Pulsatile Belly, Falling Pressure - Emergency Medicine clinical simulation case. A 74-year-old male chronic smoker with a remote history of open abdominal...
Age: 74 • Gender: Male • Setting: Emergency Triage
Clinical Presentation & History
A 74-year-old male chronic smoker with a remote history of open abdominal aortic aneurysm repair presents to triage with sudden severe back and abdominal pain after lifting a heavy toolbox, now becoming diaphoretic, hypotensive, and gray.
Acute Resuscitation Milestones & Priorities
Clinical phases and key interventions encountered in this emergency module:
The classic triad of back pain, hypotension, and pulsatile abdominal mass is present in only ~50% of ruptured AAA cases; maintain high suspicion in any elderly smoker with syncope or pain.
Permissive hypotension (SBP 80-90 mmHg) preserves the protective retroperitoneal tamponade while maintaining coronary and cerebral perfusion.
Aggressive crystalloid to normotension disrupts clot integrity, dilutes clotting factors, and accelerates exsanguination.
Massive transfusion protocol with 1:1:1 plasma:platelet:RBC ratio prevents the trauma triad of death.
EVAR is reserved for hemodynamically stable ruptured AAA with suitable anatomy and immediately available hybrid operating room.
Norepinephrine is the preferred vasopressor during anesthesia induction in ruptured AAA; beta agonism alone (dobutamine) worsens vasodilation without addressing hypovolemia.
Avoid CPR before aortic cross-clamp; compressions worsen intracranial pressure and delay definitive surgical control.
Remote history of open AAA repair raises suspicion for anastomotic pseudoaneurysm or aorto-enteric fistula as alternative etiologies of hemorrhage.
Test Your Clinical Reasoning in Real Time
Step into the active clinician role for this case. Order diagnostic tests, analyze live laboratory panels, and navigate branching clinical decisions with real-time feedback.