A 72-year-old man has the sudden onset of severe abdominal pain. He is taken to the emergency department. On admission his vital signs show T 37.1 C, P 95/min, RR 18/min, and BP 70/40 mm Hg. Peripheral pulses are weak. His skin is cool and clammy. Auscultation of the chest shows lung fields are clear. His heart rate is regular with no murmurs. His abdomen is diffusely and markedly tender with no bowel sounds present. His stool is negative for occult blood.

Initial laboratory studies show hematocrit 17%, sodium 140 mmol/L, potassium 4.0 mmol/L, chloride 105 mmol/L, CO2 26 mmol/L, glucose 71 mg/dL, creatinine 1.1 mg/dL, and amylase 43 U/L.

An abdominal CT scan shows a calcified abdominal aorta with diameter of 6 cm. There is an accumulation of fluid in the abdomen.

Questions:

3.1 What is the most likely diagnosis?

He has a ruptured atherosclerotic aortic aneurysm.

3.2 What therapeutic measures are indicated?

He requires emergent surgical repair of the abdominal aorta, typically with synthetic graft placement.

Pressor agents may be considered, but there is concern about acute renal failure with some agents (alpha-1 agonists).

Depending upon the blood loss, he may require volume expansion with crystalloids and/or blood products such as packed red blood cells. If he has lost considerable blood volume and is developing coagulopathies, he may require additional products such as platelets and fresh frozen plasma.