Abdominal aortic aneurysm

Background

• Infrarenal diameter >3cm or >50% increase in size of diameter
• Rupture Risk
  • <4cm: low risk for rupture
  • 4-5cm: 5 year risk 3-12%
  • >5cm: 25-41%
  • Rupture poss at any size, most commonly >5cm

Risk Factors

1. Age
   1. Prevalence is negligible in age < 50 yrs
2. Smoking
   1. Risk factor most strongly assoc with AAA
   2. Also promotes the rate of aneurysm growth
3. Family history
4. HTN

Diagnosis

• Triad: pain + hypotension + pulsatile mass
  • Pain often described as sudden, severe, radiating to back
• Syncope (10%)
• Pain + AAA = rupture until proven otherwise
• Acute abdomen + hypotension = possible rupture

Workup

• Ultrasound
  • ~100% sensitive for increased diameter
  • Cannot reliably visualize rupture
• CT
  • ~100% sensitive for incr diameter and rupture
  • IV contrast is preferred but not essential

Differential Diagnosis

• Renal Colic
• Pancreatitis
• Mesenteric ischemia
• Cholecystitis
• Appendicitis
• Diverticulitis
• ACS
• Musculoskeletal backpain

See Abdominal Pain

Treatment

Rupture

1. Do not waste time in ED trying to "stabilize" pt
2. Immediate surgery consultation/ go to OR
3. Crossmatch 6 units of pRBC
4. Pain control (avoid hypotension)
5. BP control
   1. Controversial
      1. Too little (ischemia), too much (increased bleeding)
         1. Consider allowing for permissive hypotension (SBP 80-100) in conscious pt
      2. Pressors
         1. Norepi 0.05mcg/kg/min IV; titrate by 0.02mcg/kg/min q5min
         2. Phenylephrine 100-180mcg/min; titrate by 25mcg/min q10min
         3. Dopamine 5mcg/kg/min; titrate by 5mcg/kg/min q10min

Asymptomatic

• Prompt vascular surgery outpatient follow-up appt

Source

• Tintinalli
• UpToDate
• Rosen's