01Approach to the Critical Patient/attcp60

Immediate priorities

›Time-critical surgical emergency recognition

›Ruptured AAA suspected

›Hypotension with abdominal or back pain

›Known AAA with new pain

›If hemodynamically unstable with known AAA, activate vascular surgery immediately

›Overall mortality approaches 80% to 90% including prehospital deaths

›Operative mortality 30% to 50%

›Door to operating room minimization

›Bedside ultrasound to confirm aneurysm

›Avoid diagnostic delay in unstable patient

›ABC and resuscitation priorities

›Two large-bore IV lines

›16 gauge or larger

›Central access if peripheral inadequate

›Permissive hypotension strategy

›Target SBP 70 to 90 mmHg in active rupture

›Avoid aggressive crystalloid to limit clot disruption

›Massive transfusion protocol activation

›Balanced ratio red cells plasma platelets

›Uncrossmatched O negative if emergent

›Key early branching

›Hemodynamically unstable pathway

›Direct to operating room with surgeon

›No delay for CT if classic presentation

›Hemodynamically stable pathway

›CT angiography to define anatomy

›EVAR candidacy assessment

02History/hx61

Presentation pattern

›Classic triad

›Hypotension

›Syncope or near-syncope

›Pre-hospital collapse

›Abdominal or back pain

›Sudden severe onset

›Tearing or ripping quality

›Pulsatile abdominal mass

›Full triad present in only about one-third of cases

›Absence does not exclude rupture

›Pain characteristics

›Flank or groin radiation

›Retroperitoneal rupture pattern

›Mimics renal colic

›Onset and progression

›Abrupt maximal at onset

›Unrelenting and severe

Risk factors

›Established AAA risk factors

›Male sex

›4 to 6 times higher prevalence than female

›Earlier age of presentation

›Advanced age

›Prevalence rises sharply after age 65

›Peak incidence seventh and eighth decades

›Smoking history

›Strongest modifiable risk factor

03Physical Exam/exam51

Vitals and general

›Hemodynamic snapshot

›Blood pressure

›Hypotension SBP less than 90 mmHg

›May be normal in contained rupture

›Heart rate

›Tachycardia from hemorrhage

›Relative bradycardia possible with vagal response

›Perfusion markers

›Cool clammy skin

›Delayed capillary refill

›General appearance

›Distress and pallor

›Agitation from hypoperfusion

›Diaphoresis

›Mental status

›Confusion as shock marker

›Syncope history

Abdominal and vascular exam

›Abdominal findings

›Pulsatile expansile mass

›Periumbilical location

›Sensitivity falls with obesity and rupture

›Abdominal tenderness

›Diffuse or focal

›Peritoneal signs with free rupture

›Abdominal distension

›Retroperitoneal or intraperitoneal blood

04Differential Diagnosis/ddx41

Life-threatening diagnoses

›Vascular catastrophes

›Ruptured abdominal aortic aneurysm

›ICD-10 I71.3 ruptured AAA

›ICD-10 I71.4 AAA without rupture

›Aortic dissection

›ICD-10 I71.0

›Pulse deficits and pressure differential

›Aortoenteric fistula

›Prior aortic graft

›Massive GI bleeding

›Intra-abdominal hemorrhage

›Ruptured visceral artery aneurysm

›Splenic or hepatic artery

›Sudden hypovolemia

›Hemorrhagic pancreatitis

›Lipase elevation

›Epigastric pain

Common mimics

›Genitourinary mimics

›Renal colic

›ICD-10 N23

›Most frequent misdiagnosis of ruptured AAA

›Pyelonephritis

›Fever and pyuria

›Costovertebral tenderness

›Gastrointestinal mimics

›Diverticulitis

05Laboratory Tests/lt34

Core labs

›Hemorrhage and resuscitation panel

›Type and crossmatch

›Crossmatch at least 6 to 10 units

›Activate massive transfusion protocol

›Complete blood count

›Hemoglobin may be normal early

›Serial values track ongoing loss

›Coagulation studies

›PT INR and aPTT

›Fibrinogen for consumptive coagulopathy

›Metabolic and organ function

›Renal function and electrolytes

›Baseline creatinine before contrast

›Hyperkalemia with hypoperfusion

›Lactate

›Marker of hypoperfusion

›Greater than 4 mmol/l indicates severe shock

Point-of-care and adjunct labs

›Bedside testing

›Point-of-care hemoglobin

›Rapid trend during resuscitation

›Guides transfusion

›Venous or arterial blood gas

›Base deficit severity

›pH and lactate

›Ionized calcium

›Citrate chelation during massive transfusion

06Diagnostic Tests/dt65

Scoring Systems

›Risk and prognostic tools

›Glasgow Aneurysm Score

›Age plus shock plus comorbidity points

›Higher score predicts operative mortality

›Hardman Index

›Five risk factors for open repair mortality

›Age over 76 creatinine ischemia hemoglobin consciousness

›Vascular Study Group scoring

›Perioperative mortality estimation

›Informs goals-of-care discussions

›Limitations

›Scores do not replace clinical judgment

›Do not delay surgery

›Adjunct for prognosis only

›Validation populations vary

›Use locally where validated

›ACEP Level C recommendation for adjunct use

MRI

›MRI and MRA role

›Generally not used in acute rupture

›Time constraints preclude unstable use

›CT angiography preferred

›Problem-solving indications

›Severe contrast allergy in stable patient

›Renal failure avoiding iodinated contrast

›Contraindications

›Hemodynamic instability

07Disposition/dispo27

Level of care

›Emergent operative pathway

