aortic aneurysm rupture

Question 1

risk factors for rupture

Answer 1

rapidly expanding
large diameter
smoking, tobacco use

Question 2

classic triad of rupture

Answer 2

hypotension
severe, tearing back or abdominal pain
painful pulsatile mass

Question 3

other symptoms of AAA rupture

Answer 3

grey turner sign or Cullen’s sign (if there is extensive retroperitoneal hepatoma)
nausea, vomiting
syncope
hematuria

Question 4

free rupture vs contained rupture

Answer 4

free rupture into the peritoneal cvity results in extensive blood loss
hemaatoma following rupture in the retroperitneaal space is sealed by the retroperitoneum, leading to less blood loss and a contained rupture

Question 5

grey turner sign

Answer 5

physical examintion finding of flnk eccymosis due to retroperitonel bleeding

Question 6

cullen sign

Answer 6

physical examination finding chracterized by priumbilical eccymosis and bluish-red discolouration
can be seen in ny dosease that causes rtroperitonel hemorrhage

Question 7

other clinical features of rupture

Answer 7

nausea, vomiting
syncope secondary to severe blood loss
hematuria

Question 8

initial treatment summary

Answer 8

continuous monitoring: telemetry, pulse oximetry, BP checks or arterial line
NPO
large bore IV access
hemodynmic support:
- fluids
- massive transfusion protocol (consent patient for blood transfusion)
- use vasopressors and ionotropes with caution
- aim for permissive hypotension SBP 70-90mm Hg
urgent vascular surgery and anaesthesia consult
- pain management with IV opioids
labs: FBC, Xmatch, order pRBCs
consider POCUS or CTA
immediate vascular surgery and anaesthetics consult for definitive treatment if ruptured aneurysm is suspected: EVAR or OSR

Question 9

why do you aim for permissive hypotension

Answer 9

Clots often form while patients are hypotensive, which help tamponade the rupture site. Raising the patient’s BP may dislodge these clots and worsen bleeding. However, the use of vasopressors may be necessary in patients who do not respond to fluid resuscitation and in whom BP remains too low to support end organ perfusion.

Question 10

prognosis

Answer 10

high mortality rate (~81%)
older age, LOC, cardiac arrest are poor prognostic factors
consider futility/palliation in older patients with numerous comorbidities

Question 11

prevention

Answer 11

lifestyle measures for ASCVD prevention
smoking cessation

Question 12

diagnostics for ruptured AAA

Answer 12

consider imaging in consultation with a vascular surgeon provided it does not delay definitive management
consider thoracoadbominal CTA to determine candidacy for EVAR and to guide operative planning
closely monitor patients clinically during transfer outside of critical care areas
otherwise if unstable, intraoperative assessment is favoured, consider POCUS to rapidly confirm if a trained operator is available, but do not use this to exclude rupture as it has low sensitivity

Question 13

what are the limitations of point of care US (POCUS) for unstable patients with suspected ruptured AAA

Answer 13

you can consider this if a trained operator is readily available and it will not delay definitive treatment
POCUS has a low sensitivity for detecting rupture in the retroperitoneal space (CTA is better for this) the entire aorta may be difficult to visualise due to overlying gas
in an unstable patient, assume that any visible AAA on POCUS is a ruptured AAA

Question 14

what might you find on labs in the patient with ruptured AAA

Answer 14

low Hb, low Hct, low RBC count
metabolic acidosis in cases of shock