| | | | | | 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)
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| | | | | | 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 qFrequently assess mental status and check for focal neurologic deficits qInitial 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 | | | | | | | | | |
| ❑ 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 | | | |
| | | | | | 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 | | Consider alternative diagnoses | | | | | |