›Unstable confirmed or suspected rupture

›Direct to operating room

›Vascular surgery and anesthesia present

›Stable confirmed rupture

›Urgent OR or hybrid suite

›EVAR versus open decision

›Postoperative ICU

›Hemodynamic monitoring

›Abdominal compartment surveillance

›Transfer criteria

›No on-site vascular surgery

›Immediate transfer to vascular center

›Resuscitate en route with permissive hypotension

›Communication and timing

›Accepting surgeon before departure

›Blood products for transport

Goals of care

›Prognosis-based decisions

›Very high operative risk

›Advanced frailty and comorbidity

›Shared decision-making

›Comfort-focused pathway

›When repair not survivable or not desired

›Palliative symptom control

›Family discussion

›Realistic mortality counseling

08Treatment/t70

Resuscitation and hemodynamic control

›Permissive hypotension

›Blood pressure target

›Maintain SBP 70 to 90 mmHg before control

›Preserve mentation in awake patient

›Fluid strategy

›Minimize crystalloid to avoid clot disruption

›Prioritize blood products over saline

›If profound hypotension, titrate to perfusion not normotension

›Avoid over-resuscitation rebleeding

›Reassess continuously

›Massive transfusion

›Balanced product ratio

›Red cells plasma platelets near 1 to 1 to 1

›Activate institutional protocol early

›Uncrossmatched blood

›O negative for emergent need

›Switch to type-specific when available

›Coagulopathy correction

›Tranexamic acid 1 g IV over 10 minutes then 1 g over 8 hours

›Fibrinogen replacement to maintain greater than 1.5 g/l

›Ionized calcium replacement during transfusion

Pain and pressure adjuncts

›Analgesia

›Opioid titration

›Fentanyl 25 to 50 mcg IV titrated to comfort

›Avoid hypotension with careful dosing

›Reassessment

09Special Populations/sp39

Pregnancy

›Pregnancy considerations

›Rarity and risk

›AAA rupture uncommon in pregnancy

›Connective tissue disorders raise risk

›Imaging approach

›Ultrasound first to limit radiation

›CT when maternal benefit outweighs fetal risk

›Resuscitation modifications

›Left lateral tilt to relieve aortocaval compression

›Maternal stabilization prioritized

›Delivery coordination

›Obstetrics and neonatology involvement

›Perimortem cesarean if maternal arrest

Geriatric

›Older adult features

›Highest prevalence group

›Most ruptures occur after age 65

›Multiple comorbidities common

›Atypical presentation

›Syncope or back pain without classic triad

›Anchoring on benign diagnoses

›Physiologic vulnerability

›Reduced cardiac and renal reserve

›Limited tolerance of hypotension

›Goals-of-care emphasis

›High operative mortality with frailty

›Shared decision-making

10Background/b58

Epidemiology

›Incidence and burden

›Prevalence pattern

›AAA present in 4% to 8% of older men

›4 to 6 times more common in men

›Rupture mortality

›Overall mortality 80% to 90% including prehospital deaths

›Operative mortality 30% to 50%

›Diagnostic error

›Misdiagnosis rate 32% to 42%

›Delay increases mortality

›Risk distribution

›Diameter-dependent rupture risk

›Annual rupture risk rises above 5.5 cm

›Very high above 7 cm

›Screening impact

›One-time ultrasound screening reduces rupture deaths

›Men aged 65 to 75 who ever smoked

Pathophysiology

›Aneurysm formation

›Wall degeneration

›Elastin and collagen breakdown

›Matrix metalloproteinase activity

›Hemodynamic stress

›Laplace law wall tension rises with radius

›Hypertension accelerates dilation

›Inflammatory contribution

›Atherosclerotic inflammation

11Patient Discharge Instructions/pdi20

copy discharge instructions

›Postoperative recovery guidance

›Wound and incision care as instructed

›Activity restrictions until cleared by surgeon

›Take all prescribed medications

›Attend all vascular surgery follow-up appointments

›Warning signs to return to ER

›Sudden severe abdominal or back pain

›Fainting or near-fainting

›Rapid heartbeat or feeling lightheaded

›New leg pain coldness or color change

›Fever or spreading redness at incision

›Blood in stool or black tarry stools

›Risk-factor management

›Stop smoking completely

›Take blood pressure medication as directed

›Keep cardiovascular follow-up appointments

›Surveillance for patients with known aneurysm

›Attend scheduled imaging surveillance

›Report any new abdominal or back pain immediately

›Inform relatives that AAA can run in families

12References/r12

Guidelines and key sources

›Guideline sources

›ACC AHA peripheral arterial disease guideline including abdominal aortic disease

›Society for Vascular Surgery practice guidelines on abdominal aortic aneurysm

›ACEP clinical policies on imaging in suspected aortic emergencies

›Evidence summaries

›Systematic review and meta-analysis on misdiagnosis of ruptured AAA

›Trials comparing endovascular versus open repair for ruptured AAA

›Reviews on permissive hypotension and damage-control resuscitation

›Coding standards

›ICD-10 I71.3 abdominal aortic aneurysm ruptured

›ICD-10 I71.4 abdominal aortic aneurysm without rupture

›SNOMED CT ruptured abdominal aortic aneurysm disorder concept

Evidence & Review

Evidence & Review