Rosen & Barkin's 5-Minute Emergency Medicine Consult (15 page)

TREATMENT

• Establish 2 large-bore IV lines
  
• Rapid transport to the nearest facility with surgical backup
  
• Alert ED staff as soon as possible to prepare the following:
  
  • Operating room
    
  • Universal donor blood
    
  • Surgical consultation
    

• 2 large-bore IV lines
  
• Crystalloid infusion
  
• Cardiac monitor
  
• Early blood transfusion
  

For patients suspected of symptomatic AAA:

• Avoid over aggressive fluid resuscitation; this leads to increased bleeding
  
• Emergent surgical consult and operative intervention
  
• Laparotomy versus endovascular aortic repair (EVAR) by vascular surgeon
  
• Diagnostic tests should not delay definitive treatment.
  

FOLLOW-UP

All patients with symptomatic AAA require emergent surgical intervention and admission.

Asymptomatic patients only

• Close vascular surgery follow-up must be arranged prior to discharge
  
• Instructions to return immediately for:
  
  • Any pain in the back, abdomen, flank, or lower extremities
    
  • Any dizziness or syncope
    

• AAA should be on the differential for any patient presenting with pain in the abdomen, back, or flank.
  
• Symptomatic AAA requires immediate treatment. Do not delay definitive care for extra studies.
  
• A hemodynamically unstable (i.e., hypotensive) patient should not be taken for CT scan.
  

• Bentz S, Jones J. Accuracy of emergency department ultrasound in detecting abdominal aortic aneurysm.
  Emerg Med J
  . 2006;23(10):803–804.
  
• Choke E, Vijaynagar B, Thompson J, et al. Changing epidemiology of abdominal aortic aneurysms in England and Wales: Older and more benign?
  Circulation
  . 2012;125(13):1617–1625.
  
• Lederle FA, Freischlag JA, Tassos C, et al. Long-term comparison of endovascular and open repair of abdominal aortic aneurysm.
  N Engl J Med
  . 2012;367:1988–1997.
  
• Rogers RL, McCormack R. Aortic disasters.
  Emerg Med Clin N Am
  . 2004;22:887–908.
  
• Tibbles C, Barkin A. The aorta. In: Cosby K, Kendall J.
  Practical Guide to Emergency Ultrasound
  . Philadelphia, PA: Lippincott Williams & Wilkins; 2006:219–236.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Aortic Dissection
  
• Peripheral Artery Disease
  

CODES

• 441.3 Abdominal aneurysm, ruptured
  
• 441.4 Abdominal aneurysm without mention of rupture
  

BASICS

• Parietal pain:
  
  • Irritating material causing peritoneal inflammation
    
  • Pain transmitted by somatic nerves
    
  • Exacerbated by changes in tension of the peritoneum
    
  • Pain is sharp, well localized with abdominal, rebound tenderness and involuntary guarding
    
• Visceral pain:
  
  • Afferent impulses result in poorly localized pain based on the embryologic origin rather than true location of an organ.
    
    • Pain of foregut structures to the epigastric area
      
    • Pain from midgut structures to the periumbilical area
      
    • Pain from hindgut structures to the suprapubic region
      
  • Distention of a viscous or organ capsule or spasm of intestinal muscularis fibers
    
    • Pain is constant and colicky
      
  • Inflammation:
    
    • Focal tenderness develops once the inflammation extends to the peritoneum
      
  • Ischemia from vascular emergencies:
    
    • Pain is severe and diffuse
      
• Referred pain:
  
  • Felt at distant location from diseased organ
    
  • Due to an overlapping supply by the affected neurosegment
    
• Abdominal wall pain:
  
  • Constant, aching with muscle spasm
    
  • Involvement of other muscle groups
    

• Peritoneal irritants:
  
  • Gastric juice, fecal material, pus, blood, bile, pancreatic enzymes
    
• Visceral obstruction:
  
