EM@3AM – Abdominal Aortic Aneurysm

Author: Erica Simon, DO, MHA (@E_M_Simon, EM Chief Resident, SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC, USAF)

Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 67 year-old patient with a history of smoking, hypertension, and hyperlipidemia presents for the evaluation of sudden onset, severe, right flank pain. ROS is remarkable only for right thigh pain and weakness of two weeks duration. Triage VS: HR 114, BP 101/78, RR 22, SpO2 92% on room air.

What is the patient’s diagnosis? What’s the next step in your evaluation and treatment?

Answer: Abdominal Aortic Aneurysm^1-3

• Risk Factors: smoking, hypertension, family history, atherosclerosis
• Presentation: sudden onset, severe pain radiating to the back/flank +/- pulsatile abdominal mass, +/- hypotension

• Unstable or Symptomatic:
  • Emergent vascular/general surgery consult
  • Bedside ultrasound
  • Type and screen 6-10U pRBCs

• Stable:
  • CT abdomen/pelvis with IV contrast

• Asymptomatic:
  • Aortic diameter > 3cm: requires follow-up for surveillance
  • Aortic diameter > 5cm (female) or >5 cm (male): surgical candidate

• Pearls:
  • Consider in patients presenting with femoral neuropathy: indicative of a ruptured aneurysm with enlarging hematoma.^2-3
  • Consider in the differential of the elderly syncope patient.

References:

1. Tintinalli J, Kelen G, Stapczynski J, Ma O, Cline D, et al. Tintinalli’s Emergency Medicine. 8^th ed. New York: McGraw-Hill; 2016. Chapter 60, Aneurysmal Disease.
2. Haddad F, Hatrick N, Shanahan D. An unusual presentation of a ruptured abdominal aortic aneurysm. J Accid Emerg Med. 1995; 12(3): 220-221.
3. Razzuk M, Linton R, Darling R. Femoral neuropathy secondary to ruptured abdominal aortic aneurysms with false aneurysms. JAMA. 1967; 201(11): 817-820.