrasound or CT aortic angiogram imaging. Treatment for AAA depends on aortic size and patient symptoms. Operative repair is indicated for any AAA over 5.5cm diameter in men, over 5.0cm diameter in women, or any size if there are signs of shock or concern for AAA rupture.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #33," in International Emergency Medicine Education Project, April 2, 2021, https://iem-student.org/2021/04/02/question-of-the-day-33/, date accessed: July 3, 2022

Selected Cardiovascular Emergencies

Cardiovascular Emergencies selected from SAEM and IFEM undergraduate curriculum recommendations are uploaded into the website. You can read, listen or download all these chapters freely. More specific disease entities are on the way.

Abdominal Aortic Aneurysm (AAA)

by Lit Sin Quek Case Presentation A 75-year-old obese man comes to the emergency department. He has history C.O.P.D., hypertension. He is a smoker and on

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Acute Coronary Syndrome (ACS)

by Khalid Mohammed Ali, Shirley Ooi – Singapore Case Presentation A 46 years old man with a past medical history of hypertension and hyperlipidemia developed

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Acute Heart Failure (AHF)

by Walid Hammad – USA Case Presentation An ambulance crew rushes into your emergency department (ED) with a 56-year-old man. He is severely short of

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Aortic Dissection

by Shanaz Sajeed Introduction Aortic dissection carries high morbidity and mortality. Although patients generally present with acute symptoms and classic signs, a subset of patients

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Deep Vein Thrombosis (DVT)

by Elif Dilek Cakal Case Presentation An 85-year-old woman, with a history of congestive heart failure, presented with right leg pain and swelling of 2

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Hypertensive Emergencies

by Sadiye Yolcu Introduction Systemic hypertension is a common medical problem. It affects over 1 million people worldwide. ER clinicians commonly encounter this problem. Rapid

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Pulmonary Embolism

by Elif Dilek Cakal Case Presentation A 45-year-old female with no prior medical history presented to the emergency department (ED) with three days of constant shortness

Read More »

Do you need more?

What is your next move?

In case you didn’t encounter an elderly with abdominal pain today!

A 72-year-old male patient presented with mild abdominal pain. BP: 145/68 mmHg, HR: 83 bpm, RR: 16/min, T: 37, SpO2: 98% in room air. He has a history of hypertension and diabetes mellitus around 25 years. On the exam, you appreciated a pulsatile mass and checked for the aorta with bedside ultrasound. Here is the cine record of the patient.

What is your next action?

Feel free to give your answers at the comment box below.

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Is this AAA going to be ruptured?

AAA rupture

Abdominal Aortic Aneurysm (AAA)

Lit Sin Quek

A 75-year-old obese man comes to the emergency department. He has history COPD, hypertension. He is a smoker and on regular follow-up with primary care. He describes sudden onset severe flank and back pain for past 2 hours. He denies any chest pain or dyspnea. He informs the physician about his chronic abdominal pain. His initial vital signs are HR 98 bpm, RR 24/min, BP 190/105 mmHg, T 36.9C. His examination revealed mild abdominal pain without rigidity or rebound tenderness. Bedside ultrasonography performed and the result is shown on the side.

What is the risk of rupture?

Touch Me

Risk of Rupture

increases with emphysema, smoking, hypertension. Regarding Powell’s (2003, 2007) study aneurisms above 5.5 cm have 9.4% to 32.4% rupture risk in one year.
Answer