A 62-year-old man comes to the emergency department due to sudden-onset, severe abdominal pain 2 hours ago. The patient states that he suddenly felt weak, diaphoretic, and without energy. Medical history includes hypertension, dyslipidemia, sigmoid diverticulosis, and irritable bowel syndrome. He has a 30-pack-year smoking history and drinks alcohol on occasion. Temperature is 36.8 C (98.2 F), blood pressure on arrival is 88/64 mm Hg, pulse is 117/min and regular, and respirations are 18/min. Physical examination shows a diffusely tender abdomen with flank ecchymoses. There is no rigidity or guarding. Bowel sounds are present. During the examination the patient becomes pale and drowsy. Intravenous fluid boluses are started. Which of the following is the most appropriate next step in management of this patient?

Question

A 62-year-old man comes to the emergency department due to sudden-onset, severe abdominal pain 2 hours ago.  The patient states that he suddenly felt weak, diaphoretic, and without energy.  Medical history includes hypertension, dyslipidemia, sigmoid diverticulosis, and irritable bowel syndrome.  He has a 30-pack-year smoking history and drinks alcohol on occasion.  Temperature is 36.8 C (98.2 F), blood pressure on arrival is 88/64 mm Hg, pulse is 117/min and regular, and respirations are 18/min.  Physical examination shows a diffusely tender abdomen with flank ecchymoses.  There is no rigidity or guarding.  Bowel sounds are present.  During the examination the patient becomes pale and drowsy.  Intravenous fluid boluses are started.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d174_9cb6_bc81_130f11e4aab5_MD0003_00 This patient with sudden-onset, severe abdominal pain, hemodynamic instability (eg, symptomatic hypotension with weakness and diaphoresis), and flank ecchymoses likely has a ruptured abdominal aortic aneurysm (AAA). Patients age >60, smokers, men, and those with a history of atherosclerosis or connective tissue diseases are at increased risk for AAA. These patients often have few symptoms until the AAA markedly expands or ruptures, leading to abdominal or flank pain that may be accompanied by a pulsatile abdominal mass. Rupture can occur into the retroperitoneum or freely into the peritoneal cavity, the latter often leading to the rapid development of hemodynamic instability and shock. The evaluation and management of a suspected symptomatic AAA depends on both the hemodynamic stability of the patient and prior knowledge of the presence of AAA. Any symptomatic patient with a known history of AAA and hemodynamic instability is considered to have rupture and should be emergently transferred to the operating room for repair. However, in patients with hemodynamic instability and signs and symptoms consistent with AAA but without a known history, a focused bedside ultrasound should be performed to confirm the diagnosis (may be completed in the operating room). For symptomatic patients with or without a known history of AAA who are hemodynamically stable, an urgent abdominal CT is most appropriate. (Choice A) CT scanning is done only in hemodynamically stable patients with suspected AAA. CT is helpful in delineating the anatomy (eg, aneurysm measurement), differentiating unruptured from ruptured aneurysm, and visualizing other intraabdominal structures, all of which can help prepare for surgery. (Choice C) For patients who undergo emergent repair without prior imaging, options include open surgical repair or endovascular aneurysm repair. Laparoscopy is only occasionally considered in stable patients undergoing elective repair. (Choice D) Amylase and lipase are elevated in acute pancreatitis, severe cases of which may be complicated by retroperitoneal hemorrhage, causing a presentation with flank ecchymoses (Grey Turner sign) and hemodynamic instability. However, hemorrhagic conversion of pancreatitis is rare, and the absence of fever, nausea, or vomiting makes the diagnosis in this patient less likely. (Choice E) Plain abdominal radiographs are generally low yield as part of the emergency evaluation of patients with suspected AAA, but they can be helpful in diagnosing bowel obstruction (eg, dilated loops of bowel) or perforation (eg, free air). Educational objective: In patients with hemodynamic instability and signs and symptoms consistent with an abdominal aortic aneurysm (AAA) but without a known history, a focused bedside ultrasound should be performed. A CT scan is helpful in symptomatic patients who are stable, while those who are unstable with a known history of AAA should undergo emergent repair. References: Abdominal aortic aneurysm. (http://www.ncbi.nlm.nih.gov/pubmed/25884861) Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm. (http://www.ncbi.nlm.nih.gov/pubmed/23406071) Overview of point-of-care abdominal ultrasound in emergency and critical care. (http://www.ncbi.nlm.nih.gov/pubmed/27529029)

A 62-Year-Old Man Comes to the Emergency Department Due to Sudden-Onset