A 68-year-old man with a history of hypertension and smoking presents to the emergency department with sudden-onset severe back pain radiating to the left flank. He is diaphoretic and anxious. Blood pressure is 160/95 mmHg in the right arm and 140/85 mmHg in the left arm. Pulse is 110/min. On examination, a pulsatile abdominal mass is palpable. Bedside ultrasound shows a dilated abdominal aorta with echogenic material suggesting a contained rupture. What is the most appropriate immediate management?

Question

Accepted Answer

B. Immediate transfer to OR for open repair after aggressive fluid resuscitation and permissive hypotension. ## Diagnosis and Pathophysiology

This patient presents with a **ruptured abdominal aortic aneurysm (rAAA)** with clinical evidence of contained rupture — sudden severe back/flank pain, hemodynamic instability, pulsatile mass, and ultrasound findings of aortic dilation with echogenic material.

**Key Point:** A contained rupture is still a surgical emergency; the aortic wall is breached but contained by surrounding tissues (retroperitoneum). Mortality remains 30–50% even with prompt intervention.

## Immediate Management Principles

**High-Yield:** The "Damage Control" approach for rAAA:

1. **Permissive hypotension** — target systolic BP 100–110 mmHg (NOT normalization)
   - Aggressive fluid resuscitation increases bleeding and mortality
   - Maintain cerebral and coronary perfusion without dislodging clot
2. **Rapid transfer to OR** — no delays for imaging
3. **Minimal IV access** — avoid aggressive fluid boluses
4. **Type & cross, activate massive transfusion protocol**
5. **Anesthesia on standby** before arrival

**Clinical Pearl:** In a hemodynamically unstable patient with clinical diagnosis of rAAA, **do NOT delay for CT**. Bedside ultrasound or clinical suspicion is sufficient to proceed to OR. CT is for stable patients with equivocal presentation.

## Why Open Repair Here?

Contained rupture with hemodynamic instability and immediate availability of OR → **open surgical repair** is the standard. Endovascular repair (EVAR) requires:
- Stable hemodynamics
- Anatomically suitable aorta (infrarenal, adequate neck)
- Experienced team and time for imaging/planning

In this acute, unstable scenario, open repair is faster and more definitive.

**Mnemonic: rAAA Triage — "STOP & GO"**
- **S**table + suitable anatomy → EVAR
- **T**ransfer to OR immediately
- **O**pen repair (default for unstable)
- **P**ermissive hypotension (SBP 100–110)
- **G**o to OR, not CT

[cite:Sabiston Textbook of Surgery 21e Ch 64]

Answer

A. CT angiography of the abdomen and pelvis with IV contrast to confirm diagnosis before any intervention

Answer

C. Observation with serial ultrasound and pain control; most contained ruptures resolve spontaneously

Answer

D. Intravenous nitroprusside and labetalol to achieve target systolic BP of 100–110 mmHg, followed by endovascular repair

Explanation

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