A 72-year-old man with chronic hypertension and COPD presents to the emergency department with sudden onset of severe hypogastric and left lower quadrant pain. Blood pressure is 85/50 mmHg, heart rate 120 bpm. Abdominal examination reveals a pulsatile mass below the umbilicus and left flank ecchymosis (Grey Turner sign). Point-of-care ultrasound shows a large heterogeneous mass in the periumbilical region with no clear intimal flap. What is the most appropriate immediate management?

Explanation

## Management of Ruptured Abdominal Aortic Aneurysm (rAAA) ### Clinical Diagnosis: Ruptured AAA **Key Point:** This patient presents with the classic triad of ruptured AAA: 1. **Hypotension (85/50 mmHg)** — profound shock from massive retroperitoneal hemorrhage 2. **Pulsatile abdominal mass** — aneurysm 3. **Grey Turner sign** (left flank ecchymosis) — pathognomonic for retroperitoneal rupture The **absence of intimal flap** on ultrasound rules out dissection and confirms simple rupture. ### Why Immediate Surgery Is Mandatory **High-Yield:** Ruptured AAA is a **surgical emergency with mortality >50% if untreated**. The patient is already in shock (SBP 85 mmHg, HR 120), indicating active hemorrhage. | Management Step | Rationale | | --- | --- | | **Activate vascular surgery NOW** | Delays for imaging increase mortality; unstable patients go directly to OR | | **Establish large-bore IV access** | Prepare for massive transfusion protocol | | **Type & cross for 10+ units PRBC** | Anticipate massive blood loss during repair | | **Avoid aggressive fluid resuscitation** | Increases bleeding; maintain SBP 80–90 mmHg (permissive hypotension) until aortic control | | **Proceed to OR for aortic clamping** | Definitive hemostasis | **Clinical Pearl:** In a hemodynamically unstable patient with clinical diagnosis of rAAA, **do NOT delay for CT imaging**. The diagnosis is made clinically (shock + pulsatile mass + flank ecchymosis); imaging is for stable patients or those with diagnostic uncertainty. ### Why Other Options Are Wrong **Warning:** Aggressive fluid resuscitation before aortic clamping worsens bleeding by increasing afterload and dislodging clots. "Permissive hypotension" (target SBP 80–90 mmHg) is preferred until surgical control is achieved. **Mnemonic: rAAA Management in Shock — "OR FIRST"** - **O**perating room (activate team immediately) - **R**esuscitation (permissive hypotension, not aggressive fluids) - **F**irst imaging (intraoperative if needed; skip preop CT in unstable patients) - **I**ncision (aortic cross-clamp) - **R**epair (open AAA repair or EVAR if anatomy permits) - **S**urvival (ICU care post-op) - **T**ransfusion protocol (massive transfusion) **Key Point:** The distinction between stable and unstable rAAA is critical: - **Stable rAAA** (contained rupture, normal BP): CTA for diagnosis, then elective repair - **Unstable rAAA** (free rupture, shock): **Direct to OR without delay for imaging** [cite:Robbins 10e Ch 11; Harrison 21e Ch 242]