Ruptured Abdominal Aortic Aneurysm

You are the vascular surgery CT1 called to the emergency department to review a 65-year old builder who was brought in by ambulance with sudden onset abdominal/back/flank pain and bilateral limb ischemia. He is in ED resus in pain but haemodynamically stable. How would you proceed?

Example answer introduction

In this scenario I would be most worried about a ruptured abdominal aortic aneurysm. I would assess this patient using an A-E approach, take a focused history and perform an abdominal examination. I would contact the vascular surgery registrar once I had put in place my initial management plan.  

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting AAA (ruptured) permissive hypotension is accepted (80-110 SBP). 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, Trop I, clotting studies, Group and Save and blood and urine cultures if spiking a temperature. 

Focused history​

  • Allergies

  • Medications 

  • Past medical history including previous surgery – cardiac arrhythmia 

  • Last meal

  • Events leading up to this point – time of onset, known history of AAA

Abdominal examination

  • Inspect – Distention, surgical/traumatic scars, bruising abdomen, flanks, back – signifying retroperitoneal haemorrhage

  • Auscultate 

  • Palpate – Gently feel for pulsatile mass

Example questions to progress the station

Q1 You feel a pulsatile mass and ask the ED Registrar for a FAST scan which confirms the diagnosis of a AAA. You feel it is leaking and are on the phone to the CT scan room when you are called back to see him as he has sudden become haemodynamically unstable. What would you do now? 

 

Q1 - Answer

 

His aneurysm has ruptured and he needs to go to theatre immediately for a repair. I would call the vascular registrar, emergency theatres and the anaesthetist on call as there can be no delay. I would keep the patient and any relatives informed, then document in the notes once safe to do so.  

Initial management

  • Analgesia according to the WHO pain ladder

  • IV crystalloids to maintain urine output of 0.5ml/kg/hr - remember permissive hypotension

  • Keep nil-by-mouth

  • Inform the surgical/vascular Registrar to IMMEDIATELY review the patient

  • Prep for theatre - consent if able to, book theatre, anaesthetics, ICU

  • Keep patient and any relatives informed

  • Document, document, document!!!

 Escalation
Ruptured AAA has an overall mortality rate 80-90%. Even after surgery it is reported to be 32-80%. This is heavily influence by the patient’s age, comorbidities and time to theatre, hence this decision will be made by your seniors. You must ensure the patient is ready for an operation should the decision be made.
People who will be involved if the patient goes to theatre:
1. Aaesthetic consultant
2. ICU consultant
3. Vascular Regestrar and consultant
4. Haematology
5. Transfusion team
Useful Resources

Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. 

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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