Clinical CT – Abdominal Aortic Aneurysm

Clinical CT for April 2016
by Adam Blumenberg MD
Special thanks to Mark Silverberg MD

A 78 year-old man presents to the ED for pre-syncope and back pain. Physical exam is remarkable for systolic blood pressure in the 80s and a pulsatile abdominal mass. Computed tomography imaging of the abdomen reveals the following:

1. What is the diagnosis?
   A contained Ruptured abdominal aortic aneurysm (AAA) with clot
   
2. What is the workup for this patient in the ER?
   – Two large-bore peripheral venous catheters
   – Notify blood blank, i.e., type and cross and consider activating massive transfusion protocol
   – Critical care monitoring
   – Expedient surgical consultation
3. What are the potential pitfalls that may delay definitive diagnosis? How would you navigate these pitfalls?
   – Misdiagnosis due to anchoring bias – One may diagnose this as renal colic, pulmonary embolism, or musculoskeletal pain.
   – Measuring from inner lumen of a thrombus may give a falsely low aortic diameter – This is especially problematic with sonography or non-contrast CT.
   – Delaying diagnosis by waiting for a contrast CT – Contrast CT requires IV access and “mandatory” creatinine level/GFR. Waiting for lab results and challenging IV access may delay this study. Point of care ultrasound and non-contrast CT are fast, effective ways to measure the diameter of the aorta.
4. What is this patient’s disposition?
   Vascular surgery for graft placement vs. IR for endovascular repair

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ablumenberg

Interests: Emergency medicine, toxicology, humanism, cooking & eating, science fiction, movies, travel, cats, photography, film making.

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