Case Presentation

1
Case Presentation

• Dr Oredein

2
Case Presentation

• 72yr old J.S
• Presented on 23rd April 2002
• At 2150hrs
• C/o Abdominal Pain Back Pain 4 and ½
  hrs Collapse

3
Case Presentation

• H/o presenting complaints
• PMH diabetes arthritis
• Drug hx methotrexate, metformin,
  testosterone, gliclazide, folic acid,
  prednisolone

4
Case Presentation

• O/e
• Conscious and alert but very tired and weak
• Palor, Anicteric, Afebrile
• Chest clinically clear, RR 24/m

5
Case Presentation

• CVS
• BP 89/62 P 116 regular
• L. Femoral pulse not palpable
• R. Femoral pulse faint
• Upper limb pulses normal
• S1S2 normal. No murmurs

6
Case Presentation

• Abdomen
• Grossly distended with slight depression across
  the umbilical area
• Slight bluish discoloration over the suprapubic
  region
• Generally tympanitic but dull to percussion on
  the sides
• Generalized mild to moderate tenderness. RT
  Guarding
• Pulsatile mass to the lt. side/LUQ of the
  umbilicus
• BS

7
Case Presentation

• CNS
• GCS 15
• No neurological signs
• GUT
• NAD. Catheterized
• MSS
• NAD

8
Case Presentation

• Impression ??
• Ruptured Abdominal Aortic Aneurysm

9
Case Presentation

• Plan
• Oxygen by face mask
• 2 Large bore IV Line
• Bloods
• FBC, Xmatch 3units (whole blood), PT/PTT, UE,
  RBS,
• ECG
• ABG
• Arterial Line

10
Case Presentation

• Surgery consult (2155)
• AE Consultant informed (2200)
• Response from surgery (2205 2210)
• AE Consultant called (2215)
• Mr Harris informed
• Patient to be prepared to go directly to theater
• Mr Harris arrives (2225)
• Pt. on his way to theater ( 2250)

11
Case Presentation

• At Surgery
• Laparotomy
• Large retroperitoneal hematoma
• Bloody fluid in abdomen
• Endaneurysmorrhaphy done
• EBL 7 liters

12
Case Presentation

• Post Surgery
• 0615
• Persistently hypotensive 40/27
• Urine output fallen off
• Abdomen tense / oozing from incision
• Imp DIC.
• Needs blood products (not available)

13
Case Presentation

• Post Surgery
• 0730
• Hypotension continues
• Coffee grounds up NGT
• No urine output in last 2 hours
• Bradycardic (No resuscitation)
• 0750
• No waveform from arterial line, no spontaneous
  respiration, no corneal reflex
• CERTIFIED DEAD

14
Ruptured Aneurysm

• Clinical features
• Pain
• Hypotension
• Mass
• Aortoenteric fistula
• Aortovenous fistula

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Ruptured Aneurysm

• Common Misdiagnosis
• Renal colic
• acute abdomen
• Intestinal ischemia
• Diverticulitis, Cholecystitis, Pancreatitis,
  Appendicitis,
• Perforated viscus
• Bowel obstruction
• Musculoskeletal backpain
• Acute myocardial infarction

16
Ruptured Aneurysm

• Diagnostic Strategies
• Plain abdominal radiographs
• Ultrasound
• Computed tomography
• Angiography
• Magnetic resonance angiography

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Ruptured Aneurysm

• Management
• Patient with ruptured AAA are unstable until the
  aorta is cross-clamped in the OR
• At least 2 large-bore IV access
• Xmatch (at least 10 units)
• Notify surgical team immediately
• Avoid attempts to fully resuscitate and normalize
  vital signs in the ED
• Hypotensive pts. need to be taken to OR ASAP.

18
Ruptured Aneurysm

• Manag.contd
• Fluid resuscitation
• Goal is to prevent irreversible end-organ damage
• Crystalloid and blood products
• Maintain sys.BP at 90-100 if possible

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Ruptured Aneurysm

• Surgery and mortality
• Uniformly fatal unless treated surgically
• Mortality is approximately 50
• Overall mortality rate is 80-90 when pt. do not
  reach the OR
• Hypotension is the most important factor
  predicting poor outcome

20
Ruptured Aneurysm

• KEY CONCEPTS
• Ruptured AAA should be considered in any pt.older
  than 50 who presents with abdominal or back pain
• Risk of rupture ? with size but small aneurysm
  can rupture at any time
• Patients with ruptured AAA who are initially
  hemodynamically stable may suddenly deteriorate
  at any time.
• Pt.with ruptured AAA should be moved
  expeditiously to OR, bypassing complete
  resuscitation and time-consuming imaging.