Abdominal aortic aneurysm: Difference between revisions
No edit summary |
|||
| Line 99: | Line 99: | ||
*Admit to OR in cases of ruptured OR | *Admit to OR in cases of ruptured OR | ||
*Vasc surgery follow up in asymptomatic cases | *Vasc surgery follow up in asymptomatic cases | ||
==External Links== | |||
* [https://rebelem.com/rebel-core-cast-49-0-abdominal-aortic-aneurysm-aaa/ REBEL EM - Abdominal Aortic Aneurysm (AAA)] | |||
* [http://www.emdocs.net/the-crashing-abdominal-aortic-aneurysm-patient/ emDocs - The Crashing Abdominal Aortic Aneurysm Patient] | |||
==References== | ==References== | ||
Revision as of 14:41, 30 June 2021
Background
- 2 Different types
- Fusiform- Bulging or ballooning of all sides of the aorta; more common
- Saccular- Bulging or ballooning of only one side of the aorta
- Infrarenal diameter >3cm or >50% increase in size of diameter
- 85% of cases are infrarenal [1]
- M to F ratio is 4:1
- Rupture Risk
- <4cm: low risk for rupture
- 4-5cm: 5 year risk 3-12%
- >5cm: 25-41%
- Rupture possible at any size, most commonly >5cm
- Mortality with rupture: 85-90% [1]
Risk Factors
- Smoking
- Risk factor most strongly associated with AAA
- Also promotes the rate of aneurysm growth
- Direct relationship between risk and number of smoking years
- Age (prevalence is negligible in age <50yrs)
- Family history
- Hypertension
- Hyperlipidemia
- Fluoroquinolone use [2]
Clinical Features
- Classic triad is pain + hypotension + pulsatile mass
- Pain often described as sudden, severe, radiating to back, ripping quality
- Syncope (10%)
- Signs of Retroperitoneal hemorrhage
- Massive GI bleed from aortoenteric fistula
- Pain + AAA = rupture until proven otherwise
- Acute abdomen + hypotension = possible rupture
- Gross hematuria can be caused by an aortocaval fistula (very rare)
Differential Diagnosis
Diffuse Abdominal pain
- Abdominal aortic aneurysm
- Acute gastroenteritis
- Aortoenteric fisulta
- Appendicitis (early)
- Bowel obstruction
- Bowel perforation
- Diabetic ketoacidosis
- Gastroparesis
- Hernia
- Hypercalcemia
- Inflammatory bowel disease
- Mesenteric ischemia
- Pancreatitis
- Peritonitis
- Sickle cell crisis
- Spontaneous bacterial peritonitis
- Volvulus
Lower Back Pain
- Spine related
- Acute ligamentous injury
- Acute muscle strain
- Disk herniation (Sciatica)
- Degenerative joint disease
- Spondylolithesis
- Epidural compression syndromes
- Thoracic and lumbar fractures and dislocations
- Cancer metastasis
- Spinal stenosis
- Transverse myelitis
- Vertebral osteomyelitis
- Ankylosing spondylitis
- Spondylolisthesis
- Discitis
- Spinal Infarct
- Renal disease
- Intra-abdominal
- Abdominal aortic aneurysm
- Ulcer perforation
- Retrocecal appendicitis
- Large bowel obstruction
- Pancreatitis
- Pelvic disease
- Other
Evaluation
Ultrasound of AAA with Thrombus (click to view).[3]
- CT
- ~100% sensitive for increased diameter and rupture
- IV contrast is preferred but not essential
Management
Rupture
- Do not waste time in ED trying to "stabilize" patient
- Immediate surgery consultation/ go to OR
- Crossmatch 6 units of pRBC
- Pain control (avoid hypotension)
- Antihypertensives (use with caution, goal SBP 110-120 mmHg or MAP 70-80)[6]
- Labetalol: 20mg IV, then 40-80mg IV q10 min (max 300mg)
- Esmolol: Bolus 500 mcg/kg, then 50-200 mcg/kg/min
- Nitroprusside: 0.3 - 0.5 mcg/kg/min, titrate to max 10 mcg/kg/min
- Controversial
- Too little (ischemia), too much (increased bleeding)
- Consider allowing for permissive hypotension (SBP 70-90) in conscious patient[7]
- Pressors
- Norepinephrine 0.05mcg/kg/min IV; titrate by 0.02mcg/kg/min q5min
- Phenylephrine 100-180mcg/min; titrate by 25mcg/min q10min
- Dopamine 5mcg/kg/min; titrate by 5mcg/kg/min q10min
- Too little (ischemia), too much (increased bleeding)
Asymptomatic
- Aneurysm > 5 cm: Prompt (within days) vascular surgery outpatient follow-up appt
- Endovascular (75%) vs open repair
- Aneurysm 3-5 cm: Can likely follow up with PCP/surgeon on non-urgent basis
- Screening frequency:
- 3-4 cm diameter: 12 months
- 4-5 cm diameter: 6 months
- 5-6 cm diameter: 1 month
- Elective Surgery indicated if:
Complications
- Aortoenteric fistula
- Aortocaval fistula
- Inflammatory abdominal aortic aneurysm
- Acute limb ischemia - embolism to lower extremities
- Graft infection
- Endoleak
Disposition
- Admit to OR in cases of ruptured OR
- Vasc surgery follow up in asymptomatic cases
External Links
References
- ↑ 1.0 1.1 1.2 1.3 Kent, K. Abdominal Aortic Aneurysms. The New England Journal of Medicine. 2014; 371:2101-8. DOI: 10.1056/NEJMcp1401430
- ↑ P. Wendling for Medscape. FDA Warns of Aortic Aneurysm Risk with Fluoroquinolones. https://www.medscape.com/viewarticle/906867. Accessed 12/26/2018.
- ↑ http://www.thepocusatlas.com/aorta-1/
- ↑ Rubano E, Mehta N, Caputo W, Paladino L, Sinert R. Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm. Acad Emerg Med. 2013;20(2):128-138. doi:10.1111/acem.12080
- ↑ Rubano E, Mehta N, Caputo W, Paladino L, Sinert R. Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm. Acad Emerg Med. 2013;20(2):128-138. doi:10.1111/acem.12080
- ↑ Reed, K. Aortic Emergencies, EB Medicine. 2006.
- ↑ Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018;67(1):2-77.e2. doi:10.1016/j.jvs.2017.10.044