01Approach to the Critical Patient/attcp60

Triage and first 5 minutes

›Instability screen

›Hypotension

›Systolic blood pressure under 90 mmHg

›Shock index over 1

›High risk pain pattern

›Sudden severe abdominal pain

›Sudden severe back or flank pain

›Perfusion threat

›Altered mental status

›Cool mottled skin

›Rupture concern

›Syncope or near syncope

›Rapid hemoglobin fall

›Early parallel actions

›Team activation

›Vascular surgery or interventional radiology activation for rupture pathway

›Anesthesia and operating room notification for high suspicion

›Monitoring

›Cardiac monitor

›Continuous pulse oximetry

›Vascular access

›Two large bore peripheral IV

›Rapid infuser availability

›Bedside imaging

›Point of care ultrasound aorta for immediate confirmation

›If unstable and positive POCUS then rupture pathway without delay

02History/hx54

Presentation patterns

›Classic symptom complex

›Pain

›Abdominal

›Back

›Syncope

›Collapse episode

›Presyncope with diaphoresis

›Hypotension

›EMS low blood pressure

›Transient response to fluids

›Atypical presentations

›Isolated flank pain

›Mimics renal colic

›Minimal abdominal tenderness

›Isolated groin or hip pain

›Iliac aneurysm involvement

›Femoral neuropathy symptoms

›Gastrointestinal symptoms

›Nausea and vomiting

›Early satiety from mass effect

Risk factors and triggers

›Atherosclerotic risk

›Smoking history

›Current smoker

›Prior heavy smoking

›Hypertension

›Longstanding

03Physical Exam/exam41

Hemodynamics and perfusion

›Vital sign pattern

›Hypotension

›Systolic blood pressure under 90 mmHg

›Narrow pulse pressure

›Tachycardia

›Heart rate over 100 beats per minute

›Relative bradycardia possible in elderly or beta blocker use

›Respiratory distress

›Tachypnea

›Hypoxia from shock

›Shock exam

›Skin perfusion

›Cool clammy

›Mottling

›Mental status

›Confusion

›Lethargy

Abdominal and vascular exam

›Abdominal findings

›Tenderness

›Diffuse

›Left sided or periumbilical

›Pulsatile mass

›Palpable midline pulsation

›Not reliably present

›Peritonitis

›Guarding

04Differential Diagnosis/ddx45

Life threatening mimics

›Aortic syndromes

›Aortic dissection

›Chest pain with back pain

›Pulse deficit

›Thoracoabdominal aneurysm rupture

›Chest to abdomen pain

›Hypotension

›Cardiac and vascular

›Acute coronary syndrome

›Epigastric pain

›Diaphoresis

›Massive pulmonary embolism

›Syncope

›Hypotension with hypoxia

›Abdominal catastrophes

›Mesenteric ischemia

›Pain out of proportion

›Elevated lactate

›Perforated viscus

›Peritonitis

›Free air on imaging

Common mimics by symptom cluster

›Flank pain predominant

›Ureterolithiasis

›Colicky pain waves

›Hematuria

›Pyelonephritis

05Laboratory Tests/lt38

Hemorrhage and transfusion readiness

›Hemorrhage evaluation

›Complete blood count

›Hemoglobin trend for bleeding severity

›Platelet count for transfusion planning

›Type and screen

›Immediate availability of uncrossmatched blood if unstable

›Crossmatch for operative planning

›Coagulation profile

›INR for warfarin effect

›aPTT for heparin effect

›Massive transfusion monitoring

›Fibrinogen

›Low fibrinogen marker of consumption

›Cryoprecipitate threshold per local protocol

›Ionized calcium

›Citrate toxicity during transfusion

›Calcium replacement guidance

Shock and end organ assessment

›Perfusion markers

›Lactate mmol per L

›Elevated lactate supports shock physiology

›Clearance trend for resuscitation response

›Venous blood gas

›Metabolic acidosis assessment

›Elevated lactate correlation

›Renal and metabolic baseline

›Creatinine and electrolytes

06Diagnostic Tests/dt69

Scoring Systems

›Prognostic scores for ruptured AAA

›Hardman index

›Age over 76 years

›Creatinine over 190 micromol per L

›Hemoglobin under 9 g per dL

›Loss of consciousness

›Ischemic ECG changes

›Glasgow aneurysm score

›Age component

›Shock component

›Myocardial disease component

›Clinical application limits

›Scores support counseling

