- The patient presented with flank pain and was found to have a ruptured abdominal aortic aneurysm on a previous CT scan. - An EVAR procedure was performed successfully to treat the ruptured aneurysm. - Abdominal aortic aneurysms commonly cause no symptoms but can sometimes present with flank, back, or abdominal pain if the aneurysm expands or ruptures. Diagnosis is typically made by CT scan and treatment involves surgery or endovascular repair depending on symptoms and aneurysm characteristics.

1. SNUH Department of Emergency Medicine
Student case conference: 2019/11/15
ER visit time: 2019.11.05 12:06
서울대학교 의과대학
2015-10373 박현준
이O수 M/67
C.C.: Flank pain (2019.11.05)

2. Present illness
Buerger’s disease 환자로 민상일 교수님 외래에서 시행한 CT에서
Ruptured aneurysm with pressure erosion at L4 vertebra로 응급실
방문 권유된 환자.
옆구리가 욱씬욱씬 쑤시는 NRS 4점 정도의 통증이 간헐적으로 발
생함. 현재는 많이 완화되었으나 한 달전 6~7점정도의 통증으로
응급실 방문한 이력 있음. 양 다리 무릎아래 절단 후 의족 착용하
고 있으며, 약간의 저린 감이 지속됨.

3. Past medical history
• Buerger’s disase
• DM/HTN/TB (-/-/-)
• Dyslipidemia/heart disease (-/-)
• Trauma history (-)
• Operation history (+) : bilateral below knee amputation (20YA)
• Current medication : Pletaal SR 2C qd

4. Family history
• Denied
Social history
• Smoking: 40PY quick 1YA
• Alcohol: (-)

5. Review of System
>General
• GW(-) Easy Fatigue (-) POI(-)
• Fever/Chill (-/-)
• Headache/Dizziness (-/-)
• Weight change (-) Night sweating (-)
>Respiratory & Cardiovascular
• Cough/Sputum/Rhinorrhea (-/-/-)
Sore throat (-)
• Dyspnea/Chest pain/Palpitation (-/-/-)
Dyspnea On Exercise (-)
>Gastrointestinal
• Anorexia/Nausea/Vomiting/Constipat
ion/Diarrhea (-/-/-/-/-)
• Abdominal pain (-)
• Hematemesis/Melena/Hematochezia
(-/-/-)
>Genitourinary
• Frequency/Dysuria/Urgency/Residual
sense (-/-/-/-)
• Red/Foamy/Turbid Urine (-/-/-)

6. V/S > 126/69-83-16-36.7
G/A >
Not so ill-looking, Alert and orientied
Abdomen >
Soft, flat abdomen
Normoactive bowel sound
T/RT (-/-)
CVAT (-/-)
Physical Examination

7. Initial assessment
Ruptured abdominal aortic aneurysm

8. Initial plan
• Lab (CBC, admission panel, Electrolyte, coagulation, hs-CRP)
• Urine analysis
• Endovascular aneurysm repair(EVAR) 시행 준비
– EKG monitoring, Cefazolin 투약, EchoCG, V/S monitoring,

9. WBC 4,580 – Hb 14.4 – Plt 200k/㎕
Lymphocyte 22.7% Monocyte 7.6% Seg. Neut. 65.1% ANC 2982
Na/K/Cl 140/4.2/107 Ca/P 8.0/2.5
BUN/Cr 11/0.76 eGFR 94.4
T.ptn/Alb 6.7/4.1 T.bil 0.4 ALP/AST/ALT 138/29/19 CRP 0.42
PT 11.6s, INR 1.03 (96%) aPTT 30.9s Fibrinogen 305
Urine Color 담황 Turbidity 청 SG 1.017 pH 6.0
ALB +/- GLU - KET - BIL - BLD +/- URO 1+ NIT - WBC(s) -
RBC <1 WBC 1-4 Squamous <1
EKG – normal sinus rythm
Laboratory findings

10. Normal LV cavity size and borderline systolic function
Calculated EF : 51%
No regional wall motion abnormality
Normal LV wall thickness
Normal valves
No intracardiac mass, thrombi or pericardial effusion
CPA: no cardiomegaly
Echocardiography

11. Abdominal CT (‘19.11.05) - Pre contrast phase

12. Abdominal CT (‘19.11.05) – Arterial phase

13. Abdominal CT (‘19.11.05) – CT angiography

14. Reassessment
Ruptured abdominal aortic aneurysm
• EVAR진행 후 Post-OP care
Further plan

15. Hospital Course
‘19.11.05 : 외과 외래 방문 후 이전 CT 상 Ruptured AAA 발견, 응급실 방문
권유
’19.11.05 12:06 응급실 방문
’19.11.05 기본 lab실시하며 pre-OP risk evaluation
’19.11.06 EVAR 시행 후 외과 병동 전동

16. POST OP(‘19.11.06)

18. Abdominal Aortic Aneurysm
Review:

19. Clinical features
Commonly produces no symptoms
- Usually detected on routine examination as a palpable, pulsatile, expansile, and
nontender mass
- Incidental finding on abdominal imaging study done for other reasons
Expansion of AAA may cause pain and other symptoms
- Flank, back, or abdominal pain: m/c
- Severe and abrupt in onset
- 50% of patients describing a ripping or tearing pain
- Syncope: due to rapid blood loss and lack of cerebral perfusion

20. Diagnosis
Plain radiograph
- May show a calcified and bulging aortic contour
- 25% cannot be visualized in X-ray
Bedside US
- Measure aneurysm in both longitudinal and transverse
- Aortic diameter < 3.0 cm excludes acute aneurysmal disease
CT scanning with IV contrast
- Best for figuring out anatomic details of aneurysm and hemorrhage
- Unenhanced CT can show aneurysmal size and hemorrhage

21. Treatment
All asymptomatic aortic aneurysm – should be followed up
- ≥ 5cm: require prompt follow-up due to risk of rupture
- 3 to 5cm: can be followed up by patient’s primary care physicians or surgeons
All symptomatic aortic aneurysm – emergent
- Require emergency surgical consultation or transfer to an institution capable of so
- Detection and arranging rapid care of hemorrhage control – key in ER
- Consult surgeon for abdominal and/or back pain, a pulsatile abdominal mass, and
hypotension
- No delay for consultation for imaging if hypotension or acute end-organ perfusion
deficit is evident even without the triad of AAA

22. Treatment
Ruptured Aortic Aneurysm
- Requires prompt operative repair
- Standard resuscitative action
- Insertion of two large-bore IV catheters
- Initiation of cardiac monitoring
- Supplemental oxygen
- Vigorous fluid resuscitation may be harmful -> limiting target of 90mmHg blood pressure as
optimal

24. Tintinalli JE, Stapczynski JS et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th ed., McGraw-Hill (2015)
Kasper DL, Fauci AS et al. Harrison’s Priciples of Internal Medicine, 19th ed. (2015), McGraw-Hill
Courtney M. Townsend, R. Daniel Beauchamp et al. Sabiston Textbook of Surgery, 20 𝑡ℎ
ed, Elsevier
References