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Day shift. You and your partner are busy absorbing the “surge” of about ten major medical players that have arrived in the last twenty minutes. Patient number nine (your turn) is a sixty year-old male brought in by the paramedics for abdominal pain and vomiting. You pause from entering orders and writing your H&P on the last patient to examine him on the stretcher. He has been sick since this morning, and mostly complains of mid-to lower stomach pains, relatively constant, and associated with vomiting. No diarrhea. New problem. No other PMH (“I don’t go to the doctor much”).

altThe EMS vitals -- no nursing assessment yet -- are P 70, BP 75/60, RR 24. “We noticed that his pressure was a little low,” says the lead medic. “Been vomiting all morning, he’s doing better since we gave him the saline bolus and Phenergan.” The EMS-stretcher exam reveals only diffuse abdominal pain in this somewhat overweight but otherwise healthy man. No rebound or guarding. He is alert & oriented, and confirms the EMS story.

You don’t like either the HR (low for someone who is dehydrated -- no beta blockers) or the blood pressure (low, might be dehydration or a measurement error, need to get the nurse to recheck it). You order fluids, labs, Zofran, cardiac panel/EKG, portable CXR and a non-contrasted CT scan of the abdomen. The patient is off to a room, you scribble the outline of an H&P on the computer, and it’s off to the next case.

It’s a good day in CT, no marathon biopsy cases or blown fuses. Twenty minutes later the tech calls you. “You need to come look at this scan”. No problem.
What does the scan show? What should you do next?
 
continued next for diagnosis
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Both CT scanning and ultrasound have revolutionized our ability to rapidly diagnose and triage this nasty vascular disaster in the ED setting. Sometimes we suspect AAA based on elements of the H&P -- in this case, new abdominal pain & N/V in the setting of low BP gives a strong clue. Other times we find it by accident while looking for a renal stone or other pathology in patients over the age of 50 years. While ultrasound is faster, CT provides more detail. In this scan, you can see not only the large 10cm AAA, but the thin calcific rim (“she’s ready to blow!”) and a hint of the preserved vascular lumen. You can also see the area of hemorrhage, noting the grey blood density extending beyond the peri-spinal region and the psoas muscle on the left side (see arrows). There is little to no blood in the peritoneal cavity, as confirmed by no blood in Morrison’s Pouch (MP).

altCT scanning is also nearly mandatory for modern endovascular surgical repair of this entity. The surgeon needs the CT scan in order to plan the operation. Therefore, in contrast to the old days when the mantra was “go straight to the OR”, now we often go straight to CT, even with a very unstable patient. In this case, we were at a hospital without a vascular surgeon, so transfer after CT imaging was in order.  While any hemorrhage from AAA is potentially life-threatening, a relatively contained retro-peritoneal leak as seen on this CT scan carries a better prognosis than free rupture into the peritoneal cavity. Call the helicopter, give a couple of units of blood, sign the transfer papers, and ... off to the next crisis.

 
 
 
Dr. Dallara practices Emergency Medicine in Virginia and North Carolina, and
directs the Emergency Medicine PREP Course. www.emprepcourse.com
 

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