Review Question - QID 103046

This patient with sudden-onset back pain and hypotension has a point of care ultrasound with findings concerning for a ruptured abdominal aortic aneurysm (AAA). For hemodynamically unstable patients with confirmed or suspected AAA, the most appropriate next step in management is emergent surgical repair.

Abdominal aortic aneurysm is a local enlargement of the abdominal aorta larger than 3 cm that is commonly observed in elderly patients. Risk factors include smoking, high blood pressure, and other heart or blood vessel diseases. AAA rupture is a true emergency with mortality exceeding 90%. The majority of patients (~70%) do not make it to the hospital alive. Symptoms include vague back, abdominal, or chest pain in addition to hypotension and hypovolemic shock. If the AAA ruptures in the intraabdominal cavity, death usually results. Retroperitoneal rupture can result in temporary tamponade which can increase survival and allow enough time for surgical intervention to be performed. Treatment is emergency operative repair. The two primary operative approaches are endovascular and open repair. Endovascular aneurysm repair is preferred and has a better survival rate than open repair.

Figure A demonstrates an ultrasound image with findings concerning for a ruptured AAA. Note the hypoechoic areas immediately surrounding the aorta indicating extravasation of blood from the ruptured aneurysm. This is indicated in red arrows in Illustration A.

Haque et. al review the pathophysiology, diagnosis and management of abdominal aortic aneurysm. They discuss various management strategies, and recommend that ruptured, hemodynamically unstable AAA be managed with emergent repair.

Incorrect Answers:
Answer 1: CT angiography of the abdomen and pelvis would be appropriate if AAA were suspected and there was no evidence of hemodynamic instability. However, it would not be appropriate for this patient with ultrasound imaging concerning for ruptured AAA and clear hemodynamic instability.

Answer 2: Discharge and serial outpatient ultrasounds would be appropriate if this patient had a stable AAA that was not tender, enlarging, or associated with unstable vital signs.

Answer 4: Tranexamic acid is an antifibrinolytic medication that has been shown to be beneficial in certain patient populations with large volume bleeding. However, it would not be appropriate alone as the next step in management for this patient with a ruptured AAA.

Answer 5: Volume resuscitation in the form of blood products would be appropriate as this patient is transferred to the operating room. However, volume resuscitation and observation alone would not definitively address this patient's ruptured AAA.

Bullet Summary:
For hemodynamically unstable patients with confirmed or suspected AAA, the most appropriate next step in management is emergent surgical repair.