›Not for denying potentially life saving care

›Use alongside surgical judgment

›Score timing sensitivity

›Prehospital physiology changes

›Resuscitation alters variables

MRI

›Limited role in acute AAA

›Hemodynamic stability requirement

›Not for unstable rupture

›Prolonged acquisition time

›Contrast considerations

›Gadolinium caution in advanced kidney disease

›Alternative when iodinated contrast contraindicated

›Potential indications

07Disposition/dispo28

Rupture and symptomatic AAA

›Ruptured AAA pathway

›Immediate definitive care

›Operating room or endovascular suite

›Avoid delays for nonessential testing

›Transfer criteria

›No vascular surgery capability onsite

›No endovascular capability when EVAR likely

›Symptomatic intact AAA

›Admission requirement

›Pain attributed to aneurysm

›Rapid aneurysm growth suspected

›Urgency

›Vascular surgery consult in ED

›CT angiography for planning if stable

Incidental small AAA

›Discharge eligibility

›Asymptomatic

›No aneurysm related pain

›Stable vital signs

›Reliable follow up

›Primary care or vascular clinic referral

›Surveillance imaging plan documented

›Follow up timeframes

›Size based surveillance

›3.0 to 3.9 cm ultrasound every 3 years

›4.0 to 4.9 cm ultrasound every 12 months

›Larger aneurysm surveillance

08Treatment/t85

Resuscitation for suspected rupture

›Hemorrhage control strategy

›Damage control resuscitation

›Early balanced transfusion

›Packed red blood cells per massive transfusion protocol

›Plasma per massive transfusion protocol

›Platelets per massive transfusion protocol

›Crystalloid minimization

›Small bolus only if no blood immediately available

›Stop crystalloid once blood products running

›Permissive hypotension targets

›Systolic blood pressure 80 to 90 mmHg

›If altered mental status then higher target individualized

›If traumatic brain injury concern then avoid hypotension

›Vasopressor bridge when needed

›Norepinephrine infusion

›Initiate 0.05 microgram per kg per minute

›Titrate every 2 to 5 minutes

›Typical range 0.05 to 0.5 microgram per kg per minute

›Goal

›Maintain minimal perfusion until hemorrhage control

›Avoid hypertension that increases bleeding

Analgesia and antiemesis

›Opioid analgesia

›Fentanyl IV

›25 to 50 microgram bolus

›Repeat every 5 to 10 minutes as needed

›Monitor for hypotension and respiratory depression

›Hydromorphone IV

›0.2 to 0.5 mg bolus

›Repeat every 10 to 15 minutes as needed

›Reduced dose in older adults

›Antiemetic options

›Ondansetron IV

›4 mg dose

›Repeat once if needed

›QT prolongation risk consideration

›Metoclopramide IV

›10 mg dose

›Akathisia risk

›Avoid in bowel obstruction concern

Anticoagulation reversal when emergent surgery likely

›Warfarin reversal

›Four factor prothrombin complex concentrate

›Weight based dosing per institutional protocol

›Higher dose for INR over 4

›Lower dose for INR 2 to 4

›Vitamin K IV

›5 to 10 mg dose

›Slower onset but sustains reversal

›Factor Xa inhibitor reversal

›Andexanet alfa when available

›High dose regimen for recent high dose ingestion per protocol

›Low dose regimen for lower exposure per protocol

›Four factor prothrombin complex concentrate alternative

›50 units per kg commonly used off label

›Thrombosis risk monitoring

Definitive management coordination

›Operative pathway selection

›Endovascular aneurysm repair suitability

›Adequate proximal neck anatomy on CT angiography

›Adequate iliac access vessels

›Open repair indications

›Unfavorable anatomy for EVAR

›Hemodynamic collapse with no endovascular option

›Perioperative adjuncts

›Antibiotic prophylaxis

›Cefazolin IV per surgical protocol

›Alternative for severe beta lactam allergy per protocol

›Temperature management

›Active warming

›Prevent hypothermia related coagulopathy

Medical management for intact AAA and prevention

›Cardiovascular risk reduction

›Smoking cessation

›Nicotine replacement options

›Counseling and follow up plan

