Sandbox Yaz

Identify cardinal findings that increase the pre-test probability of symptomatic or complicated abdominal aortic aneurysm (AAA) ❑ Known large AAA > 5.5 cm or ❑ Known rapid AAA expansion rate > 0.5 cm/year ❑ Acute abdominal/back pain that may radiate to buttocks, groin region, or lower extremities ❑ Tearing/sharp quality ❑ Increasing in intensity ❑ Pulsating abdominal mass ❑ Hypotension or shock ❑ Altered mental status ❑ Unexplained syncope ❑ Coma ❑ Muscular weakness ❑ Cold extremities ❑ Peripheral cyanosis ❑ Acute limb pain ❑ Fever or sepsis ❑ Known infective endocarditis (high risk for infected aneurysm) ❑ Presence of AAA risk factors ❑ Female gender ❑ Advanced age > 50 years ❑ Smoking ❑ Advanced atherosclerosis ❑ History of prior stroke ❑ Hypertension ❑ Transplantation (cardiac or renal) ❑ Known reduced FEV1 (obstructive pulmonary disease)

Rule out life threatening alternative diagnoses: ❑ Aortic dissection (suggestive findings: Chest pain, Abdominal pain, back pain, interscapular pain, Hypotension, Dyspnea, Nausea, Cold sweats ❑ Aortic dissection (suggestive findings: back pain, interscapular pain, aortic regurgitation, pulsus paradoxus, blood pressure discrepancy between the arms) ❑ Pulmonary embolism (suggestive findings: acute onset of dyspnea, tachypnea, hemoptysis, previous DVT) ❑ Cardiac tamponade (suggestive findings: hypotension, jugular venous distention, muffled heart sounds, pulsus paradoxus) ❑ Tension pneumothorax (suggestive findings: sudden dyspnea, tachycardia, chest trauma, unilateral absence of breath sound) ❑ Esophageal rupture (suggestive findings: vomiting, subcutaneous emphysema)

Stabilize and resuscitate the patient ❑ Attend to the patient's ABCs (Airway, Breathing, Circulation) ❑ Consider endotracheal intubation if the patient's airway is compromised, has a Glasgow coma scale (GCS < 8) or profound hemodynamic instability ❑ Administer oxygen and maintain a saturation >90% ❑ Secure 2 large-bore intravenous (IV) lines ❑ Administer fluids to reach a target systolic blood pressure (SBP) of 70 to 100 mm Hg. Excessive fluid administration in AAA is associated with worse outcomes ❑ Do NOT routinely administer vasopressors if patient is hypotensive at presentation. Vasopressor administration in AAA is controversial. Consider ANY of the following vasopressors only if patient remains hypotensive despite fluids ❑ Norepinephrine 0.05 microgram/kg/minute IV; titrate by 0.02 microgram/kg/minute every 5 minutes, OR ❑ Phenylephrine 100-180 microgram/minute; titrate by 25 microgram/minute every 10 minutes, OR ❑ Dopamine 5 microgram/kg/minute; titrate by 5 microgram/kg/minute every 10 minutes ❑ Obtain 12 lead ECG and place the patient on a cardiac monitor ❑ Place an indwelling urethral catheter and monitor urine output ❑ Frequently assess mental status and check for focal neurologic deficits ❑ Initial laboratory work-up ❑ Type and crossmatch 6 to 10 units of PRBC. FFP may also be needed in cases of massive transfusion ❑ Do not administer pre-op transfusions except if patient is unconscious or has signs or myocardial infarction ❑ Withdraw blood for CBC, electrolytes, BUN, serum creatinine, LFTS, PT, PTT, troponin I, CK, CK-MB, CRP or ESR, and multiple blood cultures Pain management ❑ Assess pain severity (self-report NRS scale 0 to 10; unconscious BPS 3-12 or CPOT 0-8). Pain considered significant if NRS≥4, BPS<5, or CPOT≥3 ❑ Administer IV opioids: Morphine 4-10 mg IV every 4 hours, infused over 4-5 minutes (dose range: 5-15 mg) ❑ Consider pre-op epidural catheter if patient meets ALL of the following criteria ❑ Patient hemodynamically stable, AND ❑ Contained leak, AND ❑ Satisfactory coagulation profile ❑ Maintain patient in a conscious state ❑ Monitor any significant undesired drop in blood pressure as pain medications are administered

Patient hemodynamically unstable despite resuscitation? ❑ Hypotension (SBP < 90 mm Hg) despite resuscitation ❑ Tachycardia (HR > 100 bpm) despite resuscitation

Yes. Patient is still hemodynamically unstable despite resuscitation.

No. Patient is hemodynamically stable following resuscitation

Is the patient known to have an AAA?

Can patient have CT scan with contrast?

Yes

No

Yes

No

❑ Proceed to operating room without further work-up

❑ Obtain focused bedside ultrasound

❑ Obtain CT scan with IV contrast of abdominal aorta and iliac arteries

❑ Obtain CT scan without IV contrast of abdominal aorta and iliac arteries

AAA confirmed on imaging?

Yes

No

Consider alternative diagnoses

Evaluate need for further management of the following AAA complications For patients suspected to have thromboembolism ❑ Obtain Duplex ultrasound of affected extremities ❑ Consider CT scan of aorta from aortic valves to iliac bifurcation For patients suspected to have infected (mycotic) aneurysm ❑ Consider gallium scanning or 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) to evaluate disease activity For patients suspected to have aortovenous fistula ❑ Obtain CT angiography For patients suspected to have aortoenteric fistula ❑ Perform EGD to rule out other possible etiologies of GI bleed among hemodynamically stable patients ❑ Obtain CT scan with IV contrast of the abdomen and iliac arteries ❑ Consider arteriography

Once diagnosis of complicated AAA is confirmed, all patients require blood cultures and empirical antibiotic therapy for gram-positive and gram-negative coverage (even if afebrile at presentation) ❑ Withdraw multiple sets of blood culture (if blood cultures were not withdrawn initially) ❑ Administer empiric combination antibiotic therapy ❑ Vancomycin 1-1.5g IV every 12 hours PLUS One of the following ❑ Ceftriaxone 2 g IV every 12 hours, OR ❑ Cefuroxime 1.5 g IV every 4 hours, OR ❑ Piperacillin-tazobactam

Proceed to further management