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.
B) Bedside abdominal ultrasound
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). Since the patient is hemodynamically unstable, a focused beside abdominal ultrasound is the most appropriate next step in management. Once AAA is confirmed, the patients should proceed to emergency endovascular or open AAA repair.
Answer choice A: Abdominal CT, is incorrect. An abdominal CT would be helpful in the management of a non-symptomatic AAA or symptomatic AAA in a patient who is hemodynamically stable. However, this patient is hemodynamically unstable, and CT would cause a delay in evaluation and treatment.
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.
Answer choice E: Emergency surgery. The most appropriate next step in management of this hemodynamically unstable patient is focused bedside ultrasound to confirm the diagnosis. In a patient with a known history of AAA and a presentation consistent with ruptured AAA with hemodynamic stability, proceeding to repair could be considered though a focused bedside ultrasound often would be done since it is fast and readily available.
Key Learning Point
Patients presenting with back pain, hypotension, and a pulsatile abdominal mass are highly suspected to have a ruptured abdominal aortic aneurysm. In this setting, focused bedside ultrasound is used to confirm the diagnosis, and the patient should then be taken for open or endovascular repair right away emergently.
