Free Rosen & Barkin's 5-Minute Emergency Medicine Consult by Jeffrey J. Schaider, Adam Z. Barkin, Roger M. Barkin, Philip Shayne, Richard E. Wolfe, Stephen R. Hayden, Peter Rosen Page A

nontender, pulsatile mass
Intact femoral pulses
Ruptured:
Classic triad (only 1/3 of the cases):
Pain
Hypotension
Pulsatile abdominal mass
Systemic:
Hypotension
Tachycardia
Evidence of systemic embolization
Abdomen:
Pulsatile, tender abdominal mass
Flank ecchymosis (Grey Turner sign) indicates retroperitoneal bleed.
Only 75% of aneurysms >5 cm are palpable.
Abdominal tenderness
Abdominal bruit
GI bleeding
Extremities:
Diminished or asymmetric pulses in the lower extremities
Complications:
Large emboli: Acute painful lower extremity
Microemboli: Cool, painful, cyanotic toes (“blue toe syndrome”)
Aneurysmal thrombosis: Acutely ischemic lower extremity
Aortoenteric fistula: GI bleeding
ESSENTIAL WORKUP
Unstable patients:
Bedside abdominal US
Explorative surgery without further ancillary studies
Stable, symptomatic patients:
Abdominal CT
DIAGNOSIS TESTS & NTERPRETATION
Lab
Type and cross-match blood
CBC
Creatinine
Urinalysis
Coagulation studies
Imaging
Plain radiographs:
Abdominal or lateral lumbar radiographs
Only if other tests are unavailable
Curvilinear calcification of the aortic wall or a paravertebral soft-tissue mass indicates abdominal aortic aneurysm (AAA) in 75% of patients.
Cannot identify rupture
Negative study does not rule out AAA.
Abdominal ultrasound:
100% sensitive and 92–99% specific for detecting AAA prior to rupture
In emergent setting, useful to determine presence of AAA.
Ultrasound findings consistent with AAA are enlarged aorta >3 cm or focal dilatation of the aorta.
Sensitivity has been reported as low as 10% following rupture.
Indicated in the unstable patient
Abdominal CT scan:
Contrast is not necessary to make the diagnosis but CT angiogram is required for surgical planning for an endovascular approach
Will demonstrate both aneurysm and site of rupture (intraperitoneal vs. retroperitoneal)
Allows more accurate measurement of aortic diameter
DIFFERENTIAL DIAGNOSIS
Other abdominal arterial aneurysms (i.e., iliac or renal)
Aortic dissection
Renal colic
Biliary colic
Musculoskeletal back pain
Pancreatitis
Cholecystitis
Appendicitis
Bowel obstruction
Perforated viscus
Mesenteric ischemia
Diverticulitis
GI hemorrhage
Aortic thromboembolism
Myocardial infarction
Addisonian crisis
Sepsis
Spinal cord compression
TREATMENT
PRE HOSPITAL
Establish 2 large-bore IV lines
Rapid transport to the nearest facility with surgical backup
Alert ED staff as soon as possible to prepare the following:
Operating room
Universal donor blood
Surgical consultation
INITIAL STABILIZATION/THERAPY
2 large-bore IV lines
Crystalloid infusion
Cardiac monitor
Early blood transfusion
ED TREATMENT/PROCEDURES
    For patients suspected of symptomatic AAA:
Avoid over aggressive fluid resuscitation; this leads to increased bleeding
Emergent surgical consult and operative intervention
Laparotomy versus endovascular aortic repair (EVAR) by vascular surgeon
Diagnostic tests should not delay definitive treatment.
FOLLOW-UP
DISPOSITION
Admission Criteria
    All patients with symptomatic AAA require emergent surgical intervention and admission.
Discharge Criteria
    Asymptomatic patients only
FOLLOW-UP RECOMMENDATIONS
Close vascular surgery follow-up must be arranged prior to discharge
Instructions to return immediately for:
Any pain in the back, abdomen, flank, or lower extremities
Any dizziness or syncope
PEARLS AND PITFALLS
AAA should be on the differential for any patient presenting with pain in the abdomen, back, or flank.
Symptomatic AAA requires immediate treatment. Do not delay definitive care for extra studies.
A hemodynamically unstable (i.e., hypotensive) patient should not be taken for CT scan.
ADDITIONAL READING
Bentz S, Jones J. Accuracy of emergency department ultrasound in detecting abdominal aortic aneurysm.
Emerg Med J
. 2006;23(10):803–804.
Choke E, Vijaynagar B, Thompson J, et al. Changing epidemiology of abdominal aortic aneurysms in England and Wales: Older and more benign?
Circulation
.