Review Question - QID 103042

For a hemodynamically unstable patient with a history of a stable AAA who presents with symptoms and physical exam signs suspicious for a ruptured abdominal aortic aneurysm (AAA), the best next course of action is emergent surgery.

Risk factors for AAA include hypertension, hypercholesterolemia, atherosclerosis, tobacco use, male gender, and increasing age. AAA are usually asymptomatic until ruptured or are discovered incidentally. A ruptured AAA presents with hypotension and severe/tearing abdominal pain radiating to the back. If a ruptured AAA is suspected and the patient is hemodynamically stable with systolic blood pressure > 90 mmHg, urgent abdominal ultrasound or CT can confirm the diagnosis. If a patient is hemodynamically unstable, he/she should be taken to surgery emergently.

Incorrect Answers:
Answer 1: Abdominal ultrasound could be the next best step in management if the diagnosis is not clear, and the history of a AAA is not known; however, the patient is frankly unstable and has signs and symptoms of rupture.

Answers 2-3: Abdominal CT with contrast (preferred) and abdominal CT without contrast would be appropriate in a stable patient without severe pain/tenderness or unstable vitals. A CT scan should only be performed if the patient is stable and there is no concern for rupture and is generally performed after a bedside ultrasound. In some emergent cases where the patient is hemodynamically unstable, the patient may still be able to have a rapid abdominal CT scan performed to determine whether endovascular aneurysm repair (EVAR) can be used. In this case, with the patient becoming unresponsive, surgery is the more appropriate initial management.

Answer 4: Abdominal MRI is not the best imaging modality for visualization of a ruptured AAA and is very time consuming in the face of hemodynamic instability.

Bullet Summary:
The best initial step in management in a ruptured AAA with unstable vitals is emergent surgery.