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:
- What is the diagnosis?A contained Ruptured abdominal aortic aneurysm (AAA) with clot
- 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
- 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.
- What is this patient’s disposition?Vascular surgery for graft placement vs. IR for endovascular repair