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Case 156: Back pain and collapse

A 65 year old man is bought in by ambulance hypotensive after collapsing at home. His main complaint is back pain and he is too distressed to provide much more information.

1. What does the CT show?

There is a large abdominal aortic aneurysm with evidence or rupture into the retroperitoneum. Blood is seen spreading into the right side and pushing the kidney forward. There is also significant mural thrombus.

2. How would you manage the problem in the emergency department?

The patient requires urgent diagnosis and operative management. Delays within the emergency department are not justified beyond instituting basic resuscitation. Two large bore (16G) IV cannulae should be inserted into large veins in the cubital fossa of each arm. Blood should be taken for full blood examination, electrolytes, renal function, coagulation studies and cross matching 6 units of blood. The anaesthetists, operating theatre staff and intensive care unit should be informed and preparing for an urgent operation. A cell saver should be used if available.

3. What are the options for operative mangement?

The standard management is midline laparotomy, vascular control and then aortic replacement with tube graft or bifurcated aorto-bi-iliac graft. There is increasing experience with urgent endoluminal stent grafts however this is only appropraite in a specialist centre and for a select group of patients.