Ruptured aortic aneurysm

Question 1

Describe the rupture rates of aortic aneurysms?

Answer 1

• <5.5cm = 1% / year
• >6cm = 25% / year

Question 2

Who is at greater risk of aortic aneurysm rupture?

Answer 2

• Hypertension
• Smokers
• Female
• Strong family history

Question 3

Describe the presentation of a ruptured aortic aneurysm?

Answer 3

• Triad of:
  
  • Sudden onset severe abdominal pain
    
    • Radiates to back or flanks (don’t dismiss as colic)
  • Shock
  • Pulsatile abdominal mass

Question 4

Describe the management of a ruptured aortic aneurysm?

Answer 4

• SURGICAL EMERGENCY
• High flow O₂
• Insert 2x large bore cannulae
  
  • Give fluid if shocked but keep SBP <100mmHg
  • Give O- blood if required
  • Blood: FBC, U&E, clotting, amylase, x-match
• Initiate the majory haemorrhage protocol
• Call vascular surgeon, anaesthetist and theatre
• Analgesia
• Antibiotic prophylaxis: Cef + met
• Urinary catheter + CVP line
• If stable and diagnosis uncertain: US or CT
• TAKE TO THEATRE

Question 5

Describe the surgical management of a ruptured aortic aneurysm?

Answer 5

• Clamp neck
• Insert dacron graft
  
  • Synthetic polyester in the shape of a tube

Question 6

Describe the mortality of a ruptured AAA?

Answer 6

• 100% without surgery
• 50% with surgery

Question 7

How can an aneurysm be classified?

Answer 7

• Site
• Underlying cause
• Morphology

Question 8

Name some common sites of aneurysm?

Answer 8

• Infrarenal aorta
• Popliteal
• Femoral
• Subclavian

Question 9

What reasons result in a patient surviving AAA rupture?

Answer 9

• Rupture is into retroperitoneum, which restricts the extent of the leak
• There is intense vasoconstriction of nonessential circulatory beds
• Patients develops prothrombotic state
• BP drops which limits blood loss

Question 10

What should not be done for someone with a ruptured AAA?

Answer 10

• Do not give large volumes of IV fluid
  
  • Would result in increased BP
  • Impaired haemostasis
  • Reduced vasoconstriction

Question 11

What are the options for repair of ruptured AAA?

Answer 11

• Clamp and graft the aorta
• Insert a stent graft (EVAR)
  
  • Control bleeding through angioplasty ballon occlusion of thoracic aorta

Question 12

Describe open AAA repair?

Answer 12

• Replace aneurysmal segment with a prosthetic graft

Question 13

BMJ best practice guidelines for the management of a ruptured AAA?

Answer 13

• Resuscitation measures
  
  • Airway management
  • SBP target 50-70, withhold fluids pre-operatively
• Urgent surgical repair
  
  • EVAR preferred
• Perioperative antibiotic therapy
  
  • Cover gram positive and negative