Ruptured abdominal aortic aneurysm

Diagnosis: The ruptured abdominal aortic aneurysm — the older male smoker (the high-risk profile), the sudden abdominal pain radiating to the back, the syncope, the hypotension (the systolic 76), and the pulsatile abdominal mass (the full classic triad). This is the surgical emergency.^[2]

Assessment: ABCDE. The airway and the breathing (the high-flow oxygen), the two large-bore cannulae, the bloods (the full blood count, the coagulation, the urea and electrolytes, the lactate, the troponin), the urgent group and crossmatch of 6 to 10 units, the ECG (the coexisting cardiac disease), the arterial blood gas.^[3]

The cardinal rule — NO CT: This patient is the unstable (the systolic 76) with the known-type aneurysm (the pulsatile mass). He goes to the immediate vascular surgery and the theatre, without the CT scanner. The delay for the CT in the unstable ruptured aneurysm is the fatal error.^[2][3]

^[3][2]Resuscitation: The permissive hypotension — the systolic held around 80 to 100 mmHg, enough for the organ perfusion but not so high as to dislodge the retroperitoneal clot and worsen the bleeding. The avoidance of the aggressive crystalloid. The analgesia (the cautious fentanyl). The activation of the massive transfusion if needed. The vascular surgery call immediately, the theatre, the anaesthetic team.

^[3]Definitive management: The open repair or the endovascular aneurysm repair (the EVAR), the choice guided by the anatomy (the CT-on-table or the intraoperative) and the local capability — the EVAR is favoured for the ruptured aneurysm where the anatomy allows, per the IMPROVE evidence.

^[2]Disposition: The theatre, then the intensive care.