›Statin therapy

›High intensity statin for atherosclerotic risk

›LDL reduction target per prevention guidelines

›Blood pressure control

›Antihypertensive adherence

›Avoid severe uncontrolled hypertension

›Surveillance and elective repair thresholds

›Elective repair size thresholds

›Men diameter 5.5 cm or greater

›Women diameter 5.0 cm or greater

›Growth thresholds

›Expansion 0.5 cm or more in 6 months

›Expansion 1.0 cm or more in 12 months

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Rare but catastrophic

›Increased blood volume masking early shock

›Maternal fetal mortality risk high with rupture

›Imaging choices

›Ultrasound preferred initial test

›CT angiography if life threatening instability and planning required

›Medication considerations

›Avoid teratogenic antihypertensives when possible

›Obstetrics consultation early

Geriatric

›Older adult considerations

›Atypical physiology

›Relative bradycardia on beta blockers

›Baseline low blood pressure

›Comorbidity burden

›Coronary disease increases perioperative risk

›Chronic kidney disease affects contrast decisions

›Frailty and goals of care

›Rapid discussion with patient and family when feasible

›Incorporate surgical risk and patient values

Pediatrics

›Pediatric AAA considerations

›Extremely rare

›Congenital aneurysm

›Connective tissue disorder

›Etiology differences

10Background/b51

Epidemiology

›Population patterns

›Age distribution

›Prevalence increases after 65 years

›Peak in older adults

›Sex distribution

›Higher prevalence in men

›Higher rupture risk in women at smaller diameters

›Smoking association

›Strongest modifiable risk factor

›Risk persists after cessation but decreases over time

›Screening impact

›One time ultrasound screening

›Men 65 to 75 ever smoked benefit highest

›Family history may justify broader screening

›Mortality reduction

›Elective repair prevents rupture deaths

›Surveillance detects expansion

Pathophysiology

›Aneurysm biology

›Wall degeneration

›Elastin breakdown

›Collagen remodeling

›Inflammation and proteolysis

›Matrix metalloproteinase activity

›Chronic inflammatory infiltrate

›Hemodynamic stress

›Increased wall tension with larger radius

11Patient Discharge Instructions/pdi24

Copy discharge instructions

›Abdominal aortic aneurysm follow up plan

›Imaging surveillance schedule

›Ultrasound timing provided based on aneurysm size

›Vascular clinic referral if near repair threshold

›Risk reduction actions

›Stop smoking support resources

›Take blood pressure and cholesterol medications as prescribed

›Return to emergency care now

›Rupture warning symptoms

›Sudden severe abdominal pain

›Sudden severe back or flank pain

›Shock warning symptoms

›Fainting or near fainting

›New severe weakness or confusion

›Limb ischemia symptoms

›New cold painful leg

›New numbness or weakness in a leg

›Activity and medication guidance

›Avoid heavy lifting until follow up if symptomatic or large aneurysm

›Discuss safe limits with vascular team

›Gradual return to activity when cleared

›Medication safety

›Do not stop anticoagulants without clinician guidance

›Report any new bleeding concerns promptly

12References/r17

Clinical guidelines and society statements

›Guideline sources

›ACC AHA guideline for aortic disease

›Screening and surveillance recommendations

›Repair threshold recommendations

›Society for Vascular Surgery clinical practice guidelines

›Elective repair thresholds

›Surveillance intervals

›European Society for Vascular Surgery AAA guidelines

›EVAR and open repair considerations

›Rupture management principles

Evidence based sources and tools

›Evidence anchors

›Major randomized trials comparing EVAR and open repair in elective AAA

›Short term outcomes comparisons

›Long term reintervention considerations

›Prognostic tools for ruptured AAA

›Hardman index derivation and validation studies

›Glasgow aneurysm score validation studies

Evidence & Review

Evidence & Review