  • Small and large intestines, gallbladder, ureters and kidneys, visceral ischemia, intestinal, renal, splenic
    
• Visceral inflammation:
  
  • Appendicitis, inflammatory bowel disorders, cholecystitis, hepatitis, peptic ulcer disease, pancreatitis, pelvic inflammatory disease, pyelonephritis
    
• Abdominal wall pain
  
• Referred pain: (e.g., intrathoracic disease)
  

DIAGNOSIS

• Pain
  
  • Nature of onset of pain
    
  • Time of onset and duration of pain
    
  • Location of pain initially and at presentation
    
  • Extra-abdominal radiations
    
  • Quality of pain (sharp, dull, crampy)
    
  • Aggravating or alleviating factors
    
  • Relation of associated finding to pain onset
    
• Anorexia
  
• Nausea
  
• Vomiting (bilious, coffee-ground emesis)
  
• Malaise
  
• Fainting or syncope
  
• Cough, dyspnea, or respiratory symptoms
  
• Change in stool characteristics (e.g., melena)
  
• Hematuria
  
• Changes in bowel or urinary habits
  
• History of trauma or visceral obstruction
  
• Gynecologic and obstetric history
  
• Postoperative (e.g., cause ileus)
  
• Family history (e.g., familial aortic aneurysm)
  
• Alcohol use and quantity
  
• Medications: (e.g., aspirin and NSAIDs)
  

• General:
  
  • Anorexia
    
  • Tachycardia
    
  • Tachypnea
    
  • Hypotension
    
  • Fever
    
  • Yellow sclera (icterus)
    
  • Distal pulses and pulse amplitudes between lower and upper extremities
    
• Abdominal:
  
  • Distended abdomen
    
  • Abnormal bowel sounds:
    
    • High-pitched rushes with bowel obstruction
      
    • Absence of sound with ileus or peritonitis
      
  • Pulsatile abdominal mass
    
  • Rebound tenderness, guarding, and cough test for peritoneal irritation (e.g., appendicitis, peritonitis)
    
  • Rovsing sign, suggestive of appendicitis:
    
    • Palpation of left lower quadrant causes pain in right lower quadrant (RLQ).
      
  • Psoas sign suggests appendicitis (on right)
    
    • Pain on extension of thigh
      
  • Obturator sign suggests pelvic appendicitis (on the right only)
    
    • Pain on rotation of the flexed thigh, especially internal rotation
      
  • McBurney point tenderness associated with appendicitis:
    
    • Palpation in RLQ 2/3 distance between umbilicus and right anterior superior iliac crest causes pain.
      
  • Murphy sign, suggestive of cholecystitis:
    
    • Pause in inspiration while examiner is palpating under liver
      
  • Carnett sign indicates abdominal wall pain
    
    • Pain when a supine patient tenses the abdominal wall by lifting the head and shoulders.
      
  • Tender or discolored hernia site
    
  • Rectal and pelvic examination:
    
    • Tenderness with pelvic peritoneal irritation
      
    • Cervical motion tenderness
      
    • Adnexal masses
      
    • Rectal mass or tenderness
      
    • Guaiac positive stool
      
• Genitourinary:
  
  • Flank pain
    
  • Dysuria
    
  • Costovertebral angle tenderness
    
  • Suprapubic tenderness
    
  • Tender adnexal mass on pelvis
    
  • Testicular pain:
    
    • May be referred from renal or appendiceal pathology
      
• Referred pain:
  
  • Kehr sign (diaphragmatic irritation due to blood or other irritants) causes shoulder pain.
    
• Extremities:
  
  • Pulse deficit or unequal femoral pulses
    
• Skin:
  
  • Jaundice
    
  • Liver disease (caput medusa)
    
  • Hemorrhage
    
    • Grey Turner sign of flank ecchymosis
      
    • Cullen sign is ecchymotic area round the umbilicus
      
  • Herpes zoster
    
  • Cellulitis
    
  • Rash (Henoch–Schönlein purpura [HSP])