96 yom presented with AMS
Paged to resuscitation room for 96 yom with hematemesis and AMS. Underwent brief compressions with ROSC, hypotensive, given vasopressors and intubated. During resusitation noted patient had history of 5 cm AAA. Curvilinear probe placed on anterior midline of abdomen and moved inferiorly. You do an aorta ultrasound and follow it with a FAST exam looking for free fluid.
Proximal abdominal aorta measuring 7.6 cm from outer wall to outer wall.
Proximal aorta with surrounding thrombus and hypoechoic fluid to left of aorta concerning for rupture.
Colorimetry showing blood flow in lumen and false lumen.
Longitudinal view of aorta showing large area of thrombus surrounding true lumen.
Negative RUQ fast view. Ruptured AAA does not necessarily cause free intraperitoneal fluid, this patient had retroperitoneal bleed seen on CT.
Patient had a ruptured AAA. Why was the fast negative? … because the aorta is a retroperitoneal structure many times it bleeds into the retroperitoneal space. This patient went on hospice and later passed.
Imaging the Aorta should include a proximal, mid and distal transverse view as well as a long view so as not to miss unusual aneurysms. Measurement should include outer wall to outer wall, include the intraluminal thrombus which is hyperechoic and not just the hypoechoic area or you may miss an aneurysm. Remember anything in the thorax >4cm or in the abdomen >3cm is abnormal. Anything greater than 5cm should likely involve a vascular surgeon especially if symptomatic.
Don’t forget management is always ABC’s, stability and impulse control with target BP of the lowest level consistent with adequate vital organ perfusion or systolic 100-120 as a starting point and aim for a HR close to 60 bpm. Beta blockers and pain control are great starting points.