Clinical CT – April 2016

clinicalct04-2016

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
The following two tabs change content below.
Interests: Emergency medicine, toxicology, humanism, cooking & eating, science fiction, movies, travel, cats, photography, film making.

Latest posts by ablumenberg (see all)

Leave a Reply

Your email address will not be published.