A 63-year-old man presents to the emergency department with 2 hours of severe back and abdominal pain. Past medical history includes hyperlipidemia and hypertension, both of which are well-controlled with medication. He reports a lifelong smoking history and only social alcohol consumption. He reports some nausea but denies any vomiting, diarrhea, melena, hemoptysis, chest pain, or shortness of breath. Vital signs are 37.0° C (98.6° F), pulse 123 beats/min, respirations 24/min, and blood pressure 88/65 mmHg. Physical examination reveals a diaphoretic man with diffuse abdominal and flank pain, as well as a palpable pulsatile abdominal mass. The remainder of the examination is normal, and resuscitation with intravenous (IV) fluids is started.
Which of the following is the most appropriate next step in management?
- A) Abdominal computed tomography (CT)
- B) Abdominal ultrasound
- C) Chest X-ray
- D) Electrocardiogram (ECG) and troponin levels
- E) Emergency surgery
E) Emergency surgery
In this older male with hypertension and long smoking history, the triad of back pain, pulsatile abdominal mass, and hypotension are strongly suggestive of a ruptured abdominal aortic aneurysm (AAA). This condition is universally fatal without immediate surgical intervention. Hemodynamically unstable patients with known AAA who present with classic symptoms and signs of should be taken to the operating room for immediate control of hemorrhage and emergency repair of the aneurysm.
Answer choice A: Abdominal CT, is incorrect. An abdominal CT would be helpful in the management of a non-symptomatic AAA. However, this patient is hemodynamically unstable, and CT would cause a delay in treatment.
Answer choice B: Abdominal ultrasound, is incorrect. An abdominal ultrasound is the test of choice for screening for AAA. It has no role in the management of this surgical emergency.
Answer choice C: Chest X-ray, is incorrect. A plain chest radiograph would be useful in differentiating causes of chest pain but would not be helpful in this patient with ruptured AAA.
Answer choice D: ECG and troponin levels, are incorrect. ECG and troponin levels would be useful in evaluating a cardiac etiology of pain. While likely to be obtained in the emergency department as a standard operating procedure for a patient in acute pain, it is not the correct management choice for this surgical emergency.
Key Learning Point
Patients presenting with back pain, hypotension, and a pulsatile abdominal mass are highly suspected to have a ruptured abdominal aortic aneurysm and should be taken to the operating room immediately.
Dr. Raj Dasgupta