A 68-year-old man with a history of hypertension presents to the emergency department with sudden-onset severe back pain, hypotension (BP 85/55 mmHg), and a pulsatile abdominal mass. He is diaphoretic and in severe distress. What is the most appropriate immediate next step in management?

Explanation

## Clinical Presentation of Ruptured Abdominal Aortic Aneurysm (RAAA) **Key Point:** A ruptured AAA is a surgical emergency with mortality rates exceeding 80% if not treated urgently. The classic triad of sudden severe back pain, hypotension, and a pulsatile abdominal mass is pathognomonic. ## Diagnosis vs. Treatment in RAAA **High-Yield:** In a haemodynamically unstable patient with clinical suspicion of RAAA, **do NOT delay for imaging**. The diagnosis is clinical, and every minute of delay increases mortality. | Finding | Implication | |---------|-------------| | Sudden severe back/flank pain | Aortic wall rupture | | Hypotension (SBP < 90) | Active bleeding, shock | | Pulsatile abdominal mass | Aneurysm present | | Diaphoresis, distress | Haemodynamic instability | ## Why Immediate OR Transfer is Correct 1. **Haemodynamic instability** (BP 85/55) indicates active rupture and ongoing haemorrhage. 2. **Clinical diagnosis is sufficient** — the constellation of sudden back pain + hypotension + pulsatile mass = RAAA until proven otherwise. 3. **Time to definitive treatment (surgery) is the strongest predictor of survival** [cite:Harrison 21e Ch 297]. 4. **Imaging delays surgery and increases mortality** — even "quick" CT takes 10–15 minutes, during which the patient continues to bleed. ## Correct Management Sequence ```mermaid flowchart TD A[Suspected RAAA with hypotension]:::outcome --> B{Haemodynamically unstable?}:::decision B -->|Yes| C[Immediate OR transfer]:::action B -->|No| D[Stable AAA: CT angiography]:::action C --> E[Resuscitation in OR]:::action C --> F[Emergency open repair or EVAR]:::action E --> G[Aortic cross-clamp]:::action G --> H[Definitive repair]:::outcome ``` **Clinical Pearl:** "Permissive hypotension" is acceptable during transport to the OR — aggressive fluid resuscitation before aortic control can dislodge clots and worsen bleeding. Target SBP 80–90 mmHg until aortic cross-clamping is achieved. **Warning:** Do not waste time on imaging in an unstable patient. Bedside ultrasound may confirm AAA diameter but does NOT change management in the acute setting.