An 81 yo female presents to the ED with abdominal pain for 3 days.  While in the ED she suddenly became unresponsive.  You put an ultrasound on her abdomen and immediately call surgery.  She has a CT which confirms your suspicion.  What's the diagnosis?  Scroll down for answer.

Answer:  Abdominal Aortic Aneurism (AAA) Rupture

• More common in the elderly, smokers, caucasians, men, patients with a history of HTN, connective tissue disease
• Consider in any patient with abdominal pain and hypotension
• Do not rely on palpating pulsatile abdoinal mass (sensitivity ranges 22-96%) and the exam may be difficult in the obese
• Abdominal ultrasound is 95% sensitive and 100% specific for AAA
• Management 
• Resuscitation measures with large bore IV access, blood transfusion (usually massive transfusion protocol), allow permissive hypotension (SBP ~ 70-80) to limit hemorrhage, protect airway
• Stat vascular surgery consult for emergent repair
• An estimated 50% of ruptured AAA reach the hospital alive, 50% of those do not survivie.  100% mortality unrepaired ruptured AAA
• Rupture risk increases with increasing diameter of AAA (0% with AAA < 4cm to 30-50% with AA > 8cm)

• Indications for elective surgery:  male with AAA > 5.5cm, female with AAA >5cm, rapid growth > 1cm/year

References:

Aggarwal, Sourabh, et al. “Abdominal Aortic Aneurysm: A Comprehensive Review.” Experimental and Clinical Cardiology, vol. 16, no. 1, 2011, pp. 11–15., www.ncbi.nlm.nih.gov/pmc/articles/PMC3076160/.