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{| class="wikitable"
==Background==
|-
*Infrarenal diameter >3cm or >50% increase in size of diameter
! System
**85% of cases are infrarenal <ref name="NJM"></ref>
! Minor or moderate overdose || Severe overdose
*M to F ratio is 4:1
|-
*Rupture Risk
! Cardiovascular
**<4cm: low risk for rupture
|
**4-5cm: 5 year risk 3-12%
||
**>5cm: 25-41%
* [[Disseminated intravascular coagulation]]
**Rupture possible at any size, most commonly >5cm
* [[Intracranial hemorrhage]]
**Mortality with rupture: 85-90% <ref name="NJM">Kent, K. Abdominal Aortic Aneurysms. The New England Journal of Medicine. 2014; 371:2101-8. DOI: 10.1056/NEJMcp1401430 </ref>
* Severe [[hypertension]] or [[hypotension]]
 
* Hypotensive bleeding
===Risk Factors===
|-
*Smoking
! Central nervous<br />system
**Risk factor most strongly associated with AAA
|
**Also promotes the rate of aneurysm growth
* Hyperreflexia
*Age (prevalence is negligible in age <50yrs)
* Agitation
*Family history
* Confusion
*Hypertension
* Paranoia
*Hyperlipidemia
* Stimulant psychosis
*Fluoroquinolone use <ref>P. Wendling for Medscape.  FDA Warns of Aortic Aneurysm Risk with Fluoroquinolones. https://www.medscape.com/viewarticle/906867.  Accessed 12/26/2018.</ref>
|
 
* Cognitive deficit
==Clinical Features==
* Coma
*Classic triad is [[abdominal pain|pain]] + [[hypotension]] + pulsatile mass
* Convulsions
**Pain often described as sudden, severe, radiating to back
* [[Hallucinations]]
*[[Syncope]] (10%)
* Loss of consciousness
*Signs of [[Retroperitoneal hemorrhage]]
* [[Serotonin syndrome]]
*Massive [[GI bleed]] from erosion into intestines
|-
*Pain + AAA = rupture until proven otherwise
! Musculoskeletal
*Acute abdomen + hypotension = possible rupture
|
*Gross [[hematuria]] can be caused by an aortocaval fistula (very rare)
|
 
* Hypertonia
==Differential Diagnosis==
* [[Rhabdomyolysis]]  
{{Abdominal Pain DDX Diffuse}}
|-
 
! Respiratory
{{Lower back pain DDX}}
|
 
|
==Evaluation==
* [[Acute respiratory distress syndrome]]
[[File:AAA.png|thumb|AAA]]
|-
[[File:AAA_with_Thrombus.gif|thumbnail|AAA with Thrombus<ref>http://www.thepocusatlas.com/aorta-1/</ref>]]
! Urinary
 
|
*[[Aortic ultrasound|Ultrasound]]
|
**~100% sensitive for increased diameter
* [[Acute kidney injury]]
**Cannot reliably visualize rupture
|-
 
! Other
*CT
|
**~100% sensitive for increased diameter and rupture
|
**IV contrast is preferred but not essential
* Cerebral edema
 
* [[Hepatitis]]
==Management==
* [[Hyperpyrexia]]  
===Rupture===
* [[Hyponatremia]] (SIAD)
*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)<ref>Reed, K. Aortic Emergencies, EB Medicine. 2006.</ref>
**[[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 80-100) in conscious patient
**[[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
 
===Asymptomatic===
*Prompt vascular surgery outpatient follow-up appt
**Endovascular (75%) vs open repair
*Screening frequency:
**3-4 cm diameter: 12 months
**4-5 cm diameter: 6 months
**5-6 cm diameter: 1 month
*Elective Surgery indicated if:
**AAA > 5.5 cm in men <ref name="NJM"></ref>
**AAA > 5 cm in women <ref name="NJM"></ref>
**increase in size > 1 cm/year
**increase in size > 5 mm/6 months
 
==Complications==
*[[Aortoenteric fistula]]
*[[Aortocaval fistula]]
*[[Inflammatory abdominal aortic aneurysm]]
*[[Acute limb ischemia]] - embolism to lower extremities
 
==Disposition==
*Admit to OR in cases of ruptured OR
*Vasc surgery follow up in asymptomatic cases
 
==References==
<references/>
 
[[Category:Cardiology]]
[[Category:Vascular]]

Revision as of 03:24, 3 October 2019

Background

  • 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
  • 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
  • Syncope (10%)
  • Signs of Retroperitoneal hemorrhage
  • Massive GI bleed from erosion into intestines
  • 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

Lower Back Pain

Evaluation

AAA
AAA with Thrombus[3]
  • Ultrasound
    • ~100% sensitive for increased diameter
    • Cannot reliably visualize rupture
  • 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)[4]
    • 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 80-100) in conscious patient
    • 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

Asymptomatic

  • Prompt vascular surgery outpatient follow-up appt
    • Endovascular (75%) vs open repair
  • Screening frequency:
    • 3-4 cm diameter: 12 months
    • 4-5 cm diameter: 6 months
    • 5-6 cm diameter: 1 month
  • Elective Surgery indicated if:
    • AAA > 5.5 cm in men [1]
    • AAA > 5 cm in women [1]
    • increase in size > 1 cm/year
    • increase in size > 5 mm/6 months

Complications

Disposition

  • Admit to OR in cases of ruptured OR
  • Vasc surgery follow up in asymptomatic cases

References

  1. ↑ 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
  2. ↑ P. Wendling for Medscape. FDA Warns of Aortic Aneurysm Risk with Fluoroquinolones. https://www.medscape.com/viewarticle/906867. Accessed 12/26/2018.
  3. ↑ http://www.thepocusatlas.com/aorta-1/
  4. ↑ Reed, K. Aortic Emergencies, EB Medicine. 2006.
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