The EMS vitals — no nursing assessment yet — are P 70, BP 75/60, RR 24. “We noticed that his pressure was a little low,” says the lead medic. “Been vomiting all morning, he’s doing better since we gave him the saline bolus and Phenergan.” The EMS-stretcher exam reveals only diffuse abdominal pain in this somewhat overweight but otherwise healthy man. No rebound or guarding. He is alert & oriented, and confirms the EMS story.
You don’t like either the HR (low for someone who is dehydrated — no beta blockers) or the blood pressure (low, might be dehydration or a measurement error, need to get the nurse to recheck it). You order fluids, labs, Zofran, cardiac panel/EKG, portable CXR and a non-contrasted CT scan of the abdomen. The patient is off to a room, you scribble the outline of an H&P on the computer, and it’s off to the next case.
It’s a good day in CT, no marathon biopsy cases or blown fuses. Twenty minutes later the tech calls you. “You need to come look at this scan”. No problem.
What does the scan show? What should you do next?
CT scanning is also nearly mandatory for modern endovascular surgical repair of this entity. The surgeon needs the CT scan in order to plan the operation. Therefore, in contrast to the old days when the mantra was “go straight to the OR”, now we often go straight to CT, even with a very unstable patient. In this case, we were at a hospital without a vascular surgeon, so transfer after CT imaging was in order. While any hemorrhage from AAA is potentially life-threatening, a relatively contained retro-peritoneal leak as seen on this CT scan carries a better prognosis than free rupture into the peritoneal cavity. Call the helicopter, give a couple of units of blood, sign the transfer papers, and … off to the next crisis.
directs the Emergency Medicine PREP Course. www.emprepcourse.com