Question of the Week # 372

372)  A 65 year old man presents to the Emergency room with complaints of severe abdominal pain that began 30 minutes ago while at rest. He reports diffuse pain that all over his abdomen, the lower back as well as in the flanks. His past medical history is significant for diabetes mellitus and peripheral vascular disease. He denies any abdominal trauma. He smokes about 1 pack cigarettes per day . On examination, he is in severe distress secondary to pain. He is afebrile, blood pressure is 80/40 mm Hg, pulse 120/min and respiratory rate 24/min. Abdomen is mildly distended with mild tenderness and a palpable pulsatile mass. Femoral and dorsalis pedis pulses are diminished.  An electrocardiogram reveals sinus tachycardia. The patient is started on intravenous fluids and is placed on a cardiac monitor. Which of the following  is the most appropriate next step?

A) CT scan of the abdomen

B) Exploratory laporotomy

C) Cardiac enzymes

D) Focused Abdominal Sonography in Trauma ( FAST)

E) Start Insulin Drip.

22 Responses

  1. b

  2. B) Exploratory laporotomy?? Ruptured AAA

    • What is the approach in patients with no known previous history of AAA but comes with abdominal pain, pulsatile mass and hypotension?

      • immediate stabilisation is needed by clamping the vessel via laparotomy.

      • Abdominal US – if AAA is > 5mm then elective surgery <5mm followup every yr

        but here he's unstable and PE showing diffuse pain that all over his abdomen, the lower back indicate ruptured AAA so does he not require emergent surgery?

  3. A) CT scan of the abdomen

    • CT takes a long time and would cause delay in this rapidly collapsing patient. Also, CT requires mobilization out of the ER which is not recommended in this highly unstable patient. What else?

  4. approach to the pt must start with ABC & stabilize the pt
    then do laporatomy
    ??????

  5. b..??

  6. B

  7. First step is to stablize the pt. Iv beta blocker, sodium nitroprusside. Then emergency ct scan and laprotomy. But in this case I would choose “d” Fast to immediately assess the extent of damage before preceding to laprotomy??

    • why would you give beta blocker, nitroprusside to a hypotensive patient? what is the triad of aortic dissection as opposed to triad of aortic aneurysm rupture?

      Triad of aortic dissection:
      Chest pain radiating to the back, Hypertension > 160/100 (usually, more) and widened mediastinum on cxr

      Triad of AAA :
      Abdominal/ flank/ back pain , Hypotension and Pulsatile abdominal mass

      But we have no prior history of AAA from the question. So, what do we do next?

      • D) Focused Abdominal Sonography in Trauma ( FAST) – Bed side?

      • Correct!!
        The approach in suspected abdominal aorta aneurysm depends on hemodynamic status and whether or not this patient has previous history of AAA
        a) If the patient is hemodynamically stable, next step is contrast enhanced CT scan as it is sensitive as well as specific for AAA rupture and since patient is stable, there is time.
        b) If the patient is hemodynamically unstable and presents with classic triad as mentioned above ( pain, pulsatile mass and hypotension) , first question is does he have a history of AAA : If such information is avilable from past records or from history, proceed with exploratory laparotomy. If such history of AAA is absent, there needs be some form of quick investigation that can be done bed side before this patient goes for surgery
        FAST ultrasound often employed in trauma settings is very useful here. It can be done bedside and emergency physicians and most residents are trained to do this. Ultrasound is sensitive in disclosing an aneurysm but is not specific for rupture – however, in the presence of right clinical setting( pain, hypotension etc) such a positive ultrasound showing AAA is 95% specific for rupture. This FAST can be completed in about 5 to 10 minutes . Then, patient immediately sent for exploratory lap

        Remember, if there is a clue in the history that the patient has a hx of AAA and if he is hemodynamically unstable at above presentation; he must go for surgery stat. ( Only 25% patients presenting with AAA rupture has previous KNOWN history of AAA – so, majority of patients will not have that clue in history) .
        If the patient is hemodynamically STABLE and came with abdominal pain and/or pulsatile mass , CT scan must be obtained irrespective of whether or not he has a known history of AAA ( The idea in that setting is since patient is stable, CT can be formed safely. CT will help confirm the rupture but will also help rule out other differential diagnoses)

      • the clinical picture is highly suggestive of ruptured aaa….so i think we can proceed to surgery in this case?

  8. D.focused abdominal sonography in trauma (FAST)

    • Correct!

  9. Thank you for correcting. Got confused with both.

  10. B

  11. Yes right, no hx of aaa them a quick us is the next step it takes only 5 min

  12. the answer is B. UNSTABLE pt with a PULSATILE mass, sudden abdo pain radiating to back and legs=ruptured AAA unless proven otherwise. Call a vascular sx to take the pt to OR stat. These days most vascular ORs hhave a hybrid room where an on-table angio or CT can be done within minutes. Plus, to stabilize the pt so that anesthesia can catch up and intubate the pt one can quickly insert a thoracic aortic baloon under angio. then pt gets intubated and you do an angiogram to see if your Dx is correct etc etc. Bedside FAST and even US done by an experienced tech both have low sensitivity and specificity since most of the times u end up lapping the pt anyway.

  13. The answer is B,i go with B

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