So our first steps here, the surgical consultation.
You wanna get that as soon as the diagnosis is suspected.
Never delay in a patient with hypotension or while awaiting imaging.
I can’t stress this enough.
If you are worried about this diagnosis, you call a surgeon.
This isn’t something you can fix in the emergency department.
This is something that will need emergent surgery.
One thing you can do is you can ensure that your patient gets adequate resuscitation.
What you wanna do in that situation is you wanna put in two large bore IVs.
You wanna send a type and cross match for your patient.
You wanna potentially give early blood.
So you wanna start volume resuscitating the patient nice and early.
Two large bore IVs just for clarification,
generally, you want something that’s an 18 gauge IV or bigger,
so an 18, a 16, or a 14.
I always like to remind students that volume resuscitating
with a triple lumen catheter is not ideal.
The lumens actually on a triple lumen catheter are really quite small and long,
and you don’t get a lot of great flow through that.
If you’re worried about your patient not having good peripheral IV access,
you can also put in an intraosseous catheter
or a Cordis which is basically a large central line
and that would be how you would get a better volume resuscitation.
The other thing that’s important to note
is that permissive hypotension actually may have a better outcome,
so just maintaining the person’s systolic blood pressure of around 90 may be okay.
So we wanna make sure that we’re not resuscitating the patients too early necessarily
but it’s okay if their blood pressure is around 90.
Other testing to get would be potentially other EKGs or labs,
looking for other causes of presenting symptoms.
So although we’re talking about AAA here,
it’s possible that the patient’s symptoms may not be due to AAA.
It’s possible they’re due to other concerning findings.
So you wanna make sure that you’re again,
keeping your differential broad
and not coming upon it really closure for this diagnosis.
Size matter when we’re talking about AAA.
Three to five centimeter triple As are less likely to rupture
so if you get your imaging and that’s the size that you see,
you can advise that your patient has outpatient follow-up.
Sometimes that’s easier said than done,
but really try and get that patient plugged in to see a vascular surgeon.
Greater than 5 cm requires urgent follow-up with a surgeon,
and what that means is generally, surgery follow-up within 3 to 5 days.
These patients are actually a pretty high risk of rupture
or greater risk of rupture than the smaller sizes,
so you wanna make sure that you go ahead
and you stress to the patient the importance that they go see someone
and also that when they’re discharged that you give them good return precautions.
Now, always keep in mind that if your patient doesn’t have the resources
or doesn’t have health insurance, or the ability to see a doctor,
that you make sure that they have some ability to kind of get in with an individual.
And then for a patient in whom you are – has asymptomatic or ruptured AAA,
you wanna get that emergent surgical consultation.
You wanna involve that surgeon again nice and early
but definitely if you’re worried that someone is symptomatic
or the imaging shows that there is rupture,
go ahead and call your surgeon who’s on call.
If you’re at a facility where there’s not the ability to repair the AAA,
go ahead and work on getting that patient emergently transferred to another facility.
There are a few options for repair.
We’re not gonna go into them in too much detail here
because we’re not talking about a vascular surgery course
but basically, endovascular versus open repair are the two options.
In the most recent years, the endovascular or the less invasive treatment
has become more readily available or more commonly used for patients
versus the open repair
and obviously, that has the advantage of it just being less invasive
and potentially better for a patient.
Now, the vascular surgeon will discuss that
and select the appropriate treatment with the patient.
So going back to our case here, so what are the best tests for this gentleman?
So, first of all, first and foremost,
we wanna maintain a high level of suspicion for this diagnosis.
While we may be thinking about other things, could he have a kidney stone?
Could he have pancreatitis? Could he have muscular back pain?
For the most part, you wanna think about in the ED,
the differential of consequence.
What is highest on your differential of consequence?
And here, what we’re talking about is the AAA,
so you’re talking about an aortic aneurysm
and potentially, a ruptured aortic aneurysm.
Involve your surgeon early.
For the most part, the surgeons wanna know about this early
so they can start planning and if you have that high level of suspicion,
get them on the phone, get them involved in the case.
For patients who have hemodynamic compromise like this gentleman,
doing a bedside ultrasound to take a look at the aorta
is gonna be a key initial study,
so it’s gonna be a key thing that you can go ahead
and take a look at, and see whether or not there’s further concern.
Definitely if you’re still worried and your ultrasound looks reassuring,
potentially, you wanna move on to get that CAT scan when your patient is more stable.
So, the conclusion here is remember to keep this on your differential:
can masquerade as it will a lot more benign conditions,
so always make sure that you’re thinking about it.
You wanna assess hemodynamic stability when thinking about the imaging modality.
For a less stable patient, go ahead and get that ultrasound first.
For a patient who’s a little bit more stable,
a CT scan with IV contrast may be a good first choice test.
You also wanna involve your surgeon early
especially when you have a high level of suspicion for the diagnosis.
Sometimes there is no need to wait for that imaging test to come back.
Bedside ultrasound patient, for patients though who are unstable,
has a pretty high sensitivity for triple A if you get a good study,
if you are able to get a good look at the aorta,
and it’s also important to remember that size matters,
so that’s gonna affect what ultimately you’re gonna do for your patient.
If the aneurysm is small,
the patient can have outpatient follow-up in a non-emergent way.
Somewhere in the middle, you wanna get them urgent follow-up
and then for those symptomatic patients,
so for patients who are having pain related to their AAA
or definitely for those patients who are ruptured,
that’s something that requires emergent treatment.
That’s the one who requires a trip to the operating room.